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Contralateral C7 to C7 cross nerve transfer has been proved to be safe and effective for patients with spastic arm paralysis due to stroke and traumatic brain injury. For the lower limb, contralateral L5 to S1 cross nerve transfer serves as a novel surgical approach. In many cases, patients with hemiplegia have both upper and lower limb dysfunction and hope to restore all limb functions within one operation. To cope with this demand, we performed combined contralateral C7 to C7 and L5 to S1 cross nerve transfer in two cases successfully.Two patients were enrolled in this study. The first patient is a 36-year-old woman who had spasticity and hemiplegia in both upper and lower limbs on the left side after a right cerebral hemorrhage 14 years prior. The second patient is a 64-year-old man who suffered from permanent muscle weakness in his right limbs, especially the leg, after a left cerebral hemorrhage 7 years prior. Both patients underwent the combined nerve transfer to improve upper and lower limb motor functions simultaneously. During the 10-month follow-up after surgery, the limb functions of both patients improved significantly.This study demonstrates the safety and benefits of combined contralateral C7 to C7 and L5 to S1 cross nerve transfer for hemiplegic patients after stroke. This novel combined surgical approach could provide an optimal choice for patients suffering from both upper and lower limb dysfunction, to reduce hospital stay while reducing financial burden.

Double crush syndrome (DCS) of the ulnar nerve, including cubital tunnel syndrome with ulnar tunnel syndrome (UTS), is uncommon. This study compares the postoperative outcomes of patients with isolated ulnar tunnel syndrome versus those with double crush syndrome of the elbow and ulnar tunnel.This study enrolled 22 patients: 12 underwent cubital tunnel surgery and ulnar tunnel surgery (double crush group); and 10 underwent only ulnar tunnel decompression (isolated UTS group). Postoperative effect evaluation of patients in both groups after at least 2.6 years (mean, 5.1 years and 5.7 years, respectively). Statistical analysis compared postoperative function, physical examination, and patient-reported satisfaction between groups.In terms of postoperative grip strength, there was no difference between the postoperative states of the two groups (0.88 ± 0.04 versus 0.87 ± 0.05), while there was statistical difference in terms of the increment of the grip strength (At a minimum of 2.6 years after the nerve decompression, the patients of isolated UTS group are likely to have superior grip strength increment than patients with a history of double crush surgery, and there is no big difference in the final recovery situation. The sensation and satisfaction of isolated UTS group after nerve release were better compared with patients following double crush surgery.

Hyperselective neurectomy is used to treat spastic arm paralysis. The aim of the study was to analyze the nerve branching patterns of elbow and wrist flexors/pronator to inform hyperselective neurectomy approached.Eighteen upper extremities of fresh cadaver specimen were dissected. The number of motor branches from the musculocutaneous nerve to biceps brachii and brachialis, median nerve to pronator teres, flexor carpi radialis and ulnar nerve to flexor carpi ulnaris were counted. The origin site of each primary motor branch was documented.Either biceps or brachialis was innervated by one or two primary motor branches. Pronator teres was innervated by one to three motor trunks and the pattern for flexor carpi radialis was a common trunk with other branches. The origin of the biceps and brachialis nerve trunk was located approximately 30% to 60% of the length of the arm. The median nerve branched to pronator teres and flexor carpi radialis at the region about 34mm (SD 18.8mm) above and 50mm (SD 14.9mm) below the medial epicondyle. Flexor carpi ulnaris was innervated by one to three motor trunks and the mean distance from the medial epicondyle to the origin of flexor carpi ulnaris nerve on ulnar nerve was 18.7 mm (SD 6.5mm).Primary motor branches to elbow flexors, wrist flexors and pronators were various, while the regions of their origins were relatively settled. It was recommended the incisions be designed according to the location of the primary motor trunks.

Crossing nerve transfer surgery has been a powerful approach for repairing injured upper extremities in patients with brachial plexus avulsion injuries. Recently, this surgery was creatively applied in the clinical treatment of brain injury and achieved substantial rehabilitation of the paralyzed arm. This functional recovery after the surgery suggests that peripheral sensorimotor intervention induces profound neuroplasticity to compensate for the loss of function after brain damage; however, the underlying neural mechanism is poorly understood. Therefore, an emergent clinical animal model is required. Here, we simulated clinical surgery to establish a protocol of direct anastomosis of bilateral brachial plexus nerves via the prespinal route in mice. Neuroanatomical, electrophysiological, and behavioral experiments helped identify that the transferred nerves of these mice successfully reinnervated the impaired forelimb and contributed to accelerating motor recovery after brain injury. Therefore, the mouse model revealed the neural mechanisms underlying rehabilitation upon crossing nerve transfer after central and peripheral nervous system injuries.

