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
• 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 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
C6-C7
T2 MRI-fat
suppressed
C7-T1
T1-T2
Left brachial plexus Imaging
T2 MRI-fat
suppressed
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
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
Post-operative Course
• Patient had an unremarkable postoperative course
• Drains were removed and patient was
discharged home with wound care on
post-operative day eight
“Peripheral nerve surgery and
nuances in regenerative
medicine”
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
• 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
• 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 endto-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
• 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
• Brain-derived
neurotrophic factor
(BDNF)
• Glial cell-derived
neurotrophic factor
(GDNF)
• Electrical stimulus
• Rolipram (PDE4
inhibitor) antiinflammatory
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
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
“A certain excessiveness seems a necessary
element in all greatness”
-Harvey Cushing
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.
Acknowledgements
•
•
•
•
•
Dr. Brown
Dr. Curtis
Neurosurgery Faculty
Neurosurgery Residents
Eric Lin