Sensory deficits after a radial nerve injury.

BACKGROUND: The aim of our study was to objectively test sensibility on the dorsal side of the hand in patients with radial nerve injury, to document deficits and to detect if surgery for sensory reconstruction is needed. METHODS: Nineteen patients of mean age 31 ± 10 years were examined at a mean of 26.4 ± 27.8 months post radial nerve injury. Sensory mechanical thresholds on the dorsal surface of the hand were evaluated using Semmes-Weinstein monofilaments. Sensation was considered significantly impaired when there was no perception of a 2.0 gr. Semmes-Weinstein filament. Nociception was evaluated using Adson forceps. RESULTS: Five patients had normal 2.0 monofilament perception. Two of these five also had normal perception of the lighter 0.05 monofilament. In nine patients, zones of impaired sensibility were restricted to the first web space. In combined radial and musculocutaneous nerve lesions, the zone of impaired sensibility extended to the dorsum of the third metacarpus and occasionally to the dorsal aspect of the thumb. This zone averaged being five times the size as in isolated radial nerve injuries. On average, the zone of decreased 0.05 monofilament perception was six times the size detected for the 2.0 monofilament. No patient had complete anesthesia over the dorsum of the hand. No patient complained about pain or numbness. Only one patient among four with a combined radial and musculocutaneous nerve injury required sensory reconstruction. CONCLUSIONS: Minimal sensory abnormalities should be expected after a radial nerve injury. Patients likely neither warrant nor request sensory reconstruction.

Results of nerve grafting in radial nerve injuries occurring proximal to the humerus, including those within the posterior cord.

OBJECTIVE Results of radial nerve grafting are largely unknown for lesions of the radial nerve that occur proximal to the humerus, including those within the posterior cord. METHODS The authors describe 13 patients with proximal radial nerve injuries who were surgically treated and then followed for at least 24 months. The patients' average age was 26 years and the average time between accident and surgery was 6 months. Sural nerve graft length averaged 12 cm. Recovery was scored according to the British Medical Research Council (BMRC) scale, which ranges from M0 to M5 (normal muscle strength). RESULTS After grafting, all 7 patients with an elbow extension palsy recovered elbow extension, scoring M4. Six of the 13 recovered M4 wrist extension, 6 had M3, and 1 had M2. Thumb and finger extension was scored M4 in 3 patients, M3 in 2, M2 in 2, and M0 in 6. CONCLUSIONS The authors consider levels of strength of M4 for elbow and wrist extension and M3 for thumb and finger extension to be good results. Based on these criteria, overall good results were obtained in only 5 of the 13 patients. In proximal radial nerve lesions, the authors now advocate combining nerve grafts with nerve or tendon transfers to reconstruct wrist, thumb, and finger extension.

Results of nerve grafting in radial nerve injuries occurring proximal to the humerus, including those within the posterior cord.

OBJECT Results of radial nerve grafting are largely unknown for lesions of the radial nerve that occur proximal to the humerus, including those within the posterior cord. METHODS The authors describe 13 patients with proximal radial nerve injuries who were surgically treated and then followed for at least 24 months. The patients' average age was 26 years and the average time between accident and surgery was 6 months. Sural nerve graft length averaged 12 cm. Recovery was scored according to the British Medical Research Council (BMRC) scale, which ranges from M0 to M5 (normal muscle strength). RESULTS After grafting, all 7 patients with an elbow extension palsy recovered elbow extension, scoring M4. Six of the 13 recovered M4 wrist extension, 6 had M3, and 1 had M2. Thumb and finger extension was scored M4 in 3 patients, M3 in 2, M2 in 2, and M0 in 6. CONCLUSIONS The authors consider levels of strength of M4 for elbow and wrist extension and M3 for thumb and finger extension to be good results. Based on these criteria, overall good results were obtained in only 5 of the 13 patients. In proximal radial nerve lesions, the authors now advocate combining nerve grafts with nerve or tendon transfers to reconstruct wrist, thumb, and finger extension.

