Purpose: In patients with late brachial plexus birth injuries, sequelae after acute flaccid myelitis, or chronic adult brachial plexus injury, donor nerves for functioning muscle transplantation are often scarce. We present the results of a potential strategy using the phrenic nerve with staged free gracilis transplantation for upper extremity reanimation in these scenarios.
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Methods: A retrospective review was performed on an institutional database of brachial plexus injury or patients with palsy. All patients underwent a staged reconstruction in which the ipsilateral phrenic nerve was extended by an autogenous nerve graft (PhNG), followed by free-functioning gracilis transplantation (PhNG-gracilis).
Conclusions: A 2-stage PhNG-gracilis may restore or enhance the residual elbow and/or finger paralysis in chronic brachial plexus injuries. A minimum follow-up period of 3 years is recommended. This technique may remain useful as one of the last reconstructive options to increase power in patients with scarce donor nerves.
Isidro Cortes-Ciriano, Christopher D. Steele, Katherine Piculell, Alyaa Al-Ibraheemi, Vanessa Eulo, Marilyn M. Bui, Aikaterini Chatzipli, Brendan C. Dickson, Dana C. Borcherding, Andrew Feber, Alon Galor, Jesse Hart, Kevin B. Jones, Justin T. Jordan, Raymond H. Kim, Daniel Lindsay, Colin Miller, Yoshihiro Nishida, Paula Z. Proszek, Jonathan Serrano, R Taylor. Sundby, Jeffrey J. Szymanski, Nicole J. Ullrich, David Viskochil, Xia Wang, Matija Snuderl, Peter J. Park, Adrienne M. Flanagan, Angela C. Hirbe, Nischalan Pillay, David T. Miller; Genomic patterns of malignant peripheral nerve sheath tumor (MPNST) evolution correlate with clinical outcome and are detectable in cell-free DNA. Cancer Discov 2023; -8290.CD-22-0786
Malignant peripheral nerve sheath tumor (MPNST), an aggressive soft-tissue sarcoma, occurs in people with neurofibromatosis type 1 (NF1) and sporadically. Whole-genome and multi-regional exome sequencing, transcriptomic, and methylation profiling of 95 tumor samples revealed the order of genomic events in tumor evolution. Following biallelic inactivation of NF1, loss of CDKN2A or TP53 with or without inactivation of polycomb repressive complex 2 (PRC2) leads to extensive somatic copy number aberrations (SCNAs). Distinct pathways of tumor evolution are associated with inactivation of PRC2 genes and H3K27 trimethylation (H3K27me3) status. Tumors with H3K27me3 loss evolve through extensive chromosomal losses followed by whole genome doubling and chromosome 8 amplification, and show lower levels of immune cell infiltration. Retention of H3K27me3 leads to extensive genomic instability, but an immune cell-rich phenotype. Specific SCNAs detected in both tumor samples and cell-free DNA (cfDNA) act as a surrogate for H3K27me3 loss and immune infiltration, and predict prognosis.
