the future of neurosurgery - university of utah school of ... · las vegas denver phoenix...

Clinical Neurosciences CenterDepartment of Neurosurgery

SURGICAL

NEUROREHABILITATION

Mark A. Mahan, MDAssistant Professor

Dept. of Neurosurgery

University of Utah


MARK A. MAHAN, MD

• Undergraduate: Princeton University

• Medical school: Columbia University

• Neurosurgical residency: Barrow

• Infolded fellowship in peripheral nerve

surgery (AANS/CNS Cahill Award)

– Robert Spinner MD at Mayo Clinic, Rochester

– Justin Brown MD at UCSD


WHY I CAME TO THE

UNIVERSITY OF UTAH


ACADEMIC NEUROSURGEONS WITH

PERIPHERAL NERVE PRACTICESSeattle

Salt Lake City

Las Vegas

Denver

Phoenix

Albuquerque

Kansas City

Dallas

OKC


ACADEMIC NEUROSURGEONS WITH

PERIPHERAL NERVE PRACTICES


PERIPHERAL NERVE TERRITORY

• Peripheral nerve tumors

• Entrapment neuropathies

• Pain

• Reconstruction

• Functional


PERIPHERAL NERVE TERRITORY• Peripheral nerve tumors

– Benign

– Syndromes, e.g., neurofibromatosis

– MPNSTs and metastases

– Non-tumors, e.g., ganglion cysts, perineuriomas


• Pain

• Reconstruction

• Functional



– Benign





• Pain

• Reconstruction

• Functional

Cutaneous schwannoma, 1/23/14



– Benign





• Pain

• Reconstruction

• Functional

Plexiform schwannoma of lateral cord, 4/15/14



– Benign





• Pain

• Reconstruction

• Functional

Malignant peripheral nerve sheath tumor of medial cord, 10/11/13



– Benign





• Pain

• Reconstruction

• Functional

Intraneural ganglion cyst, 7/16/12





– Simple: carpal, cubital

– Complex: revision, thoracic outlet syndrome

• Pain

• Reconstruction

• Functional





– Simple: carpal, cubital

– Complex: revision, thoracic outlet syndrome

• Pain

• Reconstruction

• Functional

Cervical rib resection, 11/14/13





• Pain

– Stimulation

– Neurectomies, e.g., triple neurectomy

• Reconstruction

• Functional





• Pain

– Stimulation

– Neurectomies, e.g., triple neurectomy

• Reconstruction

• Functional

Robotic triple neurectomy 2/13/13




• Pain

• Reconstruction

– Brachial plexus injuries

– Traumatic/iatrogenic nerve injuries,

including facial nerve

– Spinal cord injuries

• Functional




• Pain

• Reconstruction

– Brachial plexus injuries

– Traumatic/iatrogenic nerve injuries,

including facial nerve

– Spinal cord injuries

• Functional

Multiple nerve transfers for brachial plexus injury, 6/3/13



• Pain



• Reconstruction

• Functional

– Spasticity

– Dystonias



• Pain



• Reconstruction

• Functional

– Spasticity

– Dystonias

Sitthinamsuwan et al., Stereotact Funct Neurosurg 2013



• Pain



• Reconstruction

• Functional

– Spasticity

– Dystonias

Anderson et al., JNS 2008


DISCUSSION TODAY

• Nerve injury reconstruction

• Spinal cord injury reconstruction

• Spasticity reduction

• Robotic prostheses for amputees


NERVE INJURY

RECONSTRUCTION


BRACHIAL PLEXUS RECONSTRUCTION• Primary plexus exploration and anatomical grafting

for extraforaminal nerve ruptures

• Distal nerve transfers for late presentation and use

of extraplexal donors for avulsions, e.g.,

– Oberlin and double-fascicular transfers

– Leechavengvong triceps branch to axillary nerve

– Spinal accessory nerve to suprascapular nerve

Guiffre et al., JHS 2010

Thoracodorsal and triceps to axillary,

ulnar and median to musculocutaneous

transfers 5/23/13


NERVE GRAFTING


NERVE TRANSFER


EVEN SENSORY RESTORATION

Dorsal Ulnar Cutaneous

Lateral

Antebrachial

Cutaneous

From Brown, J. M, Mackinnon, S. “Nerve transfers in the forearm and hand.” Hand Clinics 24

(2008): 319–334.


• Use of free-functioning muscle

transfers when appropriate

• Consideration of tendon transfer

options and selective joint fusions for

optimal results

Guiffre et al., JHS 2010

• Complex obstetrical brachial

plexus reconstruction,

including hemi-contralateral

C7 transfers

Hemi-contralateral C7 for OBPP 10/31/12


FREE-FUNCTIONING MUSCLE TRANSFER

Gracilis free-functioning muscle transfer for brachial plexus injury, 12/8/14


FREE-FUNCTIONING MUSCLE TRANSFER

Intercostal

nerves

Ribs

Pectoralis

Gracilis

graft

Gracilis free-functioning muscle transfer for brachial plexus injury, 12/8/14


NERVE INJURY, TRAUMATIC OR IATROGENIC

• Common injuries

– Spinal accessory nerve injury on posterior

cervical triangle exploration

– Common peroneal grafting for knee dislocation

– Sciatic nerve palsy after total hip arthroplasty

• As well as nerve biopsy

– Sural, as outpatient

– Anywhere else, e.g.,

sciatic, superficial radial,

great auricular, etc.

