Publications by authors named "Yan-Qun Qiu"

21 Publications

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Outcomes of ulnar nerve decompression for double crush syndrome.

Br J Neurosurg 2021 Feb 27:1-9. Epub 2021 Feb 27.

Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, China.

Background: Double crush syndrome (DCS) of the ulnar nerve, including cubital tunnel syndrome with ulnar tunnel syndrome (UTS), is uncommon. This study compares the postoperative outcomes of patients with isolated ulnar tunnel syndrome versus those with double crush syndrome of the elbow and ulnar tunnel.

Methods: This study enrolled 22 patients: 12 underwent cubital tunnel surgery and ulnar tunnel surgery (double crush group); and 10 underwent only ulnar tunnel decompression (isolated UTS group). Postoperative effect evaluation of patients in both groups after at least 2.6 years (mean, 5.1 years and 5.7 years, respectively). Statistical analysis compared postoperative function, physical examination, and patient-reported satisfaction between groups.

Results: In terms of postoperative grip strength, there was no difference between the postoperative states of the two groups (0.88 ± 0.04 versus 0.87 ± 0.05), while there was statistical difference in terms of the increment of the grip strength ( = 0.036); the two-point discrimination of isolated UTS group is better than the double crush group (90% versus 83.3%); double crush patients reported lower satisfaction than the UTS group (90% versus 83.3%).

Conclusions: At a minimum of 2.6 years after the nerve decompression, the patients of isolated UTS group are likely to have superior grip strength increment than patients with a history of double crush surgery, and there is no big difference in the final recovery situation. The sensation and satisfaction of isolated UTS group after nerve release were better compared with patients following double crush surgery.
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http://dx.doi.org/10.1080/02688697.2021.1889463DOI Listing
February 2021

Contralateral seventh cervical nerve transfer can affect the pennation angle of the lower limb in spastic hemiplegia patients: An observational case series study.

Brain Behav 2019 12 13;9(12):e01460. Epub 2019 Nov 13.

Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, China.

Introduction: We previously reported transferring seventh cervical (C7) nerve from unaffected side to affected side in patients with spastic hemiplegia due to chronic cerebral injury, to improve function and reduce spasticity of paralyzed upper limb. In the clinics, some patients also reported changes of spasticity in their lower limb, which could not be detected by routine physical examinations. Pennation angle of muscle can indirectly reflect the condition of spasticity. The purpose of this study was to evaluate whether this upper limb procedure may affect spasticity of lower limb, using ultrasonography to detect changes of muscle pennation angle (PA).

Methods: Twelve spastic hemiplegia patients due to cerebral injury including stroke, cerebral palsy, and traumatic brain injury, who underwent C7 nerve transfer procedure, participated in this study. B-mode ultrasonography was used to measure PA of the gastrocnemius medialis (GM) muscle at rest preoperatively and postoperatively. The plantar load distribution of the lower limbs was evaluated using a Zebris FDM platform preoperatively and postoperatively.

Results: The PA of the GM was significantly smaller on the affected side than that of unaffected side before surgery. On the affected side, the postoperative PA was significantly larger than preoperative PA. On the unaffected side, the postoperative PA was not significantly different compared to preoperative PA. The postoperative plantar load distribution of the affected forefoot was significantly smaller than preoperative load distribution, which was consistent with ultrasonography results.

Conclusions: This study indicates that C7 nerve transfer surgery for improving upper limb function can also affect muscle properties of lower limb in spastic hemiplegia patients, which reveals a link between the upper and lower limbs. The interlimb interactions should be considered in rehabilitation physiotherapy, and the regular pattern and mechanism need to be further studied.
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http://dx.doi.org/10.1002/brb3.1460DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6908868PMC
December 2019

Simple Grading for Motor Function in Spastic Arm Paralysis: Hua-Shan Grading of Upper Extremity.

J Stroke Cerebrovasc Dis 2019 Aug 22;28(8):2140-2147. Epub 2019 May 22.

Department of Hand Surgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; Department of Hand and Upper Extremity Surgery, Jing'an District Central Hospital, Shanghai, China; Key Laboratory of Neuroregeneration of Jiangsu and Ministry of Education, Co-Innovation Center of Neuroregeneration, Nantong University, Nantong, Jiangsu Province, China; State Key Laboratory of Medical Neurobiology, Collaborative Innovation Center of Brain Science, Fudan University, Shanghai, China; Priority Among Priorities of Shanghai Municipal Clinical Medicine Center, Shanghai, China; National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China. Electronic address:

Objective: Spastic arm paralysis after central neurological injury has a long-term effect on the patient's quality of life. Effective neurosurgical treatment for this dysfunction has been described in our previous studies. It is of great significance to determine a set of unified and concise clinical standards for motor function grading in the neurosurgical treatment and management.

