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Christina K. Magill, Amy M. Moore, Ying Yan, Alice Y. Tong, Matthew R. MacEwan, Andrew Yee, Ayato Hayashi, Daniel A. Hunter, Wilson Z. Ray, Philip J. Johnson, Alexander Parsadanian, Terence M. Myckatyn and Susan E. Mackinnon

. 33 , 35 , 55 Pathway-derived GDNF promotes complete survival of motoneurons following facial nerve axotomy in neonatal mice and nerve avulsion in adult mice. 37 , 55 However, in a mouse model of amyotrophic lateral sclerosis, a disease isolated to spinal motoneurons, it has been demonstrated that only target-derived GDNF and not pathway-derived GDNF is neuroprotective. 28 Furthermore, it has been demonstrated that the expression of endogenous GDNF and its receptor GFRα1 are upregulated both in the distal nerve stump and in skeletal muscle following a nerve

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Wilson Z. Ray, Mitchell A. Pet, Andrew Yee and Susan E. Mackinnon

(excluding obstetric brachial plexus injury) . J Hand Surg Am 18 : 285 – 291 , 1993 12 Dvali L , Mackinnon S : Nerve repair, grafting, and nerve transfers . Clin Plast Surg 30 : 203 – 221 , 2003 13 Ferraresi S , Garozzo D , Buffatti P : Reinnervation of the biceps in C5–7 brachial plexus avulsion injuries: results after distal bypass surgery . Neurosurg Focus 16 : 5 E6 , 2004 14 Gentilli F , Hudson AR , Kline DG , Hunter D , Morphological and physiological alterations following internal neurolysis of normal rat sciatic nerve

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Wilson Z. Ray, Mitchell A. Pet, Michael C. Nicoson, Andrew Yee, Lorna C. Kahn and Susan E. Mackinnon

range of shoulder motion and demonstrated resolution of active scapular winging. In 2009, Uerpairojkit et al. 20 described 5 cases of TDN-to-LTN transfer for C5–6 avulsion injuries. In this series, scapular winging was eliminated in 2 patients, and reduced in the other 3. In none of these cases was there a long-term deficit in latissimus dorsii function. The medial pectoral nerve has also been described as a versatile donor for multiple nerve transfer procedures. 1 , 12 , 15 , 24 In 2002, Tomaino 17 described the use of the medial pectoral nerve as a donor to

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Susan E. Mackinnon, Andrew Yee and Wilson Z. Ray

al. 13 reported on a series of 10 patients with avulsion injuries that were treated with implantation of the ventral nerve root and nerve grafts into the spinal cord. These authors reported that 3 patients achieved meaningful (MRC Grade 4) functional recovery of proximal muscle function. Further work with this technique by Fournier et al. 18 is still in the early follow-up period, but has produced promising early results. Tadie et al. 57 described a single case in which sural nerve autografts were implanted directly into the ventral horn proximal to the site of

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Wilson Z. Ray, Chester K. Yarbrough, Andrew Yee and Susan E. Mackinnon

avulsions at C-8 and T-1. Electromyography and nerve conduction studies performed at 3 months and 4 months postinjury demonstrated no evidence of reinnervation of the muscles normally innervated by the median or ulnar nerves. Operation and Postoperative Course Surgery was performed 4 months after the initial injury. The patient underwent proximal decompression of the median nerve at the level of the pronator teres, with transfer of the brachialis nerve to the AIN. At 8 months she had early signs of FDP reinnervation of the index finger. At the most recent follow