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   Table of Contents - Current issue
Coverpage
January-March 2019
Volume 3 | Issue 1
Page Nos. 1-176

Online since Monday, February 18, 2019

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GUEST EDITOR PROFILE  

Guest Editor Profile Highly accessed article p. 1

DOI:10.4103/2589-1219.252392  
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EDITORIAL Top

The future of nerve repair and regeneration Highly accessed article p. 2
Dominic M Power
DOI:10.4103/jmsr.jmsr_103_18  
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REVIEW ARTICLES Top

Managing the nerve gap: New tools in the peripheral nerve repair toolbox p. 4
Mohammad Nassimizadeh, Abdul K Nassimizadeh, Dominic Power
DOI:10.4103/jmsr.jmsr_98_18  
End-to-end repair of a peripheral nerve transection injury remains the gold standard. Delayed repair, nerve debridement and early functional mobilisation may all increase repair site tension, which impedes axon regeneration and must be avoided. Prompt diagnosis, referral to a specialist and exploration can minimise the nerve retraction, debridement and gap size, and societal benefit will be achieved through adopting a standardised approach to management. However, early exploration may provide challenges in defining the extent of the injury zone and therefore the adequacy of nerve debridement. Repair site tension can be reduced with 'sutureless' nerve approximation in a conduit, interposition of autologous graft or with interposed processed nerve allograft. Sutures can be avoided through interposition de-tensioning grafts and use of tissue glues. However, a large gap in a conduit will not support robust regeneration and grafts have two neurorrhaphy sites for axons to negotiate. Autologous graft has a donor site morbidity that may be unacceptable. An algorithm for peripheral nerve reconstruction should include the use of conduits and allograft as de-tensioning devices, avoiding the morbidity associated with autologous nerve grafting.
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Iatrogenic nerve injuries in orthopaedics p. 9
Jun Yi Soh, Joshua Hill, Dominic M Power
DOI:10.4103/jmsr.jmsr_1_19  
Peripheral nerves are at risk of injury during both orthopaedic trauma and elective surgery. The aims of this review are to raise awareness of iatrogenic nerve injuries and recommend strategies clinicians can employ to aid diagnosis, management and improve recovery for patients. A thorough understanding of anatomy and appreciation of pathoanatomy in fracture surgery can help reduce this risk. When injuries occur, a systematic clinical assessment can usually locate the site of injury, and with a repeated examination, the physiological grade can be determined. The neurapraxic injury may deteriorate if the conditions around the nerve are unfavourable. Caution should be exerted when making a diagnosis of conduction block because close, regular clinical monitoring is necessary to detect any deterioration early. Surgery may be required in such injuries if there is a failure to progress or deterioration occurs. Higher grade injuries may require surgical exploration and reconstruction. These procedures are most appropriately performed by specialist surgeons working in regional nerve injury units. Early diagnosis and management of an iatrogenic injury reduces the emotional impact, may prevent central pain sensitisation and ensures the optimum chance of useful functional recovery.
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Pathogenesis, clinical evaluation and non-surgical management of symptomatic neuromas: A literature review p. 15
Tom Challoner, Dominic M Power, Suzanne Beale, Amit Nijran
DOI:10.4103/jmsr.jmsr_82_18  
Neuromas are an often-underdiagnosed cause of chronic pain resulting from a peripheral nerve injury. There are two main sub-types as follows: end neuromas result from nerve transection caused by transection of a nerve due to trauma, iatrogenic injury, following amputation or oncological resection and neuroma-in-continuity where axonal injury with loss of internal neural architecture following direct trauma, compression or traction results in disorganised neural regeneration with no loss of physical continuity of the nerve sheath. Pharmacological symptom control is often inadequate. A comprehensive, structured assessment and multi-modality management regimen is required to achieve favourable outcomes in neuroma management. Strategies include peripheral neuromodulation, neurorehabilitation interventions, psychological support, peripheral nerve blockade, radiofrequency ablation and surgery. Surgical interventions are aimed at restoration of nerve continuity when possible, modification of the nerve environment and neuroma relocation or capping. This review will discuss diagnostic techniques and management strategies of peripheral neuromas.
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The surgical management of traumatic neuromas p. 22
Tom Challoner, Amit Nijran, Dominic M Power
DOI:10.4103/jmsr.jmsr_81_18  
Following injury to a peripheral nerve, a neuroma may form and cause severe debilitating neuropathic pain. End neuromas are the result of an amputation or are found at the proximal stump in a complete nerve transection or rupture. Neuromas-in-continuity follows traction or compression injury and may complicate repair of a nerve transection or rupture. Symptomatic neuromas should be assessed and treated by a peripheral nerve surgeon working within a multi-professional team. The objectives of the initial treatment should encompass pain management, psychological support and physical therapies with the aim of restoration of normal nerve response thresholds to afferent stimuli and optimisation of the perineuroma environment. Surgical intervention should be reserved for non-responders and in cases where reconstruction of nerve function is deemed essential for useful functional recovery and pain resolution.
