Anatomical and functional connectivity of the transected ulnar nerve after intercostal neurotization in cats.

OBJECT: Acute transfer of three intercostal nerves to the ulnar nerve was performed in cats for histological and clinical evaluation of a distal muscle reinnervation. METHODS: Infraclavicular intercostal-ulnar communications were created after dividing the motor branches of the upper intercostal nerves in 14 adult cats. Reinnervation of distal forelimb muscles in the ulnar territory was assessed by electromyographic (EMG) studies and motor function rating each month until 18 months postsurgery. In five of these treated animals, and in tour controls, horseradish peroxidase (HRP) was applied to the ulnar or intercostal nerves to study the amount and distribution of retrograde motor neuron labeling in the spinal cord. Also, samples of reinnervated muscles and neurotized ulnar nerves were processed to assess regeneration. Simple ulnar transection without reconstruction led to permanent atrophy of ulnar muscles, lack of recovery according to EMG or clinical studies, and disappearance of the ulnar motor neuron pool. In contrast, ulnar neurotization with the intercostal nerves led to a high rate of functional recovery, which began 5 months postsurgery, and progressed from muscle activity synchronized with ventilatory movements to spontaneous movements that were independent of respiration. This recovery was accompanied by substantial retrograde labeling of intercostal motor neurons after HRP application in the ulnar nerve. Cell counts showed that practically the whole motor neuron pool of the involved intercostal nerves contributed to reinnervation of the transected ulnar nerve. CONCLUSIONS: These findings demonstrate that the use of intercostal nerves to neurotize long brachial plexus nerves can achieve long-lasting and successful reinnervation of distal forelimb muscles.     

Functional restoration of the paralyzed diaphragm in high cervical quadriplegia via phrenic nerve neurotization utilizing the functional spinal accessory nerve

The authors report a case of functional improvement of the paralyzed diaphragm in high cervical quadriplegia via phrenic nerve neurotization using a functional spinal accessory nerve. Complete spinal cord injury at the C-2 level was diagnosed in a 44-year-old man. Left diaphragm activity was decreased, and the right diaphragm was completely paralyzed. When the level of metabolism or activity (for example, fever, sitting, or speech) slightly increased, dyspnea occurred. The patient underwent neurotization of the right phrenic nerve with the trapezius branch of the right spinal accessory nerve at 11 months postinjury. Four weeks after surgery, training of the synchronous activities of the trapezius muscle and inspiration was conducted. Six months after surgery, motion was observed in the previously paralyzed right diaphragm. The lung function evaluation indicated improvements in vital capacity and tidal volume. This patient was able to sit in a wheelchair and conduct outdoor activities without assisted ventilation 12 months after surgery.     

Anatomical study of the ulnar nerve in the hand

This anatomical study is based on the dissection of fifty adult hands. The classic configuration of the ulnar nerve was found in thirty-nine cases out of fifty, and in eleven cases there were variations with respect to division. The levels of division of the different branches were precisely determined by an analysis of variations in the areas of muscular innervation.     

Radial sensory neurotization of the thumb and index finger for prehension after proximal median and ulnar nerve injuries

Proximal median nerve injuries are functionally disabling, secondary to both motor and sensory deficits. Reestablishment of sensation relies on slow axonal regeneration originating from the site of injury after either primary nerve repair or the use of autogenous nerve grafts. This regeneration can take 2 or more years to restore sensation to the hand, depending on injury location. Distal sensory nerve transfers shorten the recovery time by decreasing the required regeneration distance. The authors present two case reports of patients with proximal median nerve injury, who underwent radial sensory nerve transfers to the ulnar digital nerve of the thumb and the radial digital nerve of the index finger. Protective sensation returned to the index and thumb fingertips at 3 months. By 6 months, both patients attained sufficient sensation to permit active lateral key pinch. At 9 months, each patient had moving sensation; and by 14 months, each patient attained proper localization. Successful digital nerve transfers of the dorsal radial sensory nerves in patients with high proximal median nerve injuries return sensation faster than traditional median nerve repairs. Use of this technique will significantly reduce the insensate time in patients with this unfortunate injury.     

