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Objective: To explore the anatomic characteristics of C7 nerve localization, course, and length during cross-transfer surgery of the C7 nerve through the anterior vertebral approach and investigate the feasibility, safety, and clinical efficacy of C7 nerve transfer surgery through the anterior vertebral approach for the treatment of central upper limb spastic paralysis., Methods: Four fresh-frozen adult head and neck samples were selected. C7 nerve transfer surgery was simulated through the anterior vertebral approach. The vertical distance between the C7 nerve and the medial edge of the clavicle, the length of the C7 nerve, and the shortest distance of C7 nerve transfer required through the anterior vertebral approach were measured. This was a retrospective analysis of the clinical data of 2 patients with central upper limb spastic paralysis after C7 nerve transfer surgery at Northern Jiangsu People's Hospital affiliated with Yangzhou University. The patients were all female, aged 50 to 51 years, with upper limb paralysis on the affected side. The muscle strength was grade 0 or grade 1, and the muscle tension was relatively high. Both patients underwent C7 nerve transfer surgery through the anterior vertebral approach. Upper limb sensation and motor function were observed., Results: Bilateral C7 nerves can be fully exposed and located through the anterior vertebral approach. The C7 nerve runs between the anterior and middle scalene muscles, with a vertical distance of 1.7 to 2.5 (2.1±0.3) cm from the inner edge of the clavicle. The length of the C7 nerve is 5.6 to 6.8 (6.4±0.5) cm, and the shortest distance of C7 nerve transfer through the anterior vertebral approach is 4.8 to 5.7 (5.3±0.4 cm). Two patients with central upper limb paralysis successfully underwent C7 nerve transfer surgery using the anterior vertebral approach. Two patients had normal motor function in the healthy upper limb after surgery but experienced pain and numbness in the healthy upper limb. Both patients recovered within 1 month. Two patients experienced significant relief of spasticity symptoms in the affected upper limb. One patient was followed up for 15 months, and, at the last follow-up, sensation in the affected upper limb was normal, with proximal muscle strength at level 3 and distal muscle strength at level 2. Another patient was followed up for 11 months, and at the last follow-up, sensation in the affected upper limb was normal, with proximal muscle strength at level 1+ and distal muscle strength at level 1., Conclusion: For central upper limb spastic paralysis, C7 nerve transfer surgery through the anterior vertebral approach is safe and feasible and is a good treatment option. Related anatomic research can effectively guide clinical surgery and assist in locating the C7 nerve, and incising the musculus longus colli can shorten the distance of C7 nerve transfer., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 by Mutaz B. Habal, MD.)

