SYM18: You Want To Do Your First Nerve Transfer

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SYM18: You Want To Do Your First Nerve

Transfer

Moderator(s): Amy M. Moore, MD

Faculty: Stacy Baker, MOT, OTR/L, CHT, Jayme A. Bertelli, MD, PhD, and Christopher

J. Dy, MD, MPH, FACS

Session Handouts

Saturday, October 03, 2020

75TH VIRTUAL ANNUAL MEETING OF THE ASSH

OCTOBER 1-3, 2020

822 West Washington Blvd

Chicago, IL 60607

Phone: (312) 880-1900

Web: www.assh.org

Email: [email protected]

http://www.assh.org/

mailto:[email protected]

Nerve Transfers

Amy M. Moore, MD, Plastic and Reconstructive Surgery The Ohio State University

I. Introduction

Following high nerve injuries, motor and sensory recovery can be less than optimal. Nerve transfers can provide a distal source of motor and/or sensory innervation closer to the target end organ which allows faster recovery and improved outcome. This course will focus on the use of nerve transfers to restore function. It will include discussion on patient selection, surgical options and techniques (including demonstrative videos/case presentations). Nerve transfer (def) – transfer of an expendable donor nerve or fascicle to a denervated recipient nerve to restore function to the recipient end-organ (skin for sensation or muscle for motor). Benefits:

1. Performed closer to recipient target allowing for earlier reinnervation. 2. Can be performed outside of the zone of injury and scarred field. 3. Can be performed on patients with delayed presentations. 4. Avoids interposition nerve grafting which fosters increased regenerating nerve fibers making it to the target end-organ. (1, 2)

Goal: Reinnervation of the target muscle within 12-18 months to avoid irreversible atrophy (3, 4). Classification of Nerve Injuries

DEGREE OF INJURY

TINEL'S SIGN

PRESENT RECOVERY RATE OF

RECOVERY SURGICAL

PROCEDURE

I Neurapraxia No Complete Up to 12 Weeks None

II Axonotmesis Yes Complete 1" per month None

III Yes Varies* 1" per month None or Neurolysis

IV Neuroma In-Continuity

Yes, but no advancement None None Nerve repair,

graft, or transfer

V Neurotmesis Yes, but no

advancement None None Nerve repair, graft, or transfer

VI Mixed Injury (I to V)

Some fascicles (II,III)

Some fascicles (II,III)

Depends on degree of

injury (I-V)

Neurolysis, nerve repair,

graft, or transfer

* Recovery can vary from excellent to poor depending on the amount of scarring and the sensory versus motor axon misdirection to target receptors

Principles of nerve transfers:

1. History and Physical Exam: a. Timing from injury b. Extent of involvement (level and degree of nerve injury) c. Current functional limitations d. Presence of potential donor nerves

2. Donor Selection:

a. expendable motor nerve b. close to the motor end plates of the target muscle c. large number of motor nerve axons and MRC grade 4 strength d. synergistic muscle function - motor reeducation more straightforward

3. Preoperative Studies:

a. EMG/NCS – at 10-12 weeks post injury i. identify extent of injury and recovery

ii. identify donors intact Pearls and Pitfalls:

• Remind anesthesiologist—no long acting paralytics • Short or no tourniquet use to avoid neurapraxia and inability to stimulate nerves • Evaluate recipient with nerve stimulator before transection • Evaluate donor with nerve stimulator to confirm function and strength • “Donor DISTAL, Recipient PROXIMAL” • Perform coaptations without tension.

II. A list of common injury patterns and treatment options (both nerve transfer and

traditional treatment options):

Upper plexus injury—loss of elbow flexion: • Double fascicular nerve transfer (from median and ulnar nerves to biceps and brachialis nerve branches) • Transfer of triceps, latissimus or pectoralis nerve branches to the elbow flexors; Steindler flexorplasty, long nerve grafts Upper plexus injury—loss of shoulder function: • Spinal accessory nerve to suprascapular nerve and triceps to deltoid nerve branch transfers • Shoulder fusion, Saha procedure, long nerve grafts Lower plexus injury—loss of pronation • Brachialis or extensor carpi radialis brevis (if C7 is spared) to pronator nerve branch transfer • Biceps, brachioradialis or brachialis muscle rerouting Lower plexus injury—loss of thumb and index finger flexion • Supinator branch to anterior interosseous nerve transfer • Brachialis branch to anterior interosseous nerve transfer • Tendon transfers (brachioradialis to flexor pollicis longus and extensor carpi radialis longus to index flexor digitorum profundus) Axillary nerve injury

