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New Emirates Medical Journal

Volume 1, 2 Issues, 2020
ISSN: 0250-6882 (Online)
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Open Access Article

Surgical Outcome of Peripheral Nerve Injury



Rahul K. Nath1, *, Chandra Somasundaram1
1 Texas Nerve and Paralysis Institute 6400, Fannin st. Houston, TX-77030, United States

Abstract

This article focuses on various surgical treatments and outcomes in patients who had upper and or lower extremity musculoskeletal disorders due to peripheral nerve injuries. Here, we mainly discussed the benefits of the Nath method of surgical management in infants, children (preteen and teen), and adult patients in the following four categories of peripheral nerve damage.

Brachial plexus injury and upper extremity musculoskeletal dysfunctions:

Improvements are discussed in detail in obstetric brachial plexus palsy patients, who had the soft tissue surgical procedure, modified Quad, and the novel osseous operative technique, triangle tilt at our clinic.

Upper trunk of brachial plexus and long thoracic nerve damage and winging scapula:

There are at least 18 categories of causation/etiology of upper plexus and long thoracic nerve lesions in 575 patients who visited our clinic with winging scapula, limited shoulder movements, and pain. Furthermore, we discussed the results of the excellent recovery of hundreds of these patients, who had decompression and neurolysis of the upper trunk of brachial plexus and long thoracic nerve.

Peroneal nerve lesion and foot drop:

Our management of foot drop by nerve transfers to the deep peroneal nerve is discussed.

Sural nerve grafting to cavernous nerve impairment after prostatectomy or genital surgery:

We also discussed briefly our experience and results of the sural nerve grafting, which restores the function of cavernous nerves resected during radical prostatectomy.

Conclusion:

The lead author (Rahul K. Nath ) has developed and implemented several innovative new surgical approaches as a reconstructive microsurgeon. These surgical techniques have proven clinical and functional improvements in patients with upper and lower extremity musculoskeletal disorders due to peripheral nerve injuries.

Keywords: Brachial plexus injury, Winging scapula, Peroneal nerve damage, Foot drop, Cavernous nerve impairment, Prostatectomy.


Article Information


Identifiers and Pagination:

Year: 2020
Volume: 1
Issue: 2
First Page: 26
Last Page: 35
Publisher Id: nemj-1-26
DOI: 10.2174/0250688202002022004

Article History:

Received Date: 04/12/2019
Revision Received Date: 20/1/2020
Acceptance Date: 29/1/2020
Electronic publication date: 15/07/2020
Collection year: 2020

© 2020 Nath and Somasundaram.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: (https://creativecommons.org/licenses/by/4.0/legalcode). This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


* Address correspondence to this author at the Texas Nerve and Paralysis Institute 6400, Fannin st. Houston, TX-77030, United States; E-mail: drnath@drnathmedical.com




1. INTRODUCTION

1.1. Peripheral Nerve Injury in Upper Extremity

1.1.1. Brachial Plexus Injury and Upper Extremity Movement Disorders

The brachial plexus is a complex set of cervical nerves (C5-C8 and T1) that supplies the muscles of the shoulder, arm, elbow, wrist and hand. Brachial Plexus Injury (BPI) ranges from neuropraxia to severe cases such as rupture or avulsion, and it can be devastating. BPI may cause complete or partial paralysis of the arm, lack of muscle control, and a lack of sensation in the arm or hand [1-13]. Injuries to the brachial plexus may occur as a result of complicated birth process (obstetric or OBPI) [1, 14-26] or significant trauma (TBPI) such as automobile accident, motorcycle accident, gunshot wound, stabbing, etc [27, 28]. The entire brachial plexus is injured in twenty percent of total or Complete OBPI (COBPI) [29, 30]. COBPI severely compromises the young patient’s overall growth and functions of the upper limb. TBPI can be severe and devastating in up to 4.2% of multi-trauma victims [31]. Recently, there has been an increase in TBPI due to vigorous training in complex sports [32, 33].

There are numerous research and review articles, and case reports published that are indexed in Pubmed on BPI. We have published over 40 articles on OBPI in peer-reviewed journals indexed in Pubmed. Of these publications in Pubmed, 6 papers are on brachial plexus nerve surgeries [29, 34-38] and 35 articles on muscle and bony procedures [30, 39-64] in children, adolescents (teenagers) and adult patients.