Background: Modern nerve-to-nerve transfers are a significant advancement in peripheral nerve surgery. Nerve transfers involve transferring donor nerves or branches to recipient nerves close to the motor end unit, leading to earlier reinnervation and preservation of the musculotendinous units in proximal nerve injuries. After nerve reinnervation, function may be superior to traditional tendon transfer techniques in terms of strength and independent motion. Nerve transfer surgery has emerged as a promising treatment option for many cases of nerve injury that were previously expected to result in poor outcomes, such as proximal injuries, long nerve gaps, or unavailability of the proximal injured segment., Methods: A review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Publications that focused on upper extremity nerve transfers were included, and functional motor and sensory recovery was analyzed. Technique reports, case reports, brachial plexus injuries, and reports on multiple nerve injuries were excluded., Results: A total of 48 relevant articles were identified with search criteria, and we discuss functional outcomes on nerve transfers for ulnar nerve injury, musculocutaneous nerve injury, median nerve injury, and radial nerve injury that met inclusion criteria., Conclusions: Nerve transfers are an option for restoring hand and forearm function in patients with peripheral nerve injuries adversely affecting their ability to function. The literature demonstrates positive functional outcomes after nerve transfer operations, and thus, the utility and variations have increased. We aim to provide an overview of the outcomes of current nerve transfer techniques for ulnar, radial, median, and musculocutaneous acquired/traumatic mononeuropathies in the hand and upper extremity., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSREV/B174)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Purpose: Targeted muscle reinnervation (TMR) is a relatively recent surgical innovation that involves the coaptation of major peripheral nerves to a recipient motor branch that innervates an expendable muscle target. The original indication for TMR was augmentation and optimization of myoelectric signals in the amputated limb for use of myoelectric prosthetics. Incidentally, surgeons and patients discovered that the technique also could treat and prevent phantom and residual limb pain. TMR is performed at the time of amputation or delayed any time after the amputation, and TMR can also be performed at any level of amputation. In the upper extremity, studies have detailed the various techniques and coaptations possible at each amputation level to create intuitive myoelectric signals and treat neurogenic pain. Treatment of peripheral nerves in the amputee with TMR should be a consideration for all patients with major upper extremity amputations, especially at large institutions able to support multidisciplinary limb salvage teams. This review article summarizes the current literature and authors' techniques and recommendations surrounding TMR in the upper extremity amputee including techniques relevant to each level of upper extremity amputation., (© 2023. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Upper extremity peripheral nerve injuries present functional deficits that are amenable to management by tendon or nerve transfers. The principles of tendon and nerve transfers are discussed, with technical descriptions of preferred tendon and nerve transfers for radial, median, and ulnar nerve injuries., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Peripheral nerve lesions of the upper extremity are common and are associated with devastating limitations for the patient. Rapid and accurate diagnosis of the lesion by electroneurography, neurosonography, or even MR neurography is important for treatment planning. There are different therapeutic approaches, which may show individual differences depending on the injured nerve. If a primary nerve repair is not possible, several strategies exist to bridge the gap. These may include autologous nerve grafts, bioartificial nerve conduits, or acellular nerve allografts. Tendon and nerve transfers are also of major importance in the treatment of nerve lesions in particular with long regeneration distances. As a secondary reconstruction, in addition to tendon transfers, there is also the option for free functional muscle transfer. In amputations, the prevention of neuroma is of great importance, for which different strategies exist, such as target muscle reinnervation, regenerative peripheral nerve interface, or neurotized flaps. In this article, we give an overview of the latest methods for the therapy of peripheral nerve lesions., (© 2023. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Nerve transfer for motor nerve paralysis is an established technique for treating complex nerve injuries. However, nerve transfer for sensory reconstruction has not been widely used, and published research on this topic is limited compared to motor nerve transfer. The indications and outcomes of nerve transfer for the restoration of sensory function remain unproven. This scoping review examines the indications, outcomes and complications of sensory nerve transfer. In total, 22 studies were included; the major finding is that distal sensory nerve transfers are more successful than proximal ones in succeeding protective sensation. Although the risk of extension of the sensory deficit with donor site loss and morbidity from neuromas remain a barrier to wider adoption, these complications were not reported in the review. Further, the scarcity of studies and small patient series limit the ability to determine sensory nerve transfer success. However, sensory restoration remains an opportunity for surgeons to pursue. Level of evidence: II., Competing Interests: Declaration of conflicting interestsThe authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose: Nerve transfers to restore or augment function after spinal cord injury is an expanding field. There is a paucity of information, however, on the use of nerve transfers for patients having undergone spine surgery. The incidence of neurologic deficit after spine surgery is rare but extremely debilitating. The purpose of this study was to describe the functional benefit after upper extremity nerve transfers in the setting of nerve injury after cervical spine surgery., Methods: A single-center retrospective review of all patients who underwent nerve transfers after cervical spine surgery was completed. Patient demographics, injury features, spine surgery procedure, nerve conduction and electromyography study results, time to referral to nerve surgeon, time to surgery, surgical technique and number of nerve transfers performed, complications, postoperative muscle testing, and subjective outcomes were reviewed., Results: Fourteen nerve transfers were performed in 6 patients after cervical spine surgery. Nerve transfer procedures consisted of a transfer between a median nerve branch of flexor digitorum superficialis into a biceps nerve branch, an ulnar nerve branch of flexor carpi ulnaris into a brachialis nerve branch, a radial nerve branch of triceps muscle into the axillary nerve, and the anterior interosseous nerve into the ulnar motor nerve. Average patient age was 55 years; all patients were male and underwent surgery on their left upper extremity. Average referral time was 7 months, average time to nerve transfer was 9 months, and average follow-up was 21 months. Average preoperative muscle grading was 0.9 of 5, and average postoperative muscle grading was 4.1 of 5 ( P < 0.00001)., Conclusions: Upper extremity peripheral nerve transfers can significantly help patients regain muscle function from deficits secondary to cervical spine procedures. The morbidity of the nerve transfers is minimal with measurable improvements in muscle function., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Distal nerve transfer is a refined surgical technique involving the redirection of healthy sacrificable nerves from one part of the body to reinstate function in another area afflicted by paralysis or injury. This approach is particularly valuable when the original nerves are extensively damaged and standard repair methods, such as direct suturing or grafting, may be insufficient. As the nerve coaptation is close to the recipient muscles or skin, distal nerve transfers reduce the time to reinnervation. The harvesting of nerves for transfer should usually result in minimal or no donor morbidity, as any anticipated loss of function is compensated for by adjacent muscles or overlapping cutaneous territory. Recent years have witnessed notable progress in nerve transfer procedures, markedly enhancing the outcomes of upper limb reconstruction for conditions encompassing peripheral nerve, brachial plexus and spinal cord injuries.

Selective nerve transfers are used in the setting of upper limb amputation to improve myoelectric prosthesis control. This surgical concept is referred to as targeted muscle reinnervation (TMR) and describes the rerouting of the major nerves of the arm onto the motor branches of the residual limb musculature. Aside from providing additional myosignals for prosthetic control, TMR can treat and prevent neuroma pain and possibly also phantom limb pain. This article reviews the history and current applications of TMR in upper limb amputation, with a focus on practical considerations. It further explores and identifies technological innovations to improve the man-machine interface in amputation care, particularly regarding implantable interfaces, such as muscle electrodes and osseointegration. Finally, future clinical directions and possible scientific avenues in this field are presented and critically discussed., Competing Interests: Declaration of conflicting interestsThe authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

We report a retrospective study of 112 nerve transfers in 39 participants to investigate predictors of strength outcomes after nerve transfer surgery for upper limb reanimation in tetraplegia. We measured clinical and pre- and intraoperative neurophysiological assessment variables and compared them with strength outcomes 2 years after nerve transfer surgery. We found statistically significant improvement in Medical Research Council strength grades after nerve transfer surgery with lower cervical spine injuries (between one and two grades), lower donor nerve stimulation thresholds (half of a grade), greater motor evoked potential activity in recipient nerves (half of a grade) and greater muscle responses to intraoperative stimulation of donor (half of a grade) and recipient nerves (half of a grade). Level of evidence: III.

Prior to the 1950s, relatively few patients who suffered a transection of the cervical spinal cord survived their injury. Improved medical care and better coordination have resulted in greater numbers of patients surviving and leaving the hospital. The pioneering work of individual surgeons during the 1960s and 1970s stimulated interest in surgical restoration of upper limb function in tetraplegic patients. Since the publication of Moberg's monograph in 1978, surgical improvement of the upper limbs is regarded as one of the options that should be offered to tetraplegic individuals to improve their function. Patients are classified according to the level of spinal cord injury and the residual motor function (international classification: groups 1-9). Surgical procedures are adapted to the motor level for each group of patients. Indications for these procedures are well standardized, the techniques are well mastered, and predictable results can be expected. New nerve transfer techniques have been developed in recent years; they are currently being evaluated., (Copyright © 2021 SFCM. Published by Elsevier Masson SAS. All rights reserved.)