肘部尺神经的临床解剖学研究

目的：研究产生肘部尺神经卡压的解剖学基础。方法：观测５０侧成人尸体肘部尺神经的位置及被动屈肘时尺神经的伸长长度。临床调查并检测２００位正常人肘部尺神经的位置。结果：自肘部伸直位（０度）至完全屈肘位（１３５度），尺神经可拉长 ６．６％±０．３％（ｘ±ｓｘ自身对照，下同）；屈曲度大于 ９０度后，伸展性明显减少，为０．８％±０．１％。２００位正常人肘部尺神经半脱位发生率为９．５％（１９／２００）。结论：肘关节反复屈伸时尺神经不断被牵拉和压迫是造成肘部尺神经卡压的解剖学基础。     

Quantitation of and landmarks for the muscular branches of the ulnar nerve to the forearm for application in peripheral nerve neurotization procedures

OBJECT: In neurotization procedures, donor nerves--either whole or in part-with relatively pure motor function can be carefully chosen to provide the optimal nearby motor input with as little donor site morbidity as possible. In this context, the ulnar nerve branches to the forearm muscles are relatively dispensable; however, quantitation of and landmarks for these branches are lacking in the literature. METHODS: The ulnar branches to the flexor carpi ulnaris (FCU) and flexor digitorum profundus (FDP) muscles in 20 upper extremities obtained in adult cadaveric specimens were dissected and quantified. In the forearm, a mean of four nerve branches led to the FCU and FDP muscles. A mean of 3.4 branches led to the FCU muscle; of these, one to three were medial branches and zero to two were lateral. Medial branches to the FCU muscle originated a mean of 2.7 cm inferior to the medial epicondyle. Lateral branches to the FCU muscle originated at a mean of 3.3 cm inferior to the medial epicondyle. The mean length of the medial branches was 3.2 cm, whereas the mean length of the lateral branches was 3.3 cm. All nerves had a single trunk for the FDP muscle, and in all specimens this branch was located deep to the main ulnar nerve trunk, originating from the ulnar nerve a mean of 2.7 cm inferior to the medial epicondyle. These branches had a mean length of 5.6 cm. The mean diameter of all medial and lateral branches to the FCU muscle was 1 mm, and the mean diameter of the branch to the FDP muscle was 2.1 mm. All branches to both the FCU and FDP muscles arose from the ulnar nerve, over its first approximately 5 cm from the level of the medial epicondyle. Additionally, all branches could be easily lengthened by gentle proximal dissection from the main ulnar nerve. CONCLUSIONS: Ulnar branches to the forearm can be easily localized and used for neurotization procedures. The branch to the FDP muscle had the greatest diameter and longest length, easily reaching the median nerve and posterior interosseous nerve via a transinterosseous membrane tunneling procedure. Furthermore, this branch could be teased away from the main ulnar nerve trunk and made to reach the distal branches of the musculocutaneous nerve in the arm.     

Neurorrhaphy, nerve grafting, and neurotization: a functional comparison of nerve reconstruction techniques

This study examines the efficacy of three methods of peripheral nerve reconstruction: neurorrhaphy, nerve grafting, and neurotization. The extensor digitorum longus (EDL) neuromuscular unit of 63 New Zealand rabbits was used as the experimental model. Neuromuscular function was examined after 2, 4, and 6-month recovery periods. Variable recovery was seen after 2 months of recovery. At 6 months postoperatively, nerve grafting and neurorrhaphy were not statistically different from the unoperated control neuromuscular units. Neurotization grafting demonstrated a recovery of function of no greater than 50% at 6 months.     

