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New Proceedure for nerve repair restoring limb use

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Posted 05 February 2012 - 10:47 AM

New procedure repairs severed nerves in minutes, restoring limb use in days or weeks
February 3, 2012

American scientists believe a new procedure to repair severed nerves could result in patients recovering in days or weeks, rather than months or years. The team used a cellular mechanism similar to that used by many invertebrates to repair damage to nerve axons. Their results are published today in the Journal of Neuroscience Research.


"We have developed a procedure which can repair severed nerves within minutes so that the behavior they control can be partially restored within days and often largely restored within two to four weeks," said Professor George Bittner from the University of Texas. "If further developed in clinical trials this approach would be a great advance on current procedures that usually imperfectly restore lost function within months at best."

The team studied the mechanisms all animal cells use to repair damage to their membranes and focused on invertebrates, which have a superior ability to regenerate nerve axons compared to mammals. An axon is a long extension arising from a nerve cell body that communicates with other nerve cells or with muscles.

This research success arises from Bittner's discovery that nerve axons of invertebrates which have been severed from their cell body do not degenerate within days, as happens with mammals, but can survive for months, or even years.

The severed proximal nerve axon in invertebrates can also reconnect with its surviving distal nerve axon to produce much quicker and much better restoration of behaviour than occurs in mammals.

"Severed invertebrate nerve axons can reconnect proximal and distal ends of severed nerve axons within seven days, allowing a rate of behavioural recovery that is far superior to mammals," said Bittner. "In mammals the severed distal axonal stump degenerates within three days and it can take nerve growths from proximal axonal stumps months or years to regenerate and restore use of muscles or sensory areas, often with less accuracy and with much less function being restored."

The team described their success in applying this process to rats in two research papers published today. The team were able to repair severed sciatic nerves in the upper thigh, with results showing the rats were able to use their limb within a week and had much function restored within 2 to 4 weeks, in some cases to almost full function.

"We used rats as an experimental model to demonstrate how severed nerve axons can be repaired. Without our procedure, the return of nearly full function rarely comes close to happening," said Bittner. "The sciatic nerve controls all muscle movement of the leg of all mammals and this new approach to repairing nerve axons could almost-certainly be just as successful in humans."

To explore the long term implications and medical uses of this procedure, MD's and other scientist- collaborators at Harvard Medical School and Vanderbilt Medical School and Hospitals are conducting studies to obtain approval to begin clinical trials.

"We believe this procedure could produce a transformational change in the way nerve injuries are repaired," concluded Bittner.


Provided by Wiley (news : web)


Squirrel
Feb 03, 2012

Rank: 5 / 5 (3)

Something has been cut. The abstract explains the missing procedure:
"severed axonal ends are opened and resealing is prevented by hypotonic Ca free saline containing antioxidants (especially methylene blue) that inhibit plasmalemmal sealing in sciatic nerves. Second, a hypotonic solution of polyethylene glycol (PEG) is applied to open closely apposed (by microsutures, if cut) axonal ends to induce their membranes to ow rapidly into each other .."
Rapid, Effective, and Long-Lasting Behavioral Recovery Produced by Microsutures, Methylene Blue, and Polyethylene Glycol After Completely Cutting Rat Sciatic Nerves
G.D. Bittner, et al Journal of Neuroscience Research Early View publication



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Posted 21 March 2012 - 07:53 AM

http://gizmodo.com/5...chairs-to-shame

Wow, this device looks amazing

a cross between a segway and a wheelchair , that allows the person to stand up!
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Posted 01 May 2012 - 09:25 AM

new innovation for scoliosis

http://www.technolog...27801/?p1=blogs
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Posted 07 May 2012 - 09:52 AM

http://www.cbsnews.c...pain-sufferers/
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Posted 17 May 2012 - 09:54 AM

http://www.stuff.co....d-to-move-robot

Paralysed woman uses mind to move robot
NICKY PHILLIPS Last updated 08:41 17/05/2012

Bionic glasses to help blind 'Bionic leg' to be a New Zealand first Bionic eye dream close to reality Woman completes marathon in bionic suit

A quadriplegic woman has used her mind to control a robotic arm, taking a sip from a drink bottle unassisted for the first time in 15 years.

The 58-year-old American was one of two people, both paralysed from the neck down by a stroke, whose brains have been implanted with a tiny electronic device that translates neural impulses into commands that operate a robotic limb.

The other patient, a 66-year-old man, directed the mechanical arm to touch a foam ball.

"I just imagined moving my own arm and the [robotic] arm moved where I wanted it to go," he said.

The events mark a significant advance towards restoring mobility and independence to people paralysed by a neurological disease or injury.

As part of their research, scientists surgically implanted an electronic device, known as BrainGate, into the region of the brain that controls voluntary movement, the motor cortex, of each patient.

The pioneer of the device and co-author of the study, John Donoghue, said the device's 96 hair-thin electrodes detected the electrical impulses of nearby neurons.

Each signal then travelled through a series of thin wires connected to a computer where algorithms deciphered patterns in the electrical activity into commands that controlled the robotic arm, said Professor Donoghue, a neuroscientist at Brown University in the United States.

To program algorithms that decode the neural signals, the scientists had both patients watch the movement of the robotic arm and imagine they were moving their own limb.

The patient's intention to move, represented as brain signals, was then translated into commands that could control the robotic arm.



Professor Donoghue said the team was surprised to discover they could decode detailed information from the patient's brain patterns, such as where they wanted to position their hand in space, the speed of their movements and if they wanted to open and close their hand.

