Slide 1. Slide 2. Slide 3. The Role Of Plastic Surgery In Reducing A Patient s Disability Score A Reconstructive Approach. Peripheral Nerve Surgery

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1 Slide 1 The Role Of Plastic Surgery In Reducing A Patient s Disability Score A Reconstructive Approach Andrew I. Elkwood MD FACS Director of the Center for Treatment of Paralysis and Reconstructive Nerve Surgery Slide 2 Peripheral Nerve Surgery Disorders of Peripheral Nerves Spinal Cord Injury Stroke Peripheral Nerve Surgery Nerve Regeneration Slide 3 Peripheral Nerve Surgery Applications Peripheral Nerve Disorders Compression Neuropathy Facial Paralysis Phantom Limb pain Nerve Trauma Spinal Cord Injury Tetraplegic hand Pressure sores Ventilator dependency Bladder dysfunction Stroke Upper extremity paralysis Aspiration

2 Slide 4 Brachial Plexus Repair Facial Reanimation Prostate Grafting Foot Drop Surgery Nerve Transplantation Reanimation After Spinal Cord Injury Reanimation After Stroke Resensitization of the Buttocks Slide 5 Peripheral Nerve Surgery Return of function Decrease in pain Decrease in disability score Slide 6 Research Initiatives Treatment of Spinal Cord Injury Treatment of Stroke Resensitization of Buttocks Diaphragm Reinnervation

3 Slide 7 For any nerve repair PAIN SENSIBILITY MOTION Slide 8 Outlet Wire Motor Chain Door Slide 9 Central Nervous System vs. Peripheral Nervous System Avulsion vs. Rupture

4 Slide 10 Cannot Be Fixed Neurotization Tendon Transfer Joint fusion Slide 11 Slide 12 Can Be Fixed Primary Repair Nerve Grafting Neurotization Tendon Transfer Free Muscle Flap Joint Fusion

5 Slide 13 NEURAPRAXIA Stretching of nerve Results in nerve dysfunction Demyelination Function returns by 3 months NEUROTMESIS Significant nerve damage Nerve division No recovery Nerve repair required Slide 14 Primary Repair Interposition Graft Neurotization Slide 15

6 Slide 16 Slide 17 If a cut nerve cannot find its mate a painful neuroma may result Slide 18 CRPS is often a misdiagnosed occult neuroma

7 Slide 19 Slide 20 Sural Nerve Antebrachial Cutaneous Nerve Cervical Plexus Posterior Interosseous Nerve Nerve Conduit Allograft Slide 21

8 Slide 22 Slide 23 Take a functioning nerve to a less important muscle, and attach it to a more important muscle. Spinal accessory branches Buccal branches Intercostal nerve Nerve to subclavius m. Contralateral Nerves Slide 24

9 Slide 25 Slide 26 Slide 27

10 Slide 28 Slide 29 Slide 30 When nerve repair is required, recovery is delayed 1-2 Month Latency Nerve Growth 1 mm/day 1 inch/month Longer Distance, Longer Recovery Time

11 Slide 31 Diagnosis Work-up Nerve Studies Nerve Repair Post-op Care Rehabilitation Slide 32 PRELIMINARY WORK UP STARTS RIGHT AWAY Slide 33 FIRST EMG AT 6 WEEK TO 3 MONTHS

12 Slide 34 3 months nothing clinically or by EMG Repeat EMG at 6 months if no improvement If no improvement operate. If improvement Reassess at 9 months Slide 35 Nothing by EMG or clinically at 3 months Slide 36 Minimal Progress by EMG or clinically at 6 months

13 Slide 37 Not completely improved by 9 months Slide 38 Brachial Plexus Repair Slide 39

14 Slide 40 NERVES BONES ARTERY VEIN LUNG Slide 41 Often clouded by coma Often clouded by orthopedic injuries Often ignored Often misinformed May be subtle Slide 42 CXR EMG MRI CT Myelogram X-rays MR angiogram/venogram

15 Slide 43 Surgeons Consultants Nurses Therapists Home Care Family Slide 44 Slide 45

16 Slide 46 Slide 47 Slide 48

17 Slide 49 Slide 50 Slide 51 A 22 year old 6 months after a motorcycle accident. He has a brachial plexus injury (C5-C6)

18 Slide 52 Status post brachial plexus repair with nerve grafting Slide year old 5 months after motorcycle accident. C5, C6, C7, brachial plexus injury Slide 54 After brachial plexus repair with nerve grafting

19 Slide 55 After brachial plexus repair with nerve grafting Slide 56 Facial Paralysis Trauma Cancer Stroke Bell s Palsy Slide 57

20 Slide 58 Slide 59 Slide 60

21 Slide 61 Slide 62 Slide 63

22 Slide 64 Slide 65 Slide 66

23 Slide 67 Slide 68 Slide 69

24 Slide 70 Slide 71 Slide 72

25 Slide 73 Slide 74 Slide 75

26 Slide 76 Slide 77 C5 ROOT INTACT C6, C7, C8, T1 ROOTS AVULSED PLAN SHOULDER MOTION ELBOW FLEXION SENSATION TO HAND Slide 78

27 Slide 79 SHOULDER TRAPEZIUS TO SUPRASPINATUS ELBOW C5 TO BICEP (SURAL NERVE) BACK INTERCOSTALS TO LATISSIMUS SENSATION INTERCOSTALS TO ULNAR NERVE Slide 80 Slide 81

28 Slide 82 Slide 83 Slide 84

29 Slide 85 Slide 86 THE TEXTBOOKS ARE WRONG. DO NOT WAIT A YEAR. IF NOT IMPROVED BY 3 MONTHS, THEY WILL NOT IMPROVE. EMG AT 6-8 WEEKS. REPAIR AT ABOUT 3 MONTHS. ALLOWS FOR SECOND SHOT BEFORE ONE YEAR. Slide 87

30 Slide 88 Immobilization 3-6 Weeks Post-op Aggressive Rehab Keep Joints Supple Maintain Strength Build New Strength Relearn Muscle Movement Slide 89 Slide 90 Extra capsular Spread 14 Cases 100% Potency Multifactorial

31 Slide 91 Slide 92 Slide 93

32 Slide 94 Slide 95 Slide 96

33 Slide 97 Slide 98 Peripheral Nerve Surgery Foot Drop Slide 99

Adult Brachial Plexus Injuries: Introduction and the Role of Surgery

Adult Brachial Plexus Injuries: Introduction and the Role of Surgery Tim Hems Scottish National Brachial Plexus Injury Service Department of Orthopaedic Surgery, Queen Elizabeth University Hospital, GLASGOW.