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Failed carpal tunnel surgery: A guide to management p. 30
Martin Van, Rajive M Jose, Dominic Power
DOI:10.4103/jmsr.jmsr_78_18  
Revision surgery constitutes up to 2.7% of cases of carpal tunnel surgery in the UK. Failed carpal tunnel surgery can present as deterioration, recurrence or persistence of symptoms after surgical decompression. The causes of failed carpal tunnel decompression can often be categorised into four groups; poor surgery, poor nerve, poor diagnosis or poor luck. This situation calls for a structured review of the clinical history, examination, previous investigations and subsequently devising a management plan. We reviewed relevant articles on PubMed, Medline, Embase and Ovid, and we provided a structured approach to failed carpal tunnel surgery based on the current evidence. There are several options for revision carpal tunnel surgery that can be implemented to protect the median nerve, including local flaps, collagen and synthetic polymer wraps. A majority of patients experience improvement in symptoms after revision surgery.
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Adolf stoffel and the development of peripheral neurosurgical reconstruction for the management of paralysis: One hundred years of nerve transfer surgery p. 40
Mohammad Nassimizadeh, Abdul K Nassimizadeh, Dominic M Power
DOI:10.4103/jmsr.jmsr_95_18  
The concept of nerve transfer as an alternative solution for paralysis through rewiring a denervated motor nerve using an intact and expendable nerve branch or fascicle in proximity to the injured nerve became widely adopted as a strategy for nerve root avulsion in brachial plexus injuries. The success of the technique has encouraged clinicians to extend the indications for other complex nerve injuries, and the technique may be considered as an adjunct or replacement to nerve grafting for some proximal, high-energy, and late-presenting peripheral nerve injuries. The technique is not new. Many of the current “advances” in peripheral nerve transfer were described contemporaneously by Adolf Stoffel in 1911. He was an orthopedic surgeon working in Germany in the early 1900s. He had an interest in nerve injury reconstruction, described the functional fascicular anatomy of the peripheral nerves, developed an intraoperative nerve stimulator, and pioneered many of the techniques used today. His work was never translated from the German language and did not, therefore, receive wide acknowledgment. The aim of this study is to correct the perceived timeline of nerve transfer surgery and include the pioneering work of Adolf Stoffel.
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The evolution of nerve transfer restoration of shoulder function p. 47
Dominic M Power, Sunil Parthiban, Mohammad Nassimizadeh, Devanshi Jimulia, Lewis Turner, Richard Jones
DOI:10.4103/jmsr.jmsr_92_18  
Loss of shoulder abduction and external rotation reduces the working space for the upper limb and hand. Paralysis may follow C5 nerve root avulsion, upper trunk rupture or isolated injuries to the suprascapular and axillary nerves. Motor nerve transfer surgery involves a direct transfer of an expendable motor branch from a muscle in the vicinity of the paralyzed muscle and direct transfer with microsurgical end-to-end coaptation to the nerve to the denervated muscle close to its motor point. Reinnervation is rapid and robust. The technique was described for the restoration of deltoid function more than a century ago but was not adopted into wide spread use until the past two decades. This article explores the various options of nerve transfer surgery to restore function of shoulder function and reviews the evidence. Refinements in the procedure have resulted with the current algorithm for management, which will be described with its rationale and a review of clinical outcomes.
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Rewiring the upper limb: Motor nerve transfer surgery in the reconstruction of paralysis p. 53
Dominic Power, Mohammad Nassimizadeh, Davina Cavallaro, Pieter Jordaan, Petros Mikalef
DOI:10.4103/jmsr.jmsr_94_18  
Surgery to rewire a paralysed limb is now possible using motor nerve transfer surgery. The technique has been adapted from brachial plexus surgery and applied to other causes of paralysis with remarkable results, providing function to patients left paralysed from spinal cord injury, inflammatory neuropathy, tumour surgery and degenerative spinal disease. Adapting the techniques to peripheral nerve injury offers improved outcomes compared to anatomical reconstruction of an injured nerve. Nerve transfer surgery involves harvest of an expendable motor branch or redundant motor fascicle from a peripheral nerve and direct, tension-free coaptation to the distal motor branch of a paralysed muscle close to the motor point. Rapid re-innervation of the denervated muscle results in reliable motor recovery. Originally popularised for the reconstruction of nerve root avulsion, the technique has been adapted for use in other peripheral nerve injuries resulting in motor outcomes that are superior to those achieved through grafting of mixed motor-sensory nerve gaps. Nerve transfer surgery may be used to salvage late presenting cases, failed proximal reconstructions or as an adjunct for key motor functions in proximal nerve repairs where the time-distance phenomenon of peripheral nerve regeneration results in poor distal motor recovery, even following acute direct repair. The extension of the technique to other paralysing conditions demonstrates promise.