"Those decoding algorithms are the product of many years of essential neuroscience research on how neural signals represent the intent to move," said Professor Donoghue, whose findings are published in the journal Nature.


The experiments, which took place in April last year, also showed a person's motor cortex could function years after an injury, he said.

While each patient controlled a different type of robotic arm, which were designed to be strong and stiff as well as precise and limber, both could reach and grasp an object.

While the study was a significant advance, more research was needed for the group to reach their end goal - to reconnect the brain to a person's own limbs or connect the brains of amputees to a prosthetic limb, Professor Donoghue said.

Previously the team had shown that patients with spinal cord injuries could use their mind to control a cursor on a computer screen.

-Sydney Morning Herald
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Posted 17 May 2012 - 09:56 AM

http://www.nature.co...ysis/index.html


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Posted 17 May 2012 - 11:43 PM

http://www.stuff.co....surgery-a-first

Quadriplegic surgery a first
Last updated 14:43 16/05/2012

Nerve Transfer
A nerve transfer technique has returned partial movement to a quadriplegic's hand.

Surgeons have restored some hand function in a quadriplegic patient with a spinal cord injury at the C7 vertebra, the lowest bone in the neck.

Instead of operating on the spine itself, the Washington University School of Medicine surgeons rerouted working nerves in the upper arms.

These nerves still 'talk' to the brain because they attach to the spine above the injury.

Following the surgery, performed at Barnes-Jewish Hospital, and one year of intensive physical therapy, the patient regained some hand function, specifically the ability to bend the thumb and index finger.

He can now feed himself bite-size pieces of food and write with assistance.

The case study, published online May 15 in the Journal of Neurosurgery, is, to the authors' knowledge, the first reported case of restoring the ability to flex the thumb and index finger after a spinal cord injury.

"This procedure is unusual for treating quadriplegia because we do not attempt to go back into the spinal cord where the injury is," says surgeon Ida K. Fox, MD, assistant professor of plastic and reconstructive surgery at Washington University.

"Instead, we go out to where we know things work, in this case the elbow, so that we can borrow nerves there and reroute them to give hand function."

Although patients with spinal cord injuries at the C6 and C7 vertebra have no hand function, they do have shoulder, elbow and some wrist function because the associated nerves attach to the spinal cord above the injury and connect to the brain.

Since the surgeon must tap into these working nerves, the technique will not benefit patients who have lost all arm function due to higher injuries in vertebrae C1 through C5.

The surgery was developed and performed by the study's senior author Susan E. Mackinnon, MD, chief of the Division of Plastic and Reconstructive Surgery at Washington University School of Medicine.

Specialising in injuries to peripheral nerves, she has pioneered similar surgeries to return function to injured arms and legs.

Mackinnon originally developed this procedure for patients with arm injuries specifically damaging the nerves that provide the ability to flex the thumb and index finger.

This is the first time she has applied this peripheral nerve technique to return limb function after a spinal cord injury.

"Many times these patients say they would like to be able to do very simple things," Fox says.

"They say they would like to be able to feed themselves or write without assistance. If we can restore the ability to pinch, between thumb and index finger, it can return some very basic independence."

Mackinnon cautions that the hand function restored to the patient was not instantaneous and required intensive physical therapy.

It takes time to retrain the brain to understand that nerves that used to bend the elbow now provide pinch, she says.

Though this study reports only one case, Mackinnon and her colleagues do not anticipate a limited window of time during which a patient with a similar spinal cord injury must be treated with this nerve transfer technique.

This patient underwent the surgery almost two years after his injury.

As long as the nerve remains connected to the support and nourishment of the spinal cord, even though it no longer "talks" to the brain, the nerve and its associated muscle remain healthy, even years after the injury.

"The spinal cord is the control centre for the nerves, which run like spaghetti all the way out to the tips of the fingers and the tips of the toes," says Mackinnon.

"Even nerves below the injury remain healthy because they are still connected to the spinal cord.

"The problem is that these nerves no longer 'talk' to the brain because the spinal cord injury blocks the signals."

To detour around the block in this patient's C7 spinal cord injury and return hand function below the level of the injury, Mackinnon operated in the upper arms.

There, the working nerves that connect above the injury and the non-working nerves that connect below the injury run parallel to each other, making it possible to tap into a functional nerve and direct those signals to a non-functional neighbour.

In this case, Mackinnon took a non-working nerve that controls the ability to pinch and plugged it into a working nerve that drives one of two muscles that flex the elbow.

After the surgery, the bicep still flexes the elbow, but a second muscle, called the brachialis, that used to also provide elbow flexion, now bends the thumb and index finger.

"This is not a particularly expensive or overly complex surgery," Mackinnon said.

"It's not a hand or a face transplant, for example. It's something we would like other surgeons around the country to do."

- © Fairfax NZ News
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Posted 17 May 2012 - 11:45 PM

Click on the link to read the other links & see the diagrams

http://thejns.org/do...archHistoryKey=

Journal of Neurosurgery
Posted online on May 15, 2012.

