Spinal lymphangiomas: Case-based review of a chameleonic disease entity.

Purpose: Lymphangiomas are benign hamartomas in the spectrum of lymphatic malformations, exhibiting multifaceted clinical features. Spinal involvement is exceedingly rare, with only 35 cases reported to date. Both due to their rarity and chameleonic radiologic features, spinal lymphangiomas (SLs) are usually misdiagnosed; postoperatively, surgeons are thus confronted with an unexpected histopathological diagnosis with sparse pertinent literature and no treatment guidelines available. Methods: Here, we report the case of a 67-year-old female who underwent surgery for a T6-T7 epidural SL with transforaminal extension, manifesting with spastic paraparesis. Then, we present the results of the first systematic review of the literature on this subject, delineating the clinical and imaging features and the therapeutic implications of this rare disease entity. Results: Our patient was treated with T6-T7 hemilaminectomy and resection of the epidural mass, with complete recovery of her neurological picture. No recurrence was evident at 18 months. In the literature, 35 cases of SL were reported that can be classified as vertebral SL (n = 18), epidural SL (n = 10), intradural SL (n = 3), or intrathoracic lymphangiomas with secondary spinal involvement (n = 4). Specific treatment strategies (both surgical and nonsurgical) were adopted in relation to each of these categories. Conclusion: Gathering knowledge about SL is fundamental to promote both correct preoperative identification and appropriate perioperative management of this rare disease entity. By reviewing the literature and discussing an exemplary case, we delineate a framework that can guide surgeons facing such an unfamiliar diagnosis.

Case Report: Adjuvant image-guided radiation therapy reduces surgical invasiveness in malignant peripheral nerve sheath tumors.

Introduction: Malignant peripheral nerve sheath tumors (MPNSTs) are a group of rare soft tissue sarcomas of mesenchymal origin. These tumors generally require extensive local excision owing to their aggressive potential. Though the role of radiotherapy is controversial, in this report, we present the case of an MPNST in the forearm that was treated with microsurgery followed by image-guided radiation therapy to achieve complete tumor disappearance at the 18-month follow-up. Case report: A 69-year-old woman with underlying paranoid schizophrenia was referred to our department with pain, severe swelling, and ecchymosis of her right forearm. Physical examination showed hypoesthesia in the segments innervated by the median nerve and reduced motor strength of her right hand. A gadolinium-enhanced MRI showed a large malignant peripheral nerve sheath tumor (13 x 8 x 7 cm) of the median nerve in the forearm. She underwent microsurgical en-bloc tumor resection with sparing of the median nerve. Thirty-five days postoperatively, she underwent image-guided radiotherapy (IGRT) using volumetric modulated arc therapy (VMAT). Serial MRI scans of the forearm with Gadolinium and whole-body CT scan with contrast enhancement at 30 days, 6 months, 1 year, and 18 months postoperatively documented no tumor recurrence, remnants, or metastases. Conclusions: In this report, we demonstrate the successful use of advanced radiotherapy techniques such as IGRT while avoiding demolitive surgery for MPNST. Though a longer follow-up is necessary, at the 18-month follow-up, the patient demonstrated good outcomes from surgical resection followed by adjuvant RT for MPNST in the forearm.

The "banana splitting DREZotomy": an atraumatic method to improve pain relief after dorsal root entry zone lesioning in brachial plexus injuries. Case series and tenets for the treatment.

BACKGROUND: The treatment of neuropathic deafferentation pain due to avulsion injuries of the brachial plexus is a major problem, albeit rare, in the neurosurgical practice. The aim of the paper is to present step-by-step the main principles of a surgical upgrade of the well-known Dorsal Root Entry Zone lesioning, that we named banana splitting DREZotomy. METHODS: A comparison is made among three groups of patients, two of which were treated following the classic techniques, while in the third no physical agent is applied to the spinal cord during surgery. RESULTS: The patients operated on following the well-established surgical procedures showed a short-term success rate around 70%, online with the data of the ongoing literature. The results with the banana-splitting technique, instead, have been astonishing both in terms of resolution of pain, absence of true complications and of unpleasant side effects. CONCLUSIONS: A purely dissective technical variant of the surgical procedure called DREZ lesioning has shown better results overcoming the 30% failures of all the reported series. The profound and permanent splitting of the posterior horn and the absence of any other component (heat propagation, radiofrequency, or dotted coagulation) are the major factors which may explain such outstanding results.