Nerve transfers for elbow and finger extension reconstruction in midcervical spinal cord injuries.

OBJECT: The objective of this study was to report the results of elbow, thumb, and finger extension reconstruction via nerve transfer in midcervical spinal cord injuries. METHODS: Thirteen upper limbs from 7 patients with tetraplegia, with an average age of 26 years, were operated on an average of 7 months after a spinal cord injury. The posterior division of the axillary nerve was used to reinnervate the triceps long and upper medial head motor branches in 9 upper limbs. Both the posterior division and the branch to the middle deltoid were used in 2 upper limbs, and the anterior division of the axillary nerve in the final 2 limbs. For thumb and finger extension reconstruction, the nerve to the supinator was transferred to the posterior interosseous nerve. RESULTS: In 22 of the 27 recipient nerves, a peripheral type of palsy with muscle denervation was identified. At an average of 19 months follow-up, elbow strength scored M4 in 11 upper limbs and M3 in 2, according to the British Medical Research Council scale. Thumb extension scored M4 in 8 upper limbs and scored M3 in 4. Finger extension scored M4 in 12 hands. No donor-site deficits were reported or observed. CONCLUSIONS: Nerve transfers are effective at restoring elbow, thumb, and finger extension in patients with a midcervical spinal cord injury, which occurs in the majority of patients with a peripheral type of palsy with muscle denervation in their upper limbs. Efforts should be made to perform operations in these patients within 12 months of injury.

The median nerve consistently drives flexion of the distal phalanx of the ring and little fingers: Interest in finger flexion reconstruction by nerve transfers.

Surgeons believe that in high ulnar nerve lesion distal interphalangeal joint (DIP) flexion of the ring and little finger is abolished. In this article, we present the results of a study on innervation of the flexor digitorum profundus of the ring and little fingers in five patients with high ulnar nerve injury and in 19 patients with a brachial plexus, posterior cord, or radial nerve injury. Patients with ulnar nerve lesion were assessed clinically and during surgery for ulnar nerve repair we confirmed complete lesion of the ulnar nerve in all cases. In the remaining 19 patients, during surgery, either the median nerve (MN) or the anterior interosseous nerve (AIN) was stimulated electrically and DIP flexion of the ring and little fingers evaluated. All patients with high ulnar nerve lesions had active DIP flexion of the ring and little fingers. Strength scored M4 in the ring and M3-M4 in the little finger. Electrical stimulation of either the MN or AIN produced DIP flexion of the ring and little fingers. Contrary to common knowledge, we identified preserved flexion of the distal phalanx of the ring and little fingers in high ulnar nerve lesions. On the basis of these observations, nerve transfers to the AIN may provide flexion of all fingers.

Single-stage surgery combining nerve and tendon transfers for bilateral upper limb reconstruction in a tetraplegic patient: case report.

A 39-year-old tetraplegic patient had paralysis of elbow, thumb, and finger extension and thumb and finger flexion. We transferred axillary nerve branches to the triceps long and upper medial head motor branches, supinator motor branches to the posterior interosseous nerve, and brachioradialis tendon to the flexor pollicis longus and flexor superficialis of the index finger. Surgery was performed bilaterally 18 months after spinal cord injury. At 12 months after surgery, we performed bilateral distal radioulnar arthrodesis percutaneously. By 22 months postoperatively, we observed triceps strength scoring M3 bilaterally and full metacarpophalangeal joint extension scoring M4 bilaterally. The thumb span was 53 and 66 mm from the proximal index phalanx on the right and left sides, respectively. Pinch strength measured 1.5 kg on the left side and 2.0 kg on the right. Before surgery, the patient was incapable of grasping; after surgery, a useful grasp had been restored bilaterally.

Transfer of a flexor digitorum superficialis motor branch for wrist extension reconstruction in C5-C8 root injuries of the brachial plexus: a case series.