Article
Nerve transfers for the restoration of hand function after spinal cord injury
Case report

Susan E. Mackinnon, M.D.1,
Andrew Yee, B.S.1, and
Wilson Z. Ray, M.D.2

1Division of Plastic and Reconstructive Surgery, and 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
Abbreviations used in this paper: AIN = anterior interosseous nerve; ASIA = American Spinal Injury Association; ICSHT = International Classification for Surgery of the Hand in Tetraplegia; MRC = Medical Research Council; SCI = spinal cord injury.
Address correspondence to: Wilson Z. Ray, M.D., Department of Neurological Surgery, Washington University School of Medicine, 660 South Euclid Avenue, St. Louis, Missouri 63110. email: [email protected]

Please include this information when citing this paper: published online May 15, 2012; DOI: 10.3171/2012.3.JNS12328.
Related Articles

By Keywords:
spinal cord injury, peripheral nerve, reinnervation, bypass, nerve transfer, hand

Abstract

Spinal cord injury (SCI) remains a significant public health problem. Despite advances in understanding of the pathophysiological processes of acute and chronic SCI, corresponding advances in translational applications have lagged behind. Nerve transfers using an expendable nearby motor nerve to reinnervate a denervated nerve have resulted in more rapid and improved functional recovery than traditional nerve graft reconstructions following a peripheral nerve injury. The authors present a single case of restoration of some hand function following a complete cervical SCI utilizing nerve transfers.

Spinal cord injury is a devastating condition, representing a significant public health problem.1 The incidence of new SCIs is estimated at nearly 40 cases per million persons annually in the US.44 The average age of affected individuals is less than 40 years,40 and it is estimated that approximately 259,000 Americans are currently living with an SCI.39 Recovery from a complete SCI is exceedingly rare, leaving most patients with significant permanent disability. Spinal cord injury consists of 2 distinct injury patterns: 1) the initial mechanical injury and postinjury cord deformation, which leads to immediate cell death, and 2) the resulting activation of metabolic and vascular changes. The metabolic and vascular changes of secondary injury lead to a cascade of oxidative processes resulting in neuronal death, lipid peroxidation, free radical regeneration, and protease activation extending the zone of injury beyond the initial site of mechanical damage.3,12,16 The complex interactions that occur during this secondary injury process are not fully understood. Treatments that reduce this secondary cell-mediated injury could potentially limit the extent of injury, leading to improved long-term functional outcomes. A significant volume of work has been devoted to the investigation of neuroprotective and neuroregenerative strategies following SCI, and a host of therapeutic agents have been investigated to minimize secondary injury.2,15,17,19,21,28,29,34,35,37,38,41,43,45–48,51,53–56,58,63,64 While many of these agents have demonstrated some degree of neuroprotection, there remains a significant void in therapeutic interventions that produce a reliable and robust improvement in functional outcomes. We have developed a number of nerve transfers for forearm and hand motor function,7,20,49,59 and recently Bertelli and colleagues have described the successful reinnervation of distal musculature with preserved proximal donors after an SCI.4,5,20 We present in the current article a single case of restoration of some finger and thumb flexion that allowed this patient to feed himself after a cervical SCI.
Case Report
History

This 71-year-old previously right-hand-dominant man presented to our institution 22 months after he was injured in a motor vehicle accident in June of 2008. He had sustained multiple injuries including an ASIA A SCI with an approximate C-7 level. Shortly after his injury the patient underwent anterior and posterior surgery for spinal stabilization. He was referred to our institution for evaluation of possible tendon and nerve transfers. His ICSHT grade (Table 1)36 was 5 on the left and somewhat less than that on the right, with weak wrist flexion. On examination (Fig. 1, Videos 1 and 2), he had no pinch or grip strength in either hand.

Video 1. Clip showing the preoperative physical examination of the left upper extremity. Click here to view with Media Player. Click here to view with Quicktime.

Video 2. Clip showing the preoperative physical examination of the right upper extremity. Click here to view with Media Player. Click here to view with Quicktime.
Data table

TABLE 1: International Classification for Surgery of the Hand in Tetraplegia*
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Fig. 1. Preoperative physical examination of the left and right upper extremities. A–E: Left upper extremity. The patient exhibited strong elbow flexion (A), strong pronation (B), strong wrist flexion ©, strong wrist extension (D), but no finger or thumb movement (E). F–J: Right upper extremity. The patient exhibited strong elbow flexion (F) and his pronation was near normal in strength (slight weakness)(G). He was able to flex his wrist, but not against resistance specifically testing flexor carpi radialis (H). His wrist extension was strong with slight weakness in wrist extension (I). He exhibited no finger or thumb movement (J).

He had no finger flexion or extension. Based on the MRC grading system for muscle strength he had Grade 5 wrist extension and flexor carpi radialis function in the left hand, and Grade 4 wrist extension and Grade 3 flexor carpi radialis function in the right hand. He had preserved pronation, with a strength of Grade 4, bilaterally. His brachioradialis strength was Grade 5 on the left and Grade 4 on the right. He had Grade 5 strength of shoulder function and elbow flexion bilaterally. He had some preserved moving and static 2-point discrimination of between 5 and 6 mm in the median and ulnar nerve distributions of both hands. Both hands demonstrated profound evidence of intrinsic muscle atrophy with joint stiffness to passive range of motion in all digits. This stiffness involved all joints of all digits; all interphalangeal joints were fixed in extension with no passive flexion. Electromyography and nerve conduction studies demonstrated small motor unit potentials of the right flexor pollicis longus and left flexor digitorum profundus II and III.

