Repair of avulsed ventral nerve roots by direct ventral intraspinal implantation after brachial plexus injury

doi:10.1016/j.hcl.2004.09.001

Hand Clinics

Volume 21, Issue 1, February 2005, Pages 109-118

https://doi.org/10.1016/j.hcl.2004.09.001 Get rights and content

Section snippets

Prior research

In the 1980s, several researchers working with animal models showed that implantation of a peripheral nerve graft into the spinal cord can induce regeneration of spinal motor neurons, which grow a matter of centimeters across the graft [6], [7], [8], [9], [10], [11]. From such results, extensive work was performed to investigate the efficacy of implanting peripheral nerve grafts in the cervical cord. This work shed much light on the subject. Six weeks after nerve root avulsion, the death of

Aims

The current authors hoped to show that reimplantation can work in humans if it is performed correctly, and that it can restore function, even in patients with avulsion of multiple nerve roots controlling several different groups of muscles. The authors also wanted to show that this technique, which restores communication from the spinal cord to the periphery, can diminish or abolish deafferentation pain.

Anatomic basis of the posterior approach to the brachial plexus for repairing avulsed spinal nerve roots

The authors' first step was to understand the work of Carlstedt to account for its relative

Reimplantation surgery of the brachial plexus: the place of neurotrophic factors

With this surgical method, several questions remain unanswered and certain limitations have become clear, notably the fact that a long interval between the injury and the operation is bound to curtail the degree of recovery possible.

It was long believed that differentiated neurons could not regenerate in the adult CNS. As previously discussed, physicians now know that this capacity exists, although in the real world its power is limited.

The problem of glial healing and inhibitory substances in

Summary

Currently, the authors' research confirms that, in humans, communication between the cord and effector muscles can be re-established after multiple nerve root avulsion by the implantation of peripheral nerve grafts. Outcomes are still modest, but the possibility of improvement exists. The technique of reimplantation makes it possible to envisage global repair with the possibility of repair of all avulsed regions. The most important factor that could maximize the extent of functional recovery is

First page preview

Click to open first page preview

View PDF

References (47)

S. Loy et al.
Ulnar nerve fascicle transfer onto to the biceps muscle nerve in C5–C6 or C5–C6-C7 avulsions of the brachial plexus. Eighteen cases [in French]
Ann Chir Main Memb Super
(1997)
C. Oberlin et al.
Nerve transfer to biceps muscle using a part of ulnar nerve for C5–C6 avulsion of the brachial plexus: anatomical study and report of four cases
J Hand Surg [Am]
(1994)
A.J. Aguayo et al.
Axonal regeneration in peripheral and central nervous system transplants
Adv Cell Neurobiol
(1982)
P.M. Richardson et al.
Peripheral nerve autografts to the rat spinal cord: studies with axonal tracing methods
Brain Res
(1982)
A. Acheson et al.
Detection of brain-derived neurotrophic factor-like activity in fibroblasts and Schwann cells: inhibition by antibodies to NGF
Neuron
(1991)
G.E. Davis et al.
Parameters of neuritic growth from ciliary ganglion neurons in vitro: influence of laminin, schwannoma polyorithine-binding neurite promoting factor and ciliary neurotrophic factor
Brain Res
(1985)
B. Friedman et al.
Regulation of ciliary neurotrophic factor expression in myelin-related Schwann cells in vivo
Neuron
(1992)
T. Carlstedt et al.
Return of function after spinal cord implantation of avulsed spinal nerve root
Lancet
(1995)
M.E. Schwab
Structural plasticity of the adult CNS. Negative control by neurite growth inhibitory signals
Int J Dev Neurosci
(1996)
M.E. Schwab
Myelin-associated inhibitors of neurite growth
Exp Neurol
(1990)

M. Taketomi et al.

Nogo-A expression in mature oligodendrocytes of rat spinal cord in association with specific molecules

Neurosci Lett

(2002)

J.P. Benoit et al.

Development of microspheres for neurological disorders: from basics to clinical applications

J Control Release

(2000)

J.M. Pean et al.

NGF release from poly (d, I-lactide-co-glycolide) microspheres. Effect of some formulation parameters on encapsulated NGF stability

J Controlled Release

(1998)

A.O. Narakas

Thoughts on neurotization or nerve transfers in irreparable nerve lesions

Clin Plast Surg

(1984)

J. Ovelmen-Levitt

Abnormal physiology of the dorsal horn as related to the deafferentation syndrome

Appl Neurophysiol

(1988)

H. Asfadourian et al.

Morphometric study of the upper intercostals nerves: practical application for neurotizations in traumatic brachial plexus palsies [in French]

Chir Main

(1999)

A.J. Aguayo et al.

