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Spinal accessory nerve to triceps muscle transfer using long autologous nerve grafts for recovery of elbow extension in traumatic brachial plexus injuries

Liselotte F. Bulstra, Nadia Rbia, Michelle F. Kircher, Robert J. Spinner, Allen T. Bishop, and Alexander Y. Shin

OBJECTIVE

Reconstructive options for brachial plexus lesions continue to expand and improve. The purpose of this study was to evaluate the prevalence and quality of restored elbow extension in patients with brachial plexus injuries who underwent transfer of the spinal accessory nerve to the motor branch of the radial nerve to the long head of the triceps muscle with an intervening autologous nerve graft and to identify patient and injury factors that influence functional triceps outcome.

METHODS

A total of 42 patients were included in this retrospective review. All patients underwent transfer of the spinal accessory nerve to the motor branch of the radial nerve to the long head of the triceps muscle as part of their reconstruction plan after brachial plexus injury. The primary outcome was elbow extension strength according to the modified Medical Research Council muscle grading scale, and signs of triceps muscle recovery were recorded using electromyography.

RESULTS

When evaluating the entire study population (follow-up range 12–45 months, mean 24.3 months), 52.4% of patients achieved meaningful recovery. More specifically, 45.2% reached Grade 0 or 1 recovery, 19.1% obtained Grade 2, and 35.7% improved to Grade 3 or better. The presence of a vascular injury impaired functional outcome. In the subgroup with a minimum follow-up of 20 months (n = 26), meaningful recovery was obtained by 69.5%. In this subgroup, 7.7% had no recovery (Grade 0), 19.2% had recovery to Grade 1, and 23.1% had recovery to Grade 2. Grade 3 or better was reached by 50% of patients, of whom 34.5% obtained Grade 4 elbow extension.

CONCLUSIONS

Transfer of the spinal accessory nerve to the radial nerve branch to the long head of the triceps muscle with an interposition nerve graft is an adequate option for restoration of elbow extension, despite the relatively long time required for reinnervation. The presence of vascular injury impairs functional recovery of the triceps muscle, and the use of shorter nerve grafts is recommended when and if possible.

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Clinicoradiological features of intraneural perineuriomas obviate the need for tissue diagnosis

Thomas J. Wilson, B. Matthew Howe, Shelby A. Stewart, Robert J. Spinner, and Kimberly K. Amrami

OBJECTIVE

This study aimed to define a set of clinicoradiological parameters with a high specificity for the diagnosis of intraneural perineurioma, obviating the need for operative tissue diagnosis.

METHODS

The authors retrospectively reviewed MR images obtained in a large cohort of patients who underwent targeted fascicular biopsy and included only those patients for whom the biopsy yielded a diagnosis. Clinical and radiological findings were then tested for their ability to predict a tissue diagnosis of intraneural perineurioma. The authors propose a new set of diagnostic criteria, referred to as the Perineurioma Diagnostic Criteria. The sensitivity, specificity, positive predictive value, and negative predictive value of several clinicoradiological methods of diagnosis were compared.

RESULTS

A total of 195 patients who underwent targeted fascicular biopsy were included in the cohort, of whom 51 had a tissue diagnosis of intraneural perineurioma. When the clinicoradiological methods used in this study were compared, the highest sensitivity (0.86), negative predictive value (0.95), and F1 score (0.88) were observed for the decision trees generated in C5.0 and rPart, whereas the highest specificity (1.0) and positive predictive value (1.0) were observed for the Perineurioma Diagnostic Criteria.

CONCLUSIONS

This study identified clinical and radiological features that are associated with a diagnosis of perineurioma. The Perineurioma Diagnostic Criteria were determined to be the following: 1) no cancer history, 2) unifocal disease, 3) moderate to severe hyperintensity on T2-weighted MR images, 4) moderate to severe contrast enhancement, 5) homogeneous contrast enhancement, 6) fusiform shape, 7) enlargement of the involved nerves, and 8) age ≤ 40 years. Use of the Perineurioma Diagnostic Criteria obviates the need for tissue diagnosis when all of the criteria are satisfied.