In brachial plexus injuries, though nerve transfers and root grafts have improved the results for shoulder and elbow reconstruction, wrist extension has received little attention. We operated on three young patients with C5-C8 root injuries of the left brachial plexus, each operated upon within 6 months of trauma. For wrist extension reconstruction, we transferred a proximal branch of the flexor digitorum superficialis to the motor branch of the extensor carpi radialis brevis. Twenty-four months after surgery, all patients recovered some degree of active wrist motion, from full flexion to near neutral. Independent control of finger flexion and wrist extension was not observed. In C5-C8 root injuries of the brachial plexus, transfer of a flexor digitorum superficialis motor branch to the extensor carpi radialis brevis produces limited recovery.

The anabolic steroid nandrolone enhances motor and sensory functional recovery in rat median nerve repair with long interpositional nerve grafts.

BACKGROUND: Recovery from peripheral nerve repair is frequently incomplete. Hence drugs that enhance nerve regeneration are needed clinically. OBJECTIVES: To study the effects of nandrolone decanoate in a model of deficient reinnervation in the rat. METHODS: In 40 rats, a 40-mm segment of the left median nerve was removed and interposed between the stumps of a sectioned right median nerve. Starting 7 days after nerve grafting and continuing over a 6-month period, we administered nandrolone at a dose of 5 mg/kg/wk to half the rats (n = 20). All rats were assessed behaviorally for grasp function and nociceptive recovery for up to 6 months. At final assessment, reinnervated muscles were tested electrophysiologically and weighed. Results were compared between rats that had received versus not received nandrolone and versus 20 nongrafted controls. RESULTS: Rats in the nandrolone group recovered finger flexion faster. At 90 days postsurgery, they had recovered 42% of normal grasp strength versus just 11% in rats grafted but not treated with nandrolone. At 180 days, the average values for grasp strength recovery in the nandrolone and no-nandrolone groups were 40% and 33% of normal values for controls, respectively. At 180 days, finger flexor muscle twitch strength was 16% higher in treated versus nontreated rats. Thresholds for nociception were not detected in either group 90 days after nerve grafting. At 180 days, nociceptive thresholds were significantly lower in the nandrolone group. CONCLUSIONS: Nandrolone decanoate improved functional recovery in a model of deficient reinnervation.

Transfer of nerve branch to the brachialis to reconstruct elbow extension in incomplete tetraplegia: case report.

We undertook a brachialis to triceps nerve transfer to restore elbow extension in a 53-year-old man 5 months after he sustained a spine injury that resulted in a central cord syndrome. Within 3 months of surgery, the patient had recovered active elbow extension and had M3 level strength, which increased to M4 and 5 kg of strength by 12 months postoperatively. Despite transferring an antagonist nerve for triceps reinnervation, the patient had no problems controlling active elbow flexion-extension. Harvesting the brachialis nerve caused no permanent decrease in elbow flexion strength.

Grafting the C5 root to the musculocutaneous nerve partially restores hand sensation in complete palsies of the brachial plexus.

BACKGROUND: In complete brachial plexus palsy, we have hypothesized that grafting to the musculocutaneous nerve should restore some hand sensation because the musculocutaneous nerve can drive hand sensation directly or via communication with the radial and median nerves. OBJECTIVE: To investigate sensory recovery in the hand and forearm after C5 root grafting to the musculocutaneous nerve in patients with a total brachial plexus injury. METHODS: Eleven patients who had recovered elbow flexion after musculocutaneous nerve grafting from a preserved C5 root and who had been followed for a minimum of 3 years were screened for sensory recovery in the hand and forearm. Six matched patients who had not undergone surgery served as controls. Methods of assessment included testing for pain sensation using Adson forceps, cutaneous pressure threshold measurements using Semmes-Weinstein monofilaments, and the static 2-point discrimination test. Deep sensation was evaluated by squeezing the first web space, and thermal sensation was assessed using warm and cold water. RESULTS: All grafted patients recovered sensation in a variable territory extending from just over the thenar eminence to the entire lateral forearm and hand. Seven patients were capable of perceiving 2-0 monofilament pressure on the thenar eminence, palm, and dorsoradial aspect of the hand. All could differentiate warm and cold water. None recovered 2-point discrimination. None of the patients in the control group recovered any kind of sensation in the affected limb. CONCLUSION: Grafting the musculocutaneous nerve can restore nociceptive sensation on the radial side of the hand.