Thoracic Outlet Syndrome Part II: Consensus on the Management of Neurogenic Thoracic Outlet Syndrome by the European Association of Neurosurgical Societies' Section of Peripheral Nerve Surgery.

BACKGROUND: In the first part of this report, the European Association of Neurosurgical Societies' section of peripheral nerve surgery presented a systematic literature review and consensus statements on anatomy, classification, and diagnosis of thoracic outlet syndrome (TOS) along with a subclassification system of neurogenic TOS (nTOS). Because of the lack of level 1 evidence, especially regarding the management of nTOS, we now add a consensus statement on nTOS treatment among experienced neurosurgeons. OBJECTIVE: To document consensus and controversy on nTOS management, with emphasis on timing and types of surgical and nonsurgical nTOS treatment, and to support patient counseling and clinical decision-making within the neurosurgical community. METHODS: The literature available on PubMed/MEDLINE was systematically searched on February 13, 2021, and yielded 2853 results. Screening and classification of abstracts was performed. In an online meeting that was held on December 16, 2021, 14 recommendations on nTOS management were developed and refined in a group process according to the Delphi consensus method. RESULTS: Five RCTs reported on management strategies in nTOS. Three prospective observational studies present outcomes after therapeutic interventions. Fourteen statements on nonsurgical nTOS treatment, timing, and type of surgical therapy were developed. Within our expert group, the agreement rate was high with a mean of 97.8% (± 0.04) for each statement, ranging between 86.7% and 100%. CONCLUSION: Our work may help to improve clinical decision-making among the neurosurgical community and may guide nonspecialized or inexperienced neurosurgeons with initial patient management before patient referral to a specialized center.

Rationale and design of the peripheral nerve tumor registry: an observational cohort study.

AIM: Peripheral nerve tumors (PNT) are rare lesions. To date, no systematic multicenter studies on epidemiology, clinical symptoms, treatment strategies and outcomes, genetic and histopathologic features, as well as imaging characteristics of PNT were published. The main goal of our PNT Registry is the systematic multicenter investigation to improve our understanding of PNT and to assist future interventional studies in establishing hypotheses, determining potential endpoints, and assessing treatment efficacy. METHODS: Aims of the PNT registry were set at the 2015 Meeting of the Section of Peripheral Nerve Surgery of the German Society of Neurosurgery. A study protocol was developed by specialists in PNT care. A minimal data set on clinical status, treatment types and outcomes is reported by each participating center at initial contact with the patient and after 1 year, 2 years, and 5 years. Since the study is coordinated by the Charité Berlin, the PNR Registry was approved by the Charité ethics committee (EA4/058/17) and registered with the German Trials Registry (www.drks.de). On a national level, patient inclusion began in June 2016. The registry was rolled out across Europe at the 2019 meeting of the European Association of Neurosurgery in Dublin. RESULTS: Patient recruitment has been initiated at 10 centers throughout Europe and 14 additional centers are currently applying for local ethics approval. CONCLUSION: To date, the PNT registry has grown into an international study group with regular scientific and clinical exchange awaiting the first results of the retrospective study arm.

The reanimation of the elbow functions in avulsive injuries of the upper brachial plexus using the medial cord transfer: nuances of the technique and update.

