Refinements in the technique of 'awake' electrical nerve stimulation in the management of chronic low ulnar nerve injuries

The standard technique in the management of chronic low ulnar nerve injuries includes excision of the neuroma and reconstruction using sural nerve grafts in the fully anaesthetised patient. It has been shown that using this standard technique, disappointing results may be observed and that significant improvement in results could be obtained if intra-operative matching of sensory and motor fascicles is performed. This study reports on eight patients with chronic ulnar nerve injuries managed using the technique of electrical fascicular orientation and sural nerve grafting. In all patients, intra-operative electrical stimulation of the fascicles in the proximal stump was done in the awake state. Several refinements in technique are described including detailing pre-operative patient education, anaesthetic considerations and in the technique of nerve dissection. Assessment was done using a sensory grading system mainly based on static two-point discrimination and a motor grading system based on intrinsic muscle function and key pinch power. At final follow up satisfactory sensory (S3+ or S4) and motor (M3 or M4) recovery was obtained in almost all cases. It was concluded that intra-operative electrical fascicular orientation was reliable and that our refinements in the technique ensured better communication with the patient during surgery, resulted in a smoother awakening without apprehension, and provided an easier nerve dissection with preservation of the blood supply of the distal nerve segment.     

Surgical outcomes following nerve transfers in upper brachial plexus injuries

Background:

Brachial plexus injuries represent devastating injuries with a poor prognosis. Neurolysis, nerve repair, nerve grafts, nerve transfer, functioning free-muscle transfer and pedicle muscle transfer are the main surgical procedures for treating these injuries. Among these, nerve transfer or neurotization is mainly indicated in root avulsion injury.

Materials and Methods:

We analysed the results of various neurotization techniques in 20 patients (age group 20-41 years, mean 25.7 years) in terms of denervation time, recovery time and functional results. The inclusion criteria for the study included irreparable injuries to the upper roots of brachial plexus (C5, C6 and C7 roots in various combinations), surgery within 10 months of injury and a minimum follow-up period of 18 months. The average denervation period was 4.2 months. Shoulder functions were restored by transfer of spinal accessory nerve to suprascapular nerve (19 patients), and phrenic nerve to suprascapular nerve (1 patient). In 11 patients, axillary nerve was also neurotized using different donors - radial nerve branch to the long head triceps (7 patients), intercostal nerves (2 patients), and phrenic nerve with nerve graft (2 patients). Elbow flexion was restored by transfer of ulnar nerve motor fascicle to the motor branch of biceps (4 patients), both ulnar and median nerve motor fascicles to the biceps and brachialis motor nerves (10 patients), spinal accessory nerve to musculocutaneous nerve with an intervening sural nerve graft (1 patient), intercostal nerves (3rd, 4th and 5th) to musculocutaneous nerve (4 patients) and phrenic nerve to musculocutaneous nerve with an intervening graft (1 patient).

Results:

Motor and sensory recovery was assessed according to Medical Research Council (MRC) Scoring system. In shoulder abduction, five patients scored M4 and three patients M3+. Fair results were obtained in remaining 12 patients. The achieved abduction averaged 95 degrees (range, 50 - 170 degrees). Eight patients scored M4 power in elbow flexion and assessed as excellent results. Good results (M3+) were obtained in seven patients. Five patients had fair results (M2+ to M3).     

健侧颈7神经根移位同时修复两条神经的初步临床疗效

目的探讨用健侧颈，神经根移位同时修复2条上肢神经的临床效果。方法设计2种移位修复的方法。(1)合干法：健侧颈，前后股→尺神经→尺神经近端分2股分别和正中神经、桡神经(或肌皮神经)缝合，共5例。(2)分干法：健侧颈前后股→尺神经、腓肠神经→正中神经、桡神经(或肌皮神经)，共3例。结果合干法4例术后随访12～19个月，1例尚在随访中。正中神经运动：2例已恢复屈腕、屈指，肌力M3。2例屈腕肌力为M1。正中神经感觉：3例为S2，1例为S0。桡神经运动：2例伸腕、伸指肌力为M2。1例伸肘肌力为M2，1例伸腕肌力为M1。桡神经感觉：1例为S2，1例为S1，2例为S0。分干法1例术后随访15个月，已恢复屈腕、屈指，肌力为M3。正中神经感觉为是。肌皮神经：屈肘肌力为M3。另2例术后时间短尚在随访中。结论健侧颈，神经根移位同时修复上肢2条主要神经的新术式，初步应用结果证实是可行的、有效的。     