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The stages of rehabilitation following motor nerve transfer surgery p. 60
Joshua L Hill, Lewis C Turner, Richard D Jones, Devanshi T Jimulia, Caroline Miller, Dominic M Power
DOI:10.4103/jmsr.jmsr_79_18  
Nerve transfer surgery is a reliable technique for restoration of motor function for paralysis resulting from peripheral nerve injury. The donor motor branch or fascicle is selected in proximity to the denervated target, and a tension-free end-to-end nerve coaptation is performed allowing rapid neurotisation and functional restoration. To date, a standardised rehabilitation protocol does not exist. The Birmingham Protocol was developed to enhance communication between surgeons and physiotherapists and to improve patients' understanding of the recovery process. It is a six-phase continuous rehabilitation programme designed to improve the outcomes following motor nerve transfer surgery. The programme was developed in a regional peripheral nerve injury service and has been evaluated over 10 years in >500 motor nerve transfer procedures. The programme is simple to understand and implement, allowing patient engagement and standardisation of treatment by non-specialist physiotherapists in rehabilitation units remote from the regional centre. The phases are described with expected timelines for progression for motor nerve transfers at different sites. Core outcome measures are defined to facilitate multicentre research. It is hoped that this protocol will serve as a framework that can be applied in other centres both in the UK and the international community.
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A comparison of tendon and nerve transfer surgery for reconstruction of upper limb paralysis p. 69
Davina C Cavallaro, Petros Mikalef, Dominic M Power
DOI:10.4103/jmsr.jmsr_109_18  
Paralysis of the upper limb muscles may follow peripheral nerve injury, spinal cord injury, nerve compression, tumour resection, inflammatory neuropathy, spot-infective neuritis or as a result of a degenerative neurological disease. The goals of treatment are to restore important functions without losing important donor muscle function. Caution should be exerted when the underlying process is a progressive one because initially successful reconstruction may be followed by a delayed deterioration. Tendon transfer and nerve transfer surgery are two of the reconstructive techniques available for functional restoration of paralysis. Tendon transfer redirects a muscle-tendon unit for a more critical function losing some muscle power in the process. Nerve transfer uses an expendable donor nerve branch or fascicle from within a nerve trunk to re-innervate the paralysed muscle in its original bed. These procedures may be combined either with functioning free muscle transfers or with arthrodesis procedures to stabilise important joints and free up additional muscle-tendon or nerves for transfer. Hybrid reconstruction with combined tendon transfer and nerve transfer may achieve greater potential gains for an individual than either technique in isolation. We aim to provide the reader with a broad overview of the above techniques to better inform decision-making when faced with a patient with functional deficit of the upper limb.
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Upper limb spasticity surgery in adults: What we learned in 5 years of practicing it p. 75
Constantinos Kritiotis, Marios Tryfonidis, Anuj Mishra, Haseem Raja
DOI:10.4103/jmsr.jmsr_83_18  
We have been practicing surgical management of adult upper limb spasticity for the past 5 years. So far, we have evaluated 20 patients, and we have operated on nine patients with spasticity of the upper limb in Cyprus and the United Kingdom. We aim to present the setup and running of a new service, which is devoted to Surgery for Spasticity of the Upper Limb. We present our structure, organisational processes and service provision as well as our results in the nine cases that had surgical treatment as a part of their management (as well as our preferred techniques). We discuss our outcomes as well as our learning points from these cases. We also believe that selective neurectomy procedures can be very useful in the surgical management of upper limb spasticity. Tendon transfers to augment finger extension have a limited role and provide no significant benefits in adult spasticity cases. In addition, we found that the extensor carpi ulnaris transfer to extensor carpi radialis brevis has in our experience, reliable results regarding concentric wrist extension as well as easier rehabilitation. Furthermore, in severe cases, where no functional improvement is expected, joint fusions have a more predictable outcome. Spasticity reduction surgery does gain ground with the increase in survival of stroke patients as well as traumatic brain injury patients. Therefore, up to date methods for assessing, operating and evaluating postoperatively this category of patients need to be vigorously checked.
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COMMENTARY Top

Commentary on: Upper limb spasticity surgery in adults: What we learnt in 5 years of practice p. 84
Dominic M Power
DOI:10.4103/jmsr.jmsr_5_19  
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ORIGINAL ARTICLES Top

Interim analysis of recruitment data for a randomized control trial of digital nerve repair p. 86
Sunil Parthiban, Mark A Foster, Suzanne Beale, Dominic M Power
DOI:10.4103/jmsr.jmsr_107_18  
Objectives: Digital nerves provide a good model for testing efficacy of repair techniques. Injuries are often standardized, with high numbers of patients and reasonable follow-up time scales. The gold standard treatment for a complete, traumatic peripheral nerve lesion involves direct end-to-end microsurgical repair. Conduits may reduce tethered scar at repair sites and provide a supported segment for a sutureless repair. A randomized controlled trial (RCT) investigating the outcomes of digital nerve repair requires a two-stage recruitment process. Interim analysis of our study design aimed to identify the areas of improvement for recruitment efficiency. Methods: Patients with reduced sensation in a digital nerve distribution were referred to a research nurse for consent and first-stage recruitment to the Conduit Nerve approximation versus Neurorrhaphy Evaluation of Clinical outcome Trial (CoNNECT). Intraoperative confirmation of a complete nerve injury allowed second-stage recruitment and randomization. Analysis of screening data and recruitment logs from June 2017 to December 2018 enabled the assessment of recruitment efficiency. Results: We assessed 268 patients as suitable for CoNNECT with 82% consenting to take part in the trial. Eighty-five patients were deemed suitable intraoperatively; however, only 69 patients were successfully recruited. Patients were missed due to operating surgeons not being trained in the CoNNECT protocol, time constraints, and inadequate planning of theater resources. Conclusion: Key areas effecting recruitment include adequate provision of staff training workshops, prioritization of trial patients, and improved communication with patients. The results of this audit into recruitment to an RCT in digital nerve repair will help inform future studies in this area.
