Skip to main content
SpringerLink
Log in

A Global Approach to Upper Extremity Paralysis: The Role of Surgery in Limb Reanimation

  • Chapter
  • First Online:
Rehabilitative Surgery

Abstract

We present a comprehensive global approach to upper extremity reanimation, including a comparison of the anatomy and treatment of spastic and flaccid paralysis. Our proposal for management includes a paradigm shift in the treatment of upper extremity paralysis, advocating for the targeted conversion of spastic to flaccid paralysis in order to optimize function. We review current surgical approaches for the treatment of brachial plexopathy and upper extremity neurologic disorders requiring reanimation. Detailed descriptions of a surgical planning preoperative evaluation, including specific examination techniques and electrodiagnostic and imaging findings, are provided. We discuss key aspects of surgical planning in these complex patients, including the importance of evaluation of pain and assessment of potential muscle and nerve donors, including the possible creation of new donors in subsequent operations.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 84.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 109.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 159.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Brown Jr RH. Amyotrophic lateral sclerosis and other motor neuron diseases. In: Kasper DL, Braunwald E, Fauci AS, Hauser SL, Longo DL, Jameson JL, editors. Harrison’s principles of internal medicine. New York: McGraw-Hill Book Company; 2005. p. 2424.

    Google Scholar 

  2. Kirshblum S. Treatment alternatives for spinal cord injury related spasticity. J Spinal Cord Med. 1999;22:199–217.

    Article  CAS  PubMed  Google Scholar 

  3. Korenkov AI, Niendorf WR, Darwish N, Glaeser E, Gaab MR. Continuous intrathecal infusion of baclofen in patients with spasticity caused by spinal cord injuries. Neurosurg Rev. 2002;25:228–30.

    Article  PubMed  Google Scholar 

  4. Olney RK. Weakness, disorders of movement, and imbalance. In: Kasper DL, Braunwald E, Fauci AS, Hauser SL, Longo DL, Jameson JL, editors. Harrison’s principles of internal medicine. New York: McGraw-Hill Book Company; 2005. p. 138.

    Google Scholar 

  5. Ordia JI, Fischer E, Adamski E, Spatz EL. Chronic intrathecal delivery of baclofen by a programmable pump for the treatment of severe spasticity. J Neurosurg. 1996;85:452–7.

    Article  CAS  PubMed  Google Scholar 

  6. Roberts A. Surgical management of spasticity. J Child Orthop. 2013;7:389–94.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Roger VL, Go AS, Lloyd-Jones DM, Benjamin EJ, Berry JD, Borden WB, Bravata DM, Dai S, Ford ES, Fox CS, Fullerton HJ, Gillespie C, Hailpern SM, Heit JA, Howard VJ, Kissela BM, Kittner SJ, Lackland DT, Lichtman JH, Lisabeth LD, Makuc DM, Marcus GM, Marelli A, Matchar DB, Moy CS, Mozaffarian D, Mussolino ME, Nichol G, Paynter NP, Soliman EZ, Sorlie PD, Sotoodehnia N, Turan TN, Virani SS, Wong ND, Woo D, Turner MB, American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics – 2012 update: a report from the American Heart Association. Circulation. 2012;125:e2–220.

    Article  PubMed  Google Scholar 

  8. Devivo MJ. Epidemiology of traumatic spinal cord injury: trends and future implications. Spinal Cord. 2012;50:365–72.

    Article  CAS  PubMed  Google Scholar 

  9. Terzis JK, Papakonstantinou KC. The surgical treatment of brachial plexus injuries in adults. Plast Reconstr Surg. 2000;106:1097–122.

    Article  CAS  PubMed  Google Scholar 

  10. Growdon JH, Fink JS. Paralysis and movement disorder. In: Isselbacher KJ, Braunwald E, Wilson JD, editors. Harrison’s principles of internal medicine. New York: McGraw-Hill Book Company; 1994. p. 115–25.

    Google Scholar 

  11. Marx A, Glass JD, Sutter RW. Differential diagnosis of acute flaccid paralysis and its role in poliomyelitis surveillance. Epidemiol Rev. 2000;22:298–316.

    Article  CAS  PubMed  Google Scholar 

  12. Jain DK, Bhardwaj P, Venkataramani H, Sabapathy SR. An epidemiological study of traumatic brachial plexus injury patients treated at an Indian centre. Indian J Plast Surg. 2012;45:498–503.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Midha R. Epidemiology of brachial plexus injuries in a multitrauma population. Neurosurgery. 1997;40:1182–8.

    Article  CAS  PubMed  Google Scholar 

  14. Kalliainen LK, O’Brien VH. Current uses of botulinum toxin A as an adjunct to hand therapy interventions of hand conditions. J Hand Ther. 2014;27:85–95.

    Article  PubMed  Google Scholar 

  15. Watve SV, Sivan M, Raza WA, Jamil FF. Management of acute overdose or withdrawal state in intrathecal baclofen therapy. Spinal Cord. 2012;50:107–11.