Increased levels of Porphyromonas gingivalis are associated with ischemic and hemorrhagic cerebrovascular disease in humans: an in vivo study.

OBJECTIVE: This study investigated the role of periodontal disease in the development of stroke or cerebral infarction in patients by evaluating the clinical periodontal conditions and the subgingival levels of periodontopathogens. MATERIAL AND METHODS: Twenty patients with ischemic (I-CVA) or hemorrhagic (H-CVA) cerebrovascular episodes (test group) and 60 systemically healthy patients (control group) were evaluated for: probing depth, clinical attachment level, bleeding on probing and plaque index. Porphyromonas gingivalis and Aggregatibacter actinomycetemcomitans were both identified and quantified in subgingival plaque samples by conventional and real-time PCR, respectively. RESULTS: The test group showed a significant increase in each of the following parameters: pocket depth, clinical attachment loss, bleeding on probing, plaque index and number of missing teeth when compared to control values (p<0.05, unpaired t-test). Likewise, the test group had increased numbers of sites that were contaminated with P. gingivalis (60%x10%; p<0.001; chi-squared test) and displayed greater prevalence of periodontal disease, with an odds ratio of 48.06 (95% CI: 5.96-387.72; p<0.001). Notably, a positive correlation between probing depth and the levels of P. gingivalis in ischemic stroke was found (r=0.60; p=0.03; Spearman's rank correlation coefficient test). A. actinomycetemcomitans DNA was not detected in any of the groups by conventional or real-time PCR. CONCLUSIONS: Stroke patients had deeper pockets, more severe attachment loss, increased bleeding on probing, increased plaque indexes, and in their pockets harbored increased levels of P. gingivalis. These findings suggest that periodontal disease is a risk factor for the development of cerebral hemorrhage or infarction. Early treatment of periodontitis may counteract the development of cerebrovascular episodes.

Transfer of the distal terminal motor branch of the extensor carpi radialis brevis to the nerve of the flexor pollicis longus: an anatomic study and clinical application in a tetraplegic patient.

BACKGROUND: In tetraplegics, thumb and finger motion traditionally has been reconstructed via orthopedic procedures. Although rarely used, nerve transfers are a viable method for reconstruction in tetraplegia. OBJECTIVE: To investigate the anatomic feasibility of transferring the distal branch of the extensor carpi radialis brevis (ECRB) to the flexor pollicis longus (FPL) nerve and to report our first clinical case. METHODS: We studied the motor branch of the ECRB and FPL in 14 cadaveric upper limbs. Subsequently, a 24-year-old tetraplegic man with preserved motion in his shoulder, elbow, wrist, and finger extension, but paralysis of thumb and finger flexion underwent surgery. Seven months after trauma, we transferred the brachialis muscle with a tendon graft to the flexor digitorum profundus. The distal nerve of the ECRB was transferred to the FPL nerve. RESULTS: The branch to the ECRB entered the muscle in its anterior and proximal third. After sending out a first collateral, the nerve runs for 2.4 cm alongside the muscle and bifurcates intramuscularly. A main branch from the anterior interosseous nerve, which entered the muscle 3 cm from its origin on the radius, innervated the FPL. The ECRB and FPL nerves had similar diameters (∼1 mm) and numbers of myelinated fibers (∼180). In our patient, 14 months after surgery, pinching and grasping were restored and measured 2 and 8 kg strength, respectively. CONCLUSION: Transfer of the ECRB distal branch to the FPL is a viable option to reconstruct thumb flexion.