重建感觉的腓肠神经营养皮瓣修复足跟部缺损的临床研究

目的 利用腓肠神经皮瓣所带的腓肠神经内侧支和外侧支与创面周围胫神经端侧缝合,重建皮瓣的感觉以及恢复足背外侧感觉,以解决患者足踝部感觉缺失的痛苦并恢复覆盖足跟皮瓣的感觉.方法 1999年8月-2007年8月,收治足跟部皮肤软组织缺损25例(27足),进行腓肠神经营养血管皮瓣移植,其中14例行腓肠神经营养皮瓣与腓动脉皮瓣联合皮瓣移植.切取皮瓣时,在腓肠神经近端多取1～3cm.腓肠神经内侧支和外侧支,断端与胫神经行端侧缝合.术后6～9个月随访,按照感觉检查分级标准把皮瓣和足背外侧感觉恢复情况分成S_1～S_55级,并按感觉恢复范围分成R_1,小于25%;R_2,25%～50%;R_3,50%～75%;R＿4,75%～100%.结果 术后随访6～9个月,皮瓣及足背外侧皮肤感觉恢复情况:S_46足、S_318足、S_23足.皮瓣及足背外侧感觉恢复范围:R_412足、R_315足.结论 作腓肠神经营养皮瓣移植时行腓肠神经与创面周围胫神经端侧缝合手术简单,对胫神经无不良影响,而皮瓣和足背外侧感觉恢复较好.腓肠神经营养皮瓣与腓动脉皮瓣的联合皮瓣切取面积大,对大面积的足部皮肤缺损是一种理想的方法.     

Nerve transfer to the triceps after brachial plexus injury: report of four cases

These case reports review the clinical outcomes of 4 patients who underwent nerve transfer to a triceps motor branch of the radial nerve. Mean follow-up was 26 ± 15 months. Two patients had a transfer using an ulnar nerve fascicle to the flexor carpi ulnaris muscle, yielding a motor recovery of grade M5 elbow extension strength in one case and M4+ in the other. In 1 patient, a thoracodorsal nerve branch was used as the donor; this patient recovered M4 strength. One patient had a transfer using a radial nerve fascicle to the extensor carpi radialis longus muscle and recovered M5 strength. These outcomes indicate that expendable fascicles of the ulnar, thoracodorsal, and radial nerves are viable donors in the surgical reconstruction of elbow extension.     

Peripheral nerve schwannomas — an analysis of 16 patients

Summary 16 patients with peripheral nerve neurinomas (benign schwannomas) were operated upon in our hospital between 1990–1995. The largest tumours were found on proximal segments of peripheral nerves (brachial plexus: 15 cm, sciatic nerve: 20 cm). The average duration of symptoms was 1 1/2 years (range: 3 months — 15 years). Pain or painfull paraesthesias were the main complaints (13/16). Postoperatively, 9 patients were painfree while 4 improved. Similarly, neurological deficits were favourably influenced by the operation: Out of 5 patients with motor deficits 4 had complete, 1 patient had partial recovery. One out of 4 patients with sensory deficits had complete recovery, 2 remained unchanged, while 1 worsened. Two patients developed new motor and 6 patients new sensory deficits, which (in the course of time) did not disappear completely. New deficits developed predominantly in patients with large tumours or longstanding symptoms. Tumour recurrences were not seen during the follow-up period of 23 months. Our findings revealed that in the majority of cases peripheral nerve neurinomas can be excised with good results. Patients should be treated by a neurosurgeon with special expertise in peripheral nerve surgery. The patient should be thoroughly informed pre-operatively about any eventual new neurological deficits following surgery.     

