IC 42: Tricks and Techniques to Maximize Success with Nerve Transfers

Transcription

1 IC 42: Tricks and Techniques to Maximize Success with Nerve Transfers Moderator(s): Susan E. Mackinnon, MD Faculty: Christine B. Novak, PT, PhD, J. Megan Patterson, MD, Andrew Yee, BSc Session Handouts Friday, September 14, RD ANNUAL MEETING OF THE ASSH SEPTEMBER 13 15, 2018 BOSTON, MA 822 West Washington Blvd Chicago, IL Phone: (312) Web: All property rights in the material presented, including common-law copyright, are expressly reserved to the speaker or the ASSH. No statement or presentation made is to be regarded as dedicated to the public domain.

2 IC42 Tricks and Techniques to Maximize Success with Nerve Transfers American Society for Surgery of the Hand Annual Meeting, September 14, 2018 Boston, MA Susan E. Mackinnon, MD, St. Louis, Missouri J. Megan M. Patterson, Chapel Hill, North Carolina Christine B. Novak, PT, PhD, Toronto, Ontario Andrew Yee, BS, St. Louis, Missouri Overview: Following complex nerve injury, motor and sensory recovery can be less than optimal. For high median, ulnar and radial nerve injuries, nerve transfers can provide a distal source of motor and/or sensory innervation closer to the target end organ allowing for faster recovery and improved outcome. This course will focus on techniques to maximize success with upper extremity motor and sensory nerve transfers. Classification of Nerve Injury: 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 V Neurotmesis Yes but no advancement VI Mixed Injury Some fascicles (I to V) (II, III) None None Nerve repair, graft or transfer None None Nerve repair, graft or transfer Some fascicles Depends on Neurolysis, nerve (II, III) degree of injury repair, graft or transfer (I V) * Recovery can vary from excellent to poor depending on the amount of scarring and the sensory versus motor axon misdirection to target receptors Modified from Mackinnon & Dellon, Surgery of the Peripheral Nerve, 1988.

3 Advantages of Nerve Transfers: 1. Directs a large number of axons to denervated muscle quickly. 2. Provides faster and superior muscle reinnervation then may be seen with primary repair or grafting. Surgical Indications and Management: Motor Nerve Transfers: 1. Motor donor nerve must: Be expendable. Be close to the motor end plates of the target muscle. Contain a large number of motor nerve axons. Allow for straightforward motor reeducation by using a donor muscles that is synergistic to the target muscle 2. Common motor nerve transfers: Median nerve fascicle and ulnar nerve fascicle to biceps brachii branch and brachialis branch of musculocutaneous nerve for elbow flexion (Double Fascicular Transfer). 2

4 Anterior interosseous nerve to motor branch of ulnar for intrinsic muscle reinnervation. 3

5 Sensory Nerve Transfers: 1. Sensory donor nerve must: Provide sensation to a non-critical area. Be a pure sensory nerve. Be a good size match between donor and target nerve. 2. Common sensory nerve transfers: Nerve to the 4 th webspace to 1 st web space transfer to retore sensation to the radial side of the index and ulnar side of the thumb. End-to-side repair of 2 nd and 3 rd web space to ulnar digital nerve to the small to restore sensation to the 2 nd and 3 rd web spaces. 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. Tips and Pearls for the Beginner in the OR: Remind anesthesiologist no long acting paralytics. Don t use Marcaine/lidocaine until after you want to stimulate the nerves. Avoid use of a tourniquet especially if you are a bit slower otherwise a tourniquet palsy may complicate intraoperative direct nerve stimulation. Donor DISTAL, Recipient PROXIMAL. Neurolysis with your eyes. 4

6 Common injury patterns and treatment options: 1. Upper plexus injury loss of elbow flexion: Double fascicular transfer (median/ulnar to nerve to biceps and brachialis). Medial pectoral to musculocutaneous nerve. Thoracodorsal to musculocutaneous nerve. Steindler flexorplasty. Long nerve grafts. 2. Upper plexus injury loss of shoulder function: Spinal accessory nerve to suprascapular nerve. Triceps to axillary nerve. Medial pectoral nerve to axillary nerve. Shoulder fusion. Trapezius transfer (Saha procedure). Long nerve grafts. 3. Lower plexus injury loss of pronation: Brachialis or ECRB (if C7 is spared) to pronator nerve branch. Biceps, brachioradialis, or brachialis muscle rerouting. 4. 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 tranfers (brachioradialis to flexor pollicis longus and extensor carpi radialis longus to index finger flexor digitorum profundus). 5. Axillary nerve injury: Triceps to axillary nerve. Medial pectoral nerve to axillary nerve. Thoracodorsal nerve to axiallary nerve. Shoulder fusion. Long nerve grafts. 5

7 6. Radial nerve injury: Median (flexor carpi radialis, flexor digitorum superficialis branches) to extensor carpi radialis brevis and posterior interosseous nerve branches. 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). 7. Loss of median innervated pronation: Extensor carpi radialis brevis to pronator teres nerve branch. Biceps, brachioradialis, or brachialis muscle rerouting. 8. Loss of median innervated thumb and finger flexion: Supinator branch to anterior interosseous nerve transfer. Brachialis branch to anterior interosseous nerve transfer. Tendon tranfers (brachioradialis to flexor pollicis longus, extensor carpi radialis longus to index/long finger flexor digitorum profundus, side to side tendodesis to ulnar flexor digitorum profundus). 9. 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. 10. Distal median nerve injury: AIN to median motor branch. Opponensplasty. 11. Distal ulnar nerve injury: Anterior interosseous nerve to ulnar deep motor branch. Various static and dynamic claw hand procedures. 6

8 Rehabilitation following Nerve Transfer: Early Post-operative Management: Early range of motion is important to decrease adhesions at the nerve repair site. Postoperative dressing is removed on POD 2 to 3 and active/passive range of motion of uninvolved joints is started. Protect repair site with a splint or sling for 7-14 days. Following immobilization; regain and maintain full passive range of motion. 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. 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 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 (visual and audio) more useful than muscle stimulation. To facilitate relearning 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. Begin in gravity assisted or gravity eliminated position and progress to exercises against gravity and progressive resisted exercises. Dissociate target muscle from donor muscle contraction. References 7

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