Nerve transfer surgery (NT) constitutes an exciting option to improve upper limb functions in chronic spinal cord injury (SCI), but requires intact sublesional lower motor neuron (LMN) health. The purpose of this study was to characterize patterns of LMN abnormality in nerve-muscle groups that are the potential recipients of NT, using a standardized electrodiagnostic examination, in individuals with chronic SCI (injury duration >2 years, injury levels C4-T1). The LMN abnormality was determined using a semihierarchical approach, combining the amplitude compound muscle action potential (CMAP) and abnormal spontaneous activity on needle electromyography (EMG). Ten participants (46 potential recipient muscles) were included (median age, 42.5 years; six males and four females; median duration from injury, 15.5 years). A high frequency of LMN abnormality was observed (87%), although there was substantial variation within and between individuals. No statistically significant discordance was observed between LMN abnormality on CMAP and EMG ( p  = 0.24), however, 50% of muscles with normal CMAP demonstrated abnormal spontaneous activity. The high frequency of LMN abnormality in recipient nerve-muscle groups has implications to candidate selection for NT surgery in chronic SCI and supports the important role of the pre-operative electrodiagnostic examination. Our results further support the inclusion of both CMAP and needle EMG parameters for characterization of LMN health. Although the number of nerve-muscle groups with normal LMN health was small (13%), this underscores the neurophysiological potential of some patients with chronic injuries to benefit from NT surgery.

Learning Objectives: After studying this article and accompanying videos, the participant should be able to: 1. Understand and apply the principles of nerve transfer surgery for nerve injuries. 2. Discuss important considerations when performing nerve transfers, such as aspects of surgical technique and perioperative decision-making. 3. Understand indications for end-to-end versus supercharged reverse end-to-side nerve transfers. 4. Understand an algorithm for treating nerve injuries to include the indications and surgical techniques of five nerve transfers commonly performed for the treatment of isolated upper extremity nerve injuries. 5. Understand the outcomes and postoperative management of the discussed nerve transfers., Summary: Nerve transfers are gaining wide acceptance because of their superior results in the management of many nerve injuries of the upper extremity. This article presents five nerve transfers for the treatment of isolated nerve injuries in the authors' upper extremity nerve practice that offer reliable results. Indications, surgical techniques, outcomes, and postoperative management are reviewed. To maximize functional outcomes in patients with nerve injuries, the treatment should be individualized to the patient, and the principles for nerve transfers as described herein should be considered., (Copyright © 2021 by the American Society of Plastic Surgeons.)

Introduction: C7 nerve transfer alone can improve upper limb motor function and partial spasticity. Selective posterior rhizotomy (SPR) of the cervical nerve alone can comprehensively improve spasticity but without neuromotor regeneration. We propose a novel possible improvement of contralateral C7 (CC7) nerve transfer through the posterior vertebral approach, which was combined with SPR of the affected cervical nerve., Patient Concerns: A 33-year-old male patient presented with cerebral hemorrhage of the left basal ganglia, paralysis of the right limbs, and hypesthesia 8 months earlier. The dysfunction of the affected hand was already present at admission. The patient reported a previous history of hypertension for several years and oral antihypertensive drugs, and blood pressure was controlled within a normal range., Diagnosis: Central upper limb spastic paralysis. The muscle strength of the right lower limb was grade IV. The Fugl-Meyer score of the right upper limb was 7 points, and the modified Ashworth score was 10., Interventions: The patient underwent CC7 transfer and SPR., Outcomes: The patient successfully underwent CC7 transfer and SPR without complications. On the day after surgery, the left upper limb motions were normal. The Fugl-Meyer score was 9, and the modified Ashworth score of the right upper limb was 2., Conclusions: CC7 nerve transfer through the posterior vertebral approach combined with SPR of the affected cervical nerve can possibly improve the surgical outcomes of selected patients with upper limb motor dysfunction and partial spasticity. This method has not been reported in the literature before, and additional studies are necessary., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Targeted muscle reinnervation is an emerging surgical technique to treat neuroma pain whereby sensory and mixed motor nerves are transferred to nearby redundant motor nerve branches. In a recent randomized controlled trial, targeted muscle reinnervation was recently shown to reduce postamputation pain relative to conventional neuroma excision and muscle burying., Questions/purposes: (1) Does targeted muscle reinnervation improve residual limb pain and phantom limb pain in the period before surgery to 1 year after surgery? (2) Does targeted muscle reinnervation improve Patient-reported Outcome Measurement System (PROMIS) pain intensity and pain interference scores at 1 year after surgery? (3) After 1 year, does targeted muscle reinnervation improve functional outcome scores (Orthotics Prosthetics User Survey [OPUS] with Rasch conversion and Neuro-Quality of Life [Neuro-QOL])?, Methods: Data on patients who were ineligible for randomization or declined to be randomized and underwent targeted muscle reinnervation for pain were gathered for the present analysis. Data were collected prospectively from 2013 to 2017. Forty-three patients were enrolled in the study, 10 of whom lacked 1-year follow-up, leaving 33 patients for analysis. The primary outcomes measured were the difference in residual limb and phantom limb pain before and 1 year after surgery, assessed by an 11-point numerical rating scale (NRS). Secondary outcomes were change in PROMIS pain measures and change in limb function, assessed by the OPUS Rasch for upper limbs and Neuro-QOL for lower limbs before and 1 year after surgery., Results: By 1 year after targeted muscle reinnervation, NRS scores for residual limb pain from 6.4 ± 2.6 to 3.6 ± 2.2 (mean difference -2.7 [95% CI -4.2 to -1.3]; p < 0.001) and phantom limb pain decreased from 6.0 ± 3.1 to 3.6 ± 2.9 (mean difference -2.4 [95% CI -3.8 to -0.9]; p < 0.001). PROMIS pain intensity and pain interference scores improved with respect to residual limb and phantom limb pain (residual limb pain intensity: 53.4 ± 9.7 to 44.4 ± 7.9, mean difference -9.0 [95% CI -14.0 to -4.0]; residual limb pain interference: 60.4 ± 9.3 to 51.7 ± 8.2, mean difference -8.7 [95% CI -13.1 to -4.4]; phantom limb pain intensity: 49.3 ± 10.4 to 43.2 ± 9.3, mean difference -6.1 [95% CI -11.3 to -0.9]; phantom limb pain interference: 57.7 ± 10.4 to 50.8 ± 9.8, mean difference -6.9 [95% CI -12.1 to -1.7]; p ≤ 0.012 for all comparisons). On functional assessment, OPUS Rasch scores improved from 53.7 ± 3.4 to 56.4 ± 3.7 (mean difference +2.7 [95% CI 2.3 to 3.2]; p < 0.001) and Neuro-QOL scores improved from 32.9 ± 1.5 to 35.2 ± 1.6 (mean difference +2.3 [95% CI 1.8 to 2.9]; p < 0.001)., Conclusions: Targeted muscle reinnervation demonstrates improvement in residual limb and phantom limb pain parameters in major limb amputees. It should be considered as a first-line surgical treatment option for chronic amputation-related pain in patients with major limb amputations. Additional investigation into the effect on function and quality of life should be performed., Level of Evidence: Level IV, therapeutic study.

