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Patient G.S. Zachary R. Barnard UCSD Neurosurgery Sub-intern September 2012.

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Presentation on theme: "Patient G.S. Zachary R. Barnard UCSD Neurosurgery Sub-intern September 2012."— Presentation transcript:

1 Patient G.S. Zachary R. Barnard UCSD Neurosurgery Sub-intern September 2012

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

3 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

4 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

5 Left brachial plexus Imaging T2 MRI-fat suppressed C6-C7 C7-T1 T1-T2

6 Left brachial plexus Imaging T2 MRI-fat suppressed

7 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

8 Operations Stage 1: – Brachial plexus exploration with neuroma resection – Anterior and middle scalenectomy – C5-C6 nerve grafting to posterior cord and suprascapular nerve – 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 radialis longus and brevis

9 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

10 “Peripheral nerve surgery and nuances in regenerative medicine”

11 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

12 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

13 Ciliary neurotrophic factor promotes reinnervation of musculocutaneous nerve Aim: – Assess motor vs. sensory fibers in ability to sprout in end-to-side grafting with ciliary neurotrophic factor (CNTF) Model: – 24 Rats MS to Uln end- 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

14 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

15 BDNF and GDNF in nerve regeneration Brain-derived neurotrophic factor (BDNF) Glial cell-derived neurotrophic factor (GDNF) Electrical stimulus Rolipram (PDE 4 inhibitor) anti- inflammatory

16 Summary Clinical rule of “seven seventies” for traumatic brachial plexus lesions – Based on 1068 patients (Siqueira et al, 2011) 1.70% due to MVCs 2.Of these, 70% motorcycles 3.Of these, 70% multiple injuries 4.Overall, 70% supraclavicular lesions 5.Of these, 70% at least one root avulsion 6.Of these, 70% avulsion C7, C8, or T1 7.Of these, 70% persistent pain

17 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

18 Conclusions “A certain excessiveness seems a necessary element in all greatness” -Harvey Cushing

19 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. Ciliary neurotrophic 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.

20 Acknowledgements Dr. Brown Dr. Curtis Neurosurgery Faculty Neurosurgery Residents Eric Lin


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