Increased levels of Porphyromonas gingivalis are associated with ischemic and hemorrhagic cerebrovascular disease in humans: an in vivo study

OBJECTIVE: This study investigated the role of periodontal disease in the development of stroke or cerebral infarction in patients by evaluating the clinical periodontal conditions and the subgingival levels of periodontopathogens. MATERIAL AND METHODS: Twenty patients with ischemic (I-CVA) or hemorrhagic (H-CVA) cerebrovascular episodes (test group) and 60 systemically healthy patients (control group) were evaluated for: probing depth, clinical attachment level, bleeding on probing and plaque index. Porphyromonas gingivalis and Aggregatibacter actinomycetemcomitans were both identified and quantified in subgingival plaque samples by conventional and real-time PCR, respectively. RESULTS: The test group showed a significant increase in each of the following parameters: pocket depth, clinical attachment loss, bleeding on probing, plaque index and number of missing teeth when compared to control values (p<0.05, unpaired t-test). Likewise, the test group had increased numbers of sites that were contaminated with P. gingivalis (60 percentx10 percent; p<0.001; chi-squared test) and displayed greater prevalence of periodontal disease, with an odds ratio of 48.06 (95 percent CI: 5.96-387.72; p<0.001). Notably, a positive correlation between probing depth and the levels of P. gingivalis in ischemic stroke was found (r=0.60; p=0.03; Spearman's rank correlation coefficient test). A. actinomycetemcomitans DNA was not detected in any of the groups by conventional or real-time PCR. CONCLUSIONS: Stroke patients had deeper pockets, more severe attachment loss, increased bleeding on probing, increased plaque indexes, and in their pockets harbored increased levels of P. gingivalis. These findings suggest that periodontal disease is a risk factor for the development of cerebral hemorrhage or infarction. Early treatment of periodontitis may counteract the development of cerebrovascular episodes.

C5-8 brachial plexus root injury: the "T-1 hand".

OBJECT: Classically, C5-7 root injuries of the brachial plexus have been associated with palsies of shoulder abduction/external rotation, elbow flexion/extension, and wrist, thumb, and finger extension. However, current myotome maps generally indicate that C-8 participates in the innervation of thumb and finger extensors. Therefore, the authors have hypothesized that, for palsies of the thumb and finger extensors, the injury should affect the C-5 through C-8 roots. METHODS: The authors tested their hypothesis in 30 patients with upper-type palsies of the brachial plexus. They traced a correlation between clinical findings and root injury, as documented by CT myelography, direct visualization during surgery, and electrophysiological studies. RESULTS: In C5-8 root injuries, shoulder abduction and external rotation were paralyzed, and in all patients, wrist extensors were paralyzed. However, in 22 of the 30 patients, wrist extension was possible, because of contraction of the extensor digitorum communis and extensor pollicis longus. Wrist flexion and pronation also were preserved. The T-1 root contributed significantly to innervation of the thumb and finger flexors, ensuring 34% grasping and 40% pinch strength relative to the normal side. Hand sensation was largely preserved. CONCLUSIONS: Based on the authors' observations, they suspect that the clinical scenario previously attributed to a C5-7 root injury is, in fact, a C5-8 root injury. The authors propose referring to this partial palsy of the brachial plexus as a "T-1 hand."

Aplicação da Escala de Oswestry em pacientes com doença degenerativa da coluna lombar submetidos à artrodese / Application of the Oswestry Scale in patients with degenerative lumbar spine underwent arthrodesis

