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Natasha van Zyl MBChB, FRACS Plastic and Reconstructive Surgeon The Upper Limb Program Victorian Spinal Cord Service Austin Health Heidelberg, Victoria,

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Presentation on theme: "Natasha van Zyl MBChB, FRACS Plastic and Reconstructive Surgeon The Upper Limb Program Victorian Spinal Cord Service Austin Health Heidelberg, Victoria,"— Presentation transcript:

1 Natasha van Zyl MBChB, FRACS Plastic and Reconstructive Surgeon The Upper Limb Program Victorian Spinal Cord Service Austin Health Heidelberg, Victoria, Australia Co-Authors: Stephen Flood Michael Weymouth Catherine Cooper Jodie Hahn Andrew Nunn

2 To reconstruct:-  Elbow extension  Grasp  Release To do it:-  By using nerve transfers alone  With no/little morbidity from donor nerve harvest  While keeping the all the options for standard tendon transfer reconstruction available

3  Background to the conception of this project  Therapeutic & investigational techniques involved  Logistics of delivery & assessment of safe nerve transfer reconstruction in tetraplegia

4  Inspiration: Success of nerve transfers in BPI & PNI  Reanimate the native muscle directly  Careful choice of donor nerves can preserve muscles used for tendon transfers  These muscles can be used to reconstruct distal functions e.g. opposition, intrinsic function  No more grafts, tendon tensioning, stretching or adhesion problems, no long immobilisations  Greater than 1:1 functional exchange

5 Surgical reinnervation of a denervated muscle by transferring an expendable, intact donor nerve to the non-functional nerve of a paralysed muscle in order to reanimate that muscle with axonal ingrowth from the donor nerve

6  Donor nerves Use “obscure” muscles – difficult to be sure they are under voluntary control  Recipient nerves May be LMN or UMN denervated or a combination of both so time to surgery is an issue

7  3 Surgeons  2 Specialist Tetraplegia OT’s  Spinal Rehabilitation Physicians  Spinal Physiotherapists and OT’s  Neurologist  Neuroscience technician  (Histopathologist)

8  SCI Adults, C5-C7 motor level of injury  Complete or incomplete  Seeking surgical improvement of upper limb function  No head, BPI or PNI  No pre-existing neurological condition  Able to comply with therapy pre and post op

9  Initial consult - 3/12  Routine motor and sensory examination  Upper limb AROM and PROM  Upper limb spasticity assessment  Examination of all potential donor nerve muscles  FES of recipient nerve’s muscles

10  Details of operation  Hospital stay  Immobilisation and upper limb therapy  Time till first reinnervation expected  Full maturity may take up to 12-18m  Expected outcomes nerve vs tendon transfer  Specific risks: motor or sensory disturbance, failure of transfer  Opportunity to meet previous patients

11  Measurement of pinch and grip strength - Modified pinch meter by Jaymar which allows testing of weak/little strength  Action Research Arm Test  Grasp Release Test - A timed test of lateral pinch and grasp which records how many objects can be picked up and released in a given time  Canadian Occupational Performance Measure  Spinal Cord Independence Measure

12 Donor Muscles  Are they under voluntary control?  Is there evidence of any denervation? Recipient muscles  Are they UMN or LMN denervated?  Or a combination of both?

13  Microscope/microsurgery instruments  Nerve stimulator - Biphasic nerve/muscle stimulator with a range of stimulation control (Checkpoint® Stimulator/Locator, Cleveland, OH, USA)  Intraoperative Motor Evoked Potentials - Using trained multi pulse trans-cranial electrical stimulation of the motor cortex

14 Elbow Extension  Teres Minor  Triceps Nerve(s) (Bertelli, J. A., et al. (2011) J Neurosurg 114(5): ) Grasp  Brachialis  Anterior Interosseous Nerve (Gu, Y., et al. (2004). Microsurgery 24(5): ) Release  Supinator  Posterior Interosseous Nerve (Bertelli, J. A., et al. (2010). J Hand Surg Am 35(10): )

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16  Hospital stay 48hrs  Plaster changed to thermoplastic forearm splint and broad-arm sling  Outpatient hand therapy begins immediately  Surgical review 3 monthly for first year, then 6 monthly for second year  Outcome assessments at 12,18 and 24m

17 Phase 1  Protect the transfer Phase 2  Activate donor & watch for flicker in recipient muscle Phase 3  Strengthen recipient muscle Phase 4  Disassociate donor from recipient

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19  Relatively easy to expand the team & services needed  Learning curve: – Patient selection - Surgical techniques and timing of surgery - Utility of NCS/EMG and MEPs  Development of protocols including: - Pre op clinical evaluation - Intra op data collection - Post op nerve transfer therapy - Timing of post op reviews/outcome assessments

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