OBJECTIVES: Report on a new transfer for the reinnervation of biceps and brachialis muscles after multilevel avulsive injuries of brachial plexus provided at least T1 is viable: the Medial Cord to Musculocutaneous (MCMc) and its variant, the Medial Cord to anterior Upper Trunk (MC-aUT). The MC-aUT is indicated in agenesia of musculocutaneous nerve and when a residual function in the biceps is present. The MCMc transfer would be unfeasible in the former and contraindicated in the latter. METHODS: Three hundred and five consecutive patients, classified according to the quality of hand function, are available for a long-term follow-up after reconstructive surgery. They had multiple cervical root avulsive injuries at two (C5-C6), three (C5-C6-C7) and four (C5-C6-C7-C8) levels. The reinnervation was obtained via an end-to-end transfer from two donor fascicles located in the medial cord (MC) and aimed at the flexor carpi ulnaris or the flexor digitorum profundus. RESULTS: These transfers have no failures and no complications when the hand shows a normal function. In the case of suboptimal conditions of the hand, the technique is more challenging, but still has many satisfactory results. In the four-root avulsive injuries, on the contrary, strong limitations suggest that different strategies should be preferred. EMG shows a reinnervation in both biceps and brachialis muscles and this accounts for the quality of results. Tendon transfers for wrist and finger dorsiflexion, when required, remain unencumbered. DISCUSSION: The procedures are safe, effective and easily feasible. The ideal candidate has a C5-C6 injury and a normal hand function.

Thoracic Outlet Syndrome Part I: Systematic Review of the Literature and Consensus on Anatomy, Diagnosis, and Classification of Thoracic Outlet Syndrome by the European Association of Neurosurgical Societies' Section of Peripheral Nerve Surgery.

BACKGROUND: Although numerous articles have been published not only on the classification of thoracic outlet syndrome (TOS) but also on diagnostic standards, timing, and type of surgical intervention, there still remains some controversy because of the lack of level 1 evidence. So far, attempts to generate uniform reporting standards have not yielded conclusive results. OBJECTIVE: To systematically review the body of evidence and reach a consensus among neurosurgeons experienced in TOS regarding anatomy, diagnosis, and classification. METHODS: A systematic literature search on PubMed/MEDLINE was performed on February 13, 2021, yielding 2853 results. Abstracts were screened and classified. Recommendations were developed in a meeting held online on February 10, 2021, and refined according to the Delphi consensus method. RESULTS: Six randomized controlled trials (on surgical, conservative, and injection therapies), 4 "guideline" articles (on imaging and reporting standards), 5 observational studies (on diagnostics, hierarchic designs of physiotherapy vs surgery, and quality of life outcomes), and 6 meta-analyses were identified. The European Association of Neurosurgical Societies' section of peripheral nerve surgery established 18 statements regarding anatomy, diagnosis, and classification of TOS with agreement levels of 98.4 % (±3.0). CONCLUSION: Because of the lack of level 1 evidence, consensus statements on anatomy, diagnosis, and classification of TOS from experts of the section of peripheral nerve surgery of the European Association of Neurosurgical Societies were developed with the Delphi method. Further work on reporting standards, prospective data collections, therapy, and long-term outcome is necessary.

The Masseteric-Facial Anastomosis With Intratemporal Translocation of the Facial Nerve: Step-by-Step Technique and Results.

BACKGROUND: In the absence of a viable proximal nerve stump, damaged after surgical procedures around the skull base, numerous techniques for facial reanimation have been developed over time, aiming to restore baseline symmetry and active mimicry. OBJECTIVE: To report experience using the masseteric nerve as a direct transfer to the facial nerve rerouted after intratemporal translocation. This paper illustrates the main steps of the technique and the quality of results. METHODS: Eleven patients were treated with a masseteric direct transfer to the facial nerve. Its extratemporal rerouting toward the zygoma allowed tension-free coaptation between donor and recipient nerves. RESULTS: Of the 11 patients, 8 had a good to excellent recovery, showing different patterns of time and scores, according to age, surgical timing, and masseteric nerve function quality. The return of activity in the frontalis muscle, never obtained after reinnervation via the hypoglossal nerve, is of particular interest. The quality of the smile can be improved with re-education and practice but remains under volitional control. A true emotional response is still lacking. CONCLUSION: The masseteric nerve is an excellent alternative to the hypoglossal nerve and can reinnervate the whole territory of the facial nerve rerouted after intratemporal translocation. The overall results are remarkable, but the low quality of the trigeminal nerve, eventually affected by the first surgery, may be an important limitation. Even if the patients appear more at ease in re-education than with other techniques, a fully natural facial expression remains impossible to obtain.