    Article  CAS  PubMed  Google Scholar 

  16. Ghosh D, Mainali G, Khera J, Luciano M. Complications of intrathecal Baclofen pumps in children: experience from a tertiary care center. Pediatr Neurosurg. 2013;49(3):138–44.

    Article  PubMed  Google Scholar 

  17. Steinbok P, Hicdonmez T, Sawatzky B, Beauchamp R, Wickenheiser D. Spinal deformities after selective dorsal rhizotomy for spastic cerebral palsy. J Neurosurg. 2005;102(4 Suppl):363–73.

    PubMed  Google Scholar 

  18. Crilly MA. Selective dorsal rhizotomy remains experimental in cerebral palsy. BMJ. 2012;345:e4845.

    Article  Google Scholar 

  19. Wolfe SW, Pederson WC, Hotchkiss RN, Kozin SH, editors. Green’s operative hand surgery. Philadelphia: Elsevier Health Sciences; 2005.

    Google Scholar 

  20. Karev A. Trapezius transfer for paralysis of the deltoid. J Hand Surg Br. 1986;11:81–3.

    Article  CAS  PubMed  Google Scholar 

  21. Kotwal PP, Mittal R, Malhotra R. Trapezius transfer for deltoid paralysis. J Bone Joint Surg Br. 1998;80:114–6.

    Article  CAS  PubMed  Google Scholar 

  22. Elhassan B, Bishop A, Shin A, Spinner R. Shoulder tendon transfer options for adult patients with brachial plexus injury. J Hand Surg Am. 2010;35:1211–9.

    Article  PubMed  Google Scholar 

  23. Terzis J. Principles and techniques of peripheral nerve surgery. In: Daniel RK, editor. Reconstructive microsurgery. Boston: Little Brown & Co Inc; 1977.

    Google Scholar 

  24. Terzis JK, Strauch B. Microsurgery of the peripheral nerve: a physiological approach. Clin Orthop Relat Res. 1978;133:39–48.

    Google Scholar 

  25. Hadlock T, Elisseeff J, Langer R, Vacanti J, Cheney M. A tissue-engineered conduit for peripheral nerve repair. Arch Otolaryngol Head Neck Surg. 1998;124:1081–6.

    Article  CAS  PubMed  Google Scholar 

  26. Elkwood AI, Holland NR, Arbes SM, Rose MI, Kaufman MR, Ashinoff RL, Parikh MA, Patel TR. Nerve allograft transplantation for functional restoration of the upper extremity: case series. J Spinal Cord Med. 2011;34:241–7.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Mackinnon SE, Doolabh VB, Novak CB, Trulock EP. Clinical outcome following nerve allograft transplantation. Plast Reconstr Surg. 2001;107:1419–29.

    Article  CAS  PubMed  Google Scholar 

  28. Palmer ML, Epler M. Principles of examination techniques. In: Palmer ML, Epler M, editors. Clinical assessment procedures in physical therapy. Philadelphia: JB Lippincott; 1990. p. 8–36.

    Google Scholar 

  29. Zheng MX, Xu WD, Qiu YQ, Xu JG, Gu YD. Phrenic nerve transfer for elbow flexion and intercostal nerve transfer for elbow extension. J Hand Surg Am. 2010;35:1304–9.

    Article  PubMed  Google Scholar 

  30. Siqueira MG, Martins RS. Phrenic nerve transfer in the restoration of elbow flexion in brachial plexus avulsion injuries: how effective and safe is it? Neurosurgery. 2009;65(4 Suppl):A125–31.

    Article  PubMed  Google Scholar 

  31. Sinis N, Boettcher M, Werdin F, Kraus A, Schaller HE. Restoration of shoulder abduction function by direct muscular neurotization with the phrenic nerve fascicles and nerve grafts: a case report. Microsurgery. 2009;29:552–5.

    Article  PubMed  Google Scholar 

  32. Kaufman MR, Elkwood AI, Colicchio AR, CeCe J, Jarrahy R, Willekes LJ, Rose MI, Brown D. Functional restoration of diaphragmatic paralysis: an evaluation of phrenic nerve reconstruction. Ann Thorac Surg. 2014;97:260–6.

    Article  PubMed  Google Scholar 

  33. Kaufman MR, Elkwood AI, Rose MI, Patel T, Ashinoff R, Saad A, Caccavale R, Bocage JP, Cole J, Soriano A, Fein E. Reinnervation of the paralyzed diaphragm: application of nerve surgery techniques following unilateral phrenic nerve injury. Chest. 2011;140:191–7.

    Article  PubMed  Google Scholar 

  34. Schreiber JJ, Feinberg JH, Byun DJ, Lee SK, Wolfe SW. Preoperative donor nerve electromyography as a predictor of nerve transfer outcomes. J Hand Surg Am. 2014;39:42–9.

