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Editorial: Autologous Schwann cells

Wilson Z. Ray

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Nerve transfers for the restoration of hand function after spinal cord injury

Case report

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

Spinal cord injury (SCI) remains a significant public health problem. Despite advances in understanding of the pathophysiological processes of acute and chronic SCI, corresponding advances in translational applications have lagged behind. Nerve transfers using an expendable nearby motor nerve to reinnervate a denervated nerve have resulted in more rapid and improved functional recovery than traditional nerve graft reconstructions following a peripheral nerve injury. The authors present a single case of restoration of some hand function following a complete cervical SCI utilizing nerve transfers.

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Introduction. Awake spinal surgery: where are we now and where are we going

Wilson Z. Ray, Asdrubal Falavigna, Praveen V. Mummaneni, and Robert C. Bucelli

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Repair of a median nerve transection injury using multiple nerve transfers, with long-term functional recovery

Case report

Rory K. J. Murphy, Wilson Z. Ray, and Susan E. Mackinnon

Complete loss of median nerve motor function is a rare but devastating injury. Loss of median motor hand function and upper-extremity pronation can significantly impact a patient's ability to perform many activities of daily living independently. The authors report the long-term follow-up in a case of median nerve motor fiber transection that occurred during an arthroscopic elbow procedure, which was then treated with multiple nerve transfers. Motor reconstruction used the nerves to the supinator and extensor carpi radialis brevis to transfer to the anterior interosseous nerve and pronator. Sensory sensation was restored using the lateral antebrachial cutaneous (LABC) nerve to transfer to a portion of the sensory component of the median nerve, and a second cable of LABC nerve as a direct median nerve sensory graft. The patient ultimately recovered near normal motor function of the median nerve, but had persistent pain symptoms 4 years postinjury.

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Clinical outcomes following brachialis to anterior interosseous nerve transfers

Report of 4 cases

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

The surgical management of lower brachial plexus injuries remains a challenging problem. Although nerve transfers have improved clinical outcomes following brachial plexus injuries, the majority of work has focused on upper trunk injuries. Complete lower plexus injuries often lack suitable donors for either nerve or tendon transfers. The authors describe their experience with isolated lower trunk injuries utilizing the nerve to the brachialis to reinnervate the anterior interosseous nerve.

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Letter to the Editor: Muscle and nerve transfer in tetraplegia

Jan Fridén and Andreas Gohritz

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Stereotactic navigation with the O-arm for placement of S-2 alar iliac screws in pelvic lumbar fixation

Technical note

Wilson Z. Ray, Vijay M. Ravindra, Meic H. Schmidt, and Andrew T. Dailey

Object

Pelvic fixation is a crucial adjunct to many lumbar fusions to avoid L5–S1 pseudarthrosis. It is useful for treatment of kyphoscoliosis, high-grade spondylolisthesis, L5–S1 pseudarthrosis, sacral tumors, lumbosacral dislocations, and osteomyelitis. The most popular method, iliac fixation, has drawbacks including hardware prominence, extensive muscle dissection, and the need for connection devices. S-2 alar iliac fixation provides a useful primary or salvage alternative. The authors describe their techniques for using stereotactic navigation for screw placement.

Methods

The O-arm Surgical Imaging System allowed for CT-quality multiplanar reconstructions of the pelvis, and registration to a StealthStation Treon provided intraoperative guidance. The authors describe their technique for performing computer-assisted S-2 alar iliac fixation for various indications in 18 patients during an 18-month period.

Results

All patients underwent successful bilateral placement of screws 80–100 mm in length. All placements were confirmed with a second multiplanar reconstruction. One screw was moved because of apparent anterior breach of the ilium. There were no immediate neurological or vascular complications due to screw placement. The screw length required additional instruments including a longer pedicle finder and tap.

Conclusions

Stereotactic guidance to navigate the placement of distal pelvic fixation with bilateral S-2 alar iliac fixation can be safely performed in patients with a variety of pathological conditions. Crossing the sacroiliac joint, choosing trajectory, and ensuring adequate screw length can all be enhanced with 3D image guidance. Long-term outcome studies are underway, specifically evaluating the sacroiliac joint.

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Patient-Reported Outcomes Measurement Information System physical function and pain interference in spine surgery

Jawad M. Khalifeh, Christopher F. Dibble, Ammar H. Hawasli, and Wilson Z. Ray

OBJECTIVE

The Patient-Reported Outcomes Measurement Information System (PROMIS) is an adaptive, self-reported outcomes assessment tool that utilizes item response theory and computer adaptive testing to efficiently and precisely evaluate symptoms and perceived health status. Efforts to implement and report PROMIS outcomes in spine clinical practice remain limited. The objective of this retrospective cohort study is to evaluate the performance and psychometric properties of PROMIS physical function (PF) and pain interference (PI) among patients undergoing spine surgery.