尺神经功能束组走行模式的三维重建

目的 在组织学切片基础上，应用计算机三维成像技术，重建尺神经功能束组走行的三维图象，以期指导临床臂丛与尺神经损伤后的显微修复，为臂丛神经根性撕脱伤后手内肌功能的恢复提供必要的形态学基础。方法 制作尺神经连续断面组织切片，AchE组织化学染色，将切片转化为数字图象，人工判断功能束组性质，图形处理软件配准后，采用体数据场轮廓线表面重建方法，应用VC语言编制三维图象存储构建程序，在程序中重建尺神经功能束组走行的三维图象。结果 在程序中实现了尺神经功能束组走行的三维重建。对重建的各神经功能束的外表面进行三维显示，实现人机交互的任意三维旋转、任意断面切割。通过对感兴趣的显示对象(神经干和各束组)的选择，可以在同一三维空间同时显示任意神经功能束组的立体结构，结果反映出它们的在空问位置上的结构、毗邻关系和走行。通过与显微解剖结果对照，发现其显示图象与解剖结果基本吻合。结论 构建的尺神经功能束组的三维图象，能较真实的反映束组的走行分布情况，对临床医生理解神经内部结构，设计手术方案和在术中对照束组的分布方位调整手术方法有积极的作用。     

Severe ulnar nerve entrapment at the elbow: functional outcome after minimally invasive in situ decompression

The role of in situ decompression in patients with severe ulnar nerve compression is still controversial. Thirty patients with severe ulnar nerve compression confirmed clinically and electrophysiologically underwent simple decompression. The mean age of the patients was 58 (range 26-87) years. Through incisions ≤4?cm the nerves were fully visualized and decompressed. Outcome was measured prospectively using Modified Bishop's score (BS), grip and pinch strengths and two-point discrimination (2PD). Significant improvement in power (p?=?0.01) and pinch grip (p?=?0.001) was noted at 1 year. The grip strength continued to improve up to 1 year. According to the BS, 24 patients (80%) had good to excellent results at 1 year. Minimally invasive in situ decompression is technically simple, safe and gives good results in patients with severe nerve compression. The BS and 2PD were more reliable than grip strength in assessing these patients at follow-up.     

Evaluation of suprascapular nerve neurotization after nerve graft or transfer in the treatment of brachial plexus traction lesions

OBJECT: The aim of this retrospective study was to evaluate the restoration of shoulder function by means of suprascapular nerve neurotization in adult patients with proximal C-5 and C-6 lesions due to a severe brachial plexus traction injury. The primary goal of brachial plexus reconstructive surgery was to restore biceps muscle function and, secondarily, to reanimate shoulder function. METHODS: Suprascapular nerve neurotization was performed by grafting the C-5 nerve in 24 patients and by accessory or hypoglossal nerve transfer in 29 patients. Additional neurotization involving the axillary nerve was performed in 18 patients. Postoperative needle electromyography studies of the supraspinatus, infraspinatus, and deltoid muscles showed signs of reinnervation in most patients; however, active glenohumeral shoulder function recovery was poor. In nine (17%) of 53 patients supraspinatus muscle strength was Medical Research Council (MRC) Grade 3 or 4 and in four patients (8%) infraspinatus muscle power was MRC Grade 3 or 4. In 18 patients in whom deltoid muscle reinnervation was attempted, MRC Grade 3 or 4 function was demonstrated in two (11%). In the overall group, eight patients (15%) exhibited glenohumeral abduction with a mean of 44 +/- 17 degrees (standard deviation [SD]; median 45 degrees) and four patients (8%) exhibited glenohumeral exorotation with a mean of 48 +/- 24 degrees (SD; median 53 degrees). In only three patients (6%) were both functions regained. CONCLUSIONS: The reanimation of shoulder function in patients with proximal C-5 and C-6 brachial plexus traction injuries following suprascapular nerve neurotization is disappointingly low.     