1.1.2. Peripheral Nerve Injury in the Cervicothoracic Region and Winging Scapula

There are 71 articles published that are indexed in Pubmed on the scapula and “long thoracic nerve injury“ 38 articles on “spinal accessory nerve injury, 7 articles on “dorsal scapular nerve” injury, and 2 papers on “suprascapular nerve injury that cause winging scapula in patients. We [65-68] have published 5 research papers on this subject that are indexed in Pubmed. Lee et al. 2018 [69] reported an unusual case of scapular winging due to dorsal scapular and suprascapular nerve lesions.

Injury to the Long Thoracic Nerve (LTN) that innervates serratus anterior muscle is the common cause of scapular winging that limits the affected shoulder movements and functions [70]. The compensatory muscle activity required to maintain scapular stability is associated with pain, spasm, and tendonitis around the shoulder joint [71]. The LTN is susceptible to damage as it is superficial, long, and small in diameter.

1.1.3. Peripheral Nerve Injury in Lower Extremity and Foot Drop

Foot drop is the loss of the ability to dorsiflex, or raise the foot at the ankle, causing a floppy foot that hampers walking. Trauma or damage to nerves (sciatic, tibial, and peroneal nerves) that innervate tibialis anterior, the extensor hallucis longus, and the extensor digitorum longus can cause steppage gait or foot drop. Many factors can cause this, but most often due to an injured peroneal nerve [72-74]. A standard method of treatment is placing the foot in a “boot,” but the recovery can be limited. These patients should be evaluated for surgery within 3-4 months of loss of function to increase the likelihood of restoring their normal gait [75].

2. METHODS

2.1. Modified Quad Procedure

OBPI patients underwent latissimus dorsi and teres major muscle transfer; subscapularis, pectoralis major and minor contracture releases and axillary nerve decompression and neurolysis. Transferred muscles were sutured to the teres minor muscle, not to a bony insertion point. More detailed operative procedure has also been discussed in our previous publication [53]

2.2. Triangle Tilt Surgical Procedure

The triangle tilt surgery consisted of (1) osteotomy of the clavicle at the junction of the middle and distal thirds; (2) osteotomy of the acromion process at its junction with the spine of the scapula; (3) osteotomy of the superomedial angle of the scapula; (4) splinting of the extremity in adduction, external rotation, and forearm supination. Minor elements of the procedure included bone grafting of the acromion process osteotomy site, and semi-rigid fixation of the clavicular osteotomy segments to prevent nonunion. We have previously published on the successful outcomes of this procedure in OBPI patients [30, 39, 40, 42, 44, 47-49, 52, 54-56, 59, 60, 63, 76].

2.3. Functional free gracilis muscle transfer (FFGMT)

FFGMT is an operative procedure for restoration of elbow flexion in both COBPI and TBPI patients with severe preganglionic (avulsion) or complete plexus injuries, and in delayed or prolonged nerve denervation, as well as in patients with inadequate upper extremity function after primary nerve reconstruction [64, 77, 78].

Patients, who visited our clinic with winging scapula, limited shoulder functions and/or pain due to lesions to upper brachial plexus, long thoracic or spinal accessory nerve underwent the following operations [65, 67, 68]:

(1) Neuroplasty and external and internal neurolysis of upper trunk of brachial plexus and long thoracic and or spinal accessory nerve.

(2) Partial anterior and middle scalene muscle resection.

Our foot drop patients had the following surgeries [79, 80]:

(1) Neuroplasty, external and internal neurolysis of superficial and deep peroneal nerves, and tibial nerve.

(2) Transportation of tibial nerve branch to gastrocnemius of the deep peroneal nerve.

(3) Nerve transfer, tibial nerve branch to gastrocnemius to the deep motor branch of tibialis.