PURPOSE Electrophysiological testing has been used for the early diagnosis of iatrogenic spinal accessory nerve palsy in clinical practice. However, the presence of low-amplitude compound action potential in 70% to 90% of the patients suffering from iatrogenic nerve transection was reported in several studies. We have encountered the same issue and made minor modifications to the methods of electrophysiological testing. The purpose of this study was to retrospectively evaluate the reliability of our modified electrophysiological testing as preoperative examination in patients receiving surgical revision. METHODS In this study, we compared preoperative electrophysiological testing results with intraoperative diagnosis in the 24 patients with iatrogenic spinal accessory nerve palsy who were referred to our hospital from 2009 to 2018. RESULTS During operation, 20 patients were diagnosed with neurotmesis and the remaining 4 patients were found axonotmesis depending on the results of surgical exploration and intraoperative electrophysiological examination. Six of the 20 patients with neurotmesis demonstrated a low-amplitude compound muscle action potential of the upper trapezius during preoperative electrophysiological testing. Needle electromyography revealed voluntary motor unit potentials in 8 of the 20 patients. Meanwhile, concomitant great auricular nerve or dorsal scapular nerve injuries were preoperatively revealed in 7 of 24 patients. CONCLUSIONS The rate of low-amplitude compound muscle action potentials in these patients suffering from spinal accessory nerve neurotmesis was about 30% with our modified electrophysiological testing. We should be aware of this pitfall before surgical nerve repair. Furthermore, electrophysiological testing is an informative preoperative examination revealing the concomitant nerve injuries.

Backgrounds Contralateral cervical seventh (C7) nerve transfer aids motor and sensory recovery in total brachial plexus avulsion injuries (TBPI), but synchronous sensation often persists postoperatively. The mechanism underlying synchronous sensory phenomena remain largely unknown. Objective To investigate the role of central plasticity in sensory recovery after contralateral C7 nerve transfer. Methods Sixteen right TBPI patients who received contralateral C7 nerve transfer for more than 2 years were included. Sensory evaluations included Semmes–Weinstein monofilament assessment (SWM), synchronous sensation test, and sensory evoked action potential (SNAP) test. Smaller value in the SWM assessment and larger amplitude of SNAP indicates better tactile sensory. Functional magnetic resonance imaging was performed while stimulations delivered to each hand separately in block‐design trials for central plasticity analysis. Results The SWM value of the injured right hand was increased compared with the healthy left side (difference: 1.76, 95% confidence interval: 1.37–2.15, p, The tactile sensory of the injured hand was dominated by its ipsilateral SI in long‐term observation, and its representative area overlapped largely with representative area of the intact hands, which was the key mechanism for synchronous sensory phenomenon in patients with TBPI after contralateral C7 transfer.

Purpose The study was to explore whether the 3-dimensional printing guiding plate system could facilitate the modified procedure for arthroscopic treatment of nondisplaced scaphoid nonunion. Methods Patients, diagnosed with scaphoid nonunion without displacement, were randomly assigned into two groups. In Group A, the 3-dimensional printing guiding plate system was used for guiding fixation during the surgery. In Group B, fixation was performed with intra-operative fluoroscopy. The bone operation time was recorded during the surgery. The patients were evaluated before surgery and followed-up after six post-operative months, including motion ratio, strength ratio, Visual Analogue Scale, modified Mayo Scores, Patient Rated Wrist Evaluation scores, plain radiography and CT scan. Results Sixteen patients were recruited for the study. The average bone operation time in Group A was statistically shorter than that in Group B. Conclusions 3-dimensional printing technique-assisted arthroscopic bone graft and fixation of scaphoid nonunion constitute an effective and accurate clinical treatment option. The translational potential of this article The concept and technique of 3D printing assisted percutaneous fixation introduced in this paper have the potential to be applied in a variety of operations requiring accurate percutaneous fixation, especially for the joint injuries.

Central neurologic injury (CNI) causes dysfunctions not only in limbs but also in cognitive ability. We applied a novel peripheral nerve rewiring (PNR) surgical procedure to restore limb function. Here, we conducted a prospective study to develop estimates for the extent of preattentive processes to cognitive function changes in CNI patients after PNR. Auditory mismatch negativity (MMN) was measured in CNI patients who received the PNR surgery plus conventional rehabilitation treatment. During the 2-year follow-up, the MMN was enhanced with increased amplitude in the PNR plus rehabilitation group compared to the rehabilitation-only group as the experiment progressed, and progressive improvement in behavioural examination tests was also observed. Furthermore, we found a significant correlation between the changes in Fugl-Meyer assessment scale scores and in MMN amplitudes. These results suggested that PNR could affect the efficiency of pre-attention information processing synchronously with the recovery of motor function in the paralyzed arm of the in chronic CNI patients. Such electroencephalographic measures might provide a biological approach with which to distinguish patient subgroups after surgery, and the change in MMN may serve as an objective auxiliary index, indicating the degree of motor recovery and brain cognitive function.