Morphologic and functional study of rat median nerve repair by terminolateral neurorrhaphy of the ulnar nerve

While it has been shown that terminolateral (end-to-side) neurorrhaphy leads to successful functional motor reinnervation of the peripheral territories belonging to the severed nerve, data on the morphology of terminolateral sprouting and on the voluntary control of the motor function restored by terminolateral neurorrhaphy are still partial. In this study, the severed rat median nerve was sutured in an end-to-side fashion to the intact ulnar nerve. The progression of recovery of the flexion of the fingers was assessed by means of the grasping test. Seven months after surgery, the rats were sacrificed, and morphologic and morphometric analysis was performed on the regenerated median nerve and on the donor ulnar nerve. Results of the functional assessment showed that voluntary motor control of the muscles innervated by the median nerve was partially and progressively recovered by terminolateral neurorrhaphy, with a mean strength in the flexion of the fingers that reached about 20 percent of normal before sacrifice. Morphologic and morphometric analysis showed that nerve-fiber regeneration occurred in all repaired median nerves. Signs of nerve fiber atrophy were detected in the ulnar nerve distal to the point of suture, suggesting the possible occurrence of secondary damage to the donor nerve after terminolateral neurorrhaphy that should be taken into consideration in a clinical perspective.     

尺神经功能分支断面神经纤维定量组织学研究

目的测算尺神经分支的神经纤维数目和结缔组织面积等指标,计算各功能束组的纤维含量及比例,为临床选择性修复手内肌功能的手术设计和估计预后提供参考依据。方法新鲜尸体标本具,分离尺神经及其分支,各分支取材,福尔马林固定,常规石蜡横断面切片厚7μm,Loyez髓鞘染色法染色,应用图像分析系统对组织切片定量分析。测算各分支神经断面纤维密度、神经纤维截面积和神经干截面积,计算神经纤维数目,神经纤维和结缔组织所占比例。结果定量分析:尺神经分支有髓纤维总数为13648条,其中尺神经深支(支配手内肌)(3601±647)条,占26%;第四指间隙皮支(2327±609)条,占17%;小指尺侧皮支(2236±464)条,占16%;尺神经深支(支配手内肌)(3601±647)条,占26%;腕背支(2565±382)条,占19%;尺动脉支(418±210)条,占3%;尺侧腕屈肌远支(660±376)条,占5%;指深屈肌支(930±411)条,占7%;尺侧腕屈肌近支(914±223)条,占7%。结论手内肌功能束组是尺神经中最主要的功能束组,采用束膜缝合法选择性修复,将减少所需移位神经纤维的数目。     

桡骨远端及尺骨茎突骨折手法整复后尺神经卡压于尺骨茎突骨折端1例

患者,女,54岁,3个月前不慎摔倒,右腕部着地,当即出现右腕肿胀、畸形、功能受限,于当地医院拍片后诊断为“右桡骨远端骨折、右尺骨茎突骨折”,予以骨折手法整复术,石膏托外固定。2个月后去除石膏托行功能锻炼,发现右手尺侧麻木不适,右手无力伴肌萎缩,小鱼际萎缩明显,抓握无力,且症状渐进性加重。在当地医院予以神经营养药物内服治疗,     

Triceps nerve to deltoid nerve transfer after an unsatisfactory intra-plexus neurotization of the posterior division of the upper trunk

IntroductionOur literature review did not reveal any study on the results of triceps to deltoid nerve transfer done as a secondary procedure after an unsatisfactory primary intraplexus neurotization of the posterior division of the upper trunk.Presentation of casesWe report on three adults with C5-C6 brachial plexus injury who had an unsatisfactory deltoid function following primary intraplexus neurotization. Patients presented to our clinic late (14–16 months after injury). All patients had poor shoulder abduction (<40°) despite the presence of visible and palpable deltoid contractions. A triceps to deltoid nerve transfer resulted in an excellent shoulder abduction (> 150°) in all patients.DiscussionThe primary surgery in our patients acted as a “baby-sitter” procedure; explaining the good results of the late secondary distal nerve transfer.ConclusionGood results may be obtained from a late distal nerve transfer for the deltoid muscle as long as there is partial innervation of the muscle.