• Triceps, medial pectoral or thoracodorsal nerve to axillary nerve transfer • Shoulder fusion, long nerve grafts Radial nerve injury • Median (flexor carpi radialis, flexor digitorum superficialis branches) to radial (extensor carpi radialis brevis and posterior interosseous nerve branches) nerve transfers • Tendon transfers (pronator teres to extensor carpi radialis brevis, palmaris longus to extensor pollicis longus, and flexor carpi ulnaris, flexor carpi radialis or flexor digitorum superficialis to extensor digitorum communis) Loss of median innervated pronation • extensor carpi radialis brevis to pronator teres branch • Biceps, brachialis or brachialis muscle rerouting Loss of median innervated thumb and finger flexion • Supinator or brachialis to anterior interosseous nerve branch (combine w/ tenodesis of long to ring/small flexors) • Tendon transfers (brachioradialis or extensor carpi radialis longus to flexor pollicis longus and side to side tenodesis with ulnar flexor digitorum profundus or extensor carpi radialis longus to index/long flexor digitorum profundus) Isolated AIN injury • flexor digitorum superficialis to anterior interosseous nerve branch • brachioradialis to flexor pollicis longus tendon transfer and flexor digitorum profundus tenodesis, fusion of interphalangeal joint of thumb Distal median nerve injury • AIN to median motor branch • Opponensplasty Distal ulnar nerve injury • anterior interosseous nerve to ulnar nerve deep motor branch • Static and dynamic claw hand correction procedures

III. Nerve Transfers to Restore of Elbow Flexion (Musculocutaneous Nerve)

Double Fascicular Transfer – our preferred operation when hand function is preserved. a. FCU fascicle to biceps branch of musculocutaneous b. FCR/FDS fascicle to brachialis branch of musculocutaneous Figure 1. Double fascicular transfer demonstrating FCU fascicle to biceps branch and FCR fascicle to brachialis branch of musculocutaneous nerve Pearls and Pitfalls: • Use handheld stimulator to identify donor fascicles as well as to ensure adequate function is remaining in the donor nerve • Avoid downgrading function of donor – ensure MRC grade 4 strength • Understand the topography of the median and ulnar nerves in the upper arm. Hint: the donor

fascicles on ulnar and median nerve face each other. • Neurolyse the LABC branch away from coaptation to avoid axon loss down the sensory

pathway. • “Donor DISTAL, Recipient PROXIMAL” • Perform coaptations without tension.

IV. Nerve Transfers to Restore Radial Nerve Function

Key Points

• Patient Selection is key: Needs to be willing to wait for reinnervation window of 6-9 months (in contrast to 4-8 weeks with tendon transfers)

• As with tendon transfers – synergistic transfers should be performed: FCR/PL to PIN and FDS to ECRB

• Tensionless repair

V. High Median Nerve Injury

Nerve Transfers to restore hand function

1. Brachialis branch to anterior interosseous nerve transfer.(8) a. For patients with intact, strong elbow flexion b. Restores FPL and FDP to the index (and sometimes long finger) c. While coaptation is performed at level of arm, more extensile dissection of median nerve

and branches is often required to avoid inadvertent innervation of non-critical median fascicles (sensory, FDS/FCR or other branches)

Figure 5. Transfer of the brachialis branch to the anterior interosseous nerve.