Influences of the glial environment on the elongation of axons after injury: transplantation studies in adult rodents

J Exp Biol

(1981)

S. David et al.

Axonal elongation into peripheral nervous system “bridges” after central nervous system injury in adult rats

Science

(1981)

P.M. Richardson et al.

Regeneration of long spinal axons in the rat

J Neurocytol

(1984)

H. Chai et al.

Survival and regeneration of motoneurons in adult rats by reimplantation of ventral root following spinal root avulsion

Neuroreport

(2000)

J.L. Bixby et al.

Identification of the major proteins that promote neuronal outgrowth on Schwann cells in vitro

J Cell Biol

(1988)

M.B. Bunge

Schwann cell regulation of extracellular matrix biosynthesis and assembly

E. Fernandez et al.

Effects of topically administrated nerve growth factor on axonal regeneration in peripheral nerve autografts implanted in the spinal cord of rats

Neurosurgery

(1990)

Cited by (32)

Diagnosis and management of adult BPI: Results of first 50 cases
2021, Journal of Clinical Orthopaedics and Trauma
Citation Excerpt :
Various secondary procedures include arthrodesis for shoulder joint, flail wrist, or thumb and fingers in functional position, tendon transfer, and functional free muscle transfer.20–24 BPI remains an active area for research; which includes re-implanting or connecting nerves back into the spinal cord with nerve grafts.25–29 However, few clinical studies have shown promise and procedures at this stage remain experimental.
Commonest cause of brachial plexus injury in adults is traction injury sustained in motorcycle accidents. This article reports the results of first 50 cases done in a tertiary referral center with a brief review of literature.
First 50 patients (46 male; 4 female, age from 12 to 45 years) with post traumatic brachial plexus palsy were included. There were 30 upper plexus and 20 pan plexus injuries, 27 had preganglionic and 23 postganglionic injury. Neurolysis was done in 19 patients and various combination of nerve transfer in 31. Mean follow-up period was 13.98 months.
– Over all shoulder abduction was good in 10 patients, fair in 32 and poor in 8. Elbow flexion was good in 19 patients, fair in 18 and poor in 13 patients.
The upper plexus and partial injuries have a good outcome in a majority of cases, while the results in global palsy are far from satisfactory.
DuraSeal as a Ligature in the Anastomosis of Rat Sciatic Nerve Gap Injury
2010, Journal of Surgical Research
Citation Excerpt :
Root avulsion usually occurs in brachial plexus injury. However, the repair of root avulsion with suture is very difficult due to narrow surgical fields and the presence of surgical tension between anastomotic ends [8]. To simulate surgical tension in surgical repair, the nerve gap model was constructed by excising the sciatic nerve (5 mm in length), leaving a 5 mm nerve tissue defect between the nerve stumps.
Anastomosis of the nerve especially at narrow surgical field and presence of surgical tension is not easily accessible. DuraSeal demonstrates strong adhesive power without producing neurotoxicity. Herein, we evaluate the possibility of DuraSeal as a substitute in the repair of sciatic nerve gap injury.
The nerve gap model was constructed by excising the sciatic nerve (5 mm in length) in Sprague Dawley rats leaving a 5 mm nerve defect between nerve stumps. Animals were categorized into four groups: Group I: no treatment; Group II: 4 stitches suture; Group III: nerve approximation fixed by tissue glue; Group IV: nerve approximation fixed by DuraSeal. The motor function assessment included the CatWalk and SFI as well as electrophysiological studies. Nerve continuity and regeneration was examined at 1 and 8 wk after injury. The inflammatory cells, Schwann cell apoptosis, and Schwann cell proliferation were also investigated 1 wk after injury.
The achievement of nerve continuity and myelination by DuraSeal approached that of suture demonstrated by crystal violet and Luxol Fast Blue staining at 1 and 8 wk, respectively. Motor function and electrophysiological parameters were restored in DuraSeal and suture group. Early expression of neurofilament and bromodeoxyuridine (BrdU) was also observed in these two groups. There was no statistically significant difference in deposits of macrophages and neutrophil cells or cell apoptosis among these four groups.
DuraSeal achieved the same nerve regeneration compared with that of suture and produced better regeneration than that of the tissue glue or without any treatment. The accomplishment of nerve regeneration and continuity without causing neurotoxicity justifies using DuraSeal as a ligature in the anastomosis of nerve gap injury.
The anatomy, investigations and management of adult brachial plexus injuries
2009, Orthopaedics and Trauma
Citation Excerpt :
Repair of avulsed spinal nerve roots has been attempted by many, with Bonney and Jamieson reporting on a case in 1979. Both Jamieson and Carlstedt have published experimental work on animal models with some functional success28,29 and early work has emerged on human subjects.30,31 Despite this, to date, this surgical option has not reached the stage where it warrants inclusion in the standard surgical armamentarium.
