Intraforaminal repair of plexus spinal nerves by a posterior approach: an experimental study

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✓ Many spinal nerve roots injured due to stretch or other types of lesions are not reparable. Some spinal nerves might be repaired if they could be exposed in their intraforaminal course. A posterior subscapular approach for a more lateral exposure of the brachial plexus was combined with a facetectomy to expose intraforaminal nerves in a series of Macaca rhesus monkeys. This approach exposed a 6- to 10-mm segment of spinal nerve not approachable by a more classic anterior operation. Sural grafts were placed from the dural exit of the spinal nerves to the cord level of the plexus. Nine surviving animals were followed for 36 to 54 months and observed for clinical evidence of return of function. In each animal at least one electromyogram (EMG) was performed. The plexus was then re-exposed and intraoperative nerve action potentials were recorded across graft sites. Evoked muscle action potential and cortical potentials were recorded in six animals.

Despite the proximal level of repair, adequate regeneration was shown by clinical, electrical, and histological studies. Functional return was best to the supraspinatus and biceps muscles and to wrist and finger flexors. Clinical recovery was present, but less effective, for deltoid, wrist, and finger extensors and intrinsic muscles of the hand, despite evidence on EMG of reinnervation. Recovery of the infraspinatus muscle was poor. Nerve action potentials could be recorded across each graft site. Reinnervational activity was recorded by EMG and evoked muscle action potential studies in most of the muscles studied, despite the persistence of some denervational changes 3 years or more after injury and repair. Histological studies confirmed the presence of a large number of axons of moderate size and myelination even at the forearm level.

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Address reprint requests to: David G. Kline, M.D., Department of Neurosurgery, Louisiana State University Medical Center, 1542 Tulane Avenue, New Orleans, Louisiana 70112–2822.

© AANS, except where prohibited by US copyright law.

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Figures

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    Diagram of the proposed surgical route to proximal brachial plexus spinal nerves, a: The line of incision is indicated by dashes. b: Surgical field with the scapula abducted and the paraspinous musculature retracted. c: Surgical field after laminectomy and first rib resection. d: The nerve grafts are shown in place.

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    Photograph showing the brachial plexus 4½ years postrepair. Needle electroencephalography electrodes were used to stimulate and record nerve action potentials (NAP's). In this instance, stimulating electrodes were placed into the proximal lower trunk repair site (to the left) and electrodes to record NAP's were placed in medial cord (to the right).

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    Electromyographic recordings showing a spectrum of insertional activity, ranging from active tracings in mature biceps (upper) to quiescent in infraspinatus (Infrasp.) muscle (lower). 1st DI = first dorsal interosseous muscle.

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    Electromyographic recordings showing deinnervational activity. Fibrillations in deltoid muscle are shown at 3 years (upper) and positive sharp waves in first dorsal interosseous muscle (1st DI) at 3 years (lower). Some reduction in deinnervational change is seen in another animal's deltoid muscle by 3½ years (center).

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    Electromyographic recordings showing reinnervational activity. Three samples from first dorsal interosseous muscle (1st DI) illustrate nascent potentials. The recording shown at center is greatly amplified compared to the upper and lower tracings.

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    Recordings of evoked cortical responses (ECR's), nerve action potentials (NAP's), and muscle action potentials (MAP's) made 38 months after graft repair of the plexus in Animal No. 1564. The presence of an ECR on stimulation at the proximal repair site indicates sensory root connection to spinal cord. Enough regrowth of axons was obtained to record NAP's from the cord level and to evoke MAP's recorded from more distal muscles. See Tables 5 and 6.

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    Photomicrographs and a gross photograph of longitudinal histological sections of graft sites. A: Section at the proximal spinal nerve level where grafts were sewn in at the level of the dorsal root ganglia. Bodian, × 63. B: Gross photograph of spinal cord, graft sites, and cords of plexus removed at 3 years. The box indicates the approximate site where sections shown in C, D, E, and F were made on different animals at different time intervals. C: Proximal graft site at 2½ months showing early axon regrowth. Bodian, × 63. D: Distal graft site at 6 months showing more mature axons. Bodian, × 63. E: Midgraft site at 3 years. Not all axons were as longitudinally oriented as these. Bodian, × 63. F: Midgraft site at 4½ years. Despite lapse of time, the axons in this graft are still not of full caliber. Bodian, × 63.

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    Photomicrographs of histological cross sections. A: Distal graft site at 3½ years showing axons of moderate caliber. Bodian, × 63. B: Graft site at 3½ years. Endoneurial scar is seen. Masson, × 25. C: Graft site at 3½ years showing area of axonal disorganization and scar. Masson, × 63. D: Lateral cord at 3½ years. Axons are more mature here than at more proximal graft sites. Bodian, × 63. E: Median nerve at 4½ years. Despite the distal site, moderately mature axons are present. Bodian, × 63. F: Ulnar nerve at 4½ years. Bodian, × 63.

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    A: Photomicrograph of cross section of lateral cord-musculocutaneous nerve junction distal to grafts at the spinal nerve to cord level placed 3½ years before. Nerve distal to this site had been immersed in horseradish peroxidase/wheat germ agglutinin (HRP/WGA) for 3 days. Opposite or control musculocutaneous nerve, where there had not been a proximal graft repair, had also been immersed in HRP/WGA for 3 days. Bodian, × 63. B: Photomicrograph of HRP/WGA-treated area of anterior horn at C3–4 level showing four well-marked cells. Other marked cells were seen at C6–7 as well as at C5–6. At the control and opposite nongrafted side of the spinal cord, HRP/WGA-marked cells were confined to the C5–6 levels. Bodian, × 63.

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