Background:Brachial plexus injuries represent devastating injuries with a poor prognosis. Neurolysis, nerve repair, nerve grafts, nerve transfer, functioning free-muscle transfer and pedicle muscle transfer are the main surgical procedures for treating these injuries. Among these, nerve transfer or neurotization is mainly indicated in root avulsion injury.Materials and Methods:We analysed the results of various neurotization techniques in 20 patients (age group 20-41 years, mean 25.7 years) in terms of denervation time, recovery time and functional results. The inclusion criteria for the study included irreparable injuries to the upper roots of brachial plexus (C5, C6 and C7 roots in various combinations), surgery within 10 months of injury and a minimum follow-up period of 18 months. The average denervation period was 4.2 months. Shoulder functions were restored by transfer of spinal accessory nerve to suprascapular nerve (19 patients), and phrenic nerve to suprascapular nerve (1 patient). In 11 patients, axillary nerve was also neurotized using different donors - radial nerve branch to the long head triceps (7 patients), intercostal nerves (2 patients), and phrenic nerve with nerve graft (2 patients). Elbow flexion was restored by transfer of ulnar nerve motor fascicle to the motor branch of biceps (4 patients), both ulnar and median nerve motor fascicles to the biceps and brachialis motor nerves (10 patients), spinal accessory nerve to musculocutaneous nerve with an intervening sural nerve graft (1 patient), intercostal nerves (3rd, 4th and 5th) to musculocutaneous nerve (4 patients) and phrenic nerve to musculocutaneous nerve with an intervening graft (1 patient).Results:Motor and sensory recovery was assessed according to Medical Research Council (MRC) Scoring system. In shoulder abduction, five patients scored M4 and three patients M3+. Fair results were obtained in remaining 12 patients. The achieved abduction averaged 95 degrees (range, 50 - 170 degrees). Eight patients scored M4 power in elbow flexion and assessed as excellent results. Good results (M3+) were obtained in seven patients. Five patients had fair results (M2+ to M3).
Arteriovenous malformations (AVMs) are uncommon errors of vascular morphogenesis; haemodynamically, they are high-flow lesions. Approximately 50% of AVMs are located in the craniofacial region. Subtotal excision or proximal ligation of the feeding vessel frequently results in rapid progression of the AVMs. Hence, the correct treatment consists of highly selective embolisation (super-selective) followed by complete resection 24-48 hours later. We treated 20 patients with facial arteriovenous malformation by using this method. Most of the lesions (80%) were located within the cheek and lip. There were no procedure related complications and cosmetic results were excellent.
Peripheral nerve injuries are common, and there is no easily available formula for successful treatment. Although primary neurorrhaphy and nerve autografts are the most effective methods of repair, several newer options are at our disposal today. Though one can help speed up the nerve regeneration process to some extent, success is hindered by additional issues such as number of coaptation sites, supply of donor nerves and the limitations of nerve substitutes. There is now considerable evidence that peripheral nerves have the potential to regenerate if an appropriate microenvironment is provided. A better understanding of the biological processes involved in nerve regeneration process and the realization that nerve grafts serve as a guide for the growing neurons led to the concept of entubulation techniques. For distances of less than 3 cms, either a nerve conduit or an autologous vein graft serves equally well as nerve graft. Seeding the conduits with cultured Schwann cells has pushed the limit of nerve regeneration through a 6 cm gap. In experimental studies with Schwann cell lined bioengineered conduits gaps as large as 8cms can be bridged. Advances in bioengineering has allowed creation of composite neural tubes lined with Schwann cells and neurotropic agents that enhances regeneration of nerve fibers, block the invasion of scar tissue and autodegrade when it is no longer required. The evolution of the concept of entubulation, the early experimentation, the present development and various types of conduits are discussed here.
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