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Patient G.S. Zachary R. Barnard UCSD Neurosurgery Sub-intern September 2012. Chief Complaint. 22 year old RHM presents with flaccid paralysis of left upper extremity after a motorcycle accident 6 months ago. History of Present Illness.

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patient g s

Patient G.S.

Zachary R. Barnard

UCSD Neurosurgery Sub-intern

September2012

chief complaint
Chief Complaint

22 year old RHM presents with flaccid paralysis of left upper extremity after a motorcycle accident 6 months ago

history of present illness
History of Present Illness
  • 6 months PTA: patient presented to UCLA medical center with a GCS of 3 after being thrown 40 feet from his motorcycle that collided with a motor vehicle
    • Multiple surgeries
      • Exploratory laparotomy
      • Thoracotomy
      • Splenectomy
      • Ligation of multiple bleeding intercostal vessels
      • Reconstruction of diaphragmatic rupture
      • Left nephrectomy
      • Repair of colon laceration
    • Neurologically
      • Right frontal hemorrhagic contusion
      • Evidence of DAI
      • EVD placement
history of present illness1
History of Present Illness
  • 4 months PTA: patient was discharged from UCLA medical center
  • 2 months PTA: patient f/u with neurosurgery at UCLA for evaluation of left arm paralysis
    • Neuro exam:
      • Motor- Complete paralysis of his deltoids, biceps, triceps, pectoralis, wrist flexors, wrist extensors, and intrinsic hand muscles.
      • Sensory was showed patchy sensation proximally and no sensation distally
    • Referred to Dr. Brown for evaluation
left brachial plexus imaging
Left brachial plexus Imaging

T2 MRI-fat

suppressed

C6-C7

C7-T1

T1-T2

left brachial plexus imaging1
Left brachial plexus Imaging

T2 MRI-fat

suppressed

emg left arm
EMG: Left arm
  • Severe C4-T1 radiculopathy
  • Evidence of C7-T1 nerve root avulsions
  • C6 nerve root likely not avulsed
  • C5 nerve root avulsion indeterminate
operations
Operations

Stage 1:

  • Brachial plexus exploration with neuroma resection
  • Anterior and middle scalenectomy
  • C5-C6 nerve grafting to posterior cord and suprascapularnerve
  • Bilateral sural nerve harvest

Stage 2:

  • C5 nerve root connection to suprascapular nerve through sural nerve graft

Stage 3:

  • Motor intercostal of 3,4,5,7 grafted to musculocutaneous nerve
  • Sensory intercostal of 3,4 grafted to median nerve
  • Motor intercostal 7,8 to lateral antebrachial cutaneous nerve graft
  • Lateral antebrachial cutaneous nerve graft to extensor carpi radialislongus and brevis
post operative course
Post-operative Course
  • Patient had an unremarkable post-operative course
  • Drains were removed and patient was discharged home with wound care on post-operative day eight
background
Background
  • Earliest possible reconstruction
  • Detailed neurological exam
  • MRI imaging
  • EMG
  • Elbow flexion usually first priority, followed by shoulder abduction/external rotation/stability, then hand sensation
nerve transfer vs nerve repair for upper brachial plexus injury
Nerve transfer vs. nerve repair for upper brachial plexus injury
  • Yang, et al 2012
    • Systematic review
    • 33 studies included
      • 399 nerve transfers
      • 99 nerve repairs
      • 117 transfers + repairs
    • Inclusions
      • Age > 18, f/u > 6 months, injury (avulsion/rupture), function (elbow flexion or shoulder abduction)
    • Outcomes
      • Rates ratio
      • MRS elbow flexion & Should abduction
  • Outcomes/Results
ciliary neurotrophic factor promotes reinnervation of musculocutaneous nerve
Ciliaryneurotrophic factor promotes reinnervation of musculocutaneous nerve
  • Aim:
    • Assess motor vs. sensory fibers in ability to sprout in end-to-side grafting with ciliaryneurotrophic factor (CNTF)
  • Model:
    • 24 Rats MS to Ulnend-to-side graft
  • Endpts:
    • Measure % motor neurons
    • Fn biceps (EMG)
  • Results:
    • PBS motor neurons 9.9%
    • CNTF motor neurons 17%
    • EMG
      • Biceps brachii larger amplitude of contract in CNTF compared to PBS
      • Flexor carpi ulnaris no difference
musculocutaneous nerve graft enhancement with vegf
Musculocutaneous nerve graft enhancement with VEGF
  • Aim:
    • Assess phVEGF ability to reinnervate end-to-end, end-to-side nerve grafts
  • Model:
    • 42 Rats, cut end of nerve transfected with virus
  • Endpts:
    • Measure increase in motor neuron percent by diameter of neuron
bdnf and gdnf in nerve regeneration
BDNF and GDNF in nerve regeneration
  • Brain-derived neurotrophic factor (BDNF)
  • Glial cell-derived neurotrophic factor (GDNF)
  • Electrical stimulus
  • Rolipram (PDE4 inhibitor) anti-inflammatory
summary
Summary
  • Clinical rule of “seven seventies” for traumatic brachial plexus lesions
    • Based on 1068 patients (Siqueira et al, 2011)
    • 70% due to MVCs
      • Of these, 70% motorcycles
        • Of these, 70% multiple injuries
    • Overall, 70% supraclavicular lesions
      • Of these, 70% at least one root avulsion
        • Of these, 70% avulsion C7, C8, or T1
          • Of these, 70% persistent pain
summary1
Summary
  • Peripheral nerve surgery still in infancy
  • Conclusion on best treatment difficult due to lack of randomized controlled trials
  • Lots of basic science possibilities, but need more translational work
conclusions
Conclusions