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Patterns of injury to the infraclavicular brachial plexus following dislocation of the glenohumeral joint p. 90
Isabel A Guy, Daniel N Guerero, Colin P Shirley, Charles J Edwards, Caroline Miller, Dominic M Power
DOI:10.4103/jmsr.jmsr_87_18  
Objectives: Brachial plexus injury (BPI) often results in devastating loss of upper limb function and debilitating neuropathic pain. The medial cord is often damaged following low-energy falls and glenohumeral dislocation. Medial cord injury (MCI) is associated with poor functional hand outcome due to paralysis of intrinsic muscles innervated by median and ulnar nerves, yet management options are limited. Nerve injury severity, demographic factors and concomitant injuries are poorly defined in this group. This study aims to understand patterns of infraclavicular BPI to guide management. Methods: All consecutive cases of infraclavicular BPI presenting to a regional peripheral nerve injury service over a 3-year period were retrospectively analysed. Medical records and neurophysiology reports were reviewed, and demographics and injury details were recorded on a database. Results: Ninety-nine infraclavicular BPI cases were identified. Of these, 34 (34%) were attributed to glenohumeral dislocations sustained in low-energy falls. There were 21 females and 13 males with mean age 62 years and mean body mass index 31. Five (13%) and 11 (29%) patients sustained vascular injuries and rotator cuff tears, respectively. Twelve (35%) patients sustained 13 fractures, of the proximal humerus or greater tuberosity. Review of injury patterns identified MCI in 24 cases (71%), 12 (50%) of which were amenable to nerve transfers. Conclusion: Low-energy falls are often accompanied by glenohumeral dislocation, whereby the medial cord is commonly damaged, resulting in an intrinsic minus hand. This injury subgroup has not been previously described, yet early recognition and referral for novel nerve transfer surgery can improve outcomes for these life-changing injuries.
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A cadaveric feasibility study for a delayed supinator nerve transfer for restoration of hand function after infraclavicular brachial plexus injury p. 98
Daniel N Guerero, Isabel A Guy, Colin Shirley, Charles Edwards, Dominic M Power
DOI:10.4103/jmsr.jmsr_99_18  
Objectives: Infraclavicular brachial plexus injury is an uncommon complication of shoulder dislocation. Medial cord injury is known to yield poor functional recovery due to paralysis of the intrinsic hand muscles. This study aims to determine the anatomical feasibility of a conceptual technique involving the use of the lateral cutaneous nerve of the forearm (LCNF) as an in situ reversed vascularized graft with the nerves to supinator as the donor in a staged nerve transfer procedure for medial cord injury. Methods: Limb measurements were conducted on five fresh cadaveric upper limbs and surgical demonstration performed on a formalin-fixed upper extremity. Each arm was dissected by a peripheral nerve surgeon to identify the LCNF, nerve to flexor digitorum profundus (FDP), deep branch of the ulnar nerve (DBUN), and the anterior interosseous nerve (AIN). The distance of each nerve from recognized limb landmarks was measured and neurorrhaphies attempted in surgical demonstration. Results: The mean available length of the LCNF graft was found to be 221.4 mm (range: 103.9–304.4 mm). The mean required graft lengths for medial cord motor targets were 38.6 mm (range: 29.3–51.9 mm) for the nerve to FDP, 164.5 mm (range: 126.7–197.9) for the DBUN, and 177.1 mm (range: 151.4–202.2 mm) for the AIN. Conclusions: Based on the results of this cadaveric study, the LCNF is sufficiently long to form tension-free neurorrhaphies when used as an in situ reversed vascularized graft to reinnervate distal medial cord motor targets.