VI. Sensory Nerve Transfers

Sensory donor nerve a. non-critical sensory distribution b. pure sensory nerve c. good size match between donor and target nerve d. common sensory nerve transfers

e. Nerve to the 4th webspace to 1st web space transfer to restore sensation to the radial side of the index and ulnar side of the thumb

f. End-to-side repair of 2nd and 3rd web space to ulnar digital nerve to the small to restore sensation to the 2nd and 3rd web spaces

g. End-to-side repair of ulnar sensory and dorsal ulnar sensory nerves to median nerve to restore sensation to the small and ring fingers and ulnar dorsal skin

VII. Tips and Pearls of Nerve Transfers

“Donor distal, recipient proximal”:

• this concept is crucial to ensuring adequate length is obtained • the donor nerve is cut at it’s distal-most useful portion • the recipient nerve is divided proximally enough so that it can be mobilized • this avoids interpositional grafts, which could substantially downgrade results

Tension-free repair:

• nerve repair must be tension-free and allow full passive range of motion at the time of surgery • tension will dramatically downgrade the functional outcome

Align fascicles of the same modality (motor or sensory):

• crucial for successful recovery of function Natural cleavage planes:

• between critical fascicle groups • often identified by prominent longitudinal microvessels • can also be identified by tapping micro-forceps gently across the transverse diameter of the nerve • the forceps will “fall” into the natural cleavage plane

End-to-Side Repairs:

• A: motor donor nerves must be subjected to axotomy or a compressive stimulus for clinically relevant and timely regeneration to occur through an end-to-side repair

• B: sensory nerves demonstrate spontaneous collateral sprouting which can occur without axonal injury to the donor nerve

o The greater the perineurial window, the greater the collateral sprouting

Figure 6. Types of end-to-side repairs.

VIII. Rehabilitation following Nerve Transfers (9)

1. Early Post-operative Management • Early range of motion is important to prevent adhesions at the nerve repair site • Postoperative dressing is removed 2 to 3 days following surgery and begin active/passive

range of motion of uninvolved joints • Protect repair site with a splint or sling for 7-14 days • Following immobilization - regain and maintain full passive range of motion • If tendons are transferred or repaired concomitantly then these tendon procedures dictate

the immobilization (4 weeks shoulder immobilization if pectoralis major resuspended)

2. Late Stage Rehabilitation - Sensory & Motor Reeducation • Alteration in cortical mapping following nerve injury • Following reinnervation, can regain cortical area by increasing the sensory/motor input • motor re-education: need to increase muscle strength and central mechanisms controlling

motor function • nerve-to-nerve transfer – requires motor re-education similar to that required with tendon

transfers • biofeedback more useful than muscle stimulation • to facilitate re-learning, begin on unaffected side • initially need to contract muscle from donor nerve to achieve a contraction in the

recipient muscle • aim for control and initiation of muscle contraction

• be aware of unwanted co-contraction of antagonistic muscles • biofeedback – visual and audio • begin in gravity assisted or gravity eliminated positions and progress to exercises against

gravity and progressive resisted exercises • dissociate target muscle from donor muscle contraction • strengthen uninjured muscles weakened from disuse (i.e. scapular muscles)

Pearls and Pitfalls:

Sensory reeducation • Begin by increasing the sensory input to the appropriate sensory distribution with

different textures of material • Progress to localization exercises and finally discriminatory tasks • Cortical retraining requires repetition and purposeful movement

Motor reeducation

• need to increase muscle strength and central mechanisms controlling motor function • nerve to nerve transfer – requires motor reeducation similar to that required with tendon

transfers • restore muscle balance – be aware of co-contraction of antagonist muscles, strengthen

muscles weakened by disuse • biofeedback more useful than muscle stimulation

References Also see: http://nervesurgery.wustl.edu/Pages/default.aspx 1. Tung TH, Mackinnon SE. Nerve transfers: indications, techniques, and outcomes. The Journal of hand surgery. 2010;35(2):332-41. Epub 2010/02/10. doi: 10.1016/j.jhsa.2009.12.002. PubMed PMID: 20141906. 2. Moore AM. Nerve Transfers to Restore upper Extremity Function: A Paradigm Shift. Frontiers in neurology. 2014;5:40. doi: 10.3389/fneur.2014.00040. PubMed PMID: 24744749; PubMed Central PMCID: PMC3978351. 3. Boyd KU, Nimigan AS, Mackinnon SE. Nerve reconstruction in the hand and upper extremity. Clinics in plastic surgery. 2011;38(4):643-60. Epub 2011/10/29. doi: 10.1016/j.cps.2011.07.008. PubMed PMID: 22032591. 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. Colbert SH, Mackinnon SE. Nerve transfers for brachial plexus reconstruction. Hand clinics. 2008;24(4):341-61. doi: 10.1016/j.hcl.2008.07.001. PubMed PMID: 18928885. 6. Belzberg AJ, Dorsi MJ, Storm PB, Moriarity JL. Surgical repair of brachial plexus injury: a multinational survey of experienced peripheral nerve surgeons. J Neurosurg. 2004;101(3):365-76. Epub 2004/09/09. doi: 10.3171/jns.2004.101.3.0365. PubMed PMID: 15352592. 7. Merrell GA, Barrie KA, Katz DL, Wolfe SW. Results of nerve transfer techniques for restoration of shoulder and elbow function in the context of a meta-analysis of the English literature. The Journal of

