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Robert J. Spinner, John L. D. Atkinson, Doris E. Wenger and Michael J. Stuart

of acute sciatic nerve compression due to an avulsion fracture of the ischial tuberosity 11, 15 and those due to myositis ossificans developing soon after proximal hamstring injury. 7, 8 Case Report History This 41-year-old male football coach presented with a 2-year history of progressive weakness in the left leg, especially with dorsiflexion of the foot. He had noted some atrophy of the leg despite weight training, and a several-week history of increasing pain radiating down the back of the left leg with tingling into the left great toe and second toe

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Aaron A. Cohen-Gadol, William E. Krauss and Robert J. Spinner

Chronic subarachnoid hemorrhage may cause deposition of hemosiderin on the leptomeninges and subpial layers of the neuraxis, leading to superficial siderosis (SS). The symptoms and signs of SS are progressive and fatal. Exploration of potential sites responsible for intrathecal bleeding and subsequent hemosiderin deposition may prevent disease progression. A source of hemorrhage including dural pathological entities, tumors, and vascular lesions has been previously identified in as many as 50% of patients with SS. In this report, the authors present three patients in whom central nervous system SS developed decades after brachial plexus avulsion injury. They believe that the traumatic dural diverticula in these cases may be a potential source of bleeding. A better understanding of the pathophysiology of SS is important to develop more suitable therapies.

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Kimberly A. Barrie, Scott P. Steinmann, Alexander Y. Shin, Robert J. Spinner and Allen T. Bishop

Object

The authors report the functional outcomes after functioning free muscle transfer (FFMT) for restoration of the upper-extremity movement after brachial plexus injury (BPI).

Methods

The authors conducted a retrospective review of 36 gracilis FFMT procedures performed in 27 patients with BPI between 1990 and 2000. Eighteen patients underwent a single gracilis FFMT procedure for restoration of either elbow flexion (17 cases) or finger flexion (one case). Nine patients underwent a double free muscle transfer for simultaneous restoration of elbow flexion and wrist extension (first muscle) and finger flexion (second muscle), combined with direct triceps neurotization. The results obtained in 29 cases of FFMT in which the follow-up period was 1 year are reported.

Neurotization of the donor muscle was performed using the musculocutaneous nerve (one case), spinal accessory nerve (12 cases), or multiple intercostal motor nerves (16 cases). Two second-stage muscle flaps failed secondary to vascular insufficiency. Mean electromyography-measured reinnervation time was 5 months. At a minimum follow-up period of 1 year, five muscles achieved less than or equal to Grade M2, eight Grade M3, four Grade M4, and 12 Grade M5. Transfer for combined elbow flexion and wrist extension compared with elbow flexion alone lowered the overall results for elbow flexion strength. Seventy-nine percent of the FFMTs for elbow flexion alone (single transfer) and 63% of similarly innervated muscles transferred for combined motion achieved at least Grade M4 elbow flexion strength.

Conclusions

Functioning free muscle transfer is a viable reconstructive option for restoration of upper-extremity function in the setting of severe BPI. It is possible to achieve good to excellent outcomes in terms of muscle grades with the simultaneous reconstruction of two functions by one FFMT, making restoration of basic hand function possible. More reliable results are obtained when a single FFMT is performed for a single function.

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Huan Wang, Robert J. Spinner and Anthony J. Windebank

S ince the first transfer of the C-7 nerve from the healthy side to repair brachial plexus avulsion on the contralateral injured side in 1986, 11 , 12 this procedure has been increasingly used. Although the procedure has been proven to be safe, 9 , 13 , 14 , 20 , 29 , 32 outcomes vary. 9 , 13 , 14 , 15 , 20 , 29 , 32 Transfer of the C-7 nerve to different recipient nerves leads to variable results. Results also vary after selection of different portions of the C-7 nerve when the entire nerve is not harvested. Much remains to be studied to optimize

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R. Shane Tubbs, Neal Patel, Brian Vala Nahed, Aaron A. Cohen-Gadol and Robert J. Spinner

brain surgery. Later in his career, acceleration of his competency in intracranial surgery allowed him to limit his practice to brain surgery. The 3 newly described cases highlight Cushing's use of a broad armamentarium of peripheral nerve 9 and brachial plexus 15 reconstructive techniques. Other cases of ruptured brachial plexus were reported by Cushing and in the majority of these, scar tissue was removed from the operative site and appropriate nerve roots anastomosed. 28 Interestingly, one of these patients with plexus avulsion chose to have his entire upper

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Marie-Noëlle Hébert-Blouin, Bahram Mokri, Alexander Y. Shin, Allen T. Bishop and Robert J. Spinner

(nausea, emesis, visual changes, and others) is not unusual and has been well described. 8 , 9 The pathophysiology of preganglionic BPI can provide a direct explanation for the association between CSF volume–depletion headaches and traumatic BPIs. In BPI, forceful distraction of the arm away from the body can stretch nerves, leading to nerve root avulsions. In some cases, rents in the dura and/or arachnoid occur at one or more levels, with subsequent formation of nerve root pseudomeningoceles. Given the exponential relationship between CSF volume and CSF pressure, 6

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Harvey Chim, Michelle F. Kircher, Robert J. Spinner, Allen T. Bishop and Alexander Y. Shin

, Xu L , Fu Y : Contralateral C7 transfer for the treatment of brachial plexus root avulsions in children—a report of 12 cases . J Hand Surg Am 32 : 96 – 103 , 2007 7 Domínguez-Páez M , Socolovsky M , Di Masi G , Arráez-Sánchez MA : [Isolated traumatic injuries of the axillary nerve. Radial nerve transfer in four cases and literatura review] . Neurocirugia (Astur) 23 : 226 – 233 , 2012 . (Span) 8 Garg R , Merrell GA , Hillstrom HJ , Wolfe SW : Comparison of nerve transfers and nerve grafting for traumatic upper plexus palsy

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Chandan G. Reddy, Kimberly K. Amrami, Benjamin M. Howe and Robert J. Spinner

.70 R IIIL ACL, PCL, LCL Lat meniscus, PFL, biceps femoris 3 36 F Kickball High 39.20 R I ACL, LCL Fib head avulsion Biceps femoris 4 39 F Fall from horse High 28.08 L IIIM ACL, PCL, MCL Lat meniscus Doppler ok 5 32 M Fall from height (5 ft) High 34.80 R IIIM ACL, PCL, MCL Lat meniscus, MPFL 6 22 M Snowmobile High 23.09 L IIIL ACL, PCL, LCL Popliteus 7 36 F Fall from standing Low 42.11 R I ACL, MCL, LCL 8 73 F Presumed

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

.e., transfer of the accessory nerve to the suprascapular nerve after avulsion of a C-5 or C-6 spinal nerve, with retraction of the suprascapular nerve in the retroclavicular region, or transfer of the accessory nerve to the musculocutaneous nerve passing beneath the clavicle to an infraclavicular location). In all cases, the small accessory nerve branch to the upper trapezius was teased away from the main accessory nerve trunk in the posterior cervical triangle to ensure that the main trunk was maximally mobile during subsequent movements. In other words, this branch to the