1. Treatment of Injuries to the Brachial Plexus and Upper Extremity Andrew I. Elkwood, MD, FACS Plastic & Reconstructive Surgery Director, The Center for Treatment of Paralysis and Reconstructive Nerve Surgery Reconstructive Nerve Surgery

3. Patients with disabilities can do more with less (depending upon the quality of their rehabilitation treatment) Rehabilitative Surgery Center for Treatment of Paralysis and Reconstructive Nerve Surgery

4. Nerve Surgery The “Garage Door” Analogy Center for Treatment of Paralysis and Reconstructive Nerve Surgery

5. Nerve Surgery  The “Garage Door” Analogy  Outlet = spinal cord  Wire = nerve  Motor = muscle  Chair = tendon  Door = hand or foot Center for Treatment of Paralysis and Reconstructive Nerve Surgery

6. Rehabilitative Surgery is a process not an event Center for Treatment of Paralysis and Reconstructive Nerve Surgery

7. Rehabilitative Surgery Surgical Algorithm Nerve Repair Nerve Grafting Neurotization Tendon Transfer Tenodesis Joint Fusion Splinting Simplicity Elegance Center for Treatment of Paralysis and Reconstructive Nerve Surgery

8. Nerve Grafting  Self transfer (i.e. Sural Nerve)  Manufactured Nerve  Processed Nerve  Cadaver Transplant  Living Related Transplant Center for Treatment of Paralysis and Reconstructive Nerve Surgery

10. IN THE AREA OF THE PLEXUS  NERVES  BONES  ARTERY  VEIN  LUNG Center for Treatment of Paralysis and Reconstructive Nerve Surgery

12. BRACHIAL PLEXUS INJURIES  BIRTH INJURY  MOTOR VEHICLE ACCIDENTS  MOTORCYCLES  FALLS  INDUSTRIAL ACCIDENTS  SPORTS INJURIES  TUMORS  RADIATION Center for Treatment of Paralysis and Reconstructive Nerve Surgery

13. BRACHIAL PLEXUS INJURIES  4% OF ALL MOTORCYCLE ACCIDENTS  19% ARE COMATOSE  13% HAVE C-SPINE INJURIES Center for Treatment of Paralysis and Reconstructive Nerve Surgery

14. THREE BASIC FACTORS  PAIN  SENSIBILITY  MOTION Center for Treatment of Paralysis and Reconstructive Nerve Surgery

15. OVERVIEW  DIAGNOSIS  WORK-UP  NERVE STUDIES  NERVE REPAIR  POST-OP  REHABILITATION Center for Treatment of Paralysis and Reconstructive Nerve Surgery

16. DIAGNOSIS  Often clouded by coma, etc  Often clouded by orthopedic injuries  Often ignored  Often misinformed  May be subtle Center for Treatment of Paralysis and Reconstructive Nerve Surgery

17. WORK UP  PRELIMINARY WORK UP OF NERVE STUDIES STARTS RIGHT AWAY  FIRST EMG AT 6 WEEK TO 3 MONTHS  CXR  MRI  CT MYELOGRAM Center for Treatment of Paralysis and Reconstructive Nerve Surgery

18. WORK UP  REPEAT EMG AT 6 MONTHS IF NO IMPROVEMENT  IF IMPROVEMENT  REASSESS AT 9 MONTHS  IF NO IMPROVEMENT  OPERATE Center for Treatment of Paralysis and Reconstructive Nerve Surgery

19. TIMING  THE TEXTBOOKS ARE WRONG  DO NOT WAIT A YEAR  IF NOT IMPROVED BY 3 MONTHS, THEY WILL NOT IMPROVE  EMG AT 6-8 WEEKS  REPAIR AT ABOUT 3 MONTHS  ALLOWS FOR “SECOND SHOT” BEFORE ONE YEAR Center for Treatment of Paralysis and Reconstructive Nerve Surgery

20. SURGERY TEAM APPROACH  SURGEONS  CONSULTANTS  NURSES  THERAPISTS  HOME CARE  FAMILY Center for Treatment of Paralysis and Reconstructive Nerve Surgery

21. RECOVERY  WHEN NERVE REPAIR IS REQUIRED, RECOVERY IS DELAYED  1 - 2 MONTH LATENCY  NERVE GROWTH  1 mm/day  1 inch/month  LONGER DISTANCE, LONGER RECOVERY TIME Center for Treatment of Paralysis and Reconstructive Nerve Surgery

22. POST-OP CARE  UNDERLYING DISEASE  MULTIPLE OPERATIONS  PAIN RESISTANCE  SEVERAL OPERATIVE SITES  IMMOBILIZATION  LONG PROCEDURES  ANESTHESIA TIME Center for Treatment of Paralysis and Reconstructive Nerve Surgery

23. REHABILITATION  IMMOBILIZATION  3 - 6 WEEKS POST-OP  AGGRESSIVE REHAB  KEEP JOINTS SUPPLE  MAINTAIN STRENGTH  BUILD NEW STRENGTH  RELEARN MUSCLE MOVEMENT  BIOFEEDBACK Center for Treatment of Paralysis and Reconstructive Nerve Surgery

24. Spinal Accessory Neurotization Brachial Plexus Palsy Center for Treatment of Paralysis and Reconstructive Nerve Surgery