    Article  PubMed  Google Scholar 

  35. Rb A, Naffzinger HC. The pathology of human striated muscle following denervation. J Neurosurg. 1953;10:216–27.

    Article  Google Scholar 

  36. Mackinnon SE, Dvali LT. Basic pathology of the hand, wrist and forearm: nerve. In: Berger RA, Weiss APC, editors. Hand surgery, vol. 1. Philadelphia: Lippincott Williams & Wilkins; 2004. p. 37–48.

    Google Scholar 

  37. Sunderland S. The anatomy and physiology of nerve injury. Muscle Nerve. 1990;13:771–84.

    Article  CAS  PubMed  Google Scholar 

  38. Landi A, Copeland S. Value of the Tinel sign in brachial plexus lesions. Ann R Coll Surg Engl. 1979;61:470–1.

    CAS  PubMed  PubMed Central  Google Scholar 

  39. Ziegler‐Graham K, MacKenzie EJ, Ephraim PL, Travison TG, Brookmeyer R. Estimating the prevalence of limb loss in the United States: 2005 to 2050. Arch Phys Med Rehabil. 2008;89:422–9.

    Article  PubMed  Google Scholar 

  40. Owings M, Kozak LJ; National Center for Health S. Ambulatory and inpatient procedures in the United States, 1996. Hyattsville: U.S. Dept. of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics; 1998.

    Google Scholar 

  41. Norton KM. A brief history of prosthetics. inMotion. 2007 Nov/Dec; 17(7). Accessed at: http://www.amputee-coalition.org/inmotion/nov_dec_07/history_prosthetics.html. On 6 Oct 2015.

  42. Bueno Jr RA, French B, Cooney D, et al. Targeted muscle reinnervation of a muscle-free flap for improved prosthetic control in a shoulder amputee: case report. J Hand Surg. 2011;36A:890–3.

    Article  Google Scholar 

  43. Gart MS, Souza JM, Dumanian GA. Targeted muscle reinnervation in the upper extremity amputee: a technical road map. J Hand Surg Am. 2015;40:1877–88.

    Article  PubMed  Google Scholar 

  44. Ngheim BT, Sando IC, Gillespie RB, et al. Providing a sense of touch to prosthetic hands. Plast Reconstr Surg. 2015;135:1652–63.

    Article  Google Scholar 

  45. Souza JM, Cheesborough JE, Ko JH. Targeted muscle reinnervation: a novel approach to postamputation neuroma pain. Clin Orthop Relat Res. 2014;472:2984–90.

    Article  PubMed  PubMed Central  Google Scholar 

  46. Birch R, Bonney G, Wynn Parry CB. Results. In: Surgical disorders of the peripheral nerves. London: Churchill Livingstone; 1998.

    Google Scholar 

  47. House JH, Gwathmey FW, Fidler MO. A dynamic approach to the thumb-in-palm deformity in cerebral palsy: evaluation and results in fifty-six patients. J Bone Joint Surg Am. 1981;63:216–25.

    Article  CAS  PubMed  Google Scholar 

  48. Wolfe SW, Hotchkiss RN, Pederson WC, Kozin SH. Green’s operative hand surgery. Philadelphia: Churchill Livingston; 2011.

    Google Scholar 

  49. Teasdale G, Jennett B. Assessment of coma and impaired consciousness: a practical scale. Lancet. 1974;2:81–4.

    Article  CAS  PubMed  Google Scholar 

  50. British Medical Research Council. Reproduced from Aids to the examination of the peripheral nervous system. London: Her Majesty’s Stationary Office; 1976.

    Google Scholar 

Download references

Author information

Authors and Affiliations

  1. The Plastic Surgery Center, The Institute for Advanced Reconstruction, 535 Sycamore Ave, Shrewsbury, NJ, 07702, USA

    Andrew I. Elkwood MD, MBA, Lisa F. Schneider MD, Deborah Yu MD & Hamid Abdollahi MD

Authors
  1. Andrew I. Elkwood MD, MBA
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Lisa F. Schneider MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Deborah Yu MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Hamid Abdollahi MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Andrew I. Elkwood MD, MBA .

Editor information

Editors and Affiliations

  1. Institute for Advanced Reconstruction, The Plastic Surgery Center, Shrewsbury, New Jersey, USA

    Andrew I. Elkwood

  2. Institute for Advanced Reconstruction, The Plastic Surgery Center, Shrewsbury, New Jersey, USA

    Matthew Kaufman

  3. Institute for Advanced Reconstruction, The Plastic Surgery Center, Shrewsbury, New Jersey, USA

    Lisa F. Schneider

Rights and permissions

Reprints and permissions

Copyright information

© 2017 Springer International Publishing Switzerland

About this chapter

Cite this chapter

Elkwood, A.I., Schneider, L.F., Yu, D., Abdollahi, H. (2017). A Global Approach to Upper Extremity Paralysis: The Role of Surgery in Limb Reanimation. In: Elkwood, A., Kaufman, M., Schneider, L. (eds) Rehabilitative Surgery. Springer, Cham. https://doi.org/10.1007/978-3-319-41406-5_16

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-41406-5_16

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-41404-1

  • Online ISBN: 978-3-319-41406-5

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation