Patient G.S.

Zachary R. BarnardUCSD Neurosurgery Sub-

internSeptember 2012

Chief Complaint22 year old RHM presents with flaccid paralysis of left upper extremity after a motorcycle accident 6 months ago

History of Present Illness• 6 months PTA: patient presented to UCLA medical

center with a GCS of 3 after being thrown 40 feet from his motorcycle that collided with a motor vehicle– Multiple surgeries

• Exploratory laparotomy• Thoracotomy• Splenectomy• Ligation of multiple bleeding intercostal vessels• Reconstruction of diaphragmatic rupture• Left nephrectomy• Repair of colon laceration

– Neurologically• Right frontal hemorrhagic contusion• Evidence of DAI• EVD placement

History of Present Illness• 4 months PTA: patient was discharged from

UCLA medical center• 2 months PTA: patient f/u with neurosurgery

at UCLA for evaluation of left arm paralysis– Neuro exam:

• Motor- Complete paralysis of his deltoids, biceps, triceps, pectoralis, wrist flexors, wrist extensors, and intrinsic hand muscles.

• Sensory was showed patchy sensation proximally and no sensation distally

– Referred to Dr. Brown for evaluation

Left brachial plexus Imaging

T2 MRI-fatsuppressed

C6-C7

C7-T1

T1-T2

Left brachial plexus Imaging

T2 MRI-fatsuppressed

EMG: Left arm• Severe C4-T1 radiculopathy• Evidence of C7-T1 nerve root

avulsions• C6 nerve root likely not avulsed• C5 nerve root avulsion

indeterminate

OperationsStage 1:

– Brachial plexus exploration with neuroma resection– Anterior and middle scalenectomy– C5-C6 nerve grafting to posterior cord and suprascapular nerve– Bilateral sural nerve harvest

Stage 2:– C5 nerve root connection to suprascapular nerve through sural

nerve graftStage 3:

– Motor intercostal of 3,4,5,7 grafted to musculocutaneous nerve– Sensory intercostal of 3,4 grafted to median nerve– Motor intercostal 7,8 to lateral antebrachial cutaneous nerve graft– Lateral antebrachial cutaneous nerve graft to extensor carpi

radialis longus and brevis

Post-operative Course• Patient had an unremarkable post-

operative course• Drains were removed and patient

was discharged home with wound care on post-operative day eight

“Peripheral nerve surgery and nuances in regenerative medicine”

Background• Earliest possible reconstruction• Detailed neurological exam• MRI imaging• EMG• Elbow flexion usually first priority,

followed by shoulder abduction/external rotation/stability, then hand sensation

Nerve transfer vs. nerve repair for upper brachial plexus injury

• Yang, et al 2012– Systematic review– 33 studies included

• 399 nerve transfers• 99 nerve repairs• 117 transfers + repairs

– Inclusions• Age > 18, f/u > 6

months, injury (avulsion/rupture), function (elbow flexion or shoulder abduction)

– Outcomes• Rates ratio• MRS elbow flexion &

Should abduction

• Outcomes/Results

Ciliary neurotrophic factor promotes reinnervation of musculocutaneous nerve

• Aim:– Assess motor vs. sensory

fibers in ability to sprout in end-to-side grafting with ciliary neurotrophic factor (CNTF)

• Model: – 24 Rats MS to Uln end-

to-side graft• Endpts:

– Measure % motor neurons

– Fn biceps (EMG)

• Results:– PBS motor neurons

9.9%– CNTF motor

neurons 17%– EMG

• Biceps brachii larger amplitude of contract in CNTF compared to PBS

• Flexor carpi ulnaris no difference

Musculocutaneous nerve graft enhancement with VEGF

• Aim:– Assess phVEGF ability

to reinnervate end-to-end, end-to-side nerve grafts

• Model: – 42 Rats, cut end of

nerve transfected with virus

• Endpts:– Measure increase in

motor neuron percent by diameter of neuron

BDNF and GDNF in nerve regeneration

• Brain-derived neurotrophic factor (BDNF)

• Glial cell-derived neurotrophic factor (GDNF)

• Electrical stimulus• Rolipram (PDE4

inhibitor) anti-inflammatory

Summary• Clinical rule of “seven seventies” for

traumatic brachial plexus lesions– Based on 1068 patients (Siqueira et al,

2011)1. 70% due to MVCs

2. Of these, 70% motorcycles3. Of these, 70% multiple injuries

4. Overall, 70% supraclavicular lesions5. Of these, 70% at least one root avulsion

6. Of these, 70% avulsion C7, C8, or T17. Of these, 70% persistent pain

Summary• Peripheral nerve surgery still in

infancy• Conclusion on best treatment

difficult due to lack of randomized controlled trials

• Lots of basic science possibilities, but need more translational work

Conclusions

“A certain excessiveness seems a necessary element in all greatness”

-Harvey Cushing

References• 1. Giuffre JL, Kakar S, Bishop AT, Spinner RJ, Shin AY. Current concepts of the treatment of adult

brachial plexus injuries. The Journal of hand surgery. 2010;35(4):678-88; quiz 88. Epub 2010/04/01. doi: 10.1016/j.jhsa.2010.01.021. PubMed PMID: 20353866.

• 2. Yang LJ, Chang KW, Chung KC. A systematic review of nerve transfer and nerve repair for the treatment of adult upper brachial plexus injury. Neurosurgery. 2012;71(2):417-29; discussion 29. Epub 2012/07/20. doi: 10.1227/NEU.0b013e318257be98. PubMed PMID: 22811085.

• 3. Bao YF, Tang WJ, Zhu DQ, Li YX, Zee CS, Chen XJ, et al. Sensory neuronopathy involves the spinal cord and brachial plexus: a quantitative study employing multiple-echo data image combination (MEDIC) and turbo inversion recovery magnitude (TIRM). Neuroradiology. 2012. Epub 2012/08/28. doi: 10.1007/s00234-012-1085-x. PubMed PMID: 22922867.

• 4. Lee SK, Wolfe SW. Nerve transfers for the upper extremity: new horizons in nerve reconstruction. The Journal of the American Academy of Orthopaedic Surgeons. 2012;20(8):506-17. Epub 2012/08/03. doi: 10.5435/JAAOS-20-08-506. PubMed PMID: 22855853.

• 5. Siqueira MG, Martins RS. Surgical treatment of adult traumatic brachial plexus injuries: an overview. Arquivos de neuro-psiquiatria. 2011;69(3):528-35. Epub 2011/07/15. PubMed PMID: 21755135.

• 6. Fox IK, Mackinnon SE. Adult peripheral nerve disorders: nerve entrapment, repair, transfer, and brachial plexus disorders. Plastic and reconstructive surgery. 2011;127(5):105e-18e. Epub 2011/05/03. doi: 10.1097/PRS.0b013e31820cf556. PubMed PMID: 21532404.

• 7. Dubovy P, Raska O, Klusakova I, Stejskal L, Celakovsky P, Haninec P. Ciliary neurotrophic factor promotes motor reinnervation of the musculocutaneous nerve in an experimental model of end-to-side neurorrhaphy. BMC neuroscience. 2011;12:58. Epub 2011/06/24. doi: 10.1186/1471-2202-12-58. PubMed PMID: 21696588; PubMed Central PMCID: PMC3224149.

• 8. Haninec P, Kaiser R, Bobek V, Dubovy P. Enhancement of musculocutaneous nerve reinnervation after vascular endothelial growth factor (VEGF) gene therapy. BMC neuroscience. 2012;13:57. Epub 2012/06/08. doi: 10.1186/1471-2202-13-57. PubMed PMID: 22672575; PubMed Central PMCID: PMC3441459.

• 9. Gordon T. The role of neurotrophic factors in nerve regeneration. Neurosurgical focus. 2009;26(2):E3. Epub 2009/02/21. doi: 10.3171/FOC.2009.26.2.E3. PubMed PMID: 19228105.

Acknowledgements• Dr. Brown• Dr. Curtis• Neurosurgery Faculty• Neurosurgery Residents• Eric Lin