Radial nerve repair using an autologous denatured muscle graft: comparison with outcomes of nerve graft repair

Summary Background. The efficiency of denatured muscle grafting in nerve repair has been confirmed in experimental models and animals. The first clinical trials to repair digital nerves and mixed sensory-motor nerves were encouraging regarding sensory recovery but motor recovery was poor, probably because of delayed repair. We present the functional outcome of repair of motor nerves using denatured muscle graft and compare the results with those using standard nerve graft techniques. Methods. This prospective study included 9 radial nerve defects repaired with denatured muscle grafts and 23 radial nerve defects repaired using nerve grafts. Missile induced nerve injury, mid-arm level of lesion, a nerve gap smaller than 6 cm, and a preoperative interval of less than 5 months were characteristics shared by all patients. None of the patients had concomitant vascular injury, severe scarring, or significant soft tissue damage in the region of nerve repair. Motor recovery was estimated with 0–5 points, at least 4.7 years after surgery, according to the BMRC scale. Results. A successful outcome (≥M3) was achieved in 7 out of the 9 patients treated using a muscle graft and in 21 out of the 23 patients treated using nerve grafts (P > 0.05). Excellent recovery and the clinically significant re-establishment of thumb extension (M5 grade) were never achieved in the patients treated using muscle grafts. The average motor score was significantly better in patients treated with nerve grafts than in those who received muscle grafts (3.8 ± 0.9 and 3.2 ± 0.8; P = 0.035). With the patients who received muscle grafts, an inverse correlation existed between motor recovery and the length of the nerve gap (P = 0.017). Conclusions. Denatured muscle grafts can be useful for bridging short radial nerve defects, but the quality of recovery is significantly worse than after nerve graft repair. Even if relatively short nerve defects are bridged with denatured muscle grafts, the outcomes correlate inversely with the length of the gap.     

Contralateral motor rootlets and ipsilateral nerve transfers in brachial plexus reconstruction

OBJECT: The goal of this study was to evaluate outcomes in patients with brachial plexus avulsion injuries who underwent contralateral motor rootlet and ipsilateral nerve transfers to reconstruct shoulder abduction/external rotation and elbow flexion. METHODS: Within 6 months after the injury, 24 patients with a mean age of 21 years underwent surgery in which the contralateral C-7 motor rootlet was transferred to the suprascapular nerve by using sural nerve grafts. The biceps motor branch or the musculocutaneous nerve was repaired either by an ulnar nerve fascicular transfer or by transfer of the 11th cranial nerve or the phrenic nerve. The mean recovery in abduction was 90 degrees and 92 degrees in external rotation. In cases of total palsy, only two patients recovered external rotation and in those cases mean external rotation was 70 degrees. Elbow flexion was achieved in all cases. In cases of ulnar nerve transfer, the muscle scores were M5 in one patient, M4 in six patients, and M3+ in five patients. Elbow flexion repair involving the use of the 11th cranial nerve resulted in a score of M3+ in five patients and M4 in two patients. After surgery involving the phrenic nerve, two patients received a score of M3 + and two a score of M4. Results were clearly better in patients with partial lesions and in those who were shorter than 170 cm (p < 0.01). The length of the graft used in motor rootlet transfers affected only the recovery of external rotation. There was no permanent injury at the donor sites. CONCLUSIONS: Motor rootlet transfer represents a reliable and potent neurotizer that allows the reconstruction of abduction and external rotation in partial injuries.     

全长膈神经移位恢复伸腕指功能的解剖学研究和临床应用

目的 在应用显微解剖学方法对上臂段桡神经深支部位进行研究的基础上,探讨将全长膈神经移位到上臂段桡神经深支部分以恢复伸腕、指功能的手术疗效.方法 对16具32侧尸体标本应用显微解剖学的方法,研究桡神经深、浅支在上臂段的特点及背阔肌的肌腱止点处桡神经深支在主干中的部位;在临床上开展2例经胸将全长膈神经移位到背阏肌止点处桡神经深支部分的手术,并评价其疗效.结果 通过显微解剖学研究发现上臂段桡神经前臂支内均可看见2个大的神经束组,在背阔肌的肌腱止点处桡神经深支主要位于前臂支的内侧神经束组中.1例术后1年10个月随访,肩外展80°,屈肘90°,伸肘0°,伸腕、指到位,屈腕10°,屈指尚不能;伸腕肌力达到M4,伸指肌力达到M3.另1例术后2年随访,肩外展40°,屈肘30°,伸肘0°,伸腕到位,伸指轻限,屈腕、指尚不能;伸腕肌力M,,伸指肌力达到M3-.结论 将全长膈神经移位到背阔肌的肌腱止点处桡神经前臂支的内侧神经束组可能是恢复全臂丛根性撕脱伤患者伸腕、指功能的有效方法.     