The objective of the study was to investigate the feasibility of CUBE-SITR MRI and high-frequency ultrasound for the structural imaging of the brachial plexus to exclude neoplastic brachial plexopathy or structural variation and measure the lengths of anterior and posterior divisions of the C7 nerve, providing guidelines for surgeons before contralateral cervical 7 nerve transfer.A total of 30 patients with CNS and 20 with brachial plexus injury were enrolled in this retrospective study. All patients underwent brachial plexus CUBE-STIR MRI and high-frequency ultrasound, and the lengths of the anterior and posterior divisions of C7 nerve were measured before surgery. Precise length of anterior and posterior divisions of contralateral C7 nerve was measured during surgery.MRI-measured lengths of anterior and posterior divisions of C7 nerves were positively correlated with that measured during surgery (anterior division, r = 0.94, p .01; posterior division, r = 0.92, p .01). High agreement was found between MRI-measured and intra-surgery measured length of anterior and posterior divisions of C7 nerve by BLAD-ALTMAN analysis. Ultrasonography could feasibly image supraclavicular C7 nerve and recognize small variant branches derived from middle trunk of C7 nerve root, which could be dissected intra-operatively and confirmed by electromyography during the procedure of contralateral C7 nerve transfer.CUBE-STIR MRI had advantages for the imaging of the brachial plexus and measurement of the length of root-trunk-anterior/posterior divisions of C7 nerve. The clinical role of ultrasonography may be a simple way of evaluating general condition of C7 nerve and provide guidelines for contralateral C7 nerve transfer surgery.

Objective: Contralateral C7 nerve root transfer surgery has been successfully applied to rescue motor function of a hemiplegic upper extremity in patients with central neurological injury. This surgical technique is challenging, and limited anatomical space makes it difficult to manipulate tissues and may lead to higher complication rates. The authors hypothesis a new surgical route in which cervical nerve roots of both donor and recipient sides are exposed from a posterior intradural approach and neurorrhaphy is performed easily and clearly. The feasibility of this operation is tested in a cadaver model. Methods: A fresh cadaver was placed prone. After a standard midline incision and extensive cervical laminectomy, the dura and arachnoid were widely opened, and the spinal nerve roots of C6, C7, and C8 were exposed bilaterally. Nerve grafting was attempted between pairs of donor and recipient nerve roots on contralateral sides of the spinal cord. After completion of neurorrhaphy, the dura was closed. Results: Precise neurorrhaphy could be performed intradurally between posterior and anterior nerve roots of C7 on both sides. Multiple anastomoses of C7 to various nerve roots on the contralateral side could also be performed within the same surgical field with an interposition nerve graft. Conclusion: The posterior intradural repair idea affords many advantages, the pathway is shorter and more straightforward, which provides more access to multiple nerve roots repair in one surgical field, and is more familiar to many neurosurgeons and spine surgeons. It may potentially be adapted for clinical use.

Introduction The purpose of this study was to evaluate the application of ultrasound in the management of iatrogenic spinal accessory nerve palsy at the posterior cervical triangle area. Methods In this retrospective study, we compared ultrasonographic results with intraoperative findings in patients with iatrogenic spinal accessory nerve palsy during the time period from 2014 to 2018 at our hospital. Results Eleven patients were included. Ultrasound detected nerve transections in 9 patients and continuities in 2 patients. The ultrasonographic results were consistent with the intraoperative findings. Furthermore, ultrasound was able to accurately reveal lesion location in 8 of 9 patients with nerve transections. Discussion Ultrasound provides direct images about nerve lesions contributing to the diagnosis of iatrogenic spinal accessory nerve palsy at the posterior cervical triangle area and also reveals lesion location, assisting in formulating suitable surgical plans preoperatively. We recommend that ultrasound be integrated into the preoperative evaluation. Muscle Nerve 59:64-69, 2019.

Although some patients have successful peripheral nerve regeneration, a poor recovery of hand function often occurs after peripheral nerve injury. It is believed that the capability of brain plasticity is crucial for the recovery of hand function. The supplementary motor area may play a key role in brain remodeling after peripheral nerve injury. In this study, we explored the activation mode of the supplementary motor area during a motor imagery task. We investigated the plasticity of the central nervous system after brachial plexus injury, using the motor imagery task. Results from functional magnetic resonance imaging showed that after brachial plexus injury, the motor imagery task for the affected limbs of the patients triggered no obvious activation of bilateral supplementary motor areas. This result indicates that it is difficult to excite the supplementary motor areas of brachial plexus injury patients during a motor imagery task, thereby impacting brain remodeling. Deactivation of the supplementary motor area is likely to be a serious problem for brachial plexus injury patients in terms of preparing, initiating and executing certain movements, which may be partly responsible for the unsatisfactory clinical recovery of hand function.

