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Transfer of Anastomosed Vessels

Zhang Shaocheng, Dang Ruishan, .Zhao Jie, et al, Department of Orthopedics, Changhai Hospital, Shanghai, 200433

Objective: To reconstruct partial peripheral nerve function in complete paraplegia patients with transverse injury of thoracic spinal cord.

Methods: One side of the Inar nerve was cut off in the carpal level, of which the deep branch of the distal end was anastomosed with the pronator quadraturs muscle branch of anterior interosseous nerve, and the superficial branch of the distal ulnar nerve was anastomosed with the superficial branch of radial nerve. The proximal ulnar nerve was dissected from the subcutaneous tunnel to its origin in the axilla. The separated avascularized ulnar nerve was conducted into the lateral thoracic wall tunnel. The thoracodorsal artery and venous were exposed and anastomosed end-to-end to superior ulnar collateral vessels. The pudendal nerve, posterior cutaneous nerve of thigh and sciatic nerve were dissected in a hip incision. The ulnar nerve was bridged to the pudendal nerve with a reversed fascia pedical posterior cutaneous nerve of thigh. The deep branch and dorsal hand branch of the ulnar nerve were anastomosized to the sciatic nerve or the femoral nerve. The superficial and flexor carpi ulnaris muscle have been bridged by sural nerve, anastomosed to the lumbosacral trunk.

Results: Three and five years follow-up of four patients got basic function recovery of the done nerves. No significant claw hand was found in the donor site, and hand sensory improved to S3 and recovered to the original region.

Conclusion: Vascularized ulnar nerve transfer can reconstruct partial neurological function of complete transverse injury of the thoracic spinal cord.

Incomplete Paraplegia Treated With Intradural Microsurgical Releasing

Zhang, Shaocheng, PangYu; Department of Orthopedics, Changhai Hospital, Shanghai, 200433

Objective: Accelerate medullispinal function recovery by releasing the intradural scar and adhesion compressing spinal cord with microsurgery technique.

Method: Incise the dura mater, release the adhesion to spinal cord of pia mater, denticulate ligament, original part of nerve root and release the peripheral fibrous bind with microsurgery technique.

Results: At two to four years follow-up post-operatively, all 16 cases have lowered down the levels of the dermatomes, and muscle strength improved at least to above one muscle grade. In six of them, the muscle strength of main mass of double lower limbs has improved to above three muscle grades and recovered the ability to walk.

Conclusion: Release of the intradural adhesion and scar tissues has good effect on treatment of incomplete paralysis.

Partial Sensation Function Reconstruction In Complete Paraplegia

Zhang, Shaocheng, Yu Baoquing, Ji Rongming, et al; Department of. Orthopedics, Changhai Hospital, Shanghai, 200433

Objective: To reconstruct the sensation of buttock, lateral thigh, medial thigh and vulva in paraplegia caused by thoraco-lumbar fracture whose sensory level is between the T9 and T11.

Methods: 1-2 segments of vascularized intercostals nerve skin branch above the paraplegic level were taken. The vascularized nerve was transferred to the lateral abdominal wall from a subcutaneous tunnel and anastomosed to the excised ilioinguinal nerve and lateral cutaneous nerve of thigh in the distal end by sural nerve bridging.

Results: Six cases got 10-14 months follow-up. Five of them got a grade S2-3 recovery of sensory function in lateral buttock, lateral and medial thigh, and vulva, and this sensory area was expanded with time. No obvious sensory function abnormalities were found in the donor area.

Conclusion: The results of this operation demonstrated that patients with T9-11 paraplegia can get sensory recovery down of 3-4 segments. It is especially beneficial to the patients that their sensory function of vulva, lateral buttock, and thigh has recovered, and this operation has no further damage to their general condition and primary function.

The Transplantation of Peripheral Nerve to Treat the Later Injury of Spinal Cord

Zhang Shaocheng, Pang Yu, Zhao Yongjiang, Zhang Chuansen; Department of Orthopedic Surgery, Changhai Hospital, Shanghai, 200433

Objective: Supplying nerve fibers, nerve cells, and factors included in them to spinal cord improves the recovery of the function of the spinal cord.