In cases such as this one, it is imperative that the preoperative clinical examination be well documented and solidified in the surgeon's mind prior to surgery. Because the nerves in the arm and hand are connected to the spinal motor neuron pool below the level of cord injury, intraoperative electrical stimulation will show normal muscle contraction response in nerves that are “connected” to the brain (intact) and nerves having a motor neuron below the level of the SCI. Care must be taken to preserve all nerve fascicles that are within the patient's functional control, specifically in this case, pronation and some wrist movement.
Operation

Twenty-three months after the patient's injury (May 2010), he underwent bilateral transfer of the brachialis nerve (C-6 level) to the AIN (C-8 level) (Fig. 2). Surgery was performed initially on the patient's left side and was followed 1 week later by surgery on the right. Both procedures were carried out with the patient in the supine position under general anesthesia without the use of muscle relaxants or paralytic agents. The incisions were made in the medial aspect of the upper arm, and dissection was carried down through the soft tissues to identify the median nerve. Intraoperative motor mapping was performed with a handheld nerve stimulator (Vari-Stim III, Medtronic) to identify and protect the fascicular portions of the median nerve that were functioning. The median nerve fascicles in the arm that were protected were the flexor carpi radialis, pronator teres, and the lateral sensory component of the median nerve. The anterior interosseous fascicle was then identified within the medial/posterior portion of the median nerve and separated. Intraoperative stimulation confirmed viable distal motor contraction with robust movement of both the flexor pollicis longus and flexor digitorum profundus within the limits of the severe joint stiffness (Fig. 3). The anterior interosseous fascicle was then separated from the median nerve proximally and divided; a small section was harvested for histomorphometric analysis (Fig. 4). The brachialis nerve was identified, separated, divided distally in keeping with our mantra of “donor distal/recipient proximal” to ensure no tension at the repair site (Figs. 5 and 6). A tension-free repair was performed with 9-0 nylon and fibrin glue.
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Fig. 2. Musculocutaneous and median nerve anatomy relevant to the brachialis nerve to AIN transfer in C-7 SCI. A: The donor brachialis branch divides from the musculocutaneous nerve on its medial aspect. After this branch point, the musculocutaneous nerve becomes the lateral antebrachial cutaneous nerve. B: The recipient AIN branches from the median nerve in the forearm on its lateral aspect, but courses proximally into the arm on its posterior/medial aspect. The donor brachialis nerve is transferred into the anterior interosseous fascicle in the arm. C: The AIN fascicle in the arm is located on the posterior/medial aspect of the median nerve, between the palmaris longus/flexor digitorum superficialis/flexor carpi radialis fascicle and the sensory component of the median nerve. The fascicular group to the pronator teres is located in the anterior portion of the median nerve, while the sensory fibers are lateral and the motor fibers medial. A = anterior; L = lateral; M = medial; N = nerve; P = posterior; R = radial; U = ulnar.
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Fig. 3. Intraoperative electrical stimulation of the nonintact nerves. A: Stimulation of the right anterior interosseous fascicle with the hand at rest and contraction of the flexor pollicis longus and median nerve–innervated flexor digitorum profundus. B: Stimulation of the right ulnar nerve with the hand at rest and contraction of the intrinsic muscles, more apparent on the lateral aspect. C: Stimulation of the left anterior interosseous fascicle with the hand at rest and contraction. The blue arrows indicate change from the nonstimulated to the stimulated condition.
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Fig. 4. Qualitative histological assessment of the brachialis nerve and AIN in the right extremity. Upper: A small fascicle of the brachialis nerve reveals normal myelinated nerve fibers. This fascicle is not representative of the brachialis branch used as the donor nerve for transfer. Lower: Assessment of the nonintact AIN reveals sporadic myelinated fibers. Original magnification × 100.
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Fig. 5. Brachialis nerve–AIN transfer in the left upper extremity. A: The anterior interosseous fascicle was separated from the median nerve on its posterior/medial aspect. B: The distal branches of the brachialis nerve were identified. C: The brachialis nerve was transected distally and the anterior interosseous fascicle was separated proximally for transection. D: The donor brachialis nerve was transferred to the recipient anterior interosseous fascicle. LABC = lateral antebrachial cutaneous.
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Fig. 6. Brachialis nerve–AIN transfer in the right extremity. A: The AIN was identified distally and followed proximally to identify its fascicular component. B: The distal branches of the brachialis nerve were identified. C: The brachialis nerve was transected distally and the anterior interosseous fascicle was separated proximally. D: The donor brachialis nerve was transferred to the recipient anterior interosseous fascicle.

Intraoperatively, we stimulated both the median and ulnar nerves and had essentially normal response to movement in the hand with respect to the amount of active range of motion that we could obtain with very stiff hands (Video 3).

Video 3. Clip showing intraoperative electrical stimulation of the anterior interosseous fascicle in the left upper extremities. Muscle contraction is evident following electrical stimulation of nonintact nerve, demonstrating that muscles are still innervated below the level of the SCI. Click here to view with Media Player. Click here to view with Quicktime.

We had obtained consent for innervating the AIN, but the fact that we could accurately predict the motor topography of the median and ulnar nerves with direct stimulation was intriguing for other potential innervations.
Postoperative Course

The patient began to exhibit movement in the flexor pollicis longus and flexor digitorum profundus at approximately 8 months postoperatively in the left hand and 10 months postoperatively in the right hand. He continues to participate in active hand therapy and currently has MRC Grade 3 flexor pollicis longus and flexor digitorum profundus strength at 15 months following surgery (Fig. 7A–D, Videos 4–6).

Video 4. Intraoperative stimulation of the anterior interosseous fascicle and ulnar nerve in the right upper extremity. Muscle contraction is evident following electrical stimulation of nonintact nerve, demonstrating that muscles are still innervated below the level of the SCI. Click here to view with Media Player. Click here to view with Quicktime.

Video 5. Clip showing postoperative physical examination of the left upper extremity. Click here to view with Media Player. Click here to view with Quicktime.

