Nerve Transfers Flashcards
Major indications for nerve transfer
Proximal nerve stump not available
Distance to target is prohibitive to recovery
The timeline of muscle atrophy must still be respected with nerve transfers except in wich condition?
Sensory nerve transfers and tetraplegia transfers
types of nerve
transfers
End-to-end (he called copulation)
End-to-side (he called inoculation)
reverse end-to-side supercharge
Partial nerve transfers of up to 30% Abspaltung
Muscles will atrophy if not reinnervated within 12 to 18 months
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The prognosis for sensory recovery likely declines over time
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recovering nerve may
be utilized. In devastating multinerve injuries or cervical spinal cord
injuries
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regeneration
of only 12% to 30% ofthe native axons leads to motor function equivalent to preinjury function
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donor nerves with over 74%
the number ofaxons in the target nerve led to improved outcomes in
cross-facial nerve grafts for facial palsy
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n patients with injury to the musculocutaneous nerve and loss of elbow flexion what are the options?
flexor digitorum superficialis (FDS) branch or a fascicle of flexor carpi ulnaris (FCU) to transfer· to the biceps
In case of prevous question why do we prefer to use the ulnar nerve rather than median
Considering that the
biceps is a supinating muscle and that the median nerve controls pronation,
initial retraining following intercostal nerve transfers to the biceps,
the patient must learn to inhale to initiate elbow flexion
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, full voluntary control is possible irrespective of breathing
patterns
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The children need special training for cortical reeducation
F Excellent cortical plasticity in children often enables the motor
reeducation of the transferred nerve without learned tricks
It may be intuitive to place the repair
distal on the recipient nerve to shorten the distance to the target, but
a repair with excessive tension risks poor outcomes
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The most significant advantage
of ETS is that donor morbidity is minimized
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ETS is useful when donor nerves are scarce نادر
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ETS transfers have been increasingly used to reconstruct
birth-related brachia! plexus injuries
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reverse ETS or supercharge ETS
indicates leaving the
recipient nerve intact and coapting the proximal end of the donor
nerve to the side of the recipient nerve
Indications of reversend to side?
a large mixed motor and sensory nerve is injured proximally
partial nerve injuries. For example,
in a partial ulnar injury where electrodiagnostic studies indicate axons
in continuity to muscles, but severely reduced in number
both sensory and motor nerves can be utilized to preserve muscle mass.
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Facial muscle has short reinnervation window
F Facial muscle differs from skeletal muscle and is
thought to have a longer reinnervation window, considered to be
up to 12 to 24 months after injury
Two of the most integral movements for facial function are
eye closure and smile,
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The most common nerve transfer in the face
Nerve to masseter
advantages of the masseteric nerve
■ Robust axonal supply
■ Ability to be transferred without a graft
■ Reliable location
■ Low donor site morbidity
Use
of the masseteric nerve typically results in less spontaneous and emotional movement,
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n adults who have had smile movement
powered by the masseteric nerve, 85% achieve the ability to smile without biting
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smile spontaneity occurring routinely in 59%with the masseteric nerve
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hypoglossal nerve has yielded
greater results with respect to resting tone compare with masseteric one
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Differential innervation of separate facial movements candecrease
unnatural mass movements or unwanted synkinetic movements.
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The masseteric nerve is located on the deep surface of the masseter muscle at
a point 3 cm anterior to the tragus and I cm inferior to the inferior border
of the zygomatic arch
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Regardless of facial movement,
corneal anesthesia can be reconstructed
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corneal neurotization all patients regained normal sensation
F all patients achieving
protective sensation
Branches of the trigeminal nerve can be
transferred directly or with a nerve graft to reinnervate important
sensory distributions of the face
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Option for suprascapular nerve transferee
. Transfer of the spinal accessory
Transfer of the rhomboid nerve to suprascapular
In the dissection of the spinal accessory nerve, there are anterior and posterior approach wich is better?
The anterior approach combines well with a cervical
approach to the brachia! plexus
A posterior approach is used to release the suprascapular notch, In larger patients, this dissection can be quite deep
and lighted retractors are necessary
Options for axillary nerve?
Radial branch to triceps (Somsak)
Medial pectoral
Originally, the branch to the long head of the triceps was favored
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Others have argued in favor of the medial branch
because it has a longer extramuscular course
In axillary nerve repair grafting is better or nerve transfer is better?
A metaanalysis
of grafting versus nerve transfer outcomes for isolated axillary injuries
showed no significant differences between the two techniques,
Option for Musculocutaneous?