3. RESULTS

3.1. Surgical Outcomes of Brachial Plexus Nerve Injury

The Nath Method of treatment for pediatric and adult patients with BPI is from over 30 years of his (Rahul K. Nath , the lead author and reconstructive microsurgeon) experience and several thousand patients [29, 30, 35-37, 39-50, 52-68, 76, 79-99]. We investigated the transfer of median nerve bundles to the musculocutaneous nerve as an alternative to the Oberlin technique [100]. All patients who had C5-C6 root avulsions in our study showed an increase in biceps muscle function, regained movement against gravity (90%), progress in overall quality of life (QOL), lack of need for medication and a significant lessening of postoperative pain. There were only minor sensory disturbances due to the redirection of part of the healthy median nerve for three months after surgery. This alternative strategy is more effective and, in many cases, preferable to ulnar nerve fascicle transfer [35].

3.2. Outcomes of Modified Quad Procedures in OBPI Children, Adolescent, and Adult Patients

The modified Quad surgical operation significantly increased the active shoulder abduction to mean 162° from the mean of 45° in OBPI children in our study [53]. This procedure also improved shoulder functional movements in pre-teen and adolescent OBPI patients [58]. The mean total Mallet score increased to 20 from the mean preoperative total Mallet score of 15. We have found that the median nerve conduction was significantly increased to 9.3 from 8.0 (P < 0.02) after mod Quad surgery in these OBPI patients. The cervical responses were lower pre-operatively in amplitude in the affected arm [46].

Furthermore, we compared the outcomes of our revision surgical operations in OBPI patients to the results of conventional operative procedures at other institutions [56]. This modified Mallet functional score was increased to 18 from 12.0, at least one year after revision surgical procedures. Radiological scores such as the percentage of the humeral head anterior to the glenoid fossa (PHHA) and glenoid version were also corrected significantly to 32, -16 from their mean pre-triangle tilt (yet after other surgeon's surgeries) of 15 and -32 respectively. Fifteen of 17 children maintained their recovered upper extremity functions for a long extended period (mean, ten years). This progress was not only maintained for an extended period but also improved (mean total Mallet score, 20) in some patients [54].

Recently, we have shown that the mod Quad procedure also significantly increases active abduction and other shoulder functions in untreated three female adult OBPI patients (46, 23, and 21 years old [82].

3.3. Outcomes of Bony Surgical Procedure (Triangle Tilt) in OBPI Children, Adolescent, and Adult Patients

Forty-four OBPI children underwent a novel surgical procedure called the 'triangle tilt' operation in our clinic to correct this bony shoulder joint deformity [48]. Surgical leveling of the distal acromioclavicular triangle combined with tightening of the posterior glenohumeral capsule (capsulorrhaphy) corrected the glenohumeral axis and improved shoulder function in these patients. The arm posture at rest was improved. There was a mean increase of 5 points of the Mallet shoulder function score after the triangle tilt surgery (Fig. 1).

Fig. (1)
Upper panel: Modified Mallet functions performed by a 5 years old obstetric brachial plexus palsy child before his surgery.
Middle and lower panels: Photographs of the same child performing the same upper extremity functional movements one-year (middle panel) and 2 years (lower panel) after mod Quad and triangle tilt surgeries at our clinic.

We identified 14 OBPI patients up to 18 years old with Medial Rotation Contracture (MRC) of the shoulder and Scapular Hypoplasia, Elevation and Rotation (SHEAR) deformity along with supination deformity of the forearm during a study period of 1.5 years. There were eight patients available for long-term follow-up [60]. Medial rotation contracture was corrected using triangle tilt or humeral osteotomy. The fixed supination deformity was corrected by radial osteotomy. The function was assessed using the modified Mallet scale, examination of apparent supination, and appearance of the extremity at rest. The forearm position was not significantly changed (from an average of 5 degrees to an average of 34 degrees maximum apparent supination) after these two corrective surgeries [60].

3.4. Restoration of Elbow Flexion in Patients with COBPI and TBPI After FFGMT

The management of total or root avulsion in severe OBPI and TBPI is challenging with nerve surgical operations due to its complexity of the lesion. Therefore, we performed FFGMT on these patients. They gained antigravity biceps muscle strength of M3-4/5 and better in comparison with their mean preoperative score (M0-1/5) [64].