神经端侧吻合的腓肠神经营养血管皮瓣修复足踝部缺损的临床研究

目的利用腓肠神经皮瓣所带的腓肠神经内侧支和外侧支与创面周围的腓深神经或胫神经端侧吻合，重建皮瓣的感觉以及恢复足背外侧感觉。以解决患者足踝部感觉缺失的痛苦。方法从2000年1月至2003年5月，收治足踝部软组织缺损40例(43足)，其中A组20例(22足)直接进行腓肠神经营养血管皮瓣移植，B组20例(21足)在切取皮瓣时，在腓肠神经近端多取1～2cm腓肠神经内侧支和外侧支，在覆盖创面时，先分离出创面周围的腓浅神经或胫神经，把腓肠神经断端与腓浅神经或胫神经作端侧吻合，再按腓肠神经营养皮瓣处理。两组都在术后3、6、9个月分别进行随访，按照感觉检查分级标准把皮瓣和足背外侧感觉恢复情况分成S1～S5 5级，并按感觉恢复范围分成R1：小于25％；R2：25％～50％，R3：50％～75％，R4：75％～100％。结果术后3个月，皮瓣及足背外侧皮肤感觉恢复情况：A组，S1 18足、S2 4足、R1 22足，B组，S1 17足、S2 4足，R1 21足；两组皮瓣和足背外侧皮肤感觉恢复情况无差别、术后6个月，皮瓣及足背外侧皮肤感觉恢复情况：A组，S1 15足、S2 6足、S3 1足，R1 18足、R24足，B组，S16足、S36足、S49足，R2 4足、R3 12足、R4 5足；B组无论皮瓣及足背外侧感觉恢复的等级还是感觉恢复的范围都比A组好。术后9个月，皮瓣及足背外侧皮肤感觉恢复情况：A组，S1 14足、S2 7足、S3 1足，R1 17足、R2 5足，B组，S3 2足、S44足、S5 15足，R35足、R416足；B组皮瓣及足背外侧感觉基本恢复正常，A组感觉恢复进展不大。供体神经功能无明显影响。结论作腓肠神经营养皮瓣移植时行腓肠神经与创面周围胫神经或腓浅神经端侧吻合手术简单，对胫神经或腓浅神经无不良影响，而皮瓣和足背外侧感觉恢复较好。     

CO2气腔内窥镜下腓肠神经切取术的临床应用

目的介绍CO2注气形成皮下气腔、内窥镜下腓肠神经切取术的方法及其临床应用结果。方法7例周围神经缺损患者，男5例，女2例。神经缺损长度5～8cm，共切取9侧小腿自体腓肠神经移植。在小腿上端腓肠神经走行上作-1．0-1．5cm横切口为腔镜入口，其外侧作-0．5～1.0cm横切口为操作入口。利用腹腔镜系统，通过气腹机注入CO2气体，气压维持在10-15mmHg，形成皮下气腔。于内窥镜下游离并切取腓肠神经，以电缆式移植修复周围神经缺损。结果9侧小腿上腓肠神经均顺利游离和切取，长度为30-42cm，手术时间平均每侧约30min。镜下全段观察腓肠神经未见外膜损伤，切取小段送病理检查，未见神经纤维损伤。术中无碳酸血症和气体栓塞发生，术后小腿无皮下积气、血肿。全部病例随访6-10个月，移植神经功能恢复良好，所支配肌肉肌力恢复至2-4级，感觉恢复至S3-S4级。神经生长速度与传统方法切取腓肠神经移植手术相当。结论CO2气腔内窥镜下腓肠神经切取术操作简单，方法实用，与传统的长直切口、多个阶梯状横切口开放切取腓肠神经手术比较，供区创伤小、美观、恢复快。     

Radial nerve entrapment after fracture of the supracondylar humerus: a rare case of a 6-year-old