hand surgery. 2001;26(2):303-14. Epub 2001/04/03. doi: 10.1053/jhsu.2001.21518. PubMed PMID: 11279578. 8. Ray WZ, Yarbrough CK, Yee A, Mackinnon SE. Clinical outcomes following brachialis to anterior interosseous nerve transfers. J Neurosurg. 2012;117(3):604-9. Epub 2012/07/24. doi: 10.3171/2012.6.JNS111332. PubMed PMID: 22817905. 9. Moore AM, Novak CB. Advances in nerve transfer surgery. Journal of hand therapy : official journal of the American Society of Hand Therapists. 2014;27(2):96-104; quiz 5. doi: 10.1016/j.jht.2013.12.007. PubMed PMID: 24513183.

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Is this patient a good candidate?SYM18: You Want To Do Your First Nerve Transfer

Christopher J. Dy, MD MPH FACSWashington University Orthopedics

@ChrisDyMD

DISCLOSURES

Christopher J. Dy, MD, MPH, FACS

Speaker has no relevant financial relationships with commercial interest to disclose.

nerveresearch.wustl.edu | @ChrisDyMD

KEY QUESTIONS

1. What is the natural history of this injury?2. Is reinnervation still possible?3. Will nerve transfers compromise other options?4. Is re-education feasible?5. What is the patient’s timeframe?

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WHAT IS THE NATURAL HISTORY?

Will reinnervation occur on its own?

If not…• What is anticipated recovery with “traditional” treatments?• Can nerve transfer provide a better outcome?


IS REINNERVATION STILL POSSIBLE?

Time to regenerationLocation of injuryCMAP findingsEMG characteristics

Recipient muscleDonor nerve/muscle


DONOR NERVE CONSIDERATIONS

What’s the magic number of axons?30% threshold? Or is more better? ≥70% is ideal - Schreiber/Wolfe 2015

Injured donorsGradient of injury - Tzou/Chuang 2017

MUAP pattern - Schreiber/Wolfe 2014

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WILL A NERVE TRANSFER

COMPROMISE FUTURE OPTIONS?


IS RE-EDUCATION FEASIBLE?

Synergism of donor and recipient

Your teamHigh variability in surgeon/therapist experience

In general, lack of standardized protocolsNeed to keep patient engaged during “doldrums of reinnervation”


IS RE-EDUCATION FEASIBLE?

Patient personality: will the patient “get it”?Mental health issues accompany nerve injuries1/3rd of BPI patients have suicidal ideation (Landers 2018)40% of BPI patients have new-onset depression or anxiety (Yannascoli 2018)Depression associated with poorer nerve transfer outcomes (Wilson 2016)

Patient resourcesFinancial loss after accident7 in 10 uninsured trauma patients at risk for catastrophic health expenditure(Scott – Annals of Surgery 2018)

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WHAT IS THE PATIENT’S TIMEFRAME?

“AMAZING” functional recovery1.5 years later

“Good enough” functional recovery3 months later


KEY QUESTIONS

1. What is the natural history of this injury?2. Is reinnervation still possible?3. Will nerve transfers compromise other options?4. Is re-education feasible?5. What is the patient’s timeframe?