3.5. Excellent and Rapid Recovery of Serratus Anterior Muscle Function and Shoulder Movements After Microneurolysis and Decompression of Long Thoracic Nerve in Winging Scapula Patients

Patients in our study who suffered winging scapula between 2 months and 12 years recovered their shoulder abduction (10% or greater) within a day after decompression, neurolysis, and tetanic electrical stimulation of LTN [61, 65, 67, 68]. Decompression of LTN and neurolysis corrected winging in all except one patient and pain reduction in over 85% of patients. They were not only able to achieve their shoulder abduction and reduced winging but also maintained in the follow-up [61, 65, 67, 68] (Fig. 2).

Fig. (2)
Upper panel: Pre-operative photographs showing clearly winged scapula and a limited shoulder abduction of 120° in a 44 years old male patient, who had winging scapula due to laying down for long hours at his back, drilling to install cabinets. Lower panel: Post-operative photographs showing excellent recovery of the winged scapula and full active range of motion (shoulder abduction of 180◦) after 14 months of the following surgeries:
1) Neuroplasty and external and internal neurolysis of upper trunk of brachial plexus and long thoracic nerve.
2) Partial anterior and middle scalene muscle resection.

Sixteen teen patients, mostly athletes in our most recent study, had paralysis for an average of 15 months [65]. All patients in our study underwent a preoperative electromyographic assessment in addition to clinical evaluation to confirm their nerve damage. Scapula winging was severe in the majority of patients in our study. Poor shoulder movements restored to 180° in all patients except one patient, who recovered to 120° at least 2 months after LTND and neurolysis. The winged scapula was completely corrected post-surgically in most of our patients, and it was less prominent in other patients [61, 65, 67, 68].

3.6. Management of Foot Drop by Nerve Transfers To The Deep Peroneal Nerve

Significant clinical recovery of ankle dorsiflexion and eversion to postoperative BMRC grade of 3.6 was achieved in most of our foot drop patients following the transfer of functional nerve fascicles of either the superficial peroneal nerve or the tibial nerve to the deep peroneal nerve. They gained their antigravity and were able to walk with minimal steppage gait (Fig. 3). In the other few patients, there was an improvement in ankle eversion [79, 80].

Fig. (3)
Upper panel: Foot drop (left) in a 48 years old male patient with left peroneal nerve injury, resulting from the previous lumbar spine surgery at the other clinic. The patient was unable to dorsiflex the ankle before surgery.
Lower panel: Significant improvement in ankle dorsiflexion, and the patient was able to walk without slapping or tripping of the foot after (1.5 years) the following surgeries:
1) Neuroplasty, external and internal neurolysis of superficial and deep peroneal nerves, and tibial nerve.
2) Transportation of tibial nerve branch to gastrocnemius of the deep peroneal nerve.
3) Nerve transfer, tibial nerve branch to gastrocnemius to the deep motor branch of tibialis anterior.

4. DISCUSSION

Nerve reconstruction has been adopted in OBPI patients who do not show recovery of biceps function by six months of age [17, 20, 26, 101]. However, we and other investigators have found recently that nerve reconstruction may be unnecessary in most of these OBPI patients [25, 102, 103]. One of our studies on OBPI found that these patients, who underwent nerve surgical procedure required a mean of 2.4 times as many surgeries as patients without nerve reconstruction [34]. We have suggested addressing the soft tissue/muscle and bone complications as a useful approach. Nerve reconstructive surgeries should be reserved for those patients, where the C5 and C6 nerve roots will not recover.

OBPI children have a high incidence of musculoskeletal complications stemming from the initial nerve damage during the delivery process [104-106]. The presence of muscle imbalances and contractures during development leads to typical bony changes affecting the shoulder joint, causing glenohumeral dysplasia (GHD) [104] and the SHEAR deformity [52, 88]. The SHEAR deformity occurs in conjunction with the MRC of the arm. Clinical examination after the triangle tilt procedure showed significant progress in the functional movement in these children as assessed by the modified Mallet scoring, definitely improving on what was achieved by humeral osteotomy [48]. Triangle tilt surgery also improved shoulder anatomy and clinical functions in complete OBPI [30, 40] and showed better outcomes if performed before the age of 2 years [59].