Supracondylar fracture of the humerus is one of the most common fractures seen in children, and posteromedial displacement of the distal fragment in extension-type supracondylar humerus fractures can cause injury to the radial nerve. A 6-year old girl who presented with symptoms of radial nerve injury after a supracondylar fracture of the right humerus with complete posteromedial displacement of the distal fragment (Gartland type III) underwent surgery where closed reduction and percutaneous pinning was performed. The patient was routinely followed up and at 6 months postoperatively no neurological improvement was seen. Exploratory surgery revealed complete discontinuation of the radial nerve at the fracture site and entrapment of the nerve stumps in healed bone callus. A gap of 2 cm was observed between nerve stumps, and sural nerve cable grafting was performed with good results. If neurological symptoms do not improve over time, appropriate differential diagnosis and, if necessary, exploratory surgery should be considered. Despite limited reports and their conflicting outcomes, sural nerve cable grafting could be a useful option to bridge the gap of discontinued nerve injury.Level of Evidence: Level IV, Case Report     

Vascularized nerve grafts for the treatment of large nerve gap after severe trauma to an upper extremity

We reviewed the clinical outcomes of vascularized nerve grafts for the repair of large nerve gaps (longer than 20 cm) after severe trauma to an upper extremity. Six patients who underwent vascularized sural nerve grafting (five to the median nerve and one to the ulnar nerve) with a monitoring skin flap were evaluated. The length of the vascularized sural nerve grafts ranged from 20 to 30 cm, with a mean length of 23.3 cm. All but one of the monitoring skin flap grafts was successful. In those patients for whom the monitoring skin flap graft was successful, the mean static-2PD at the corresponding fingertip was 14.2 mm (range 10–20 mm). Evaluation of these patients with the Semmes-Weinstein test produced the following results: filament 6, two patients; filament 10, three patients. The results of this study show that vascularized sural nerve grafting should be considered as a clinical alternative for nerve reconstruction in patients with nerve defects longer than 20 cm.     

Alternatives to sural nerve grafts in the upper extremity

Background

The sural nerve is the most common nerve graft donor despite requiring a second operative limb and causing numbness of the lateral foot. The purposes of this study were to review our experience using nerve autografts in upper extremity nerve reconstruction and develop recommendations for donor selection.

Methods

A retrospective case series study was performed of all consecutive patients undergoing nerve grafting procedures for upper extremity nerve injuries over an 11-year period (2001–2012).

Results

Eighty-six patients received 109 nerve grafts over the study period. Mean patient age was 42.9 ± 18.3 years; 57 % were male. There were 51 median (59 %), 26 ulnar (30 %), 14 digital (13 %), 13 radial (16 %), and 3 musculocutaneous (4 %) nerve injuries repaired with 99 nerve autografts (71 from upper extremity, 28 from lower extremity). Multiple upper extremity nerve autograft donors were utilized, including the medial antebrachial cutaneous nerve (MABC), third webspace branch of median, lateral antebrachial cutaneous nerve (LABC), palmar cutaneous, and dorsal cutaneous branch of ulnar nerve. By using an upper-extremity donor, a second operative limb was avoided in 58 patients (67 %), and a second incision was avoided in 26 patients (30 %). The frequency of sural graft use declined from 40 % (n = 17/43) to 11 % (n = 7/64).

Conclusions

Our algorithm for selecting nerve graft material has evolved with our growing understanding of nerve internal topography and the drive to minimize additional incisions, maximize ease of harvest, and limit donor morbidity. This has led us away from using the sural nerve when possible and allowed us to avoid a second operative limb in two thirds of the cases.     

Results of interfascicular nerve grafting for radial nerve lesions

During the 10 year interval 1979–1989, 20 patients underwent nerve grafting of a radial nerve lesion, 13 high radial and 7 posterior interosseous. Average follow-up was 38 months (range 12 months–10 years). Overall 72% of patients achieved a Highet Scale rating of M3 or better function and 44% M4 or better recovery. Age of the patient and length of the nerve graft did not seem to influence outcome. Time from initial injury to nerve grafting did affect outcome, with 85% of patients grafted within 6 months obtaining M3 or better recovery. No patient grafted 12 months after injury recovered any useful function. Lesions of the posterior interosseous nerve had a consistently superior recovery. Power grip strength in the affected hand of patients averaged 60% of the unaffected hand while key pinch averaged 74%. There was good correlation between the Highet Scale rating of recovery and the ultimate power grip or key pinch strength obtained. Hand dexterity, as assessed by the turning and displacing tests of the Minnesota Rate of Manipulation Test, displayed a wide range of scores in both affected and unaffected hands. Nevertheless, a relative score derived from the results obtained in the displacing test did show correlation with the Highet Scale rating. All patients with M4 or better recovery obtained relative scores for the affected hand that were in the middle of the range of scores considered an average performance for a normal population. Patients who achieved M4 or better nerve recovery following radial nerve grafting also obtained a functional hand as evidenced by the results of grip, key pinch strength, and hand dexterity testing. Lesser degrees of recovery were accompanied by poorer strength and dexterity ratings reflecting inferior function. © 1997 Wiley-Liss, Inc. MICROSURGERY 17:431–437 1996     