Neurofibromin Deficiency and Extracellular Matrix Cooperate to Increase Transforming Potential through FAK-Dependent Signaling.

Plexiform neurofibromas (Pnfs) are benign peripheral nerve sheath tumors that are major features of the human genetic syndrome, neurofibromatosis type 1 (NF1). Pnfs are derived from Schwann cells (SCs) undergoing loss of heterozygosity (LOH) at the NF1 locus in an NF1+/- milieu and thus are variably lacking in the key Ras-controlling protein, neurofibromin (Nfn). As these SCs are embedded in a dense desmoplastic milieu of stromal cells and abnormal extracellular matrix (ECM), cell-cell cooperativity (CCC) and the molecular microenvironment play essential roles in Pnf progression towards a malignant peripheral nerve sheath tumor (MPNST). The complexity of Pnf biology makes treatment challenging. The only approved drug, the MEK inhibitor Selumetinib, displays a variable and partial therapeutic response. Here, we explored ECM contributions to the growth of cells lacking Nfn. In a 3D in vitro culture, NF1 loss sensitizes cells to signals from a Pnf-mimicking ECM through focal adhesion kinase (FAK) hyperactivation. This hyperactivation correlated with phosphorylation of the downstream effectors, Src, ERK, and AKT, and with colony formation. Expression of the GAP-related domain of Nfn only partially decreased activation of this signaling pathway and only slowed down 3D colony growth of cells lacking Nfn. However, combinatorial treatment with both the FAK inhibitor Defactinib (VS-6063) and Selumetinib (AZD6244) fully suppressed colony growth. These observations pave the way for a new combined therapeutic strategy simultaneously interfering with both intracellular signals and the interplay between the various tumor cells and the ECM.

Neurosurgery in times of a pandemic: a survey of neurosurgical services during the COVID-19 outbreak in the Veneto region in Italy.

OBJECTIVE: The purpose of this study was to analyze the effect of the coronavirus disease 2019 (COVID-19) outbreak and of the subsequent lockdown on the neurosurgical services of the Veneto region in Italy compared to the previous 4 years. METHODS: A survey was conducted in all 6 neurosurgical departments in the Veneto region to collect data about surgical, inpatient care and endovascular procedures during the month of March for each year from 2016 to 2020. Safety measures to avoid infection from SARS-CoV-2 and any COVID-19 cases reported among neurosurgical patients or staff members were considered. RESULTS: The mean number of neurosurgical admissions for the month of March over the 2016-2019 period was 663, whereas in March 2020 admissions decreased by 42%. Emergency admissions decreased by 23%. The average number of neurosurgical procedures was 697, and declined by 30% (range -10% to -51% in individual centers). Emergency procedures decreased in the same period by 23%. Subarachnoid hemorrhage and spontaneous intracerebral hemorrhage both decreased in Veneto-by 25% and 22%, respectively. Coiling for unruptured aneurysm, coiling for ruptured aneurysm, and surgery for ruptured aneurysm or arteriovenous malformation diminished by 49%, 27%, and 78%, respectively. Endovascular procedures for acute ischemic stroke (AIS) increased by 33% in 2020 (28 procedures in total). There was a slight decrease (8%) in brain tumor surgeries. Neurosurgical admissions decreased by 25% and 35% for head trauma and spinal trauma, respectively, while surgical procedures for head trauma diminished by 19% and procedures for spinal trauma declined by 26%. Admissions and surgical treatments for degenerative spine were halved. Eleven healthcare workers and 8 patients were infected in the acute phase of the pandemic. CONCLUSIONS: This multicenter study describes the effects of a COVID-19 outbreak on neurosurgical activities in a vast region in Italy. Remodulation of neurosurgical activities has resulted in a significant reduction of elective and emergency surgeries compared to previous years. Most likely this is a combined result of cancellation of elective and postponable surgeries, increase of conservative management, increase in social restrictions, and in patients' fear of accessing hospitals. Curiously, only endovascular procedures for AIS have increased, possibly due to reduced physical activity or increased thrombosis in SARS-CoV-2. The confounding effect of thrombectomy increase over time cannot be excluded. No conclusion can be drawn on AIS incidence. Active monitoring with nasopharyngeal swabs, wearing face masks, and using separate pathways for infected patients reduce the risk of infection.

