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Objective: To experimentally compare the treatment outcome of the injured upper limb of the root avulsion of C5 and C6 of the brachial plexus repaired by ipsilateral C7 nerve root transfer and other three multiple nerve transfers., Methods: One hundred and twenty SD rats of simulated C5 and C6 root avulsion randomly divided into 4 groups, and 30 each underwent various combined nerve transfers. Group A: the ipsilateral C7 root transferred to the upper trunk of brachial plexus and the spinal accessory nerve to the suprascapular nerve; Group B: partial fascicles of the ulnar nerve transferred to the biceps branch (Oberlin's procedure), the spinal accessory to the suprascapular and branches to the triceps long head to the axillary nerve; Group C: the phrenic transferred to the musculocutaneous, cervical plexus motor branches to the lower trunk (axillary nerve) of brachial plexus and the spinal accessory nerve to the suprascapular nerve; Group D: the phrenic transferred to the musculocutaneous and the spinal accessory nerve to the suprascapular nerve. Neurotization outcomes were evaluated at 3, 6 and 12 weeks postoperatively by comparing changes of behavioral tests (Ochiai clinical scores, Barth Foot-fault test and Terzis grooming test), neurophysiological investigations and muscular histology., Results: At 3 weeks after operation, no significant difference was found between Group A and other three control groups in the three behavioral evaluations. Neurophysiologic investigations of the axillary nerve showed that Group A was superior to the other three groups. Muscular histological outcome of the axillary nerve and deltoid muscle showed that Group A was superior to the Group C and D, while no significant difference was found between Group A and B. Except that the thruput of regenerating medullated musculocutaneous nerve fibers of Group A was superior to Group C, neurophysiological and histological outcome of the musculocutaneous nerve and biceps showed that no significant difference was found between Group A and other three groups. At 12 weeks postoperatively, nearly all the behavioral, neurophysiological and histological determination showed that Group A was superior to the other three groups., Conclusions: Ipsilateral C7 transfer to the upper trunk of brachial plexus combined with the spinal accessory nerve to the suprascapular nerve is found to be significantly effective on treatment of the root avulsion of C5 and C6 of the brachial plexus.

Objective: To investigate the effect of extract of Ginkgo biloba leaves (EGb50) on the expression of inducible nitric oxide synthase (iNOS) after sciatic nerve injury., Methods: 156 male SD rats were randomly divided into 3 groups: experiment group (n=72), undergoing section and anastomosis of sciatic nerve and then gastric perfusion of EGb50 200 mg.kg-1.d-1; injury control group (n=72), undergoing section and anastomosis of sciatic nerve and then gastric perfusion of normal saline daily; and sham operation group (n=12), undergoing sham operation and gastric perfusion of normal saline daily. The rats were killed at different time points: 1, 3, 7, 14, 21, and 28 days after the operation. The sciatic nerve distant to the anastomotic sites with a length of 0.5 cm was cut out to undergo immunohistochemistry and RT-PCR to detect the protein and mRNA expression of iNOS., Results: No obvious iNOS protein and mRNA expression was seen in the sham operation group. 3, 7, 14, and 21 days after operation the mean values of absorbance of iNOS in the sciatic nerve specimens of the experiment group were all significantly lower than those of the injury control group (P<0.05, P<0.01). High mRNA expression of iNOS began to be shown in the sciatic nerve specimens since 1day after the operation and remained at a high level till 7 days after and then began to decrease in the injury control group. The levels of mRNA expression of iNOS in the sciatic nerve specimens 1, 3, and 7 days after the operation of the experiment group were all significantly lower than those of the injury control group (all P<0.01), and there was no significant difference in the levels mRNA expression of iNOS 14, 21, and 28 days after the operation between the experiment group and injury control group (all>0.05)., Conclusion: The extract of Gingko biloba promotes the regeneration of nervous tissues, probably by inhibiting the expression of iNOS.