The muscle imbalances at the level of the forearm can lead to a fixed supination deformity in a small number of OBPI patients [60]. MRC and supination deformity can cause severe functional limitations without surgical intervention. The presence of two opposing deformities in the same arm simultaneously will visually offset each other at wrist and hand, giving the false impression of neutral positioning [60]. The apparent neutral position of the hand indicates a fixed supination posture of the forearm. These two deformities were addressed surgically. Triangle tilt surgery was applied as a salvage procedure for failed shoulder surgery in OBPI children, who had previously undergone several operative procedures at other hospitals before presenting at our institute [41]. Our report on a meta-analysis of triangle tilt versus humeral surgery showed that the triangle tilt surgery improves further on what was achieved by humeral osteotomy in the recovery of shoulder function in our OBPI patients [63].

We and several other investigators have reported several functional muscle transfer procedures and the outcomes involving latissimus dorsi, trapezius transfer, pectoralis major, rectus femoris muscle, and gracilis to restore elbow flexion, hand and shoulder functions for severe BPI. Kawamura et al. [107] used latissimus dorsi transfer and found it too long and had to shorten it at the distal end to achieve sufficient elbow flexion in about 50% of patients. Maldonado et al. [108], and Gardiner and Nanchahal [109] showed 67.7% and 91% to 99% success in achieving elbow flexion after FFGMT transfer in their TBPI patients, respectively. Another investigator reported a failure rate of 15.4% [110]. Hattori et al. [111] used spinal accessory (SAN) and intercostal nerve (ICN) reinnervation and reported that the contraction rate was significantly higher in SAN innervated muscles. Chung et al. [112] achieved 78% success using the gracilis muscle flap and transfer of ICNs than ulnar fascicles in 23 of their patients. We have not found such significant differences in the outcome based on the nerves used in FFGMT. We have used a part of the transplanted vascularized median or radial or ulnar nerve as a motor source of a free muscle graft. A significant number of our patients (92%) in both OBPI and TBPI groups had recovery and improvement in elbow flexion [64].

There are at least 18 categories of causation/etiology of upper plexus and long thoracic nerve lesions in 575 patients who visited our clinic with winging scapula, limited shoulder movements, and or pain. Young athletes, in general, have been found to have shoulder pain and or winging scapula resulting from an accident (fall) and stretch injuries due to overuse, and poor sports techniques [65]. Our meta-analysis report suggests that nerve surgeries such as LTND and neurolysis are effective techniques in correcting winging scapula in comparison with muscle transfer operations [61]. Decompression, neurolysis, and tetanic electrical stimulation of LTN or the damaged nerve should be considered a primary modality of functional restoration in winging scapula patients [61, 65, 67, 68].

We have demonstrated an alternative strategy of transfer of functional nerve fascicles of either the superficial peroneal nerve or the tibial nerve as the donor for reanimation of foot drop following deep peroneal nerve palsy [79, 80, 83].

4.1. Sural Nerve Grafting To Cavernous Nerve Injury After Prostatectomy Or Genital Surgery

Cavernous nerves are susceptible to damage after prostatectomy or genital surgery. Nath RK (a peripheral nerve specialist and a plastic surgeon with extensive experience in reconstructive microsurgery and nerve grafting), and a team of experienced oncologic surgeons [92-94, 96, 98] demonstrated that the interposition of sural nerve restores the function of cavernous nerves resected during radical prostatectomy.

CONCLUSION

The lead author (Rahul K. Nath ) has developed and implemented several innovative new surgical approaches as a reconstructive microsurgeon. These surgical techniques have proven clinical and functional improvements in patients with upper and lower extremity musculoskeletal disorders due to peripheral nerve injuries.

CONSENT FOR PUBLICATION

Written informed consent was obtained from all patients for publication and accompanying images. A copy of the written consent is available for review on request.

FUNDING

None.

CONFLICT OF INTEREST

The authors declare no conflict of interest, financial or otherwise.

ACKNOWLEDGEMENTS

The authors thank the patients and family who participated in this study.

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Editor-in-Chief

Abdullah Shehab
Emirates Cardiac Society
Emirates Medical Association
Dubai
(UAE)

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