Introdução: A Escala de Oswestry (The OswestryDisability Index - ODI) é um instrumento doença?específicopara avaliação das desordens da coluna, onde são avaliadosdez critérios com seis alternativas de resposta paracada. A artrodese lombar para tratamento de doença degenerativaalcança melhores resultados com adequada seleçãode pacientes, e apesar de numerosos estudos, ainda hácontrovérsia de seu real benefício. Objetivos: Descrever amudança na qualidade de vida pós?cirurgia dos pacientescom doença degenerativa da coluna lombar submetidos àartrodese, por meio do ODI. Métodos: Estudo observacional,longitudinal, prospectivo e não controlado, realizadoatravés da aplicação da escala no pré ? operatório durantea internação e um mês após a cirurgia por contato telefônico.Resultados: A amostra foi constituída por seis indivíduos,com média de idade de 63 anos, predominânciado gênero masculino, casados, apenas um estava em auxílio?doença. O ODI médio pré ? operatório foi de 72,3%, oque os categoriza em incapacitados funcionais, enquanto amédia pós ? operatória foi de 51%, severamente desabilitados.A redução média de pontuação da ODI foi de 21,3%(p<0,001). Conclusões: Apesar da redução média do ODIter sido significativa, mostrando que houve uma melhorana qualidade de vida e que a artrodese lombar pode ser umtratamento efetivo em curto prazo, não se pode inferir omesmo em longo prazo, devido à pequena amostra e poucotempo de seguimento.

The Oswestry Disability Index (ODI) is a condition specificoutcome measure used in the management of spinal disorders.It includes 10 questions with six possible answers(alternatives of response). The most important determinantof success - incluir para tratamento da doença degenerativalombar - in spinal fusion is an appropriate patientselection. In spite of numerous studies that have been publishedon this matter, controversy still exists. Objectives:To describe changes in quality of life post surgery in patientswith lumbar degenerative disease, who underwentarthrodesis by the neurosurgery department, through ODI.Methods: Observational, longitudinal, prospective andnon controlled study. The ODI was applied to all subjectsprior to surgery ( as inpatient), and one month after throughphone contact. Results: The sample included six subjectswith mean age of 63 years. Male gender and marriedas marital status was predominant, only one was in disabilityinsurance. The mean preoperative ODI was 72.3%,which means cripple, while mean postoperative ODI was51%, severe disability category. The mean reduction was21.3% in ODI (p<0,001). Conclusions: Despite mean reductionof ODI had been significative, showing some improvementin quality of life and that lumbar arthrodesiscould be an effective treatment option in a short term, wecannot be conclusive, because of the small sample andshort follow up.

Abduction in internal rotation: a test for the diagnosis of axillary nerve palsy.

PURPOSE: To describe and validate the use of a test of abduction in internal rotation for the assessment of axillary nerve injury. METHODS: A total of 14 male patients with a mean age of 29 years (SD ± 6 y), with axillary nerve lesions lasting an average of 6 months, participated. We measured their shoulder range of motion. In the upright position, with the trunk bending forward, we asked our patients to actively extend the shoulder (swallowtail test), and then we extended the shoulders and asked each patient to hold them in that position (deltoid extension lag test). For the abduction in internal rotation test, we asked patients to abduct the shoulder in internal rotation. If full abduction compared with the normal contralateral side was not possible, the examiner passively held the affected limb in maximal abduction and internal rotation. The patient was instructed to maintain the position when the examiner released the limb. In each test, any lag compared with the normal side accounted for deltoid palsy. RESULTS: All patients exhibited abduction beyond horizontal and full external rotation. The swallowtail test and the deltoid extension lag test identified the axillary nerve lesion in 10 of 14 patients. The abduction in internal rotation test recognized the axillary nerve injury in all 14. The average difference in the range of abduction in internal rotation between the normal and affected side was 37° (abduction lag). CONCLUSIONS: Compensatory abduction in axillary nerve palsy has been attributed to the action of the supraspinatus, biceps, coracobrachialis, and pectoralis major. During abduction in internal rotation, compensatory abduction is impaired, clearly indicating deltoid muscle dysfunction.

Mesh epineurial splinting for late median nerve repair in older patients: a preliminary report.