Spinal accessory nerve iatrogenic injury, s/p failed exploration by

another neurosurgeon, grafted 11/26/12


Internal neurolysis of

common peroneal nerve

Common peroneal

nerve (encased in

scar)

Tibial nerve

Transferred one of the 2 lateral gastroc branches to

the deep branch of the common peroneal nerve

Lateral head of

gastroc

Two branches to

lateral gastroc

Medial gastroc

branches

Tibial nerve to

post tib, foot,

etc.

Lateral gastroc branch transfer to deep peroneal fascicles, 12/23/14


FACIAL REANIMATION• Immediate nerve transfer options for distal

nerve injuries and intracranial injury– Masseter branch of trigeminal nerve

– Cross-facial with or without side-to-end hypoglossal baby-sitter

– Hemihypoglossal

– Spinal accessory nerve

– Deep temporal branch of trigeminal nerve

• Free-functioning muscle transfers for late presentation or failed conservative management

Klebuc, PRS 2011


NERVE INJURY

• Early referral is paramount

– Avulsion / nerve transection: immediate

surgery

– Stretch: surgery within 3-6 months

• All patients with neurological loss, even

brachial neuritis, may be a candidate for

reconstruction


SPINAL CORD INJURY


NERVE TRANSFERS FOR SPINAL

CORD INJURY

• Grasp• Brachialis branch to anterior interosseous nerve

• Brachialis branch to extensor carpi radialis longus

• ECRL branch to flexor policis longus

• Release• Supinator branch to posterior interosseous nerve

• Elbow extension • Posterior axillary branch to triceps

• Teres minor branch to triceps

• Bladder function


SUPINATOR to PIN

Radial Sensory

ECRB

PIN

Supinator


AXILLARY TO TRICEPS

Triceps branch

Axillary nerve

Axillary nerveRadial nerve and

triceps branches


SPINAL CORD INJURY

• Referral during acute phase is beneficial

for patient mindset

• Extensive counselling and retraining is

key to mastery of new functions

• Nerve transfers for restoration of the

injured segment should be done prior to 6

months


SURGICAL OPTIONS FOR

SPASTICITY


ESSENTIAL RUBRIC

• Peripheral nerve / muscle

Focal spasticity

• Lumbar dorsal rhizotomies

Spastic diplegia

• Continuous intrathecal baclofen (iTB) infusion

Generalized spasticity


TREATMENT OPTIONS

After failure of conservative / medications

• Peripheral neurotomies / neurectomies

• Tendon lengthening / muscle transfer

• Chemodenervation


SURGICAL NEUROTOMY


THE LOWER LIMB

• Obturator neurotomySpasticity of the adductor muscles

• Hamstring neurotomySpasticity of knee flexion

• Tibial neurotomySpastic foot & equinovarus

• Anterior tibial neurotomyEHL spasticity

• Femoral neurotomy Spasticity of the quadriceps


THE UPPER LIMB

• Pectoralis major and teres major neurotomies

Spasticity of shoulder internal rotators

• Musculocutaneous neurotomy

Spasticity of elbow flexion

• Median and ulnar neurotomies

Spasticity of the pronators and flexors of the wrist and finger


Radial neurotomies for triceps spasticity due to incomplete spinal cord injury, 3/27/13


RESULTS

• Better positioning

• Reduced risk for contractures

• Greater mobility

• Increased use

• Broader independence

• Lower medication side effects

Sitthinamsuwan et al., Stereotact Funct Neurosurg 2013


PHYSIOLOGIC RATIONALE


REDUCE AFFERENT PATHOLOGY

• Varying on nerve & muscle type, ~25% to

~50% of a motor branch is efferent

• Desire to reduce information from afferent

type I and II fibers from muscle spindles

that mediate stretch reflexes

Gottschall J, et al. Anatomy and embryology 160:285-300, 1980

The goal is not to create palsy


DENERVATION AND REINNERVATION

• New motor endplates appear, and the size of motor units increases in proportion to the degree of denervation1

– On average, motor units increase by about five times their original size

• Reinnervation of the muscle spindles is generally non-functional

– Absence of long-term recovery of H-reflex

1: Dengler et al. Neurosci Lett 97:118-122, 1989


EXTENT OF SECTION

• Scant scientific basis – individual

variability

• Most surgeons advocate 50% to 80%

(usually 75%) of branches to a particular

muscle1

• Maximal reinnervation – 8 months (H-

reflex)

1: Sindou et al. Childs Nerv Syst 23:957-970, 2007


CERVICAL DYSTONIA

• Selective denervation and myomectomy for cervical dystonia

• Multidimensional care with EMG-guided Botox injections

Anderson et al., JNS 2008


AMPUTEE


MORE TO COME


Thank you

Mark A. Mahan, MD

[email protected]

Office 801-585-7917

Cell 602-400-9697

Scheduling RN for provider

referrals 801-581-5200

the future of neurosurgery - university of utah school of ... · las vegas denver phoenix...

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