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Delayed compression of the common peroneal nerve following rotational lateral gastrocnemius flap: case report

Benjamin T. Himes, Thomas J. Wilson, Andres A. Maldonado, Naveen S. Murthy, and Robert J. Spinner

The authors present a case of delayed peroneal neuropathy following a lateral gastrocnemius rotational flap reconstruction. The patient presented 1.5 years after surgery with a new partial foot drop, which progressed over 3 years. At operation, a fascial band on the deep side of the gastrocnemius flap was compressing the common peroneal nerve proximal to the fibular head, correlating with preoperative imaging. Release of this fascial band and selective muscle resection led to immediate improvement in symptoms postoperatively.

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Posterior interosseous nerve discontinuity due to compression by lipoma: report of 2 cases

Andrés A. Maldonado, Benjamin M. Howe, and Robert J. Spinner

Paralysis of the posterior interosseous nerve (PIN) secondary to compression is a rare clinical condition. Entrapment neuropathy may occur at fibrous bands at the proximal, middle, or distal edge of the supinator. Tumors are a relatively rare but well-known potential cause. The authors present 2 cases of PIN lesions in which compression by a benign lipoma at the level of the elbow resulted in near transection (discontinuity) of the nerve. They hypothesize a mechanism—a “sandwich effect”—by which compression was produced from below by the mass and from above by a fibrous band in the supinator muscle (i.e., the leading edge of the proximal supinator muscle [arcade of Fröhse] in one patient and the distal edge of the supinator muscle in the other). A Grade V Sunderland nerve lesion resulted from the advanced, chronic compression. The authors are unaware of a similar case with such an advanced pathoanatomical finding.

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A novel method of lengthening the accessory nerve for direct coaptation during nerve repair and nerve transfer procedures

R. Shane Tubbs, Andrés A. Maldonado, Yolanda Stoves, Fabian N. Fries, Rong Li, Marios Loukas, Rod J. Oskouian, and Robert J. Spinner

OBJECTIVE

The accessory nerve is frequently repaired or used for nerve transfer. The length of accessory nerve available is often insufficient or marginal (under tension) for allowing direct coaptation during nerve repair or nerve transfer (neurotization), necessitating an interpositional graft. An attractive maneuver would facilitate lengthening of the accessory nerve for direct coaptation. The aim of the present study was to identify an anatomical method for such lengthening.

METHODS

In 20 adult cadavers, the C-2 or C-3 connections to the accessory nerve were identified medial to the sternocleidomastoid (SCM) muscle and the anatomy of the accessory nerve/cervical nerve fibers within the SCM was documented. The cervical nerve connections were cut. Lengths of the accessory nerve were measured. Samples of the cut C-2 and C-3 nerves were examined using immunohistochemistry.

RESULTS

The anatomy and adjacent neural connections within the SCM are complicated. However, after the accessory nerve was “detethered” from within the SCM and following transection, the additional length of the accessory nerve increased from a mean of 6 cm to a mean of 10.5 cm (increase of 4.5 cm) after cutting the C-2 connections, and from a mean of 6 cm to a mean length of 9 cm (increase of 3.5 cm) after cutting the C-3 connections. The additional length of accessory nerve even allowed direct repair of an infraclavicular target (i.e., the proximal musculocutaneous nerve). The cervical nerve connections were shown not to contain motor fibers.

CONCLUSIONS

An additional length of the accessory nerve made available in the posterior cervical triangle can facilitate direct repair or neurotization procedures, thus eliminating the need for an interpositional nerve graft, decreasing the time/distance for regeneration and potentially improving clinical outcomes.

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Abstracts of the 2017 AANS/CNS Joint Section on Disorders of the Spine and Peripheral Nerves Las Vegas, Nevada • March 8–11, 2017

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Introduction: Peripheral nerve surgery

Mark A. Mahan, Wilson Z. Ray, Lynda J. S. Yang, and Robert J. Spinner

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The nearly invisible intraneural cyst: a new and emerging part of the spectrum

Thomas J. Wilson, Marie-Noëlle Hébert-Blouin, Naveen S. Murthy, Joaquín J. García, Kimberly K. Amrami, and Robert J. Spinner

OBJECTIVE

The authors have observed that a subset of patients referred for evaluation of peroneal neuropathy with “negative” findings on MRI of the knee have subtle evidence of a peroneal intraneural ganglion cyst on subsequent closer inspection. The objective of this study was to introduce the nearly invisible peroneal intraneural ganglion cyst and provide illustrative cases. The authors further wanted to identify clues to the presence of a nearly invisible cyst.