[email protected] @ChrisDyMD

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Jayme A. Bertelli, MD, PhD

Speaker has no relevant financial relationships with commercial interest to disclose

My Favorite (and Reliable) Nerve Transfers

for High Nerve Injuries

Dr Bertelli

Florianópolis-SC- Brazil

High Median Nerve Paralysis

Sensibility on the pulp of the thumb and index

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Pain following nerve injury

• When possible, the site of nerve injury should be explored and the nerve repaired

• Nerve repair can cure pain

• Nerve pain is an emergency and should be addressed beforebecoming chronic

Transfer of radial sensory branches to the proper palmar digital nerves of the median nerve

High

Med

ian N

erve Paralysis

Finger Flexion Reconstruction

Transfer of the extensorcarpi radialismotor branch to the anterior interosseous nerve

High

Med

ian N

erve Paralysis

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•DONOR NERVE •RECIPIENT NERVE

High

Med

ian N

erve Paralysis

• Thenar Reinnervation

ADQ TO THENAR BRANCH

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•H

igh M

edian

Nerve Paralysis

• Tendon Transfer High

Med

ian N

erve Paralysis

Low Median Nerve Injury

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High Ulnar Nerve Paralysis

30% of patients have no clawing

No difference in above and below elbow

Strength deficit of 50% of the normalStrength deficit of 95% of the normal

Sub-terminal Lateral Pinch Terminal Lateral Pinch

High

Uln

ar Nerve Paralysis

Thumb Weakness

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Transfer of the opponens motor branch to the terminal division of the deep branch of the ulnar nerve

High

Uln

ar Nerve Paralysis

Transfer of the opponens motor branch to the terminal division of the deep branch of the ulnar nerve

High

Uln

ar Nerve Paralysis

Transfer of the opponens motor branch to the terminaldivision of the deep branch of the ulnar nerve

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Results

First series (operated withing 30 days) –90% of subterminal key pinch strength recovery

Second series (operated within 2 and 12 months) –50% of subterminal key pinch strength recovery

High

Uln

ar Nerve Paralysis

Low Ulnar Nerve Paralysis

Opponens nerve transfer

Subterminal Key Pinch3kg 0kg

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Getting across the Finish Line-

Perioperative Rehabilitation, Orthosis Use

and Re-education

Stacy Baker MOT, OTR/L, CHTWashington University Occupational Therapy Program

Milliken Hand Rehabilitation Center

Disclosures

• No Disclosures

Overview

• Rehabilitation Approach

• Perioperative Rehabilitation

• Orthosis Use

• Re-education

Rehabilitative Approach

Donor Activated Focused Rehabilitative Approach (DAFRA)1

• Phase I – Pre/Post op

• Phase 2

• Phase 3

• Theory based on anatomy, cortical plasticity and motor relearning2

Phase 1: Perioperative Rehab

Thorough Evaluation

• ROM

• Muscle Strength of potential donors

• Sensibility Testing


Patient Education

• Anatomy

• Relationship of nerve/muscle

• Set realistic expectations

Edema Management3

• Address early

• Prevention scar tissue

Manual Muscle Test


Pain management

• Heat vs cold

• Compression

Coritical Re-Organization2,4,5

• Tactile stimulation

• GMI

• Motor relearning strategies


Looking at the Donor

• Strengthening/Activation of the donor muscle(s)

FDS strengthening ECRB Strengthening Pronator Strengthening

Phase 1: Pre and/or Post Operative

Patterning

• Motor Relearning Strategies2,4

• Combine movements (passive recipient and active donor)

• Use cortical plasticity to train the brain to understand these two motion go

together to prepare the nerve transfer

• Perform Frequently2,4

Median to Radial Combo WF with finger/thumb

extension

Phase 1: Pre and/or Post Operative

Muscle Imbalance

• Early intervention is the key

• PROM of joints

Joint Contractures

• Stretching orthosis

Positioning

• Resting position – day/night

• Sleeping

Phase 1: Orthosis

Top Reasons for Orthosis

• Promote function

• Maintain muscle length

• Prevent contractures

Radial

Median

Ulnar

Phase 2: Re-Education

Phase 2: Monitoring for return of function

• Initiated when a twitch is noted in the recipient muscle

• Continue Phase 1

• Low reps/high frequency exercises

• Educate on respecting fatigue


Rehab techniques

• Place and Hold

• Bilateral exercises

• Relate to functional activities

• Advance resistance for donor

muscles


Phase 3: Resistive Exercises

• Progress once 3/5 Muscle strength is achieved

• Advance to BTE Program or Strengthening Program

• Respect fatigue

• Thank You

References

1. Kahn, L.C. and Moore, A.M., 2016. Donor Activation Focused Rehabilitation Approach. Hand Clinics, 32(2), 263-277.

2. Anastakis, D.J., Malessy, M.J., Chen, R., and Davis, K.D., 2008. Cortical Plasticity Following Nerve Transfer in the Upper

Extremity. Hand Clinics, 24(4), 425-444.