Ulnar branch to FCU (Oberlin)
Median branch to FDS/FCR
Thoracodorsal
Medial pectoral
single versus double nerve transfer resulted
in similar elbow flexion strength and disabilities of arm
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What is the difference between the single and double nerve transfer for musclucutanouse nerve ?
Only significant difference was in grip strength 63% of the contralateral side whereas the single nerve transfer resulted in 43%
In the scenario of complete plexus avulsion what are the options
the distal spinal accessory or intercostal nerves can be used with an interposition nerve graft
Radial nerve options?
Ulnar branch to FCU
Median branch to FDS/FCR
musculocutaneous branch to brachialis
Elbow extension restored via ulnar nerve (FCU to the medial triceps)
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In the hand
via median donors
FCR and FDS, and motor
branch to pronator quadratus-transferred to (PIN) and (ECRP)
How you can achieve individual finger extension
Nerve transfer to the PIN is the only method of achieving individual finger extension
If biceps function is intact, the PIN
fascicle to supinator should be excluded to maximize reinnervation
of the more critical extensors
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restore radial
hand sensation,ist possible?
lateral antebrachial cutaneous nerve (LABC) to radial sensory can be used
Options for ulnar nerve ?
Transfer of the median AIN branch of
pronator quadratus to the motor branch of the ulnar nerv
Option for sensory ulnar nerve ?
the median branch to the third webspace
median palmar cutaneous
the LABC
Comparison
of grafting versus motor and sensory transfers in proximal ulnar nerve
injuries which are better?
significantly improved functional outcomes: 80% were at least M3 in the nerve transfer
while versus 22% with grafting Interestingly,
sensory outcomes were not significantly different
Median N. options ?
Ulnar branch to FCU
Radial branch to ECRB
Musculocutaneous branch to the brachialis
Ulnar to 3rd lumbrical
Ulnar to abductor digiti minimi
Radial to EDQ/ECU
Before reinnervation,
FPL may lengthen why?
due to unopposed EPL pull and become less effective thus interphalangeal extension blocking can be a helpful adjunct
during reinnervation
The median recurrent motor branch can be
restored through
an ulnar motor branch to the third lumbrical,
nerve to abductor digiti quinti,
or a radialPIN branch to extensor digiti quinti
and extensor carpi ulnaris
Can we restore the sensation of the median nerve
Transfer of the sensory digital nerve of the 4th webspace
end-to-end to the sensory component of the median nerve can be used
to restore sensation in the median distribution of the hand (Bertilli)
In case of Flail Arm what is the option ?
Intercostal (IC) nerve or nerve to rectus transferred to the musculocutaneous nerve, either directly or with an interposition nerve graft,
can be used to restore elbow flexion or elbow extension
Hoe many intercostal nerve we can transfere ?
transfer of two to
four nerves, although up to seven have been reported anecdotally
The risk of iatrogenic pneumothorax in this dissection is 15%
F 9%
patients
with combined phrenic and intercostal nerve transfers showed no
impact on respiratory function compared to phrenic transfer alone
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Distal nerve transfers advantages in Birth-Related Brachia! Plexus Palsy
■ Avoid morbidity ofneuroma dissection
■ Avoid graft donor site morbidity
■ Reduce distance to target muscle (especially advantageous in late
presentations)
no significant differences in outcomes from grafting CS to suprascapular versus
the spinal accessory transfer.
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The spinal accessory to suprascapular nerve transfer wasaccepted early, because the spinal accessory nerve in the field of the standard cervical approach to the plexus
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improved supination with the grafting versus transfer
F improved supination with the
transfer versus grafting
whereas grafting
resulted in greater pronation
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The triple transfer of spinal accessory to suprascapular, Oberlin transfer, and radial
to axillary shows improved supination and shoulder external rotation
compared to grafting
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Femoral nerve options
anterior branch of the obturator, supplying the gracilis, adductor longus, and adductor brevis, can serve as a donor to the femoral branches
to rectus femoris and vastus medialis
Loss of protective sensation to the plantar foot is linked
to failure of limb salvage
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Sensation can
be restored with a saphenous to tibial nerve transfer, but the distance
between these nerves requires an interposition graft
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Tibial nerve options?
Branches to the vastus medialis and vastus
lateralis can be transferred to the tibial branches of the gastrocnemius
Peronial nerve?
The tibial nerve branches to flexor
digitorum longus or flexor hallucis longus can be used as donors to the
anterior tibialis to restore extension
Cortical remapping is
essential for successful outcomes in both motor and sensory nerve
transfers
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Patients begin working with a therapist who is knowledgeable
about motor retraining ideally preoperatively and then beginning at
3 to 4 weeks postoperatively to begin contractions of donor nerve
muscles.
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