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Acute flaccid myelitis (AFM) is a disabling, polio-like illness mainly affecting children. Outbreaks of AFM have occurred across multiple global regions since 2012, and the disease appears to be caused by non-polio enterovirus infection, posing a major public health challenge. The clinical presentation of flaccid and often profound muscle weakness (which can invoke respiratory failure and other critical complications) can mimic several other acute neurological illnesses. There is no single sensitive and specific test for AFM, and the diagnosis relies on identification of several important clinical, neuroimaging, and cerebrospinal fluid characteristics. Following the acute phase of AFM, patients typically have substantial residual disability and unique long-term rehabilitation needs. In this Review we describe the epidemiology, clinical features, course, and outcomes of AFM to help to guide diagnosis, management, and rehabilitation. Future research directions include further studies evaluating host and pathogen factors, including investigations into genetic, viral, and immunological features of affected patients, host-virus interactions, and investigations of targeted therapeutic approaches to improve the long-term outcomes in this population.

Background At least 128,000 patients in the United States each year suffer from foot drop. This is a debilitating condition, marked by the inability to dorsiflex and/or evert the affected ankle. Such patients are rendered to a lifetime of relying on an ankle-foot orthosis (AFO) for walking and nighttime to prevent an equinovarus contracture. Methods This narrative review explores the differential diagnosis of foot drop, with a particular focus on clinical presentation and recovery, whether spontaneously or through surgery. Results Contrary to popular belief, foot drop can be caused by more than just insult to the common peroneal nerve at the fibular head (fibular tunnel). It is a common endpoint for a diverse spectrum of nerve injuries, which may explain its relatively high prevalence. From proximal to distal, these conditions include lumbar spine nerve root damage, sciatic nerve palsy at the sciatic notch, and common peroneal nerve injury at the fibular head. Each nerve condition is marked by a unique clinical presentation, frequency, likelihood for spontaneous recovery, and cadre of peripheral nerve techniques. Conclusion The ideal surgical technique for treating foot drop, other than neurolysis for compression, remains elusive as traditional peripheral nerve procedures have been marred by a wide spectrum of functional results. Based on a careful understanding of why past techniques have achieved limited success, we can formulate a working set of principles to help guide surgical innovation moving forward, such as fascicular nerve transfer. [ABSTRACT FROM AUTHOR]

Background: Brachial plexus reconstruction (BPR) is a rapidly advancing field within hand surgery. BPR procedures are complex, time-intensive, and require microsurgical expertise. As physician reimbursement rates for BPR are poorly defined, relative to more common hand procedures, we sought to analyze compensation for BPR across different payor groups and understand the factors contributing to their reimbursement. Methods: A retrospective review was performed of surgeries by a single senior staff member in a 4-year period to evaluate Current Procedural Terminology (CPT) codes from BPR cases. For comparison, all finger fracture fixations and skin graft reconstructions performed by the same surgeon over the same time period were analyzed as well. Results: A total of 57 BPR cases, 94 finger fracture fixation cases, and 69 skin grafting cases met inclusion criteria. Among the top 5 insurance providers, average work relative value unit (wRVU)/hour was 6.55, 3.49, and 12.67 for BPR, fracture fixation, and skin grafts, respectively. Reimbursements were an average $685.76/hour for BPR, compared to $590.10/hour for fracture fixation and $1,197.94/hour for skin grafts. Conclusions: BPR demonstrates a relative undervaluation, in terms of reimbursement per hour, given the time and surgical skill required for such cases, particularly compared to shorter, less complex cases such as skin grafting and fracture fixation. We find that this discrepancy is amplified across multiple levels of coding, billing, and reimbursement. We suggest specific strategies for physician leadership to more directly participate in the financial decisions that affect themselves, their patients, and their specialty. [ABSTRACT FROM AUTHOR]

To provide recommendations for pre- and post-operative occupational and physical therapy for children with acute flaccid myelitis (AFM). Writing panel members consisted of an interdisciplinary team of seven healthcare professionals specializing in the care of children with AFM. The panel reviewed background material on AFM, nerve transfer, and rehabilitation principles applied to pediatrics. Recommendations were prioritized if evidence was available. Where there was no known evidence to support a recommendation, this was noted. Communication and coordination among interprofessional team members are vital to a comprehensive family-centered rehabilitation program. Surgical planning should include team preparation accounting for frequency, duration, and timing of treatment, as well as individual characteristics and developmental status of the child. Recommendations for pre-operative and six phases of post-operative therapy address assessment, strengthening, range of motion, orthoses, performance of functional activity, and support of the family. Rehabilitation following nerve transfer in children with AFM requires interdisciplinary collaboration and a multisystem approach to assessment and treatment. As new evidence becomes available, recommendations may be revised or replaced accordingly. [ABSTRACT FROM AUTHOR]

Background: The purpose of this study was to systematically review outcomes following intercostal nerve (ICN) transfer for restoration of elbow flexion, with a focus on identifying the optimal number of nerve transfers. Methods: A systematic review was performed following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines to identify studies describing ICN transfers to the musculocutaneous nerve (MCN) for traumatic brachial plexus injuries in patients 16 years or older. Demographics were recorded, including age, time to operation, and level of brachial plexus injury. Muscle strength was scored based upon the British Medical Research Council scale. Results: Twelve studies met inclusion criteria for a total of 196 patients. Either 2 (n = 113), 3 (n = 69), or 4 (n = 11) ICNs were transferred to the MCN in each patient. The groups were similar with regard to patient demographics. Elbow flexion ≥M3 was achieved in 71.3% (95% confidence interval [CI], 61.1%-79.7%) of patients with 2 ICNs, 67.7% (95% CI, 55.3%-78.0%) of patients with 3 ICNs, and 77.0% (95% CI, 44.9%-93.2%) of patients with 4 ICNs (P = .79). Elbow flexion ≥M4 was achieved in 51.1% (95% CI, 37.4%-64.6%) of patients with 2 ICNs, 42.1% (95% CI, 29.5%-55.9%) of patients with 3 ICNs, and 48.4% (95% CI, 19.2%-78.8%) of patients with 4 ICNs (P = .66). Conclusions: Previous reports have described 2.5 times increased morbidity with each additional ICN harvest. Based on the equivalent strength of elbow flexion irrespective of the number of nerves transferred, 2 ICNs are recommended to the MCN to avoid further donor-site morbidity. [ABSTRACT FROM AUTHOR]