Introduction: Spinal cord injury is a devastating condition affecting a person's independence and quality of life. Nerve transfers are increasingly used to restore critical upper extremity function. Electrodiagnostic studies guide operative planning but the implications for clinical outcomes is not well defined. This case study delineates how clinical examination and electrodiagnostics can define the varying patterns of neuronal injury to guide timing and strategy for optimal outcomes in nerve transfers., Case Presentation: We discuss a 20-year-old man with a C6-7 spinal cord injury (SCI). We illustrate how history, physical examination, and electrodiagnostic studies predicted patterns of upper and lower motor neuron injury, confirmed intraoperatively via direct nerve stimulation. We undertook brachialis nerve transfer to the median fascicles supplying flexor digitorum superficialis and anterior interosseous nerve (to restore digit flexion), and supinator nerve transfer to posterior interosseous nerve (to restore digit extension). Preoperative electrodiagnostics of the right upper extremity demonstrated a pure upper motor neuron injury to median innervated muscles, and mixed upper and lower motor neuron injury to radial innervated muscles. These findings were confirmed via intraoperative direct neuromuscular stimulation. The preoperative studies provided important information regarding the anatomic basis and time sensitivity of the proposed nerve transfers. At 2 years post operatively the reconstructed digit flexion and extension resulted in improved hand function and independence., Discussion: Upper and lower motor neuron injuries can coexist in individuals with SCI. This example provides proof-of-concept that preoperative electrodiagnostic studies predict LMN injury, and surgery can achieve positive outcomes if completed soon after SCI.

Nerve transfers are increasingly utilized for upper limb reconstruction in tetraplegia. We reviewed the literature for results achieved by nerve transfers for elbow extension, wrist control and finger and thumb flexion and extension. Muscle strength grading was the only outcome measure consistently reported. The results confirm that nerve transfers can effectively reanimate muscles in selected cases, with comparable strength with those achieved with tendon transfer for elbow extension but inferior strength for finger and thumb flexion. Transfer of supinator nerve branches to the posterior interosseous nerve appears to be reliable and offers increased span and better hand opening than is observed after tendon transfers. Only one publication demonstrated how reinnervation of muscles with nerve transfers translated into improved function, activity and participation for patients. More prospective studies, using standardized outcome measures, are needed to define the precise role of nerve transfers.

Background: Loss of upper extremity function after cervical spinal cord injury greatly affects independence, including social, vocational, and community engagement. Nerve transfer surgery offers an exciting new option for the reanimation of upper limb function in tetraplegia. The aim of this study was to evaluate the outcomes of nerve transfer surgery used for the reanimation of upper limb function in tetraplegia., Methods: In this prospective case series, we consecutively recruited people of any age with early (<18 months post-injury) cervical spinal cord injury of motor level C5 and below, who had been referred to a single centre for upper extremity reanimation and were deemed suitable for nerve transfer. All participants underwent single or multiple nerve transfers in one or both upper limbs, sometimes combined with tendon transfers, for restoration of elbow extension, grasp, pinch, and hand opening. Participants were assessed at 12 months and 24 months post-surgery. Primary outcome measures were the action research arm test (ARAT), grasp release test (GRT), and spinal cord independence measure (SCIM)., Findings: Between April 14, 2014, and Nov 22, 2018, we recruited 16 participants (27 limbs) with traumatic spinal cord injury, among whom 59 nerve transfers were done. In ten participants (12 limbs), nerve transfers were combined with tendon transfers. 24-month follow-up data were unavailable for three patients (five limbs). At 24 months, significant improvements from baseline in median ARAT total score (34·0 [IQR 24·0-38·3] at 24 months vs 16·5 [12·0-22·0] at baseline, p<0·0001) and GRT total score (125·2 [65·1-154·4] vs 35·0 [21·0-52·3], p<0·0001) were observed. Mean total SCIM score and mobility in the room and toilet SCIM score improved by more than the minimal detectable change and the minimal clinically important difference, and the mean self-care SCIM score improved by more than the minimal detectable change between baseline and 24 months. Median Medical Research Council strength grades were 3 (IQR 2-3) for triceps and 4 (IQR 4-4) for digital extensor muscles after 24 months. Mean grasp strength at 24 months was 3·2 kg (SD 1·5) in participants who underwent distal nerve transfers (n=5), 2·8 kg (3·2) in those who had proximal nerve transfers (n=9), and 3·9 kg (2·4) in those who had tendon transfers (n=8). There were six adverse events related to the surgery, none of which had any ongoing functional consequences., Interpretation: Early nerve transfer surgery is a safe and effective addition to surgical techniques for upper limb reanimation in tetraplegia. Nerve transfers can lead to significant functional improvement and can be successfully combined with tendon transfers to maximise functional benefits., Funding: Institute for Safety, Compensation, and Recovery Research (Australia)., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