Video 6. Clip showing postoperative physical examination of the right upper extremity. Click here to view with Media Player. Click here to view with Quicktime.
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Fig. 7. Postoperative examination of the left and right hands following brachialis nerve–AIN transfer. A and B: Left and right hands in resting position. C and D: Left and right hands performing AIN function through pinch with simultaneous activation of the donor brachialis nerve through elbow flexion. E and F: Functional recovery included the ability to grasp small objects such as a ball. G and H: The patient has recovered the ability to feed himself.

He appears to have some weak intrinsic motor recovery, which may be related to a Martin-Gruber anastomosis. He can now use his right hand to perform simple hand-to-mouth movements (Fig. 7E and F, Video 7).

Video 7. Clip showing functional results and examination of the left and right upper extremities with the ability to manipulate objects and self-feed. Click here to view with Media Player. Click here to view with Quicktime.

With his left hand, he is able to feed himself and perform rudimentary writing activities (Fig. 7G and H). Because recovery of the right hand has been slower than that of the left hand, mirror therapy is being used to further rehabilitate his weaker right hand with the use of his left hand (Fig. 8, Video 8).

Video 8. Clip showing mirror therapy utilizing the left hand to rehabilitate the weaker right hand. Click here to view with Media Player. Click here to view with Quicktime.
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Fig. 8. Mirror therapy utilizing the left hand to rehabilitate the weaker right hand. Left: The patient used the left hand, with its recovered AIN function, to visualize the mirror image as the right hand during cocontraction. Right: The right hand within the mirror box.
Discussion

The use of nerve transfers has gained significant momentum over the last decade and has changed the treatment algorithm in patients with nerve injuries.32 Although tendon transfers have an established role in the management of patients with tetraplegia,55 only recently have nerve transfers been considered as a potential treatment option in patients with cervical SCIs.4,5 The concept that the nerve to the brachialis muscle would potentially be an expendable donor for transfer evolved from the discussion around the merits of reinnervating it in patients who had no elbow function due to brachial plexus injury.6,11,42,60 While our own experience has evolved to include reinnervation of both the biceps brachii and brachialis,60 some authors have suggested the innervation of the brachialis is not critical to recovery of elbow flexion.11,42 Similarly, we have found, in cases of brachial plexus and median nerve injuries, that the entire nerve to the brachialis can be taken as a donor nerve without any deficit in elbow flexion strength. Based on this experience, we have used the brachialis nerve as a donor to restore AIN function in patients who have peripheral nerve injuries, but not in those with spinal nerve injuries. In our first experience with the use of the nerve to the brachialis to innervate the AIN, we noted recovery of MRC Grade 3–4 strength in 5 patients with early reinnervation by 1 year and improving strength over the course of 4 years.50 In the current paper, we report the successful reinnervation of the AIN to restore some finger and thumb flexion in a patient with a complete cervical SCI 22 months after injury.

Nerve transfer for SCI is not a new concept—SCI “bypass” techniques have been investigated in both animal22,25,26,33,52,61,62 and human studies.14,24,27,30,31,44,65 Most of the reports involving humans relied upon the transfer of intercostal nerves proximal to the level of SCI to lumbar nerve roots distal to the site of injury. Dai et al.14 report their experience with 21 patients with complete SCIs who underwent transfer of intercostal nerves to the L2–4 lumbar nerve roots. The authors reported that 5 patients achieved at least some return of lower-extremity motor function (MRC Grade 1–3). Zhang et al.65 describe their extensive experience in 23 patients treated with intercostal nerve–lumbar nerve root transfers. The authors report that 78% of treated patients regained some ability to ambulate with assistance.

While the use of expendable intercostal nerves as donors has received significant attention, several authors have also described techniques for reimplanting peripheral nerve grafts directly into the spinal cord itself. Carlstedt et al.13 reported on a series of 10 patients with avulsion injuries that were treated with implantation of the ventral nerve root and nerve grafts into the spinal cord. These authors reported that 3 patients achieved meaningful (MRC Grade 4) functional recovery of proximal muscle function. Further work with this technique by Fournier et al.18 is still in the early follow-up period, but has produced promising early results. Tadie et al.57 described a single case in which sural nerve autografts were implanted directly into the ventral horn proximal to the site of SCI. The grafts were then connected to the L2–4 lumbar ventral roots. These authors reported some volitional return of bilateral adductor longus and left rectus femoris function. Brunelli9 and Brunelli and von Wild10 have reported their experience using a novel implantation strategy that utilizes reimplantation of peroneal nerve autograft into the corticospinal tract and subsequent neurotization with the gluteus maximus, gluteus medius, and quadriceps. Their ongoing follow-up has demonstrated some voluntary activation of the reinnervated muscles with some patients achieving ambulatory status with assistive devices. We have completed sensory nerve transfers from the upper extremity (medial antebrachial cutaneous nerve) to the lower extremity (lateral femoral nerve) to innervate the cutaneous territory of the tensor fascia lata to facilitate the transfer of a sensate flap in a paraplegic patient with persistent pressure ulcers.

More recently, Bertelli et al.5 reported their experience with the reinnervation of the posterior interosseous nerve using the supinator as a donor, in a patient with a C-6 SCI. The authors reported restoration of useful finger and thumb extension, with no deficits in donor function. This same group also reported a case of reinnervation of the triceps brachii using the teres minor motor branch in a patient with a C-6 SCI.4 This patient regained MRC Grade 4 strength in elbow extension. As with our patient, in both cases reported by Bertelli and colleagues,4,5 the patients underwent transfer more than 6 months after the initial injury. In contrast to brachial plexus or more distal nerve injuries, SCIs result in upper motor neuron paralysis, preserving the integrity of the neuromuscular junction. Although limited to case reports, these results suggest a longer and perhaps indefinite window for treating patients with SCIs.