Method: After releasing the spinal cord, incises it vertically at the appropriate length and depth.

One's own peripheral nerve (usually the sural nerve), which is removed its epineurium, nearilemma and incised it open and cut off a proportion of nerve fibers with microsurgery technique so that its character and appearance looks like cauda equine is transplanted in a multi-striped fashion, vertically inside the spinal cord incised and fastened appropriately to dura mater with 8"0"nylon thread and covered with sacrospinal muscle flap.

Results: At 1/2-3 years follow up post-operation, according to classification of Frankel: four cases recovered above 2 grade, and 2 cases recovered above 1 grade.

Conclusion: This method can supply good environment of nerve growth and function of bridge and plank to segment of injured spinal cord, thus accelerating the recovery of spinal cord.

Gatism Treated with Neuroanastamosis

S. C. Zhang, M.D., and J. Zhao; Department of Orthopedics, Changhai Hospital

Objective: To solve Gatism (loss of control of bowel and bladder due to paraplegia).

The authors advised a method for anastamosing an intercostals nerve to the pudendal nerve. The transplanted nerve was conjoined to the pudendal nerve using vascularized nerve bridging. The procedure was performed on 20 cadavers prior to use in humans. The procedure has been done on six patients. During emergency surgery, the patient's spinal cord was found to be completely destroyed. Electromyogram (EMG) confirmed loss of the nervi erigens. Six months after this severe injury, the above anastamosis was performed, joining the pudendal nerve with an intercostals nerve using a 16-21 cm piece of the nervi suralis along with the saphena parva. One-three year follow-up, perineal sensation returned on the patient's right side, and EMG showed a conductive potential of 30 msec. For this measurement, the intercostals nerve was stimulated even though the action potential of the rectal and urethral sphincters was not marked. This patient can now sense imminent excretal contamination and, prior to bowel evacuation, can ask for help. The benefit of this procedure for Gatism in paraplegic patients seems clear, provided the patient is below the age of 40, and it has been proved that the spinal cord injury is irreversible.

Nerve Degeneration of Lower Extremity After Paraplegia

Zhang, Shaocheng, Xiu Xianlun, Li Quanhua, Zhao Jie, Yu Jinguo, Yu Baoqing, Zhang Xuesong; Department of  Orthopedics, Changhai Hospital, Second Military Medical University, Shanghai, 200433 

Objective: To study the nerve degeneration of lower extremity after paraplegia.

Methods: (1) The spinal cords of experimental dogs were severed between T11-12. The section of main nerve trunks of lower extremities were studied under microscope after 3-6 weeks; (2) The sural nerve of later paraplegic experimental dogs and later paraplegic patients.

Conclusion: No obvious degeneration is found in lower extremity nerve if the injury place is higher than T11.

Treatment for Paraplegia with Bridging Vascularized Intercostal Nerve to Spinal Cord Nerve Root

Zhang, Shaocheng, Ji Rongming, Yu Baoqing, et al.; Department of Orthopedics, Changhai Hospital, Shanghai, 200433.

Objective: To reconstruct partial function for the later paraplegic patients.

Method: After releasing and decompressing the injured part of the spinal cord microsurgically, two intercostal nerves with vessels, of which the distal ends were handled by microsurgical technique, were transferred and bridged to the spinal cord nerve root, commonly anastomosed to caude equine. Sometimes the sural nerve with small saphena vein grafted if necessary.

Results: 31 patients followed up for 1-3 years (average 2.5 years) postoperatively, regained the muscular power of the lower extremities obviously and could stand up and walk a short distance with crutches and braces. Of the 31 cases, 9 cases had got obvious improvement of stool and urination function, means from Frankel's classification A or B to D, 17 cases had the proprioception recovered completely, the stool and urination function improved slightly and no movable function, means from Franckel's A to B or C; 4 cases only had descending of sensational plane and recovery of noumenon deep sensation of two feet, means from Frankel's A to B; one case failed.

Conclusion: The results show that this method is effective for the younger patients who have had no recoveries after 1/2-1 year since injury and the continuity of spinal cord was still present as confirmed by MRI.