25. BRACHIAL PLEXUS PALSY Center for Treatment of Paralysis and Reconstructive Nerve Surgery

26. Nerve Transplants  Its all about spare parts  No need to prioritize  Can’t go to home depot  Cadaver  Living related donor Center for Treatment of Paralysis and Reconstructive Nerve Surgery

27. Nerve Transplant  NO NEED TO PRIORITIZE Center for Treatment of Paralysis and Reconstructive Nerve Surgery

28. Nerve Transplantation  Allograft  Abo Compatibility  Prograf  Wrist Monitoring  Steroid Rescue Center for Treatment of Paralysis and Reconstructive Nerve Surgery

29. Nerve Transplantation  Who’s a candidate?  Injury about 1 year  Good health  Good support system  Massive injury Center for Treatment of Paralysis and Reconstructive Nerve Surgery

30. Nerve Transplantation  Who’s a good donor?  Good health  Abo match  No communicable disease Center for Treatment of Paralysis and Reconstructive Nerve Surgery

31. Nerve Transplantation CADAVER VS. LIVING RELATED DONOR Center for Treatment of Paralysis and Reconstructive Nerve Surgery

32. Spinal Cord Injury Can we treat spinal cord injuries like bilateral brachial plexus injuries? Center for Treatment of Paralysis and Reconstructive Nerve Surgery

33. Spinal Cord Injury Tetraplegic Hand Surgery Center for Treatment of Paralysis and Reconstructive Nerve Surgery

34. Spinal Cord Injury Hand Surgery  Minimize Spasticity  Maximize passive range of motion  Maximize active range of motion  Tendon Lengthening  Joint Stabilization/Joint Fusion  Splinting Static/Dynamic  Tendon Transfer/ Tenodesis Effect  Neurotization Center for Treatment of Paralysis and Reconstructive Nerve Surgery

35. Spinal Cord Paralysis We can’t fix the problem but we can help to RESTORE FUNCTION Center for Treatment of Paralysis and Reconstructive Nerve Surgery

36. Spinal Cord Injury  Need for Functioning Donors  Nerve donors above the lesion  Muscle donors for tendon transfers  Free muscle donors  Sacrifice contra lateral side? Center for Treatment of Paralysis and Reconstructive Nerve Surgery

37. Spinal Cord Paralysis  Level of Injury  Cranial nerves always spared  Cervical plexus always spared Center for Treatment of Paralysis and Reconstructive Nerve Surgery

38. Spinal Cord Paralysis  Prioritize Function  Arm Abduction  Triceps  Bicep  Wrist Extension  Finger Extension/Flexion  Individualize for Patient Center for Treatment of Paralysis and Reconstructive Nerve Surgery

39. Spinal Cord Injury Timing  Need to let injury evolve  Need to maximize therapy  Need to maintain existing function  Motor end plates do not degrade  Spasm must be balanced  Can take advantage of two-stage procedures Center for Treatment of Paralysis and Reconstructive Nerve Surgery

40. Spinal Cord Injury  Trapezius to Deltoid Transfer  Neurotization from spinal accessory nerve  Nerve to levator scapulae  Nerve to sternocleidomastoid  Latissmmus to bicep  Latissimus to triceps Center for Treatment of Paralysis and Reconstructive Nerve Surgery

41. Stroke Why can’t we treat a stroke patient like a brachial plexus patient? Medical problems Spasm Center for Treatment of Paralysis and Reconstructive Nerve Surgery

42. Spinal Cord Injury Pressure Sores  Can occur over any bony prominence  Sacrum most common  Scalp  Ischium  Hip  Heels Center for Treatment of Paralysis and Reconstructive Nerve Surgery

43. Spinal Cord Injury Pressure Sores  Prevention Center for Treatment of Paralysis and Reconstructive Nerve Surgery

44. Spinal Cord Injury Pressure Sores  Any pressure above capillary perfusion pressure is to high  Only a Clinitron works to heal a wound  Other mattresses may work to help prevent  Floating the pressure point is best  Extra padding is bad  Prevention is HARD work Center for Treatment of Paralysis and Reconstructive Nerve Surgery

45. Spinal Cord Injury Treatment of Pressure Sores  Grading scale has no value  Maximize inflow  Maximize protoplasm  Remove “bacteria food”  Means of debridement is not of great importance  Re-educate patient  The VAC does not debride Center for Treatment of Paralysis and Reconstructive Nerve Surgery

46. Spinal Cord Injury Pressure Sore Treatment  High recurrence rate  Maximize everything  Quality of soft tissue coverage  Bed trial  Social support  Prognosis Center for Treatment of Paralysis and Reconstructive Nerve Surgery

47. Spinal Cord Injury Pressure Sores  Prevention Center for Treatment of Paralysis and Reconstructive Nerve Surgery

48. Spinal Cord Injury Pressure Sores  Neurotization for protective sensibility Center for Treatment of Paralysis and Reconstructive Nerve Surgery

49. Spinal Cord Injury Summary  We do not have a cure  We have treatments to deal with complications  We have cutting edge methods to maximize function and impact lives  Education is our greatest hurdle Center for Treatment of Paralysis and Reconstructive Nerve Surgery

51. Thank You! Center for Treatment of Paralysis and Reconstructive Nerve Surgery

52. Complex Injuries: “A Legal Perspective” James Maggs, Esq Maggs & McDermott, LLC