Our knowledge that the nerve to the brachialis is an expendable donor evolved from the discussion around the merits of reinnervating it in patients with brachial plexus injuries who have no elbow flexion.11,42 While our own experience has evolved to include reinnervation of both the biceps brachii and brachialis muscles, some authors have suggested that the innervation of the brachialis is not critical to recovery of elbow flexion.11 This prompted us to conclude that in a patient with normal elbow flexion, the nerve to the brachialis is entirely expendable. Our first transfer of the brachialis nerve to the AIN was in 2007, and we noted no functional donor deficits.50 Similarly, we have found in other cases of brachial plexus and median nerve injuries that the entire nerve to the brachialis can be taken as a donor without any deficit in elbow flexion strength.50 Based on this experience, we have used the brachialis nerve as a donor to restore AIN function. The examination videos accompanying this communication show no index finger or thumb flexion preoperatively and some recovery in the left hand at 15 months with minimal recovery in the right hand at the same time point (Videos 1, 2, 4, and 5). The patient's dense interphalangeal fixed joint contractures make the visual results less impressive than the improved function he now enjoys in his left hand. Our experience with this transfer in nerve injury50 suggests optimism for continued improvement for this patient over the next 3 years. Given that our patient can now feed himself light foods and write with assistance, we present this recovery of hand function for consideration.

In the situation of a patient with an SCI (unlike a nerve injury) both the recipient and the donor fascicular groups are available for electrical stimulation. Thus, in contrast to patients with peripheral nerve injuries, in whom the AIN will not respond to electrical stimulation, in patients with SCIs the surgeon will be able to tease out the fascicular group that innervates the AIN-innervated muscles. We do think, however, that it is appropriate for the readership doing this procedure to know that the AIN group will be found on the medial aspect of the median nerve in the posterior quadrant (Fig. 2) (KU Boyd, G Dhaliwal, A Yee, et al., presented at the American Society for Peripheral Nerve annual meeting, 2012). This will allow surgeons to separate that section of the median nerve first, stimulate that section, and visualize a response in the thumb and index finger. Importantly, while the surgeon will be able to stimulate that part of the median nerve to give thumb and index finger function, the patient himself will not be able to volitionally control that function, as it is below the cord injury. In contrast, the pronator teres fascicle, which is in the anterior portion of the median nerve, will be within the patient's control, and care must be taken not to injure any nerves that are functioning that the patient has control of, such as the nerve to the pronator or the flexor carpi radialis. All of the motor neural elements in the median nerve will respond to direct electrical stimulation despite the interruption at the site of SCI.

The nerves to the muscle and tendon units used with established tendon transfers (for example, the nerves to the supinator or brachioradialis) are also theoretically available as expendable donor nerves for motor nerve transfers. In our patient, we noted intraoperatively that electrical stimulation of the ulnar nerve in the arm resulted in the contraction of extrinsic and intrinsic ulnar nerve–innervated muscles. Thus, we envision utilizing the nerve to the supinator or brachioradialis as a donor, repaired to a long nerve graft in the forearm, to carry regenerating motor axons along the graft to the wrist. At a second procedure, approximately 12 months later, the distal end of the nerve graft would be coapted to the proximal end of a freshly transected motor fascicular component of the ulnar nerve at the wrist in an end-to-end fashion to reinnervate the ulnar intrinsic muscles in the hand.8 This is conceptually similar to the 2-staged cross-facial nerve graft procedure,23 where the nerve graft is placed across the face with the proximal connection and the distal repair to a free muscle is performed months later, after the nerves have had time to traverse the graft to minimize time of muscle denervation.
Conclusions

To our knowledge, this is the first reported case of thumb and finger flexor reinnervation after an SCI. While the results in this patient are usually modest, due to the severe joint stiffness, his function has improved significantly with his ability to feed himself. We have noticed in our patients with peripheral nerve injuries who have undergone brachialis nerve–AIN transfer that they recover Grade 3 motor power by 12 months and continue to recover Grade 4 motor power with longer follow-up.50 In the case reported in the present paper, the patient's histological sections showed essentially normal findings in the AIN in keeping with its preserved connection to the motor nerve pool below the level of injury. As Bertelli et al.4,5 have previously demonstrated, the use of nerve transfers may represent a significant breakthrough toward improved independent function in select patients with cervical SCIs. Given the muscle preservation provided by the intact motor neuron pool, the time frame for performing nerve transfers following an SCI is not a factor as it is in peripheral nerve injuries. Further studies will be required to assess reliable clinical outcomes and optimal timing for surgical intervention.
Disclosure

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Author contributions to the study and manuscript preparation include the following. Conception and design: Mackinnon. Acquisition of data: Ray. Analysis and interpretation of data: Ray. Drafting the article: Ray. Critically revising the arcticle: all authors. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Ray. Videos and imaging: Yee.
Acknowledgments

The authors would like to acknowledge Ms. Cynthia C. Ivy, O.T., and Lorna Kahn, P.T., for their expertise with motor reeducation of this transfer; Daniel Hunter for the preparation of histomorphometry; and Dr. Martin Robson for independent physical examination of and introduction to this patient.
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Posted 01 June 2012 - 05:37 PM


Paralysed rats walk again in Swiss lab study
Chris Wickham, ReutersJune 1, 2012, 6:01 am


LONDON (Reuters) - Scientists in Switzerland have restored full movement to rats paralysed by spinal cord injuries in a study that might eventually be used in people with similar injuries.