Dorsal root entry zone lesion: nuances of the technique and long-term results.

The treatment of deafferentation pain is a primary goal of a referral center for peripheral nerve surgery. DREZ is an important asset in the neurosurgeon's armamentarium. The surgical technique and long-term results are analyzed in two series, with or without intraoperative monitoring (IOM). DREZotomy is highly effective in lumbar root avulsive injuries but is ineffective in resolving pain due to spinal cord injuries. Cervical DREZotomy for cancer pain is not superior to intrathecal morphine. In brachial plexus avulsive injuries, the largest series shows a 74% success rate, but the efficacy of the procedure is lost over time. No relevant difference has been observed since the introduction of IOM. The video can be found here: https://youtu.be/uG_kkQj5m1U.

Acute pulmonary embolism after post-traumatic spinal epidural hematoma: Use of catheter-direct treatment.

We report the case of a 35-year-old man who developed a massive pulmonary embolism (PE) after spine surgery. After an accidental axial fall, the patient developed a spinal epidural hematoma (SHE). Because major trauma, recent surgery and known bleeding risk are considered absolute contraindications to systemic thrombolysis, the patient was treated with catheter-directed therapy (CDT). CDT remains a useful treatment in massive PE, especially when systemic thrombolysis is contraindicated or has failed.

In lumbosacral plexus injuries can we identify indicators that predict spontaneous recovery or the need for surgical treatment? Results from a clinical study on 72 patients.

BACKGROUND: Post-traumatic lumbosacral plexus injuries seem to be rare events, spontaneously recovering in high percentage: as surgery is often challenging and results in poor outcome, many Authors have advocated conservative treatment only. Nevertheless surgery should not be ruled out: in invalidating injuries, it can restore basic function in the lower extremities.Therefore, it might be necessary to establish guidelines for the management and the indication to surgery in such cases.This study aims to identify indicators predicting spontaneous recovery or the need for surgery. METHOD: The clinical and radiological data of 72 patients with a post-traumatic lumbosacral plexus injury were reviewed. A follow up equal or superior to 3 years is available in 42 cases. RESULTS: Lumbosacral plexus injuries mostly occurred during road accidents. The incidence of associated lesions was relevant: bone injuries were found in 85% of patients, internal lesions in 30% and vascular injuries in 8%.Lumbosacral trunk and sacral plexus palsies were the most frequent injury patterns.Root avulsions were revealed in 23% of cases and only in sacral plexus and complete lumbosacral plexus injuries: L5 and S1 were the roots more prone to avulsions.About 70% of cases recovered spontaneously, mostly in 18 months. Spontaneous recovery was the rule in lumbar plexus and lumbosacral trunk injuries (where root avulsions never occurred) or in sacral and complete lumbosacral plexus palsies due to compression injuries.The causative mechanism correlated with the injury pattern, the associated bone injury being often predictive of the severity of the nerve injury.Lumbosacral plexus injuries occurred in car crashes were generally associated with fractures causing compression on the nerves, thus resulting in injuries often amenable of spontaneous recovery.Motorcycle accidents implied high kinetic energy traumas where traction played an important role, as the high percentage of sacroiliac joint separations demonstrated (found in more than 50% of cases and always associated to root avulsions).Loss of sphincteral control and excruciating leg pain were also invariably associated with avulsions. CONCLUSIONS: Clinical and radiological data can help to predict the occurrence of spontaneous recovery or the need for surgery in post-traumatic lumbosacral plexus injuries.