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A cadaveric feasibility study for a staged musculocutaneous to medial cord nerve transfer for restoration of hand function following infraclavicular brachial plexus injury p. 104
Daniel N Guerero, Isabel A Guy, Colin Shirley, Charles Edwards, Dominic M Power
DOI:10.4103/jmsr.jmsr_96_18  
Objectives: Axonotmetic medial cord injury results in poor functional hand outcomes due to paralysis of long finger flexors and intrinsic hand muscles. The current management techniques have been reported to yield minimal functional recovery. This study aimed to determine the feasibility of a staged musculocutaneous nerve (MCN) to medial cord nerve transfer using the medial antebrachial cutaneous nerve (MACN) as an in situ reversed vascularized graft for the restoration of hand function in infraclavicular brachial plexus injury. The medial cord targets to be investigated include the nerve to flexor digitorum profundus (FDP), the deep branch of the ulnar nerve (DBUN), and the anterior interosseous nerve (AIN). Methods: Limb measurements were conducted on four fresh cadaveric upper limbs. Each upper limb was dissected by a peripheral nerve surgeon to expose the MACN, the nerve to FDP, the DBUN, and the AIN. The length of the MACN and the distance from the origin of each nerve to recognized forearm bone landmarks were measured. The surgical demonstration of the two-stage nerve transfer was demonstrated on a formalin-fixed upper extremity. Results: The mean graft length of the MACN was 223 mm (range: 179–295 mm). This was sufficient to bridge the calculated mean nerve gap to the nerve to FDP (88 mm, range: 79–101 mm) and DBUN (214 mm, range: 176–247 mm). The mean nerve gap to the AIN (228 mm, range: 201–252 mm) was greater than the mean MACN graft length. Conclusions: Motor nerve transfer of the brachialis muscle branch of the MCN to the medial cord using an interposed MACN graft was shown to allow tension-free neurorrhaphy formation with the nerve to FDP.
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The role of processed nerve allograft in peripheral nerve surgery p. 110
Amit Nijran, Tom J Challoner, Pieter Jordaan, Dominic M Power
DOI:10.4103/jmsr.jmsr_86_18  
Objective: Peripheral nerve surgery involves the direct repair of peripheral nerves after trauma, reconstruction of nerve gaps and the management of painful nerve conditions such as end neuroma. There are a variety of situations where direct microsurgical repair is not possible or not the preferred option. Processed nerve allograft (PNA) offers a bespoke solution in the management of nerve gaps without the morbidity associated with autografts. Methods: A prospective database was populated for patients having nerve allograft implantation in the management of peripheral nerve injury. Results: Between July 2015 and November 2018 (40 months), 62 nerves in 45 patients were treated with AVANCE® PNA at the Birmingham Hand Centre at the Queen Elizabeth Hospital, Birmingham, UK. The mean age at implantation was 43 (range 16–77). Digital nerve reconstruction formed 50% of the total nerve repairs. Indications were 20 digital neuroma reconstructions, 13 neuromas after amputation, 20 traumatic injuries with nerve tissue loss, 8 delayed presentation after trauma, 3 contraindications to general anaesthesia, 4 insufficient autografts, 1 failed autograft and 3 tumour reconstructions. Conclusion: AVANCE® PNA is a useful tool in the reconstruction of peripheral nerve injury and the management of painful neuromas. An absolute indication is the management of painful neuromas in sensitised patients where avoidance of an additional site of neuropathic pain at a donor site is an important consideration. In digital neuroma management, there is good evidence to support use with equivalent efficacy to autologous sensory nerve grafts of a similar length.
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Nerve allograft reconstruction of digital neuromata p. 116
Kathryn E Dickson, Pieter W Jordaan, Dalia Mohamed, Dominic M Power
DOI:10.4103/jmsr.jmsr_77_18  
Objective: A symptomatic digital neuroma may have a devastating impact on a person's life. There is no gold standard method of treatment. We hypothesise that the reconstruction of neuroma with nerve allograft will reduce the sensitisation and cortical reorganisation associated with peripheral nerve injury. In this study, we aim to assess the effect of neuroma reconstruction with nerve allograft on patient-reported pain and satisfaction. Methods: We conducted a retrospective review of patients who underwent nerve allograft reconstruction for painful digital neuroma at our unit, from July 2015 to July 2018. We measured pre- and post-operative visual analogue scale (VAS) pain scores, patient satisfaction and patient evaluation measure (PEM) scores. Results: In 10 patients, we reconstructed 12 neuromata. In nine of these patients (11 neuromata), we demonstrated a post-operative reduction in pain, with a change in median VAS score from 7.5 to 1. Patients were satisfied with their operation, with a median satisfaction score of 10/10. The procedure was unsuccessful in two patients, one with a static VAS score and one with a satisfaction score of <8/10, giving a success rate of 80%. Conclusion: Our results show that neuroma reconstruction with nerve allograft can improve patient-reported pain with a success rate of 80%. In our unit, this has become a primary indication for the use of allograft.