BACKGROUND Acute flaccid myelitis is an emerging polio-like illness mostly affecting young children, characterized by rapid onset of extremity weakness and paralysis in 1 or more limbs. Certain viruses, including enteroviruses such as EV-68, EV-71, poliovirus, and West Nile virus, can cause this disorder. The largest known outbreak of EVD68 in the United States was in the summer of 2014, causing severe respiratory illness and acute flaccid myelitis, mainly in young children. Furthermore, the US Centers for Disease Control and Prevention noted an increase in the number of patients with clinical symptoms of acute flaccid myelitis in 2018, and 134 confirmed cases by December 2018 were reported in the USA. CASE REPORT The patient in our present study was a 5-year-old female who had significant weakness and paralysis in all 4 extremities due to acute flaccid myelitis. EV-D68 had caused this disorder in this patient in August 2014. Conservative management had not helped her condition. Specific areas of concern were both shoulders and biceps, and the femoral and peroneal nerves in both sides. Of these, the right shoulder function was the worst, at less than grade 3. The patient also had marked atrophy and weakness of the right quadricep muscles. The patient underwent surgical treatment and had steady improvements in all 4 extremity functional movements. CONCLUSIONS We demonstrated that decompression, neurolysis, and nerve transfer surgical procedures can be used successfully to correct the paralyzed upper and lower extremity movements in acute flaccid myelitis patients.

Nerve transfer has become a common and often effective reconstructive strategy for proximal and complex peripheral nerve injuries of the upper limb. This case-based discussion explores the principles and potential benefits of nerve transfer surgery and offers in-depth discussion of several established and valuable techniques including: motor transfer for elbow flexion after musculocutaneous nerve injury, deltoid reanimation for axillary nerve palsy, intrinsic re-innervation following proximal ulnar nerve repair, and critical sensory recovery despite non-reconstructable median nerve lesions.

While upper limb nerve transfers were first described and performed several years ago, they have seen expanded use in the past 20 years. Initially indicated for surgical repair of brachial plexus injuries with nerve root avulsion, the indications have been extended to post-ganglionic lesions because of the excellent results of certain intraplexus nerve transfers. The traditional nerve repair techniques - primary suture and nerve grafting - form the basis of nerve surgery. Although nerve transfer does not replace them, they are a useful supplement as they provide a targeted approach to reinnervation and recovery of key functions of the upper limb. The goal of this review is to provide an overview of the various possible transfers by the function being restored and the quality of the outcomes., (Copyright © 2017 SFCM. Published by Elsevier Masson SAS. All rights reserved.)

OBJECT Donor-side morbidity associated with contralateral C-7 (CC7) nerve transfer remains controversial. The purpose of this study was to evaluate functional deficits in the donor limb resulting from prespinal route CC7 nerve transfer. METHODS A total of 63 patients were included. Forty-one patients had undergone CC7 nerve transfer surgery at least 6 months previously and were assigned to one of 2 groups based on the duration of postoperative follow-up. Group 1 (n = 21) consisted of patients who had undergone surgery between 6 months and 2 years previously, and Group 2 (n = 20) consisted of patients who had undergone surgery more than 2 years previously. An additional 22 patients who underwent CC7 nerve transfer surgery later than those in Groups 1 and 2 were included as a control group (Group 3). Results of preoperative testing in these patients and postoperative testing in Groups 1 and 2 were compared. Testing included subjective assessments and objective examinations. An additional 3 patients had undergone surgery more than 6 months previously but had severe motor weakness and were therefore evaluated separately; these 3 patients were not included in any of the study groups. RESULTS The revised Short-Form McGill Pain Questionnaire (SF-MPQ-2) was the only subjective test that showed a significant difference between Group 3 and the other 2 groups, while no significant differences were found in objective sensory, motor, or dexterity outcomes. The interval from injury to surgery for patients with a normal SF-MPQ-2 score in Groups 1 and 2 was significantly less than for those with abnormal SF-MFQ-2 scores (2.4 ± 1.1 months vs 4.6 ± 2.9 months, p = 0.002). The 3 patients with obvious motor weakness showed a tendency to gradually recover. CONCLUSIONS Although some patients suffered from long-term sensory disturbances, resection of the C-7 nerve had little effect on the function of the donor limb. Shortening preoperative delay time can improve sensory recovery of the donor limb.