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Layout table for study information Study Type : Interventional (Clinical Trial) EstimatedEnrollment : 40 participants Allocation: Randomized Intervention Model: Parallel Assignment Intervention Model Description: Patients who consent to participation will then be randomized using a random number generator to receive either a forearm nerve block or local anesthetic infiltration, there will be 20 patients assigned to each group. Masking: None (Open Label) Masking Description: The study will be open-label as both the patient and resident/surgeon will be aware of the type of block (forearm vs local) performed. Primary Purpose: Treatment Official Title: The Effect of Forearm Nerve Blocks on Pain-free Tourniquet Time Compared to Local Anesthetic for Awake Hand Surgery Estimated Study Start Date : December 1, 2022 Estimated Primary Completion Date : March 1, 2023 Estimated Study Completion Date : May 1, 2023 Arms and Interventions Go to Top of Page Study Description Study Design Arms and Interventions Outcome Measures Eligibility Criteria Contacts and Locations More Information Arm Intervention/treatment Experimental: Forearm Nerve BlockPatients will receive a nerve block of the radial, median, and ulnar nerves at the level of the forearm using 1% lidocaine with epinephrine. The lidocaine will be injected subcutaneously, using a total dose of less than 7mg per kilogram. Procedure: Forearm nerve blockLocal anesthesia will be used to perform a forearm block of the median, radial, and ulnar nerves. Active Comparator: Local Anesthetic InfiltrationPatients will receive local anesthetic infiltration, using 1% lidocaine with epinephrine, to the fracture site and surrounding tissue. No nerve blocks will be performed. The lidocaine will be injected subcutaneously, using a total dose of less than 7mg per kilogram. Procedure: Local anesthetic infiltrationLocal anesthesia will be infiltrated at the site of injury Outcome Measures Go to Top of Page Study Description Study Design Arms and Interventions Outcome Measures Eligibility Criteria Contacts and Locations More Information Primary Outcome Measures : Pain-free tourniquet time (minutes) [ Time Frame: Pain-free tourniquet time; from the time of tourniquet inflation until the patient experiences tourniquet pain, whichever occurs first ]When upper extremity surgery is performed with local anesthesia and a tourniquet, the tourniquet must be removed after roughly 20 minutes as patients begin to feel tingling and pain in their hand.
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Many of the 1 somatosensory afferent terminals are enveloped in a connective tissue capsule along with surrounding muscle, tendon or cutaneous cells, or end on hair follicles. The hair follicles and the encapsulated tissue adjacent to the 1 afferent terminals (i.e., skin, muscle, tendon, and joint tissues) contain no synaptic specializations and do not generate receptor potentials or release neural transmitters. The complex of encapsulated tissue and afferent endings and the complex of hair follicle and afferent endings play a role in the receptor transduction process, and each complex is considered to form a "somatosensory receptor". Many other 1 somatosensory axons branch and terminate in skin, muscle, or joint as free nerve endings. These endings are bare of myelin, are not encapsulated and are not associated with a specific type of tissue.
Some of the somatosensory receptors in skin (i.e., the cutaneous receptors) are classified as encapsulated receptors as the 1 afferent terminal and surrounding cutaneous tissue are encapsulated by a thin sheath (Table II). The encapsulated cutaneous receptors include Meissner corpuscles, Pacinian corpuscles and Ruffini corpuscles (See Figure 2.11). Other cutaneous receptors are unencapsulated and include the hair follicle receptor (the 1 afferent ends on hair follicles) and the Merkel complex (the 1 afferent ends at the base of a specialized receptor cell called the Merkel cell). The sensory receptors of the crude touch, pain and temperature senses are bare or free nerve endings. That is, they are unencapsulated, do not end on or near specialized tissue, and may be mechanoreceptors, nociceptors or thermoreceptors.
Free Nerve Endings. Free nerve endings are found throughout the body, in skin (Figure 2.11), muscles, tendons, joints, mucous membranes, cornea, body mesentery, the dura, the viscera, etc. The free nerve endings in skin are stimulated by tissue-damaging (nociceptive) stimuli that produce the sensation of pain or by cooling of the skin or the warming of skin or by touch. Notice that although all cutaneous free nerve endings appear very similar morphologically, there are different functional types of free nerve endings, with each responding to specific types of cutaneous stimuli (e.g., nociceptive, cooling, warming or touch).
Proprioceptors are located in muscles, tendons, joint ligaments and in joint capsules. There are no specialized sensory receptor cells for body proprioception4. In skeletal (striated) muscle, there are two types of encapsulated proprioceptors, muscle spindles and Golgi tendon organs (Figure 2.22), as well as numerous free nerve endings. Within the joints, there are encapsulated endings similar to those in skin, as well as numerous free nerve endings.
Muscle Spindles. Muscle spindles are found in nearly all striated muscles. A muscle spindle is encapsulated and consists of small muscle fibers, called intrafusal muscle fibers, and afferent and efferent nerve terminals (Figure 2.23). 2ff7e9595c
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