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The efficacy of vein ensheathing in protecting peripheral nerve repair sites p. 123
Andal Thirumalai, Rajive M Jose, Dominic Power
DOI:10.4103/jmsr.jmsr_75_18  
Objectives: Peripheral nerve repairs can have a variable outcome depending on several factors. Neuroma in continuity at the repair site may limit functional recovery and is frequently associated with localised pain and sensitivity to mechanical stimulation. Extraneural scar may constrict the repair site, impeding axonal regeneration and resulting in adhesions to the nerve repair bed, reducing nerve glide and causing neurostenalgia. This study looked at the outcomes of using a segment of vein to ensheathe peripheral nerve repair sites in twenty patients to measure efficacy with validated functional outcomes and complications. Methods: This was a retrospective review of twenty cases performed in our unit between 2011 and 2015. Thirteen cases of vein ensheathing were performed to protect primary neurorrhaphy following traumatic lacerations without significant nerve loss. Seven cases were performed in secondary nerve repairs, of which five followed excision of a neuroma and two following neurolysis and repair. Results: There were 19 cases with a follow-up ranging from 24 to 72 months (mean of 32 months). One patient did not respond and was lost to follow-up. Twelve patients attended clinic for the long-term follow-up appointment and seven opted for a telephone evaluation. There were no clinical neuromata identified at the repair sites in the 12 patients attending the research clinic. Eighteen patients reported no scar hypersensitivity and 17 reported some sensory recovery following the repair. Two patients reported no sensory recovery following the nerve repair and 17 had diminished or protective sensations. Twelve patients had formal quantitative sensory testing with two-point discrimination of which two patients achieved only S3 (poor), nine patients achieved S3+ (good), and one achieved S4 (excellent) using the Mackinnon and Dellon classification of sensory recovery. Conclusion: Vein ensheathing is a useful technique which decreases the risk of symptomatic neuromas and adhesions following repair of sensory nerves in the upper limb. However, a randomised controlled trial will be needed to further validate the use of this technique.
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Management of the scarred nerve using porcine submucosa extracellular matrix nerve wraps Highly accessed article p. 128
Pieter Willem Jordaan, Okezika Uhiara, Dominic Power
DOI:10.4103/jmsr.jmsr_69_18  
Objectives: Scar tissue formation around the peripheral nerves causes nerve compression and ischemia, but it also causes adherence of nerves to the surrounding tissues, decreasing the nerve's ability to glide, and therefore, causing neurostenalgia – nerve pain with motion due to tether. Our unit has been using a porcine submucosal extracellular matrix (AxoGuard® AxoGen Inc., Alachua, FL, USA) nerve wrap to prevent nerve scarring. The aim of this study is to present a case series of our use of the AxoGuard® and early follow-up data. Methods: This study describes the use of AxoGuard® nerve protectors, including the indications, anatomic locations, and complications. After obtaining ethics approval from the Institutional Audit Review Board, a retrospective review was performed of all cases where AxoGuard® nerve protectors were used from June 2015 to July 2018. Results: Over a 3-year period, AxoGuard® nerve wraps were used in 71 cases. The indication for surgery was a scarred nerve after trauma surgery in 32 cases, scarring after primary nerve surgery in 19 cases, primary trauma in 9 cases, nerve scarring after elective nonnerve surgery in 5 cases, and nerve tumors in 5 cases. There have been no complications directly related to the use of the AxoGuard® nerve protector and no cases of postoperative infection. Conclusions: The AxoGuard® nerve protector has many clinical indications, an excellent safety profile with no reported complications directly related to the nerve wrap, and is effective in mitigating the effects of neurostenalgia following revision neurolysis.
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The effect of shoulder abduction and medial epicondylectomy on ulnar nerve strain: A preliminary study p. 134
Carla G Barberio, Tahseen Chaudhry, Dominic M Power, Bernard M Lawless, Daniel M Espino, Simon Tan, Joanne C Wilton
DOI:10.4103/jmsr.jmsr_93_18  
Objectives: The primary aim was to determine whether a dynamic suture marker method of measuring ulnar nerve strain yields comparable results to strain gauges. The secondary aim was to assess the effect of elbow flexion, shoulder abduction and medial epicondylectomy on strain. Methods: In four embalmed elbows, ulnar nerve strain was measured using suture markers during elbow flexion and shoulder abduction before and after medial epicondylectomy. Linear regression analysis and Wilcoxon signed-rank test were used to analyse the results. Results: Ulnar nerve strain increased in direct proportion to elbow flexion angle before and after medial epicondylectomy, with one exception. At 90° shoulder abduction, strain was 0%–17%. Strain was greatest at 90° and least at 110° before and after medial epicondylectomy, P > 0.05. The effect of medial epicondylectomy varied. Strain was reduced at 90° by 5%, at 110° by 0% and at 120° by 1%; P > 0.05. Conclusions: The suture marker method yielded comparable results to strain gauges. Both shoulder abduction and medial epicondylectomy did not have statistically significant effects on ulnar nerve strain. However, only four embalmed elbows were studied in this preliminary study, so a large difference would be needed to produce a significant change. The finding that medial epicondylectomy fails to reduce strain raises questions about its role in treating cubital tunnel syndrome and highlights the need for further research. The authors believe that the technique described for dynamic strain assessment is applicable in an in vivo setting and therefore, should be used to compare strain properties of cadaveric and in vivo nerves.
