Dear All,

I have compiled below my original post and the replies received - thanks
to everyone who responded.  Apologies for the length of the post.  If
anyone has anything further to add, please do so - although it might be
a good idea not to include all the text below.

Cathy

........................................................

A very interesting case .......  (from Dubai)

We have recently been referred a 30 year-old male patient who had a
complete lesion of the left brachial plexus during a motor cycle
accident in December 1998.  From clinical tests, MRI's etc. a complete
avulsion of all 5 roots C5-T1 was found, also trapezius muscle is
partially denervated.

He was operated on December 4th 1999 in another country, with the
following nerve transfers:

contralateral C7 transfer
accessory nerve via a nerve graft to the lateral root of the median
nerve
supraclavicular nerve via nerve grafts to the lateral root of the median

nerve
motor branch of the cervical plexus via a nerve graft to the long
thoracic nerve
phrenic nerve via a nerve graft to the suprascapular and the lateral
pectoralis nerve
intercostal nerve II, III, IV via neurorrhaphy to the musculocutaneous
nerve
intercostal nerve V and VI via nerve graft to the radial nerve
C7 posterior division via nerve graft to the radial nerve
C7 anterior division via nerve graft to the medial root of the median
nerve and the ulnar nerve

He made a good postoperative recovery and the left arm was fixed in a
head-thorax-arm plaster cast.  Once discharged, the patient went back to

his home country for physiotherapy, which consisted of passive stretches

and electrical stimulation.   Unfortunately, 6 weeks after the surgery,
he suffered multiple pulmonary emboli, which he made a good recovery
from, but delayed his continuing physiotherapy.

He only returned to Dubai at the beginning of April, with no apparent
active movement or flickers of contraction to the newly innervated
muscles.  We have been continuing with the passive movements/stretches,
PNF, hydrotherapy buoyancy assisted and supported exercises, electrical
stimulation, also the patient has his own stimulator for home use.  In
the pool with the upper limb supported, the patient is able to adduct
and medially rotate the shoulder, although any muscle contraction is
barely detectable.  Nil else is apparent.  As he has some shoulder
girdle movement, he compensates for lack of abduction with shoulder
girdle elevation.

The surgeon (who is a specialist in this field) does not appear to be
very willing to give us or the patient, an indication of what we should
be expecting by now, with regard to muscle innervation.

I believe that this type of surgery is not very common, but does anyone
have any experience of a similar patient.

What I am concerned about, is that if there is no sign of muscle
activity by this time, is it likely??

Is there something else that we should be doing?

This young man does not have medical insurance, and has paid for the
surgery and physiotherapy himself.  He realises that the surgery was
completed later than the 'window of opportunity', but remains hopeful of

some results that will at least give him some kind of function in his
upper limb.

Any responses would be welcome.

Thanks,

Cathy

............................................

   From:
        Mark or Alison Hamersley <[log in to unmask]>
     To:
        [log in to unmask]

Dear Cathy,
A surgeon I worked with in Perth, Western Australia a few years ago was
doing Intercostal neurotization using 3rd and 4th intercostal nerves
into
the musculocutaneous nerve for patients with brachial plexus lesions. At

approximately 6 - 8 months post-op we could sometimes detect a flicker
of
biceps contraction when the patient took a deep breath. It was then a
matter of trying to re-educate the patient to achieve a voluntary
contraction, biofeedback was useful for this. The best result I saw was
elbow flexion against gravity but not through full range, but not until
at
least 12 months post-op. The best results were achieved if the surgery
was
done within 6 months of the initial injury. The surgeon I worked with
certainly wasn't as ambitious to try all of the transfers your patient
has
had done. Good luck with the rehab!
Regards, Alison.

...............................................................

   From:
        karen robb <[log in to unmask]>
     To:
        [log in to unmask]


Hi Catherine
I know at the National Orthopaedic Hospital in Stanmore, North London,
they
have a specialist surgeon called Mr Birch who deals with these types of
injuries. I am confident if you should call either his dept or the
physio
dept at Stanmore, they would be able to give you some advice.
Hope this helps
Karen (research physio, Pain Team  Royal Marsden )

...........................................................

   From:
        "Herb Silver, PT," <[log in to unmask]>
     To:
        [log in to unmask]


Nerves must grow from the surgical site to the muscle at a rate of 1-3
inches a month.  I would expect to just start seeing activity at 4-6
months
in the deltoid, supraspinatus and infraspinatus.  Triceps should START
at
6-8 months.  Forearm muscles at 10-12 months and the hand around 15
months.
 It would be best to follow this progress with "serial" EMGs every 4-6
months.

Herb Silver, PT ECS
USA

..........................................................................

From:
            "Herb Silver, PT," <[log in to unmask]>
        To:
            [log in to unmask]
 References:
            1

My experience is actually with Cranial nerve transfers, so I have no
experience with the type of surgery you describe.  In the cervical
spine,
motor nerves avulse distal to the cell body, sensory nerves avulse with
the
cell body intact but separated from the CNS.  This is a classic kind of
finding with EMG and nerve conduction studies--I have seen plenty of
nerve
avulsions in the cervical spine during my experience with nerve
conduction
studies.  The nerve grafts you described are all distal to the motor
nerve
cell body--once an axon is separated from the cell body, it dies from
that
point on distally.  So, these grafts would have to grow distally from
the
graft site.  This will be an interesting case to follow, as the
intention
of the surgery is to apparently bridge the gap presented by the injury.
So, the time frames listed in my reply should be accurate.  Now, one
thing
I found doing serial studies to a nerve after a axonotomesis (the axon
is
damaged by the nerve lining remains intact and hence the nerve grows
back
from the injury site distally), was that even after the muscle was
reinnervated, it required some sort of facilitation to restore function
to
the muscle--the nerve was intact, the person just "forgot" how to move
the
area.  It happened several times doing an EMG when the person had
feedback,
they would start moving the muscle for the first time.  As far as using
Estim in the interum, I believe that most studies do not support this
intervention.  At any rate, you must use relatively long durations,
usually
longer than are found on "muscle stim" units as the currents on those
units
are for normally innervated muscle, and deneravated muscle requires long

durations and higher intensities.

Herb Silver, PT

.................................................................

From:
            Anuradha <[log in to unmask]>
   Reply-To:
            [log in to unmask]
        To:
            PHYSIO <[log in to unmask]>
 References:
            1

Hello Catherine and all,
There have been some evidences that electrical stimulation may infact
delay
the nerve regeneration. Some time I had posted the reference  in view of

management of facial nerve palsy. The surgery was done about 5 mths ago
could you specify as to what exactly you mean by that there was a good
post
op recovery? I mean was there any good recovery of muscle strength etc??

Has a repeat EMG and NCV study done to establish prognosis?
If the prognosis is poor it is good to let some tightness develop so
that
the patients can use the tenodesis (I am not sure if this is the right
word)
actionalso it helps some stabilisation of the affected joints where
there is
complete loss of active restraints
Hope this helps
Mrs. Anuradha S. Sawant, B.Sc.P.T.SRPT
Sr. Physical Therapist
Ministry of Health
Bahrain
Arabian Gulf





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