METHODS

The authors identified all patients who underwent spine surgery at their institution between 2016 and 2018, and for whom there was retrievable PROMIS data. Descriptive statistics were calculated to summarize demographics, operative characteristics, and patient-reported outcomes. Assessments were evaluated preoperatively, and postoperatively within 2 months (early), 6 months (intermediate), and up to 2 years (late). Pairwise change scores were calculated to evaluate within-subjects differences and construct responsiveness over time. Pearson’s correlation coefficients were used to evaluate the association between PROMIS PF and PI domains. Subgroup analysis was performed based on the primary diagnoses of cervical radiculopathy, cervical myelopathy, or lumbar degenerative disease.

RESULTS

A total of 2770 patients (1395 males, 50.4%) were included in the analysis. The mean age at the time of surgery was 57.3 ± 14.4 years. Mean postoperative follow-up duration was 7.6 ± 6.2 months. Preoperatively, patients scored an average 15.1 ± 7.4 points below the normative population (mean 50 ± 10 points) in PF, and 15.8 ± 6.8 points above the mean in PI. PROMIS PF required a mean of 4.1 ± 0.6 questions and median 40 seconds (interquartile range [IQR] 29–58 seconds) to be completed, which was similar to PI (median 4.3 ± 1.1 questions and 38 seconds [IQR 27–59 seconds]). Patients experienced clinically meaningful improvements in PF and PI, which were sustained throughout the postoperative course. PROMIS instruments were able to capture anticipated changes in PF and PI, although to a lesser degree in PF early postoperatively. There was a strong negative correlation between PROMIS PF and PI scores at baseline (Pearson’s r = −0.72) and during follow-up appointments (early, intermediate, and late |r| > 0.6, each). Subgroup analysis demonstrated similar results within diagnostic groups compared to the overall cohort. However, the burden of PF limitations and PI was greater within the lumbar spine disease subgroup, compared to patients with cervical radiculopathy and myelopathy.

CONCLUSIONS

Patients receiving care at a tertiary spine surgery outpatient clinic experience significant overall disability and PI, as measured by PROMIS PF and PI computer adaptive tests. PROMIS PF and PI health domains are strongly correlated, responsive to changes over time, and facilitate time-efficient evaluations of perceived health status outcomes in patients undergoing spine surgery.

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Therapeutic electrical stimulation of injured peripheral nerve tissue using implantable thin-film wireless nerve stimulators

Matthew R. MacEwan, Paul Gamble, Manu Stephen, and Wilson Z. Ray

OBJECTIVE

Electrical stimulation of peripheral nerve tissue has been shown to accelerate axonal regeneration. Yet existing methods of applying electrical stimulation to injured peripheral nerves have presented significant barriers to clinical translation. In this study, the authors examined the use of a novel implantable wireless nerve stimulator capable of simultaneously delivering therapeutic electrical stimulation of injured peripheral nerve tissue and providing postoperative serial assessment of functional recovery.

METHODS

Flexible wireless stimulators were fabricated and implanted into Lewis rats. Thin-film implants were used to deliver brief electrical stimulation (1 hour, 20 Hz) to sciatic nerves after nerve crush or nerve transection-and-repair injuries.

RESULTS

Electrical stimulation of injured nerves via implanted wireless stimulators significantly improved functional recovery. Brief electrical stimulation was observed to increase the rate of functional recovery after both nerve crush and nerve transection-and-repair injuries. Wireless stimulators successfully facilitated therapeutic stimulation of peripheral nerve tissue and serial assessment of nerve recovery.

CONCLUSIONS

Implantable wireless stimulators can deliver therapeutic electrical stimulation to injured peripheral nerve tissue. Implantable wireless nerve stimulators might represent a novel means of facilitating therapeutic electrical stimulation in both intraoperative and postoperative settings.

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Pseudotumor cerebri following tapered corticosteroid treatment in an 8-month-old infant

Case report

Wilson Z. Ray, Amy Lee, Spiros L. Blackburn, Gregg T. Lueder, and Jeffrey R. Leonard

✓The authors report on an 8-month-old infant with an orbital capillary hemangioma. The patient had been treated with high-dose corticosteroid therapy and had had a recent decrease in dose. The patient presented to the emergency department with increased irritability and bulging fontanelles. On lumbar puncture the opening pressure was > 55 cm H2O. Ophthalmological examination revealed interval development of papilledema. The child was treated with high-volume lumbar puncture, subsequent drainage of 10 ml of cerebrospinal fluid, resumption of the previous steroid dose, and acetazolomide therapy. The patient's symptoms resolved and follow-up ophthalmological examination revealed interval resolution of papilledema. The authors present the youngest reported case of pseudotumor development after corticosteroid tapering.