Hand and upper extremity function is instrumental to basic activities of daily living and level of independence in cervical spinal cord injury (SCI). Nerve transfer surgery is a novel and alternate approach for restoring function in SCI. This article discusses the biologic basis of nerve transfers in SCI, patient evaluation, management, and surgical approaches. Although the application of this technique is not new; recent case reports and case series in the literature have increased interest in this field. The challenges are to improve function, achieve maximal gains in function, avoid complications, and to primum non nocere., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: This is a systematic review for evaluating the evidence for functional outcomes after decellularized nerve use in clinical setting. Decellularized nerves are allografts whose antigenic components have been removed, leaving only a scaffold that promotes the full regeneration of axons., Methods: Literature research was performed using the PubMed/MEDLINE database for English language studies with the keywords "decellularized nerve" and "processed nerve allograft." Inclusion criteria were prospective and retrospective case reviews in clinical settings. Exclusion criteria were case reports and case series., Results: We retrieved six level VIII studies and one level VI study (classified according to the Jovell and Navarro-Rubio scale) with a total of 131 reconstructions. The basic data ranges of the studies were as follows: patient age, 18 to 86 years; duration between initial injury and nerve reconstruction procedure, 8 hours to 4 years; and follow-up period, 40 days to 2 years. The maximum lengths of the nerve gap for chemically washed decellularized nerves and cryopreserved decellularized nerves were 50 and 100 mm, respectively. Quantitatively, the functional outcome ranges were as follows: static two-point discrimination, 3 to 5 mm; and moving two-point discrimination, 2 to 15 mm. For motor assessment, all patients had a > M3 Medical Research Council score. It is also important to notice that a large variability occurs in almost every factor in the reviewed studies., Conclusion: Our study is the first to summarize the clinical results of decellularized nerves. Decellularized nerves have been used to bridge nerve gaps ranging from 5 to 100 mm with associated satisfactory outcomes in static and moving two-point discriminations., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Background: Cervical spinal cord injury can result in profound loss of upper extremity function. Recent interest in the use of nerve transfers to restore volitional control is an exciting development in the care of these complex patients. In this article, the authors review preliminary results of nerve transfers in spinal cord injury., Methods: Review of the literature and the authors' cases series of 13 operations in nine spinal cord injury nerve transfer recipients was performed. Representative cases were reviewed to explore critical concepts and preliminary outcomes., Results: The nerve transfers used expendable donors (e.g., teres minor, deltoid, supinator, and brachialis) innervated above the level of the spinal cord injury to restore volitional control of missing function such as elbow extension, wrist extension, and/or hand function (posterior interosseous nerve or anterior interosseous nerve/finger flexors reinnervated). Results from the literature and the authors' patients (after a mean postsurgical follow-up of 12 months) indicate gains in function as assessed by both manual muscle testing and patients' self-reported outcomes measures., Conclusions: Nerve transfers can provide an alternative and consistent means of reestablishing volitional control of upper extremity function in people with cervical level spinal cord injury. Early outcomes provide evidence of substantial improvements in self-reported function despite relatively subtle objective gains in isolated muscle strength. Further work to investigate the optimal timing and combination of nerve transfer operations, the combination of these with traditional treatments (tendon transfer and functional electrical stimulation), and measurement of outcomes is imperative for determining the precise role of these operations., Clinical Question/level of Evidence: Therapeutic, IV.

Targeted muscle reinnervation (TMR) offers the potential for improved prosthetic function by reclaiming the neural control information that is lost as a result of upper extremity amputation. In addition to the prosthetic control benefits, TMR is a potential treatment for postamputation neuroma pain. Here, we present our surgical technique for TMR nerve transfers in transhumeral and shoulder disarticulation patients., (Copyright © 2015 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Background: In lower brachial plexus injury, finger flexion after brachialis motor branch transfer is relatively weak. We sought to screen potential branches of the median nerve from the upper trunk for strengthening finger flexion in addition to the brachialis motor branch. However, the spinal origin of the muscular branches of the median nerve based on electrophysiological study was unclear., Objective: To determine the spinal origin of the muscular branches of the median nerve., Methods: An intraoperative electrophysiological study was carried out in 18 patients who underwent contralateral C7 nerve transfer. After exposure of the brachial plexus nerve roots on the healthy side, the amplitude of the compound muscle action potential of each median nerve-innervated muscle was recorded while the different nerve roots were stimulated., Results: The pronator teres received fibers from C5, C6, and C7. It had more contribution from C5 and C6 than from C7 (P<.05). The flexor carpi radialis was innervated mainly by C6 and C7. The nerve branches of the palmaris longus and flexor digitorum superficialis stemmed primarily from C7 and the lower trunk, and no significant difference was found between them (P>.05). The flexor digitorum profundus, flexor pollicis longus, pronator quadratus, and abductor pollicis brevis were innervated predominantly by the lower trunk (P<.05)., Conclusion: This electrophysiological study indicates that the pronator teres branch might be the most feasible alternative donor nerve to supplement the brachialis motor branch and strengthen finger flexion after lower brachial plexus injury.

Background: Central neurological injury (CNI) is a major contributor to physical disability that affects both adults and children all over the world. The main sequelae of chronic stage CNI are spasticity, paresis of specific muscles, and poor selective motor control. Here, we apply the concept of contralateral peripheral neurotization in spasticity releasing and motor function restoration of the affected upper extremity., Objective: A clinical investigation was performed to verify the clinical efficacy of contralateral C7 neurotization for rescuing the affected upper extremity after CNI., Methods: In the present study, 6 adult hemiplegia patients received the nerve transfer surgery of contralateral C7 to C7 of the affected side. Another 6 patients with matched pathological and demographic status were assigned to the control group that received rehabilitation only. During the 2-year follow-up, muscle strength of bilateral upper extremities was assessed. The Modified Ashworth Scale and Fugl-Meyer Assessment Scale were used for evaluating spasticity and functional use of the affected upper extremity, respectively., Results: Both flexor spasticity release and motor functional improvements were observed in the affected upper extremity in all 6 patients who had surgery. The muscle strength of the extensor muscles and the motor control of the affected upper extremity improved significantly. There was no permanent loss of sensorimotor function of the unaffected upper extremity., Conclusion: This contralateral C7 neurotization approach may open a door to promote functional recovery of upper extremity paralysis after CNI.