METHODS

Illustrative cases demonstrating nearly invisible peroneal intraneural ganglion cysts were retrospectively reviewed and are presented. Case history and physical examination, imaging, and intraoperative findings were reviewed for each case. The outcomes of interest were the size and configuration of peroneal intraneural ganglion cysts over time, relative to various interventions that were performed, and in relation to physical examination and electrodiagnostic findings.

RESULTS

The authors present a series of cases that highlight the dynamic nature of peroneal intraneural ganglion cysts and introduce the nearly invisible cyst as a new and emerging part of the spectrum. The cases demonstrate changes in size and morphology over time of both the intraneural and extraneural compartments of these cysts. Despite “negative” MR imaging findings, nearly invisible cysts can be identified in a subset of patients.

CONCLUSIONS

The authors demonstrate here that peroneal intraneural ganglion cysts ride a roller coaster of change in both size and morphology over time, and they describe the nearly invisible cyst as one end of the spectrum. They identified clues to the presence of a nearly invisible cyst, including deep peroneal predominant symptoms, fluctuating symptoms, denervation changes in the tibialis anterior muscle, and abnormalities of the superior tibiofibular joint, and they correlate the subtle imaging findings to the internal fascicular topography of the common peroneal nerve. The description of the nearly invisible cyst may allow for increased recognition of this pathological entity that occurs with a spectrum of findings.

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A new pattern of lipomatosis of nerve: case report

Nikhil K. Prasad, Mark A. Mahan, Benjamin M. Howe, Kimberly K. Amrami, and Robert J. Spinner

Lipomatosis of nerve (LN) is a rare disorder of peripheral nerves that produces proliferation of interfascicular adipose tissue. It may be associated with soft-tissue and bony overgrowth within the affected nerve territory. LN has been almost exclusively reported in appendicular peripheral nerves; the median nerve at the wrist and palm is among the most common locations. The authors present a new pattern of LN that shows circumferential proliferation of fat around the epineurium of the nerve. They believe that this case and the two other documented examples in the literature (also affecting cervical and thoracic spinal nerves) share the same new pattern of LN. Defining the full spectrum of adipose lesions of the nerve and establishing a cause-effect relationship with nerve-territory overgrowth disorders may offer options for future management through targeted nerve lesioning.

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Targeted fascicular biopsy of the brachial plexus: rationale and operative technique

Pierre Laumonerie, Stepan Capek, Kimberly K. Amrami, P. James B. Dyck, and Robert J. Spinner

OBJECTIVE

Nerve biopsy is useful in the management of neuromuscular disorders and is commonly performed in distal, noncritical cutaneous nerves. In general, these procedures are diagnostic in only 20%–50%. In selected cases in which preoperative evaluation points toward a more localized process, targeted biopsy would likely improve diagnostic yield. The authors report their experience with targeted fascicular biopsy of the brachial plexus and provide a description of the operative technique.

METHODS

All cases of targeted biopsy of the brachial plexus biopsy performed between 2003 and 2015 were reviewed. Targeted nerve biopsy was performed using a supraclavicular, infraclavicular, or proximal medial arm approach. Demographic data and clinical presentation as well as the details of the procedure, adverse events (temporary or permanent), and final pathological findings were recorded.

RESULTS

Brachial plexus biopsy was performed in 74 patients (47 women and 27 men). The patients' mean age was 57.7 years. All patients had abnormal findings on physical examination, electrodiagnostic studies, and MRI. The overall diagnostic yield of biopsy was 74.3% (n = 55). The most common diagnoses included inflammatory demyelination (19), breast carcinoma (17), neurolymphomatosis (8), and perineurioma (7). There was a 19% complication rate; most of the complications were minor or transient, but 4 patients (5.4%) had increased numbness and 3 (4.0%) had additional weakness following biopsy.

CONCLUSIONS

Targeted fascicular biopsy of the brachial plexus is an effective diagnostic procedure, and in highly selected cases should be considered as the initial procedure over nontargeted, distal cutaneous nerve biopsy. Using MRI to guide the location of a fascicular biopsy, the authors found this technique to produce a higher diagnostic yield than historical norms as well as providing justification for definitive treatment.