Gregoire Courtine and his team at Ecole Polytechnique Federale de Lausanne saw rats with severe paralysis walking and running again after a couple of weeks following a combination of electrical and chemical stimulation of the spinal cord together with robotic support.

"Our rats are not only voluntarily initiating a walking gait, but they are soon sprinting, climbing up stairs and avoiding obstacles," said Courtine, whose results from the five-year study will be published in the journal Science on Friday.

Courtine is quick to point out that it remains unclear if a similar technique could help people with spinal cord damage but he adds the technique does hint at new ways of treating paralysis.

Other scientists agree.

"This is ground-breaking research and offers great hope for the future of restoring function to spinal injured patients," said Elizabeth Bradbury, a Medical Research Council senior fellow at King's College London.

But Bradbury notes that very few human spinal cord injuries are the result of a direct cut through the cord, which is what the rats had. Human injuries are most often the result of bruising or compression and it is unclear if the technique could be translated across to this type of injury.

It is also unclear if this kind of electro-chemical "kick-start" could help a spinal cord that has been damaged for a long time, with complications like scar tissue, holes and where a large number of nerve cells and fibres have died or degenerated.

Nevertheless, Courtine's work does demonstrate a way of encouraging and increasing the innate ability of the spinal cord to repair itself, a quality known as neuroplasticity.

Other attempts to repair spinal cords have focused on stem cell therapy, although Geron, the world's leading embryonic stem cell company, last year closed its pioneering work in the field.

The brain and spinal cord can adapt and recover from small injuries but until now that ability was far too limited to overcome severe damage. This new study proves that recovery from severe injury is possible if the dormant spinal column is "woken up".

Norman Saunders, a neuroscientist at the University of Melbourne in Australia, said in an emailed statement reacting to the study that although it remains to be seen whether the technique can be translated to people, "it looks more promising than previously proposed treatments for spinal cord injury".

Bryce Vissel, head of the Neurodegenerative Diseases Research Laboratory at the Garvan Institute of Medical Research in Sydney, said the study "suggests we are on the edge of a truly profound advance in modern medicine: the prospect of repairing the spinal cord after injury".

Courtine hopes to start human trials in a year or two at Balgrist University Hospital Spinal Cord Injury Centre in Zurich.

"Our rats have become athletes when just weeks before they were completely paralysed," he said. "I am talking about 100 percent recuperation of voluntary movement."

(Editing by Ben Hirschler and Alessandra Rizzo)


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Posted 17 June 2012 - 10:39 AM

Vein grown using girl's stem cells

JOHN VON RADOWITZ THURSDAY 14 JUNE 2012


NHS to remove 750 women's implants

[A 10-year-old girl has been given a vein transplant using a blood vessel grown from her own stem cell

It is the first time such an operation has been undertaken, marking a milestone in tissue engineering.

Similar techniques may in future offer hope for at-risk patients undergoing bypass surgery.

The girl had a blocked hepatic portal vein, which drains blood from the gut and spleen to the liver.

Without treatment, the condition can lead to serious complications including internal bleeding, spleen enlargement and even death.

Traditionally bypass surgery has been used to restore portal blood flow, using sections of vein taken from other parts of the body. This can cause other problems and is not always successful.

The new technique involved growing a new section of portal vein from the girl's own bone marrow stem cells.

First, a nine centimetre segment of groin vein was taken from a deceased donor and stripped of cellular tissue, leaving a tubular protein "scaffold".

Maturing stem cells were "seeded" into the scaffold, which two weeks later was implanted into the girl's body.

Normal blood flow was restored, but after a year the graft had to be lengthened with another piece of vein made from stem cells.

The girl has remained well since and even managed to take part in gymnastics, the Swedish team reported in the latest online edition of The Lancet medical journal.

The researchers, led Professor Suchitra Sumitran-Holdgersson, from the University of Gothenburg, wrote: "The new stem cells-derived graft resulted not only in good blood flow rates and normal laboratory test values but also in strikingly improved quality of life for the patient."

Because the graft was built from the girl's own cells, it was accepted by her immune system.

Two British experts commenting in The Lancet said the technique looked promising but was yet to be properly tested in clinical trials.

Professor Martin Birchall and Professor George Hamilton, both from University College London, wrote: "The young girl in this report was spared the trauma of having veins harvested from the deep neck or leg, with the associated risk of lower limb disorders, and avoided the need for a liver or multivisceral transplantation."

However they pointed out that the high cost of such procedures might be an obstacle to making them more widely available.

PA
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Posted 13 August 2012 - 10:17 PM

http://www.news.com....0-1226448484876

Woman born without a thumb and finger grows them back as part of a phantom limb after hand amputated


Ian Horswill
news.com.au
August 12, 2012 9:01AM

Read more: http://www.news.com....6#ixzz23Q44s2qi


14
Fingers on hand

A WOMAN born missing a right hand finger and a thumb has "grew" them back as part of a phantom limb after her hand was amputated.

University of California neuroscientists in San Diego said the experience of the woman - known as RN - showed the brain has its own internal template of how the body should look, regardless of what they actually look like .

The woman was born with only three fingers on her right hand and had the hand amputated after a car accident when she was aged 18. She later began to feel that her missing limb was still present and developed a "phantom" hand.

"But here's the interesting thing," Paul McGeoch at the University of California, San Diego, told New Scientist. "Her phantom hand didn't have three digits, it had five."