Group fascicular vein grafts with interposition of nerve slices for long ulnar nerve defects: Report of three cases

Group fascicular vein grafts with interposition of nerve slices were designed for reconstruction of three ulnar nerves with defects of 2.5–4.5 cm. The veins were taken from superficial veins in the forearm and reversed to bridge the fascicles in both stumps. Normal nerve slices were sectioned from fascicles in the proximal stump and inserted inside the corresponding vein conduits. Postoperatively, the Tinel's sign was detected across the vein conduits, and electromyography showed reinnervation of intrinsic muscles of the hands. Follow-up for more than 2 years revealed motor recovery to M4 and sensory recovery to S3–S4 in these three cases. This technique may be a promising alternative to group fascicular nerve grafting for long defects in peripheral nerve trunks. © 1993 Wiley-Liss Inc.     

Radial nerve palsy associated with high-energy humeral shaft fractures

PURPOSE: To determine whether the radial nerve should be explored when there is a complete sensory and motor deficit after a high-energy fracture of the humeral diaphysis. METHODS: Twenty-four patients aged 16 years or older with a high-energy, diaphyseal fracture of the humerus and complete motor and sensory radial nerve palsy were reviewed retrospectively. Eleven fractures were open-6 of these were part of a very complex upper-extremity injury (multiple ipsilateral fractures in 3 patients and near amputation in 3). All 11 patients with open fractures and 3 of 13 patients with closed injuries had radial nerve exploration. RESULTS: All 6 patients with a transected radial nerve had an open humerus fracture and were part of a complex upper-extremity injury. Five of 6 had primary repair of the radial nerve, and none recovered. All 8 intact explored nerves and 9 of 10 unexplored nerves recovered; the only nonrecovery occurred in a patient treated with closed intramedullary rod fixation who may have had iatrogenic nerve injury. The average time to initial signs of recovery was 7 weeks (range, 1-25 weeks). The average time to full recovery was 6 months (range, 1-21 months). CONCLUSIONS: Transection of the radial nerve is usually associated with open fractures of the humerus that are part of a very complex upper-extremity injury. The results of primary nerve repair in this circumstance are poor, likely related to an extensive zone of injury and the need for nerve grafting. Intact nerves and nerve palsies that are part of a closed fracture nearly always recover, even after high-energy injuries. Because the first signs of nerve recovery and complete recovery of the nerve can be quite delayed, patience is merited before considering tendon transfers.     

An analysis of results after selective tendon transfers through the interosseous membrane to provide selective finger and thumb extension in chronic irreparable radial nerve lesions

PURPOSE: We present the results of a modified tendon transfer for the restoration of wrist and finger extension in irreparable radial nerve lesions. METHODS: Restoration of wrist extension, finger extension, thumb extension, and thumb abduction was done in 29 patients (20 males and 9 females; age range: 10-58 years) with isolated, irreparable radial nerve palsy. We used a modified tendon transfer technique using the flexor digitorum superficialis (FDS) 3 (to extensor indicis proprius [EIP] and extensor pollicis longus [EPL]) and FDS 4 (to extensor digitorum communis 2-4 [EDC]) as donors for the reconstruction of selective finger and thumb extension (all patients) and pronator teres (PT) for wrist extension (25 patients). Thumb abduction was achieved by transferring the palmaris longus (PL) tendon to the abductor pollicis longus (APL) (all patients). RESULTS: Results show that near-normal wrist extension was achieved in 22 of 25 patients with extension strength of M4+. In the other 3 patients, wrist extension strength did not exceed M3 (1 patient) or M4 (2 patients). Extension of long fingers with a completely extended wrist joint was achieved in 12 of 29 patients. In the remaining 17 patients, full-range finger extension was possible only with the wrist in neutral. The advantage of the selective tendon transfer (FDS 3 to EIP and EPL and FDS 4 to EDC 2-4) resulted in selective extension of the index finger and thumb, as well as other digits, in all patients. Thumb abduction and rotation was achieved in all. CONCLUSIONS: Tendon transfers are indicated in longstanding, irreparable, isolated radial nerve lesions. Selective tendon transfer of FDS 3 to EIP and EPL and FDS 4 to EDC through the interosseous membrane results in reliable selective extension of these digits. The sacrifice of FDS 3 and 4 to reconstruct finger extension results in bowing of the donor digits. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.     