Background Contralateral seventh cervical nerve transfer (contralateral C7 transfer) is a novel treatment for patients with spastic paralysis, including stroke and traumatic brain injury. However, little is known on changes in plasticity that occur in the intact hemisphere after C7 transfer. An appropriate surgical model is required. New method We described in detail the anatomy of the C7 in a mouse model. We designed a pretracheal route by excising the contralateral C6 lamina ventralis, and the largest nerve defect necessary for direct neurorrhaphy was compared with defect lengths in a prespinal route. To test feasibility, we performed in-vivo surgery and assessed nerve regeneration by immunofluorescence, histology, electrophysiology, and behavioral examinations. Results Two types of branching were found in the anterior and posterior divisions of C7, both of which were significantly larger than the sural nerve. The length of the nerve defect was drastically reduced after contralateral C6 lamina ventralis excision. Direct tension-free neurorrhaphy was achieved in 66.7% of mice. The expression of neurofilament in the distal segment of the regenerated C7 increased. Histological examination revealed remyelination. Behavioral tests and electrophysiology tests showed functional recovery in a traumatic brain injury mouse. Comparison with existing methods This is the first direct tension-free neurorrhaphy mouse model of contralateral C7 transfer which shortened the time of nerve regeneration; previous models have used nerve grafting. Conclusions This paper describes a simple, reproducible, and effective mouse model of contralateral C7 transfer for studying brain plasticity and exploring potential new therapies after unilateral cerebral injury.

Background Spasticity and muscle weakness are common severe neurologic sequelae after stroke. Contralateral peripheral neurotization has been applied successfully to promote motor function of the hemiplegic upper extremity in patients with central neurological injury. To our knowledge, we present the first report of contralateral lumbar to sacral nerve transfer for the lower extremities in hemiplegic patients after stroke. Case Description Two patients were enrolled in the study. The first patient is a 57-year-old man who experienced permanent muscle weakness in his left leg after a right cerebral infarction. The second patient is a 42-year-old man who had spasticity and hemiplegia in both upper and lower limbs on the right side 32 months after a left cerebral hemorrhage. Both patients underwent contralateral lumbar–to–sacral nerve rerouting to improve lower-limb motor function. Twenty months after surgery, both patients experienced significant improvement in ambulatory status. Conclusions Although long-term follow-up and a randomized controlled trial are required, this study demonstrates the safety and possible benefits of contralateral lumbar–to–sacral nerve transfer for hemiplegic patients after stroke. This novel surgical approach could provide a new means for lower-limb motor functional recovery.

Electrical stimulation could enhance nerve regeneration and functional recovery. The objective of this study was to evaluate the regenerative effects of implanted electrodes with different contacts in resected sciatic nerve. Sciatic nerve resection and microsurgical repair models were established and randomly divided into four groups (point contact, 1/4 circle contact; whole-circle contact; no electrodes as control). Electrical stimulation was performed and electrophysiological, morphological and histological exams (of the sciatic nerve and muscle) were conducted at 4 and 10 weeks post-implantation. Point and 1/4 circle contact groups showed significantly higher scores in the sciatic functional index (SFI), increased amplitude of compound muscle action potential (AMP) and motor nerve conduction velocity (MNCV) compared to the control group at both 4 and 10 weeks post-implantation. Point and 1/4 circle contact morphologically promoted sciatic nerve regeneration and reduced muscular atrophy with less mechanical injury to the nerve trunk observed compared with the whole-circle contact group at both 4 and 10 weeks post-implantation. Electrodes with point and 1/4 circle contacts represented an alternatively portable and effective method of electrical stimulation to facilitate injured sciatic nerve regeneration and reduce subsequent muscular atrophy, which might offer a promising approach for treating peripheral nerve injuries.

Background Few studies look into cerebral blood flow (CBF) changes during emergence from general anaesthesia for craniotomy. The purpose of this study was to assess CBF changes during emergence from general anaesthesia for craniotomy, through monitoring blood oxygen saturation of jugular vein bulb (SjvO2) and transcranial Doppler (TCD). Methods We enrolled 30 patients undergoing selective craniotomy (group C) for supratentorial brain tumour resection and 30 patients undergoing selective abdominal surgery (group A). Mean velocity of middle cerebral artery (Vmca), mean arterial pressure (MAP), SjvO2 (only measured in group C), and arterial CO2 partial pressure were measured before anaesthesia, at tracheal extubation, and 30, 60, 90, 120 min after extubation. Results Vmca of the same side of tumour was significantly higher than contralateral Vmca before anaesthesia and at all times after extubation in group C. The ipsilateral Vmca increased significantly (95.7 ± 16.9 cm/s vs. 63.7 ± 6.7 cm/s, P