Restoration of elbow extension, grasp, key pinch, and release are major goals in low-level tetraplegia. Traditionally, these functions are achieved using tendon transfers. In this case these goals were achieved using nerve transfers. We present a 21-year-old man with a C6 level of tetraplegia. The left upper limb was treated 6 months after injury with a triple nerve transfer. A teres minor nerve branch to long head of triceps nerve branch, brachialis nerve branch to anterior interosseous nerve, and supinator nerve branch to posterior interosseous nerve transfer were used successfully to reconstruct elbow extension, key pinch, grasp, and release simultaneously., (Copyright © 2014 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Upper extremity reconstruction forces the surgeon to chose between several available procedures, among them tendon and nerve transfer. Few guidelines exist to assist the surgeon in this regard, and the authors, therefore, undertook a retrospective review of case series describing tendon and nerve transfer. The authors discovered a scarcity of robust reporting, particularly in regard to tendon transfer, making an objective comparison between the two techniques difficult. Tendon transfers are popular and familiar. Nerve transfers promise distinct advantages; however, excellent evidence of their superiority is lacking., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Object: Contralateral C-7 nerve transfer was developed for the treatment of patients with brachial plexus avulsion injury (BPAI). In the surgical procedure the affected recipient nerve is connected to the ipsilateral motor cortex, and the dramatic peripheral alteration may trigger extensive cortical reorganization. However, little is known about the long-term results after such specific nerve transfers. The purpose of this study was to investigate the long-term cortical adaptive plasticity after BPAI and contralateral C-7 nerve transfer., Methods: In this study, 9 healthy male volunteers and 5 male patients who suffered from right-sided BPAI and had undergone contralateral C-7-transfer more than 5 years earlier were included. Functional MRI studies were used for the investigation of long-term cerebral plasticity., Results: The neuroimaging results suggested that the ongoing cortical remodeling process after contralateral C-7 nerve transfer could last for a long period; at least for 5 years. The motor control of the reinnervated limb may finally transfer from the ipsilateral to the contralateral hemisphere exclusively, instead of the bilateral neural network activation., Conclusions: The authors believe that the cortical remodeling may last for a long period after peripheral rearrangement and that the successful cortical transfer is the foundation of the independent motor recovery.

We propose a new nomenclature for the consistent, additional nerves that branch from the posterior cord of the brachial plexus. We hope this will aid the plexus surgeon and the evolution of plexus reconstruction for both obstetric and adult cases of injury., (Copyright © 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Nerve transfers are key components of the surgeon's armamentarium in brachial plexus and complex nerve reconstruction. Advantages of nerve transfers are that nerve regeneration distances are shortened, pure motor or sensory nerve fascicles can be selected as donors, and nerve grafts are generally not required. Similar to the principle of tendon transfers, expendable donor nerves are transferred to denervated nerves with the goal of functional recovery. Transfers may be subdivided into intraplexal, extraplexal, and distal types; each has a unique role in the reconstructive process. A thorough diagnostic workup and intraoperative assessment help guide the surgeon in their use. Nerve transfers have made a positive impact on the outcomes of nerve surgery and are essential tools in complex nerve reconstruction.

The upper brachial plexus injury leads to paralysis of muscles innervated by C5 and C6 nerve roots. In this report, we present our experience on the use of the combined nerve transfers for reconstruction of the upper brachial plexus injury. Nine male patients with the upper brachial plexus injury were treated with combined nerve transfers. The time interval between injury and surgery ranged from 3 to 11 months (average, 7 months). The combined nerve transfers include fascicles of the ulnar nerve and/or the median nerve transfer to the biceps and/or the brachialis motor branch, and the spinal accessory nerve (SAN) to the suprascapular nerve (SSN) and triceps branches to the axillary nerve through a posterior approach. At an average of 33 months of follow-up, all patients recovered the full range of the elbow flexion. Six out of nine patients were able to perform the normal range of shoulder abduction with the strength degraded to M3 or M4. These results showed that the technique of the combined nerve transfers, specifically the SAN to the SSN and triceps branches to the axillary nerve through a posterior approach, may be a valuable alternative in the repair of the upper brachial plexus injury. Further evaluations of this technique are necessary., (Copyright © 2011 Wiley-Liss, Inc.)

This article provides an update of the current strategies of motor and sensory nerve transfers for peripheral nerve lesions of the upper extremity. Indications, techniques, and outcomes are summarized for both well-established transfers used in the management of proximal and brachial plexus injuries as well as those more recently developed for more distal and isolated nerve injuries in the forearm and hand., (Copyright 2010. Published by Elsevier Inc.)

With increasing clinical experience, peripheral nerve surgeons have come to appreciate the important role that cortical plasticity and motor relearning play in functional recovery following a nerve transfer. Neurostimulation (transcranial magnetic stimulation), and neuroimaging (functional MRI, structural MRI, magnetoencephalography) measure different aspects of cortical physiology and when used together are powerful tools in the study of cortical plasticity. The mechanisms of cortical plasticity, according to current and widely accepted opinions, involve the unmasking of previously ineffective connections or the sprouting of intact afferents from adjacent cortical or subcortical territories. Although significant strides have been made in our understanding of cortical plasticity following nerve transfer and during motor relearning, a great deal remains that we do not understand. Cortical plasticity and its manipulation may one day become important contributors to improve functional outcome following nerve transfer.

Purpose: In most complete brachial plexus injuries, at least 1 root still is available for grafting. We report on the results obtained with reconstruction of the brachial plexus using short sural nerve grafts that connect nonavulsed roots to the anterior, posterior, or both divisions of the upper trunk., Methods: We prospectively studied 22 young adults with complete brachial plexus palsy who had surgical repair an average of 5 months after trauma. Sural nerve grafts connected the C5 root to the anterior division and the C6 root to the posterior division of the upper trunk. When the C6 root was not available, the posterior division of the upper trunk was repaired by means of a nerve transfer. In all cases except one, the suprascapular nerve was repaired via a nerve transfer. Outcomes were assessed an average of 35 months after surgery, focusing on recovery of muscle strength, categorized using the Medical Research Council scale. We compared the results obtained after a single root graft, either C5 (n = 11) or C6 (n = 1), with those observed after double root grafting (i.e., C5 + C6; n = 9). The single case of 3 roots available for grafting was excluded for this comparative study., Results: With grafting of the anterior division of the upper trunk, 17 of the 22 patients (n = 15) regained useful pectoralis major and biceps function of at least M3. Grafting the anterior and the posterior divisions of the upper trunk resulted in 18 of the 22 patients (n = 18) recovering shoulder abduction-adduction and either elbow flexion or extension. In only 5 cases (5 of 22 patients), however, was shoulder abduction-adduction achieved with concomitant recovery of both elbow flexion and extension. Grafting the posterior division of the upper trunk did not enhance the recovery of shoulder abduction, but it did restore elbow extension in approximately 6 of the 9 patients. In terms of muscle strength, an average of 2.3 muscles scored M3 or M4 in the single-root group, compared with 3.1 in the C5/C6 group (p < .05). The relative probability of recovering elbow flexion and shoulder adduction did not differ between patients with 1 versus 2 root grafts. The results of nerve transfers to the posterior division and of forearm muscle reinnervation were poor., Conclusions: Grafting the divisions of the brachial plexus ensured multiple function reconstruction in 18 of the 22 patients (n = 18). However, only 5 of 22 patients (n = 4) experienced restoration of elbow flexion and extension., Type of Study/level of Evidence: Prognostic II.