3. Villeco JP. 2012. Edema: a silent but important factor. Journal of Hand Therapy, 25(2), 153-162.

4. van Meeteren, et al, Exercise Training improves functional recovery and motor nerve conduction velocity after sciatic nerve

crush lesion in the rat, Archives of Physical Medicine and Rehabilitation, 1997, 78:70-77.

5. Nudo, Plautz and Frost, 2001. Role of adaptive plasticity in recovery of function after damage to motor cortex. Nerve and

Muscle, 24: 1000–1019, 2001.

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DISCLOSURES

Amy M. Moore, MD

Speaker has no relevant financial relationships

with commercial interest to disclose.

Cases and Top 10

SYM18: You Want to Do Your First Nerve Transfer

Amy M. Moore, MD FACSChristopher J. Dy, MD, MPH FACSJayme A. Bertelli, MD PhDStacy Baker MOT, OTR/L, CHT

Case 1

• 42 yo 3 month s/p MVC

• Left brachial plexus injury

• On exam:• Lacks Shoulder

• Elbow Flexion

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Studies?

EMG

CT Myelogram

C5 Avulsion C6 Avulsion

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Surgical Plan?

• Reconstructive Goals? • Elbow Flexion• Double Fascicular Transfer

• Shoulder External Rotation• SAN- SSC

• Shoulder Abduction• Triceps to Axillary

(n) median

Tung TH, Novak CB, Mackinnon SE. Nerve transfers to the biceps and

brachialis nerves improve elbow flexion strength following brachial plexus

injuries. J Neurosurg 98:313-318, 2003.

(n) ulnar

(n) pronator teres

(n) FDS/FCR

(n) AIN

(n) FCU

Median and Ulnar Fascicular Anatomy

(n)Musculocutaneous

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Spinal Accessory to Suprascapular Nerve Transfer

(n) suprascapular

(n) spinal accessory(n) spinal accessory

(n) suprascapular

Posterior Approach (End-to-end)

Spinal Accessory to SuprascapularNerve Transfer

Triceps Branch to Axillary Nerve Transfer

(m) teres major

(n) axillary

(n) superior lateralcutaneous

(n) medial triceps branch

(n) superior lateralcutaneous

(n) deltoid branches

(n) teres minor branch

(n) medial triceps branch

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Outcomes

10 steps for success with nerve transfers

#1. Recognize the Injury

• Time = Muscle

• REFERRALS

• Educate

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#2 Build Relationship with Neurologist

• Critical to understand injury/ recovery

• More important: Potential donors

Radial and Ulnar Nerves intact

#3. Appropriate Patient Selection

• Goals of Patient

• Occupation

• Time for Regeneration

• Access to Therapy?

#4 Develop Plan

• Identify Donors• Serial Examinations

• Review EMGs/NCS

• Prioritize Function 4 months

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#5 Phone a Friend

• Share Ideas

• Sound plan?

#6 Know your anatomy

• Cadaver Dissections

• Courses ( ASSH)

• Videos

• “Be Aware”

#7 Remember Intraoperative Pearls

• “Donor Distal, Recipient Proximal”

• No Tension

• Release distal entrapments

CTR

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#8 Engage your Hand Therapist

• Motor re-education

• Sensory re-education

• Splinting

• Joint suppleness

#9 Close Follow-Up

• Be the Cheerleader

• Encourage PT/OT

#10 Critical Analysis Of Results

• Keep records

• Take videos

• Compare to published data

• Keep INNOVATING

ECRB to AIN

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[email protected]

Thank You!

Saint Louis, MO

Columbus, OH

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SYM18: You Want To Do Your First Nerve Transfer

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Transcript of SYM18: You Want To Do Your First Nerve Transfer