Eleven patients over 40 years old, with median nerve lesions at the wrist, were operated on an average of 5 months after their injury. In six patients, the median nerve was repaired using a polypropylene mesh applied to secure the nerve stumps in contact, thereby allowing for direct repair with microsutures. Six patients had their median nerve repaired with sural grafts. The average gap length was 2.8 cm for the mesh repair, whereas it was 3.7 cm for the graft repair group. Eighteen months after surgery, pressure thresholds were perceived in the index and thumb pulp by all six patients with a mesh repair but in only two of five patients with a graft repair. Five in the mesh repair group recovered function in the abductor pollicis brevis muscle, versus none in the graft group. These preliminary results suggest that, in older patients, the use of a mesh to splint the coaptation site followed by direct nerve repair yields better recovery than conventional sural grafts.

Transfer of axillary nerve branches to reconstruct elbow extension in tetraplegics: a laboratory investigation of surgical feasibility.

In spinal cord injuries at the C6 level, elbow extension is lost and needs reconstruction. Traditionally, elbow extension has been reconstructed by muscle transfers, which improve function only moderately. We have hypothesized that outcomes could be ameliorated by nerve transfers rather than muscle transfers. We anatomically investigated nerve branches to the teres minor and posterior deltoid as donors for transfer to triceps motor branches. In eight formalin-fixed cadavers, the axillary nerve, the teres minor branch, the posterior deltoid branch, the triceps long and upper medial head motor branches, and the thoracodorsal nerve were dissected bilaterally, their diameters measured and their myelinated fibers counted. To simulate surgery, using an axillary approach in two fresh cadavers, we transferred the teres minor or the posterior deltoid branch to the triceps long head and to the thoracodorsal nerve. The posterior division of the axillary nerve gave off the teres minor motor branch and then the branch to the posterior deltoid, terminating as the superior lateral brachial cutaneous nerve. The diameters of the teres minor motor branch, posterior deltoid, triceps long and upper medial head branches, and the thoracodorsal nerve all were ∼2 mm, with minimal variation. The nerves varied little in their numbers of myelinated fibers, being consistently about 1,000. Via an axillary approach, either the teres minor or the posterior deltoid branch could be transferred directly to the thoracodorsal nerve or to triceps branches without any tension.

Very distal sensory nerve transfers in high median nerve lesions.

PURPOSE: We report on the results of reconstruction of fingertip sensation by very distal nerve transfer in 8 patients with high median nerve lesions. METHODS: Before surgery, patients underwent sensory testing of the hand using Semmes-Weinstein monofilaments. All patients had surgery within 1 year of trauma. For sensory reconstruction, branches of the radial nerve on the proximal phalanx of the index and thumb were sutured to the ulnar proper digital nerve of the thumb and radial proper digital nerve of the index finger. Patients were followed up for 12 months. RESULTS: After median nerve lesions, zones of lost protective sensation were confined to the middle and index finger and the thumb. Sensation on the palm of the hand and proximal phalanx was preserved. Radial nerve transfer to palmar nerves restored protective or better sensation to the fingertips in all patients. Better results were observed for the thumb. Locognosia was acquired in all thumbs, and in 4 of 8 index fingers. Good results were detected even in patients who had undergone surgery later than 6 months after injury. CONCLUSIONS: Fingertip sensation can be restored by very distal nerve transfer of radial nerve branches to palmar nerves at the level of the proximal phalanx. This method of reconstruction appears useful in high median nerve lesions. In chronic lesions of the median nerve at the wrist and lesions in older patients, very distal nerve transfers might be adjunct to nerve grafting.

Transfer of the teres minor motor branch for triceps reinnervation in tetraplegia.

In a case involving tetraplegia and paralysis of elbow extension, the authors transferred teres minor branches to the nerve of the triceps long head. Surgery was performed bilaterally 9 months after the patient sustained a spinal cord injury. Fourteen months postoperatively, elbow extension was complete (British Medical Research Council Score M4). Harvesting of the teres minor motor branch produced no deficits in shoulder function. In patients with tetraplegia, nerve transfer seems to be a promising new alternative for elbow extension reconstruction.