Feasibility of diffusion tensor tractography of brachial plexus injuries at 1.5 T.

OBJECTIVE: The objective of this study was to examine the feasibility of diffusion tensor imaging and diffusion tensor tractography (DTT) at 1.5 T for the detection of nerve root avulsions in patients with brachial plexus injuries (BPI). MATERIALS AND METHODS: We performed a 1.5-T magnetic resonance imaging on 28 patients (mean [SD] age, 25 [9.1]) with BPI using the following imaging protocol: (a) magnetic resonance myelography (MRM), (b) magnetic resonance neurography, and (c) diffusion tensor imaging. A reproducible tractography approach was developed to assess the myeloradicular continuity, which consists of multiple regions of interests placed on each hemicord, including the ventral and dorsal rootlets from C4 to T2 nerve roots. Two independent observers blindly evaluated DTT and MRM studies. The degree of agreement between DTT and MRM findings was estimated on a per-root basis on the 140 nerve roots (C5-T1) on the injured side by calculation of the κ coefficient (K value) and the Bland-Altman plot analysis. The diagnostic accuracy of DTT was assessed by comparing it with the MRM findings of the 140 nerve roots on the injured side on a per-root basis. RESULTS: Diffusion tensor tractography allowed a complete visualization of the C5-T1 intact nerve roots on the normal side in 100% of studies.Complete nerve root avulsions were recognized on DTT either as a total loss of fibers or as a very short segment of incoherent fibers in apparent continuity with the spinal cord.The MRM identified 88 intact nerve roots (62.9%), 44 completely avulsed nerve roots (31.4%), and 8 partially avulsed nerve roots (5.7%). The DTT and MRM were concordant in 127 of the 140 nerve roots (90.7%) and exhibited an excellent overall agreement (K value, 80.8). The brachial plexus DTT had an 88.1% sensitivity, 98.1% positive predictive value, 98.8% specificity, 92.6 negative predictive value, and a 94.5% overall accuracy for detecting the presence of a nerve root avulsion. The κ coefficients for the interobserver reliability of DTT and MRM were 0.85 and 0.80, respectively. CONCLUSIONS: Our results suggest that cervical nerve root avulsions can be successfully visualized at 1.5 T in patients with BPI despite the anatomical complexity and susceptibility and motion artifacts. We propose that DTT is a reliable and reproducible method for the investigation of BPI because it provides a successful anatomical and functional display of neural structures that are not otherwise attainable with conventional studies.

Perineurioma of the sciatic nerve: a possible cause of idiopathic foot drop in children: report of 4 cases.

The authors report on a loss of foot dorsiflexion in pediatric-age individuals and suggest that the possible cause could be a perineurioma of the sciatic nerve. The authors describe 4 cases in which foot drop in the absence of sensory discomfort was the heralding sign of perineurioma of the sciatic nerve. Magnetic resonance imaging showed a focal enlargement of the sciatic nerve, but the tumor was confined only to its lateral compartment. Treatment in 2 cases involved excision of the affected segment and subsequent graft repair. The two other patients shared the same clinical, radiological, and surgical findings, but no nerve biopsy sample was obtained; the patients underwent only a tibialis posterior muscle transfer. Long-term recovery of nerve function never occurred. Because tumor resection and nerve graft yield no functional results, a tendon transfer to restore walking may be the sole useful surgical procedure in these cases. Removal of the tumor may not be necessary because long-term follow-up confirms that perineuriomas are self-limiting and the final prognosis is favorable.