In this article, the author focuses on functioning free muscle transplantation (FFMT), an advanced microneurovascular technique indicated in patients who have an advanced injury with a major brachial muscle or muscle group loss or denervation and in whom no locally available or ideal musculotendinous donor unit exists. FFMTs have been successfully applied clinically in cases involving adult brachial plexus palsy, obstetric brachial plexus palsy, facial palsy, severe Volkmann's ischemia, and severe crushing and traction injuries of the forearm or arm with major muscle loss. As the author notes, FFMT is a new challenge for the reconstructive surgeon. He outlines the eight major principles for nerve transfer with FFMT, basing his conclusions on the more than 333 patients who received FFMT between 1995 and 2005 in his hospital.

Objectives: To fit and evaluate the control of a complex prosthesis for a shoulder disarticulation-level amputee with targeted muscle reinnervation., Design: One participant who had targeted muscle reinnervation surgery was fitted with an advanced prosthesis and his use of this device was compared with the device that he used in the home setting., Setting: The experiments were completed within a laboratory setting., Participant: The first recipient of targeted muscle reinnervation: a bilateral shoulder disarticulation-level amputee., Interventions: Two years after surgery, the subject was fitted with a 6 degree of freedom (DOF) prosthesis (shoulder flexion, humeral rotation, elbow flexion, wrist rotation, wrist flexion, and hand control). Control of this device was compared with that of his commercially available 3-DOF system (elbow, wrist rotation, and powered hook terminal device)., Main Outcome Measure: In order to assess performance, movement analysis and timed movement tasks were executed., Results: The subject was able to independently operate all 6 arm functions with good control. He could simultaneously operate 2 DOF of several different joint combinations with relative ease. He operated up to 4 DOF simultaneously, but with poor control. Work space was markedly increased and some timed tasks were faster with the 6-DOF system., Conclusions: This proof-of-concept study shows that advances in control of shoulder disarticulation-level prostheses can improve the quality of movement. Additional control sources may spur the development of more advanced and complex componentry for these amputees.

Brachial plexus injuries result in devastating loss of function for patients and present incredible challenges for peripheral nerve surgeons. Recently, nerve transfers have produced superior results compared with traditional interposition nerve grafts for brachial plexus reconstruction. The authors present a review of current surgical options for treatment of partial and complete adult brachial plexus injuries using nerve transfers.

Modern nerve-to-nerve transfers represent one of the greatest advances in peripheral nerve surgery. Lessons of tendon transfers have taught that nerves to specific musculotendinous units are expendable, and greater understanding of peripheral nerve topography has revealed redundant fascicles in peripheral nerves. Transfer of these redundant or expendable nerves to recipient nerves close to the end organ allows for earlier reinnervation and preservation of those musculotendinous units. Such nerve transfers provide significantly better treatment options in many cases of nerve injury where previous outcomes were expected to be poor, such as with proximal injuries, long nerve gaps, or unavailability of the proximal injured segment. This article will review current nerve transfers in the hand and upper extremity.

Advances in the field of microsurgery have improved the results after peripheral nerve surgery and have extended the types of nerve repair that can be accomplished. Innovative techniques using microsurgical dissection, such as nerve transfers and end-to-side repairs are direct consequences of these advances.

We report 3 cases of successful vascularized ulnar nerve graft for reconstructing a large median or radial nerve defect after severe trauma of the upper extremity.

The reconstructive strategies for avulsion in-juries vary from patient to patient and over time,continue to evolve depending on the surgeon's philosophy, available facilities and therapy, the elapsed time from injury to intervention, the severity of injury, and patient age and motivation. The author's results show that nerve transfer can obtain an average of 60 degrees (range, 20 degrees - 180 degrees) of shoulder elevation without shoulder arthrodesis, M3 to M4 muscle strength of elbow flexion, M2 to M4 elbow extension, and M3 finger flexion and sensation. Intrinsic hand function was obtained with help of dynamic splinting for interphalangeal joint extension and arthrodesis of thumb joints asa post for opposition.

A retrospective study was undertaken to determine the effectiveness of end-to-side nerve transfer. Twenty patients with peripheral nerve lesions of varying aetiology underwent 23 end-to-side nerve transfers over a 15-month period. The mean patient age was 30 years and 18 were male. The mean delay in presentation was 2.4 months. All underwent end-to-side nerve repairs and were reviewed in outpatients at regular intervals. Ten patients were lost to follow-up before 12 months and were therefore excluded from the study. The remaining ten patients, who had undergone 13 end-to-side procedures, had a mean follow-up period of 16 months. None demonstrated objective evidence of motor recovery at the end of the study period. Four patients had modest recovery of deep protective sensation, and two patients suffered a subtle degree of "donor" nerve morbidity. We have abandoned this technique in our centre in preference for standard nerve grafting techniques.