Brachial plexus injuries have increased in numbers since the turn of the twentieth century in line with the increased use of motorcycles. Advances in microsurgical and tissue transfer techniques have seen the management of such injuries change dramatically during this time period. As a result, surgery for plexus injuries is now considered a legitimate option. Such injuries require extensive medical input in a multidisciplinary environment. All patients should be thoroughly investigated to establish the exact extent of the injury and managed on an individual basis. The options available are conservative or surgical. Conservative options include physiotherapy, orthotics and pain control. Surgical reconstruction of the plexus may involve neurolysis, nerve grafting, nerve transfer and late peripheral reconstruction including arthrodesis, tendon transfers, free muscle transfers and amputation. Despite many advances in the field, injuries still result in considerable disability and loss of working days.
Brachial plexus reconstruction based on the new definition of level of injury
2008, Injury
Citation Excerpt :
The purpose of this article is to provide strategies for reconstruction of traumatic brachial plexus injuries in the adult, based on the different levels of the injury. Various classifications of the level of brachial plexus injury (BPI) have been proposed 2–4,6–14,17 (Table 1). A more recent classification reported by Chuang 5 has more precisely defined the level of lesions.
Although brachial plexus reconstruction remains a challenge to microsurgeons, especially when attempting to reconstruct cases with total root avulsion, much improvement in results has been recently achieved by a better understanding of various new methods of reconstruction, such as nerve transfer, functioning free muscle transplantation and prolonged postoperative rehabilitation. To better understand these improved results, we classified our patients into four levels of injury: (1) preganglionic root; (2) postganglionic spinal nerve; (3) pre- and retro-clavicular; (4) infraclavicular brachial plexus injury. Nerve transfer, functioning free muscle transplantation or local muscle transfer are the only possible solutions for the level 1 injury. Nerve transfers include extraplexus, intraplexus, close-target and end-to-side neurotisation. Neurolysis, nerve repair, nerve grafts, C-loop vascularised ulnar nerve grafts, nerve transfer and functioning free muscle transplantation are options for levels 2, 3 and 4 injuries. Tendon transfer, functioning or functional muscle transfer, arthrodesis or orthotics can be used for late palliative reconstruction. Taken together, these options can make brachial plexus surgery a worthy pursuit and make a useless limb useful.
Functional reconstruction following brachial plexus avulsion
2007, Neural Regeneration Research
To sum up the treatment of brachial plexus root avulsion and the progress in functional reconstruction and rehabilitation following brachial plexus root avulsion.
A search of Medline was performed to select functional reconstruction and rehabilitation following brachial plexus injury-related English articles published between January 1990 and July 2006, with key words of “brachial plexus injury, reconstruction and rehabilitation”. Meanwhile, a computer-based search of CBM was carried out to select the similar Chinese articles published between January 1998 and July 2006, with key words of “brachial plexus injury, reconstruction and rehabilitation”.
The materials were checked primarily, and the literatures of functional reconstruction and rehabilitation of brachial plexus injury were selected and the full texts were retrieved. Inclusive criteria:
Functional reconstruction following brachial plexus injury.
Rehabilitation method of brachial plexus injury. Exclusive criteria: Reviews, repetitive study, and Meta analytical papers.
Forty-six literatures about functional reconstruction following brachial plexus injury were collected, and 36 of them met the inclusive criteria.
Brachial plexus injury causes the complete or incomplete palsy of muscle of upper extremity. The treatment of brachial plexus is to displace not very important nerves to the distal end of very important nerve, called nerve transfer, which is an important method to treat brachial plexus injury. Postoperative rehabilitations consist of sensory training and motor functional training. It is very important to keep the initiativeness of exercise. Besides recovering peripheral nerve continuity by operation, combined treatment and accelerating neural regeneration, active motors of cerebral cortex is also the important factor to reconstruct peripheral nerve function.
Consciously and actively strengthening functional exercise after operation is helpful to form cerebral plasticity and produce voluntary movements, can re-educate re-dominated muscle, obviously improves postoperative therapeutic effect and promote functional reconstruction.
Celsr2 Knockout Alleviates Inhibitory Synaptic Stripping and Benefits Motoneuron Survival and Axon Regeneration After Branchial Plexus Avulsion
2023, Molecular Neurobiology

View all citing articles on Scopus

View full text