“A certain excessiveness seems a necessary element in all greatness”

-Harvey Cushing

references
References
  • 1. Giuffre JL, Kakar S, Bishop AT, Spinner RJ, Shin AY. Current concepts of the treatment of adult brachial plexus injuries. The Journal of hand surgery. 2010;35(4):678-88; quiz 88. Epub 2010/04/01. doi: 10.1016/j.jhsa.2010.01.021. PubMed PMID: 20353866.
  • 2. Yang LJ, Chang KW, Chung KC. A systematic review of nerve transfer and nerve repair for the treatment of adult upper brachial plexus injury. Neurosurgery. 2012;71(2):417-29; discussion 29. Epub 2012/07/20. doi: 10.1227/NEU.0b013e318257be98. PubMed PMID: 22811085.
  • 3. Bao YF, Tang WJ, Zhu DQ, Li YX, Zee CS, Chen XJ, et al. Sensory neuronopathy involves the spinal cord and brachial plexus: a quantitative study employing multiple-echo data image combination (MEDIC) and turbo inversion recovery magnitude (TIRM). Neuroradiology. 2012. Epub 2012/08/28. doi: 10.1007/s00234-012-1085-x. PubMed PMID: 22922867.
  • 4. Lee SK, Wolfe SW. Nerve transfers for the upper extremity: new horizons in nerve reconstruction. The Journal of the American Academy of Orthopaedic Surgeons. 2012;20(8):506-17. Epub 2012/08/03. doi: 10.5435/JAAOS-20-08-506. PubMed PMID: 22855853.
  • 5. Siqueira MG, Martins RS. Surgical treatment of adult traumatic brachial plexus injuries: an overview. Arquivos de neuro-psiquiatria. 2011;69(3):528-35. Epub 2011/07/15. PubMed PMID: 21755135.
  • 6. Fox IK, Mackinnon SE. Adult peripheral nerve disorders: nerve entrapment, repair, transfer, and brachial plexus disorders. Plastic and reconstructive surgery. 2011;127(5):105e-18e. Epub 2011/05/03. doi: 10.1097/PRS.0b013e31820cf556. PubMed PMID: 21532404.
  • 7. Dubovy P, Raska O, Klusakova I, Stejskal L, Celakovsky P, Haninec P. Ciliaryneurotrophic factor promotes motor reinnervation of the musculocutaneous nerve in an experimental model of end-to-side neurorrhaphy. BMC neuroscience. 2011;12:58. Epub 2011/06/24. doi: 10.1186/1471-2202-12-58. PubMed PMID: 21696588; PubMed Central PMCID: PMC3224149.
  • 8. Haninec P, Kaiser R, Bobek V, Dubovy P. Enhancement of musculocutaneous nerve reinnervation after vascular endothelial growth factor (VEGF) gene therapy. BMC neuroscience. 2012;13:57. Epub 2012/06/08. doi: 10.1186/1471-2202-13-57. PubMed PMID: 22672575; PubMed Central PMCID: PMC3441459.
  • 9. Gordon T. The role of neurotrophic factors in nerve regeneration. Neurosurgical focus. 2009;26(2):E3. Epub 2009/02/21. doi: 10.3171/FOC.2009.26.2.E3. PubMed PMID: 19228105.
acknowledgements
Acknowledgements
  • Dr. Brown
  • Dr. Curtis
  • Neurosurgery Faculty
  • Neurosurgery Residents
  • Eric Lin