Objective: To study the long-term impact of transfer of phrenic nerve on respiratory system of children., Methods: Thirty-four children with brachial plexus injury, 25 boys and 9 girls, underwent transfer of phrenic nerve and were divided into 3 groups according to the age when they underwent operation: group of the age of 0 - 12 months (n = 17), group of 13 - 36 months (n = 11), and group of 37 - 60 months (n = 6). Thirty-four sex, height, and body weight-matched healthy children were used as controls. Follow-up, including physical examination, pulmonary function examination (tidal volume, ventilation, etc), blood gas analysis, and chest radiography, was conducted for 4.03 years (3 - 7 years)., Results: The values of maximum vital capacity of the group of 0 - 12 months and group of 13 - 36 months were 1.0 L +/- 0.2 L and 1.2 L +/- 0.4 L, both significantly lower than those of the corresponding control groups (1.3 L +/- 0.3 L and 1.4 L +/- 0.5 L, both P < 0.05). The values of one-second vital capacity of the group of 0 - 12 months and group of 13 - 36 months were 0.8 L +/- 0.1 L and 0.9 L +/- 0.1 L, both significantly lower than those of the corresponding control groups (1.0 L +/- 0.1 L and 1.0 L +/- 0.1 L, both P < 0.05). However, the values of the maximum vital capacity and one-second vital capacity of the group of 37 - 60 months were 1.6 L +/- 0.3 L and 1.8 L +/- 0.5 L respectively, both not significantly different from those of the controls (both P > 0.05). The results of blood gas analysis of the 3 operation groups were not significantly different from those of the corresponding controls. Chest radiograph showed that the diaphragm top was raised by 1.93 intercostal spaces (0.5 - 3.5 intercostal spaces) in comparison with the contralateral sides with significant differences between the group of 0 - 12 months and the group of 13 - 36 months and between the group of 0 - 12 months and the group of 37 - 60 months (both P < 0.05). The recurrent respiratory infection rate and of the groups of 0 - 12 months and 13 - 36 months were 47.1% and 27.3% respectively, both significantly higher than that of the group of 37 - 60 months (0%). The thorax deformity rate of the groups of 0 - 12 months and 13 - 36 months were 41.2% and 9.1% respectively, both significantly higher than that of the group of 37 - 60 months (0%). Three of the children in the group of 0 - 12 months (17.6%) had digestive system symptoms., Conclusion: Transfer of phrenic nerve operated on children younger than 3 years may cause abnormalities of respiratory system, thorax, and digestive system. The younger the patients the more severe the consequences of the operation. The children older than 3 years tolerate the operation better.

Objective: To identify the risk factors and related degrees associated to obstetric brachial plexus palsy(OBPP)., Methods: A case-control study was performed. Neonatal records of thirty-one cases with OBPP and their corresponding maternal records from the Department of Gynecology and Obstetrics of eight hospitals in Shanghai city from 1988 to 2002 were reviewed. Four controls, all living in Shanghai were selected to match each case and were born within the same year at the same hospital. The control group also included 124 cases without OBPP. According to the uniformed data and tables used were from medical records and from pregnant women. Epidemiological study was carried out on both case group and control group. Variables for analyses would include: (1) race, age, height, family history, pre-pregnancy weight, body mass index at the pre-pregnancy (weight/height2) on those pregnant women as well as on parity of their mothers; (2) the process of delivery which includeing clinic pelvis evaluation, height of uterus, abdomen circumference,antepartum weight,body mass index before delivery, mode of delivery,the duration of active phase and 2nd stage of labor, shoulder dystocia; (3) on neonates: sex, gestational age, birth weight,affected limb, Apgar scores of 1 and 5 minutes, other birth trauma and resuscitation of infant. Statistical tests applied to these data would include Student's T test for continuous variables and chi2 analysis for discrete data. Risk calculation of OBPP was performed by univariable and multivariable conditional logistic regression analysis., Results: 12 factors related to expsure were identified for OBPP through univariable conditional logistic regression analysis. When multivariable conditional logistic regression model at P = 0.1 was applied, four factors such as cesarean (OR = 0.060), forceps (OR = 65.237), birth weight (OR = 35.468), and pre-pregnancy body mass index (OR = 23.901) were selected., Conclusion: Forceps delivery,macrosomia, and increase of pre-pregnancy body mass index (> or = 21) were risk factors of OBPP in the order of degrees to risk while cesarean seemed to serve as a protective factor.

Objective: To map dynamic changes of primary motor cortex after total brachial plexus traction injury by using functional magnetic resonance imaging, and to explore underlying probable mechanisms., Methods: Five patients with total traumatic root avulsions of the brachial plexus underwent varied kinds of nerve transfer to restore partially shoulder or elbow function. Four of them (cases 1, 3, 4, 5) accepted the first fMRI examination prior to surgery treatment, and four of them (cases 2, 3, 4, 5) accepted second or third or fourth fMRI follow-up re-examinations after surgery treatment. Maps of neuronal activation within the motor cortex were generated for both hands in each patient by using BOLD-fMRI and the cluster size and position were recorded. The motor tasks consisted of simple hand grasping of both hands respectively. Patients with paralytic hand were asked to complete task under "virtual" condition. The cluster size and intensity as well as location of motor activation within the primary motor cortex of the affected hand generated were compared with those of unaffected hand generated as reference in single subject, and the resultant maps of follow-up re-examinations were also compared with those of the prior examinations., Results: All patients' unaffected hand movement generated strong signal change within the contralateral primary motor cortex. In contrast, the clusters generated by affected hand showed very small and lower intensity than usual (2 cases) or could not be induced (2 case) in the first examination that prior to surgery treatment and seemed larger gradually in the following re-examination with time increasing., Conclusion: Peripheral nerve injury can produced significant changes in the motor cortex of human brain. fMRI is a valuable tool to evaluate neural plasticity in motor cortex after peripheral nerve injury.