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The late diagnosis of nerve injuries following interscalene block and shoulder surgery Highly accessed article p. 141
Guang H Yim, Zhimin Lin, Colin P Shirley, Peter Isherwood, Dominic M Power
DOI:10.4103/jmsr.jmsr_65_18  
Objectives: Interscalene blocks are commonly performed with the shoulder surgery, nerve injuries are reported to have the prevalence of 14% at 10 days postoperatively. While clinicians may be aware of the associated risk of nerve injury from either the surgery or the block, they may not recognize these nerve injuries. Our objectives were to determine factors contributing to injury and late referral. Methods: We searched our peripheral nerve injury database to identify a consecutive series of nerve injuries-associated with interscalene nerve block and the shoulder surgery. The identified cases were subject to clinical review and a review of the medical records including the consent form, anesthetic records, operation note, and the neurophysiology records. Results: Six cases of nerve injury were identified during a 24-month period. Half the patients experienced a delay of >6 months from injury to review, despite the documentation of persisting sensory and motor dysfunction. Regional anesthesia technique was not uniform. All patients required a specialist treatment from a regional peripheral nerve injury service. Conclusions: Clinicians should be aware that prolonged block duration is a feature of the potential nerve injury. The presence of a Tinel sign, autonomic dysfunction, and nerve pain in the distribution of the injured nerve are features suggesting nerve injury. Orthopedic surgeons should be able to recognize the nerve injury and seek early referral to the appropriate specialists. Where doubt exists, the patient should be referred for an urgent review by a peripheral nerve injury specialist.
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Restoring upper-limb function following cervical spinal cord injury: Current practice in the United Kingdom Highly accessed article p. 146
Joseph A Ward, Dominic M Power
DOI:10.4103/jmsr.jmsr_68_18  
Objectives: Cervical spinal cord injury (CSCI) is a devastating consequence of trauma that results in disabling loss of upper-limb function. Functional reconstruction through surgical intervention can improve quality of life, reduce long-term care needs, and is highly rated by patients. Internationally, limited information exists on the number of patients eligible for surgical intervention, procedures undertaken, and provision of services. Our objective was to answer these questions to inform service developments in the United Kingdom (UK) and abroad. Methods: A postal questionnaire survey was distributed to the clinical leads of each of the 12 UK and Republic of Ireland spinal cord injury centres (SCICs). Information was requested on the local CSCI caseload, referral of CSCI patients to reconstructive upper-limb services, and surgical procedures undertaken locally during defined periods. Nonresponders were followed up with freedom of information requests. Results: Eleven SCICs responded (response rate: 92%) with a mean of 49.6 any-level CSCI patients admitted annually (>C5: 27.9 patients, C5/6: 18 patients, <C6: 6.5 patients). No SCIC reported referring CSCI patients for nerve transfer or awareness of any peripheral nerve service. Five SCICs stated that they referred CSCI patients for surgery to restore upper-limb function. Conclusions: Surgery to restore upper-limb function following CSCI is still developing in the UK. Provision of services to this small but deserving group varies regionally. Clinical expertise is limited to a handful of SCICs where surgeons perform tendon-related procedures. No SCIC reported undertaking nerve transfer surgery. Assessment of upper-limb function should be a standard of care for functional reconstruction of CSCI with awareness of surgery among health-care professionals and patients raised.
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Nerve transfers following cervical spinal cord injury: A review and reconstructive algorithm p. 152
Joseph A Ward, Dominic M Power
DOI:10.4103/jmsr.jmsr_101_18  
Background: Cervical spinal cord injury (CSCI) is a devastating consequence of trauma. Restoration of upper limb function can improve quality of life, reduce long-term care needs and is highly rated by patients. Methods: We performed a non-systematic review of all studies reporting nerve transfer in CSCI to derive a putative reconstructive algorithm based primarily on nerve transfers. Results: For CSCIs above C5, no intraplexal donors exist. For CSCIs at C5 or below, axillary nerve (C5) branches may be transferred to triceps to restore elbow extension, musculocutaneous nerve (C6) branches may be transferred to the median nerve to restore pronation/ finger flexion whilst nerve branches to supinator (C6) may be transferred to re-innervate finger extensors. Further functional gains such as re-innervation of hand intrinsics, accessory respiratory function and postural control of the trunk may be possible but are not reported. Conclusions: Nerve transfers following CSCI represent an emerging area of upper limb surgery where bespoke surgical strategies undertaken early during rehabilitation course have the potential to change functional outcomes.