End-to-side intrapetrous hypoglossal-facialanastomosis for reanimation of the face. Technical note.

The aim of this paper was to report on further experience with a new technique for reanimation of the facial nerve. This procedure allows a straight end-to-side hypoglossal-facial anastomosis without interruption of the 12th cranial nerve or the need for graft interposition. It is technically demanding and time consuming but offers an effective, reliable, and extraordinarily quick means of reinnervating the facial muscles, including the orbicularis oculi muscle, thus avoiding the need for a gold weight in the eyelid or a fascial sling.

Reinnervation of the biceps in C5-7 brachial plexus avulsion injuries: results after distal bypass surgery.

OBJECT: The authors report various techniques, and their results, after performing median and ulnar nerve transfers to reanimate the biceps muscle in C5-7 avulsion-related brachial plexus injuries (BPIs). METHODS: Forty-three adult patients with BPIs of the upper-middle plexus underwent reinnervation of the biceps muscle; neurotization of the musculocutaneous nerve was performed using fascicles from the ulnar nerve (39 cases) and the median nerve (four cases). The different techniques included sectioning, rerouting, and direct suturing of the entire musculocutaneous nerve (35 cases); direct reinnervation of the motor branches of the musculocutaneous nerve (three cases); and reinnervation using small grafts to the motor fascicles that enter the biceps muscle (five cases). Elbow flexion recovery ranged from M2 to M4, according to the patient's age and the level of integrity of the hand. No surgery-related failure occurred. No significant difference in outcome was related to any of the technical variants. In patients younger than age 45 years and exhibiting a normal hand function a score of M4 or better was always achieved. On average, reinnervation occurred 6 months after surgery. There was no clinical evidence of donor nerve dysfunction. CONCLUSIONS: When accurate selection criteria are met, the results after this type of neurotization have proved excellent.

Common peroneal nerve injuries: results with one-stage nerve repair and tendon transfer.

The authors report their experience in the treatment of common peroneal nerve (CPN) injuries using a one-stage procedure of nerve repair and tibialis posterior tendon transfer. A series of 45 patients with traumatic injury and graft repair of the CPN is presented. From 1988 to 1991, the six patients elected for surgery had only nerve repair: five ultimately did not recover, while muscle contraction in the remaining patient was graded M1-2. Since 1991, nerve surgery in our clinic was associated with tendon transfer procedures (39 cases) which were followed by a satisfactory reinnervation rate. Nerve transection and iatrogenic injuries, torsion/dislocation of the knee, complex biosseous fractures of the leg, and gunshot wounds showed excellent to fair results in decreasing order: in nerve sections, muscle recovery scored M3 or M4+ in all the patients, and in nerve ruptures due to severe dislocation of the knee, it was M3 or M4+ in 85% of cases. The association of microsurgical nerve repair and tendon transfer has changed the course of CPN injuries.

Hemihypoglossal nerve transfer in brachial plexus repair: technique and results.

OBJECTIVE: In multiple avulsions of the brachial plexus, the search for extraplexal donor nerves in the hope of achieving motor neurotization is a major goal. We explored the possibility of using the hypoglossal nerve as a transfer point to reanimate muscles in the upper limb. METHODS: The hypoglossal nerve was used as a donor nerve for neurotization in seven patients with avulsive injuries of the brachial plexus. The surgical technique--an end-to-side microsuture using approximately half of the nerve fascicles--is basically the same as that used in the hypoglossal nerve-facial nerve jump graft, which is a well-known technique in facial nerve reanimation. The recipient nerves were the suprascapular (two patients), the musculocutaneous (one patient), the posterior division of the upper trunk (two patients), and the medial contribution to the median nerve (two patients). RESULTS: In spite of a connection documented by electromyography and selective activation in three of seven patients, the functional results in our patients were extremely disappointing: no patient had an outcome better than M1 in the reinnervated muscles. CONCLUSION: This technique was of no help to the patients and thus has been abandoned at our institution.