Objective: To determine the age-related expression features of slit2 mRNA at various intervals at the proximal and distal parts of sciatic nerve during re-innervation after severance injury, and to investigate the molecular biological reason why co-contraction occurs more commonly in the young rats than in the adults after peripheral nerve injury., Methods: The right sciatic nerve was transected sharply at the midthigh in the young and adult rats, 28 in each group. The proximal and distal stumps were inserted into a medical silicone tube with a gap of 3 mm. Before the injury, and 1, 3 and 7 days (6 rats at each interval) after sciatic nerve severance injury, both stumps of the sciatic nerve were harvested. Reverse transcription polymerase chain reaction (RT-PCR) was use to examine the expression of slit2 mRNA in the young and adult group rats. In situ hybridization was done to detect the cell location of slit2 mRNA expression in young and adult rats, 4 rats in each group, 2 rats used before the injury and 2 rats used on the postoperative third day., Results: RT-PCR results suggested that slit2 mRNA at both stumps was significantly lower in the young group of rats than in the adult except that at the proximal part on the postoperative 7th day. There was statistically significant difference (P < 0.01). In situ hybridization studies indicated that the slit2 mRNA was specifically expressed in the cytoplasm of Schwann cells both in the young and adult rats before injury and 3 days after injury., Conclusion: The expression of slit2 mRNA by Schwann cells in the young rats is lower than that in the adult rats after peripheral nerve injury. These findings suggests the lower expression of chemotactic factor (slit2) by Schwann cells in the young group is likely to be the molecular biological reason for the higher incidence of co-contraction between agonists and antagonists in the younger rats.

Objective: To study the influence of the electric stimulation of denervated muscle atrophy., Methods: Sixteen SD rats were made the model of denervated skeletal muscle in two lower limbs by cutting off the sciatic nerve and femoral nerve. The right gastrocnemius muscle was stimulated with JNR-II nerve & muscle recovery instrument by skin as the experimental side and the left was not treated as the control side. The muscle histology, ultrastructure, fibrillation potential amplitude, Na(+)-K(+)-ATPase and Ca(2+)-ATPase activities were observed 2 weeks and 4 weeks after operation., Results: Electric stimulation could protect mitochondria and sarcoplasmic reticulum from the degeneration. The reduction rates of muscle cell diameter and cross section in the experimental side were slower significantly than those in control side. There was no influence on fibrillation potential amplitude in the both sides after electric stimulation. The reduction rates of Na(+)-K(+)-ATPase activity in the experimental side were slower 15.59% and 27.38% respectively than those in the control side. The reduction rates of Ca(2+)-ATPase activity in the experimental side were slower 4.83% and 21.64% respectively than those in the control side., Conclusion: The electric stimulation can protect muscle histology, electrophysiology and enzymic histochemistry of denervated skeletal muscle from the degeneration. The electric stimulation is an effective method to prevent and treat muscle atrophy.