Impact of unilateral sural nerve graft on recovery of potency and continence following radical prostatectomy: 3-year longitudinal study

PURPOSE: We conducted a 3-year longitudinal study assessing the impact of unilateral sural nerve graft on recovery of potency and continence following radical prostatectomy. MATERIALS AND METHODS: A total of 113 patients undergoing radical retropubic prostatectomy were classified into 3 groups according to the degree of nerve sparing, that is unilateral nerve preservation with contralateral sural nerve graft interposition, bilateral nerve sparing and unilateral nerve sparing. Urinary continence and potency were estimated by the UCLA Prostate Cancer Index questionnaire. RESULTS: Patients in the nerve sparing plus sural nerve graft group were younger than those in the bilateral nerve sparing or unilateral nerve sparing groups. At baseline the unilateral nerve sparing plus sural nerve graft group and the bilateral nerve sparing group reported better sexual function than the unilateral nerve sparing group (62.1 and 61.5 vs 49.9, p<0.05). The bilateral nerve sparing group showed more rapid recovery than the unilateral nerve sparing plus sural nerve graft group after radical retropubic prostatectomy (p<0.01). After 24 months there were no significant differences observed between the bilateral nerve sparing and the unilateral nerve sparing plus sural nerve graft group (28.7 vs 32.9). The bilateral nerve sparing group reported a better sexual function score than the unilateral nerve sparing group throughout the postoperative period (p<0.05). The bilateral nerve sparing group maintained significantly better urinary function at 1 month after radical retropubic prostatectomy than the unilateral nerve sparing plus sural nerve graft group (p <0.05). After 3 months these groups were almost continent. The unilateral nerve sparing group reported lower urinary function scores during the first year compared to the other groups. CONCLUSIONS: The nerve graft procedure may contribute to the recovery of urinary function as well as sexual function after radical retropubic prostatectomy. This finding needs to be validated in a randomized trial.     

Robotic assisted laparoscopic sural nerve grafting during radical prostatectomy: initial experience

PURPOSE: Sural nerve grafting has been done in select patients undergoing radical prostatectomy with unilateral or bilateral wide excision of the neurovascular bundle in an effort to preserve potency. We describe a novel technique of laparoscopic sural nerve grafting after radical prostatectomy using the da Vinci (Intuitive Surgical, Mountain View, California) robot. MATERIALS AND METHODS: The procedure was performed successfully in 3 potent men 48, 49 and 59 years old, respectively. In patient 1 the entire procedure was performed robotically using a 6 port transperitoneal approach. In patients 2 and 3 the robot was used only for sural nerve grafting and urethrovesical anastomosis, while radical prostatectomy was performed by conventional laparoscopy. After the completion of radical prostatectomy with deliberate wide resection of the 2 neurovascular bundles in patients 1 and 3, and unilateral excision of the left neurovascular bundle in patient 2 a plastic surgery team harvested 10 to 15 cm of sural nerve from the left calf. Sural nerve grafts were interposed robotically by placing 4 to 6 interrupted perineural stitches of 6 or 7-zero polypropylene sutures. RESULTS: Mean operative time was 6.5 hours, mean blood loss was 216 cc and mean hospital stay was 2.3 days. Surgical margins were focally positive at the apex in the patients 1 and 3. During a followup of 7, 5 and 1 months patient 1 reported penile engorgement with sildenafil not sufficient for penetration, patient 2 with unilateral nerve preservation was potent without any medication and patient 3 did not achieve any degree of erection, respectively. CONCLUSIONS: The da Vinci remote robotic system technically facilitates sural nerve grafting during laparoscopic radical prostatectomy. Long-term potency data are essential to validate the technical success.