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COMMENTARY Top

Commentary on: Nerve transfers following cervical spinal cord injury: A review and reconstructive algorithm p. 160
Bassam M J Addas
DOI:10.4103/jmsr.jmsr_105_18  
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TECHNICAL NOTE Top

The infraclavicular approach for neurectomy of the spastic shoulder p. 161
Dominic M Power, Mohammed Nassimizadeh, Petros Mikalef
DOI:10.4103/jmsr.jmsr_104_18  
Objectives: Total or partial motor neurectomy may be used in the management of recalcitrant spasticity. A shoulder posture with adduction and internal rotation, impair function, and left untreated may result in established contractures. The aims of this anatomical study and clinical case series were to define a safe surgical approach to the infraclavicular plexus for selected motor neurectomy that avoids the axillary skin and can be readily completed in the presence of early axillary contractures. Methods: Using a cadaveric model, we adopted the pectoralis major muscle-splitting approach to the brachial plexus to afford access to the infraclavicular motor branches to the shoulder. The pectoral nerve origins can be identified and traced to their respective cords. Following pectoralis minor tenotomy, the interval between the lateral cord and the axillary artery is developed to expose the posterior cord. The subscapular and thoracodorsal nerves are identified using nerve stimulation. Results: The procedure has been used in the four non-functional limbs with shoulder adduction and internal rotation deformity with early axillary contractures resistant to physiotherapy and splinting. A mean of 6.25 nerves were sectioned in each case. All patients or their caregivers reported improvements in shoulder posture and pain with examination, demonstrating a mean increase passive in brachiothoracic angle of 45° (range: 30°–60°) facilitating washing and dressing. The improvements have been maintained at 12-month follow-up. Conclusion: Management of the painful adducted and internally rotated spastic shoulder is challenging. A mini-incision pectoralis major splitting incision provides access to the key motor nerves to the shoulder for neurectomy. Comparative studies evaluating neurectomy and tenotomy at the shoulder are required to demonstrate efficacy.
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CASE REPORTS Top

Delayed motor nerve transfer reconstruction for C5 and C6 resection during tumour surgery p. 166
Sunil Parthiban, Dominic M Power
DOI:10.4103/jmsr.jmsr_84_18  
We present a case of a delayed motor nerve reconstruction following resection of the C5 nerve root due to a recurrent aneurysmal bone cyst. Our patient, a 17-year-old male, presented with a major motor radiculopathy of C5 and revision surgery requiring resection of the C5 root. Four peripheral nerve transfers were undertaken to successfully reconstruct the functional loss at more than 14 months from the paralysis onset. Nerve transfer is usually considered only when the target muscles can be reinnervated within 9 months after lower motor neurone loss. The strategies for reducing reinnervation time and the differences in nerve transfer surgery for traumatic lesions will be discussed. Tumour surgeons should consider early involvement of a peripheral nerve surgeon when nerve must be sacrificed during tumour clearance. This allows the option of early targeted reconstruction and provides guidance to the patient on anticipated outcomes after surgery.
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An iatropathic tibial nerve injury in a patient following total ankle replacement p. 169
Richard D Jones, Lewis C Turner, Devanshi T Jimulia, Dominic M Power
DOI:10.4103/jmsr.jmsr_85_18  
Ankle arthroplasty is an infrequent procedure, and there is a risk of injury to nearby neurovascular structures from direct injury and from traction. The risk of nerve injury is difficult to quantify due to low-procedure numbers, non-mandatory nerve injury reporting to the National Joint Registry in the UK and delayed recognition of nerve injury despite the British Orthopaedic Association Standards for Trauma 5 guidelines on the management of peripheral nerve injury. Neuropathic pain following a major joint procedure with disordered sensation, motor paralysis and alterations in autonomic function in the distal skin are suggestive of nerve injury. A Tinel's sign at the site of suspected injury is diagnostic and the nerve should be promptly explored by a surgeon familiar with the operative assessment and reconstruction options for nerve injury. Processed nerve allograft is a useful adjunct in the reconstruction algorithm in cases of non-critical nerve disruption and central sensitisation to avoid the harvest of an intact sensory autologous nerve and risking further exacerbation of neuropathic pain at another site. The case presented discusses an iatropathic tibial nerve injury in a 48-year-old man who underwent reconstruction using nerve allograft.
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PROTOCOL Top

How reliable is manual muscle testing and does it correlate with functional and quality of life outcomes in patients with upper brachial plexus injury and cervical spine pathology: A protocol p. 173
Caroline Miller, Martin Holmes, Dominic M Power
DOI:10.4103/jmsr.jmsr_102_18  
Objectives: Measurement of muscle force using the Medical Research Council (MRC) Grades (0 to 5) is frequently used to evaluate the outcome following a brachial plexus injury (BPI). BPIs result in significant functional and psychosocial issues. It is unclear whether improvements in muscle force correlate with functional and quality of life (QoL) outcomes. Our aim is to assess the inter-rater reliability of the MRC grading system with patients with upper trunk BPIs and weakness from C5/6 cervical pathology and to explore whether the grading systems correlate with function and QoL. Methods: Forty participants with upper trunk BPIs and those with weakness secondary to cervical C5/C6 pathology will be recruited. Two clinicians will assess muscle power using the MRC muscle grading scale. Each clinician will be blinded to the others' score. Each participant will complete a quick Disabilities of the Arm, Shoulder, and Hand (DASH) and also a EuroQol five-dimensional scale. Statistical Analysis: Inter-rater reliability of the MRC manual testing will be calculated using a weighted kappa. To assess for the correlation between the DASH and QoL and the muscle testing results, a Spearman correlation will be used.
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