Objective: To determine the location of the vertebral artery foramens from C(3) to C(6) and their relationship to the point 1 mm medial to the center of the lateral mass and to identify the value of oblique radiograph for cervical lateral mass screw trajectory by a cadaveric study., Methods: (1) Twenty-eight cervical specimens (C(3)-C(7)) of human cadavers aged from 28 to 79 years were analysed. The transverse radiographs of C(3)-C(6) vertebrae were taken and the angle between the parasagittal plane and the line connecting the point of the lateral mass with the lateral limit of the transverse process foramen of C(3)-C(6) were measured. (2) The K-wires were drilled into lateral mass of C(3)-C(6) starting 1 mm medial to the center of the lateral mass and exiting by the juncture between the transverse process and the facet in ten specimens. Four wire placements under direct visualization, including placement of the wire tip staying the ventral cortex and 2, 4, 6 mm over-penetration of the ventral cortex of lateral mass, were performed separately on each specimen. After each placement, radiographs were taken on 45 degrees oblique left and 45 degrees oblique right views. Each intervertebral foramen on the oblique radiographs was divided into two parts: superior and inferior parts. The former is the true intervertebral foramen, while the latter is the intertransverse foramen on the gross specimen. The number of wire tips in each part was quantified for each placement. All results on the radiographs were compared with those on the gross anatomy., Results: (1) The angles between the parasagittal plane and the line connecting the posterior starting point of the lateral mass with the lateral limit of the transverse foramen (C(3)-C(6)) were lateral to the sagittal plane, ranging from 5 degrees to 12 degrees. Among the vertebrae, there were no statistically significant difference (P > 0.05). (2) 15% of the wires without over-penetration and 41.3% with 2 mm over-penetration were found in the inferior parts of the intervertebral foramen in oblique views, while the wires were not noted in the intervertebral foramen by gross anatomy. with 4 mm over-penetration of the ventral cortex, 35% and 65% of wires were noted in the superior and inferior parts of the intervertebral foramen respectively, while only 28.8% of wires were found in the inferior part approximating the nerve roots in gross specimens. With 6 mm over-penetration, the number in the intervertebral foramen were 63.8% superiorly and 36.2% inferiorly on the oblique radiographs while all the tips were at the inferior part (intertransverse foramens) in gross specimens. The tip of wire crossed the line connecting the posterior borders of the intervertebral foramens in oblique radiographs when it penetrated the ventral cortex of lateral mass 4 mm or more., Conclusions: (1) There is no risk of damaging the vertebral artery if a screw is directed more than 15 degrees lateral to the sagittal plane at C(3 approximately 6) starting 1 mm medial to the center of the lateral mass. (2) Ideal screw tip position on oblique radiograph may not cross the line connecting the posterior borders of the intervertebral foramen on radiograph. If the screw tip is noted in the superior part of intervertebral foramen on the oblique radiograph, the screw may be identified as dangerous.

Objective: To construct eukaryotic expression vector of rat myogenin gene for further study on its functions in skeletal muscle denervated atrophy and repair., Methods: The cloning vectors (containing full length of myogenin cDNA and two restriction sites: Hind III and Xho I) were first cut by two restriction endonuclease: Hind III and Xho I, and the same as the eukaryotic expression vector; then, the myogenin cDNA and the digested vector were ligated by T4 DNA ligase, and recombinant eukaryotic expression vector was formed. Its length was certificated by agarose gel electrophoresis analysis, digestion with Hind III and Xho I, PCR; and the rightness of the myogenin cDNA sequence was confirmed by sequencing., Results: The results of agarose gel electrophoresis analysis, digestion, and PCR confirmed the right length of inserted DNA, which was the same as the myogenin cDNA, and the sequencing result of pcDNA3-myogenin was identical with the reported., Conclusion: pcDNA3-myogenin a eukaryotic expression vector, is successfully constructed.

Objective: To observe the ultrastructural changes and number of satellite cells in different muscles with different denervation interval and investigate the mechanism of denervation atrophy., Methods: Muscles of different denervation interval were harvested, which were 6 biceps brachii and 6 abductor digiti minimi. The ultrastructure of the samples were observed under transmission electron microscope. The number of nucleus and satellite cells were counted to calculate the percentage content of satellite cells., Results: In early stage of denervation, the myofilament and sarcomere of the majority were well oriented. The nucleoli of some muscle cell nucleus were enlarged and pale. Vacuolarization was also seen in some mitochondria. There was no obvious proliferation of collagen fiber around myofibers. After denervation of half a year, rupture and disorientation of myofilament was seen. The nucleus became smaller, dark stained, and some of them were condensed. There was proliferation of fibroblasts, adipose cells and collagen fibers around myofibers. Motor endplate was not recognized one year after denervation. In the early stage of denervation, satellite cell percentage of the two muscles was relatively high. It then declined with time. One year after denervation, satellite cells were scarcely detected. Comparison of the curves for satellite cell declination in two muscles revealed that the declination of the abductor digiti minimi was faster than that of biceps brachii. Decrease of the former started 3 months after denervation, while the latter started after 6 months., Conclusion: Disappearing of motor endplate and proliferation of collagen fibers are main factors that affect the treatment outcome in late cases. Decrease of satellite cell number is another cause. The correlation of less satellite cell in abductor digiti minimi and poorer recovery of hand intrinsic muscles indicates that increment of satellite cells in long-term denervated muscles may be one of the effective measures to improve treatment outcome.