However RN's phantom thumb and index finger were less than half the usual length and were painful.

Dr McGeoch and Professor V.S Ramachandran used a mirror box which reflected the woman's left hand to make it look like she had a pair of limbs.

After two weeks of training RN was able to extend the short fingers on her phantom limb, which relieved her pain.

McGeoch said the study indicates that there is a hardwired representation in the brain of what the body should look like, regardless of how it actually appears in real life. It showed more about the balance between the external and innate representations of a limb, he said.

"The presence of the deformed hand was suppressing the brain's innate representation of her fingers which is why they appeared shorter, but after the hand was removed and the inhibition taken away, the innate representation kicks in again."

Matthew Longo at Birkbeck, University of London
, told Mail on Sunday that the case study. "Contributes to a growing literature suggesting that our conscious experience of our body is, at least in part, dependent on the intrinsic organisation of the brain, rather than a result of experience."

Read more: http://www.news.com....6#ixzz23Q4PctFH
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Posted 13 August 2012 - 10:34 PM

http://www.newscient...antom-form.html

Woman's missing digits grow back in phantom form


11:55 10 August 2012 by Helen Thomson

A woman born missing a finger and a thumb has grown them back – albeit as part of a phantom limb. This extraordinary occurrence shows that our brain contains a fully functional map of our body image, regardless of what our limbs actually look like.

The woman, RN, was born with just three fingers on her right hand. Aged 18, RN had the hand amputated after a car accident. She later began to feel that her missing limb was still present, and developed a "phantom" hand.

"But here's the interesting thing," says Paul McGeoch at the University of California, San Diego. "Her phantom hand didn't have three digits, it had five."

RN was aware of a full complement of fingers, but her phantom thumb and index finger were less than half the usual length.

With training using a mirror box trick – a tool that creates the visual illusion of two hands – McGeoch and V.S Ramachandran, also at San Diego, managed to extend her short phantom finger and thumb to normal length.

McGeoch says this study indicates that there is a hardwired representation in the brain of what the body should look like, regardless of how it actually appears in real life. It shows us more about the balance between the external and innate representations of a limb, he says.

"The presence of the deformed hand was suppressing the brain's innate representation of her fingers which is why they appeared shorter, but after the hand was removed and the inhibition taken away, the innate representation kicks in again."

Matthew Longo at Birkbeck, University of London
, says it is a fascinating case study. "It contributes to a growing literature suggesting that our conscious experience of our body is, at least in part, dependent on the intrinsic organisation of the brain, rather than a result of experience."

Journal reference: Neurocase, DOI: 10.1080/13554794.2011.556128
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Posted 14 June 2013 - 05:19 PM

What is a stump?

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A series on small but significant insights into disabled life

http://www.bbc.co.uk...s-ouch-22887103

14 June 2013 Last updated at 00:48 GMT Share this pageEmail Print Share this page

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What is a stump? Comments Ouchlets
A series on small but significant insights into disabled life


This man lost his arms and legs after suffering meningitis
The Paralympics brought prosthetics such as running blades into the limelight. But what about the body parts that keep them attached?

What is a stump?

After an amputation, the bit that's left beyond a healthy joint is called a residual limb, or more commonly, a stump.

People born without all or part of an arm or leg, are said instead to have a limb difference.

How is a stump created?
Continue reading the main story
How common are amputations?
Approximately 5-6,000 major limb amputations carried out in the UK every year
Most common reason for leg amputation is a loss of blood supply to affected limb (critical ischaemia)
Trauma is most common reason for upper limb amputation
Diabetes sufferers are 15 times more likely to need an amputation than general population, because high blood glucose levels can damage blood vessels, leading to restriction in blood supply
More than half of all amputations performed in people aged 70 or over; men twice as likely to need an amputation as women
NHS Choices: Amputation
To amputate, surgeons cut through skin, muscle, blood vessels, nerves and bone. The exposed bone then gets filed smooth, with rounded edges. Nerves are cut slightly higher than the main amputation area and retracted up into the muscle, to prevent potentially painful bundles of nerve cells from forming close to the stump's surface.

The remaining muscle gets re-attached to bone, providing protective padding and helping to shape the stump. Skin is sewn together in such a way that once healed, the scar won't rub against an artificial limb.

Do stumps change over time?
Stumps shrink so much during their first months that the socket of a prosthesis fitted before surgery becomes too big and needs replacing. In the meantime, thick stump socks are worn to keep the prosthesis in place.

Once stable, stumps are checked at least once a year for potential problems. Growing children may need surgery to trim the bone. Heather Mills had a revision amputation in 2003, after muscle detached itself, causing skin and bone to rub painfully against each other as she walked.


CBeebies presenter Cerrie Burnell was born with a limb difference
Do stumps need looking after?
Skin wasn't designed to spend hours each day inside a plastic socket. Diane Mulligan, who lost her leg above the knee in a motorbike accident eight years ago, likens wearing a false leg to wearing the same pear of 80s jelly shoes, every single day.

Continue reading the main story
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"My skin rubs against the plastic and breaks down very easily," she says. "I get sores and cracked skin as a result."

She uses an anti-chafing cream that works "like Teflon on a non-stick saucepan".

Diane says she tried Botox to reduce sweating because her stump smelled so badly. When in-growing hairs on her stump became infected, she couldn't wear her prosthesis for weeks. And like many amputees, she gets pain in the place where her missing limb was. This is known as phantom limb pain.

Diane's top stump care tips are to "keep it really clean and take your prosthesis off as much as possible."

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