Methods: We first conducted a retrospective study that included 51 hemiplegic patients from the Neurosurgery and Microsurgery outpatient database of Huashan Hospital. The neurosurgeons cooperated with rehabilitation experts to design and administer the new rating system (Hua-Shan Grading of Upper Extremity, H-S grading) after analyzing the scale scores and video records of these patients. We then randomly enrolled 64 patients with unilateral spastic arm paralysis after stroke or brain trauma. The Fugl-Meyer Assessment, the Ashworth scale and the new grading system were applied and analyzed to evaluate the participants' motor function.

Results: Based on rehabilitation medicine scales and long-term follow-up, a feasible and concise grading system was applied that was based on the patients' characteristics and the examination experiences of neurosurgeons and rehabilitation experts in clinical practice. This method could effectively grade upper extremity motor function, usually in 3-5 minutes. A significant correlation was found between H-S grading and the Fugl-Meyer score by the Spearman test (r = .937, P < .01). The mean difference between any two levels of the new grading system was significant (P < .05). And good test-retest reliability, the Cronbach's alpha coefficient and the validity indices were presented. In addition, it was more sensitive to motor function compared with the Ashworth scale.

Conclusion: As a supplement to the classic scales, H-S grading was developed in the area of spastic hemiplegia treatment. It is standardized and simplified for patients in the chronic stage after central neurological injury.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2019.04.006DOI Listing
August 2019

Contralateral hemi-fifth-lumbar nerve transfer for unilateral lower limb dysfunction due to incomplete traumatic spinal cord injury: A report of two cases.

Microsurgery 2020 Feb 21;40(2):234-240. Epub 2019 May 21.

Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, China.

Current strategies for the chronic stage of spinal cord injury (SCI) had seen little progress. In this report, we present the use of contralateral L5 nerve transfer for the treatment of incomplete SCI patients with unilateral lower limb dysfunction in two male patients. One was diagnosed with L2 vertebral fracture and dislocation combined with coni medullaris injury 10 months prior, and the other was diagnosed with T6 and T7 vertebral fractures with SCI 24 months prior. The patients were treated with decompression surgery within 24 hr after injury. The patients reached a recovery plateau after 6-8 months of spontaneous recovery of locomotion and sustained paralysis in the right leg and were left confined to the wheelchair. The score on the lower-extremity Fugl-Meyer assessment (FMA-LE) was 7 for both patients. The patients were then enrolled, and they underwent half of the anterior root of the contralateral L5 transfer to S1 and S2 to improve lower limb motor function. A posterior approach was performed to expose the L5, S1, and S2 nerve roots. Half of the anterior root of the left L5 was cut, and end-to-end neurorrhaphy from the left L5 to the right S1 and S2 was performed subdurally. After the surgery, routine rehabilitation treatments were prescribed. Muscle strength decreased transiently in the donor-side before recovering within 12 months postoperatively. Muscle strength was significantly improved on the affected side 2 years postoperatively, when the FMA-LE scores increased to 14 and 15, respectively. The patients regained independent walking ability with crutches. This report suggests that contralateral hemi-5th-lumbar nerve transfer is safe and can benefit incomplete SCI patients with unilateral lower limb dysfunction.
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http://dx.doi.org/10.1002/micr.30470DOI Listing
February 2020

Application of CUBE-STIR MRI and high-frequency ultrasound in contralateral cervical 7 nerve transfer surgery.

Br J Neurosurg 2019 Mar 12:1-6. Epub 2019 Mar 12.

a Department of Hand Surgery, Huashan Hospital, Shanghai Medical College , Fudan University , Shanghai , China.

Objective: The objective of the study was to investigate the feasibility of CUBE-SITR MRI and high-frequency ultrasound for the structural imaging of the brachial plexus to exclude neoplastic brachial plexopathy or structural variation and measure the lengths of anterior and posterior divisions of the C7 nerve, providing guidelines for surgeons before contralateral cervical 7 nerve transfer.

Methods: A total of 30 patients with CNS and 20 with brachial plexus injury were enrolled in this retrospective study. All patients underwent brachial plexus CUBE-STIR MRI and high-frequency ultrasound, and the lengths of the anterior and posterior divisions of C7 nerve were measured before surgery. Precise length of anterior and posterior divisions of contralateral C7 nerve was measured during surgery.

Results: MRI-measured lengths of anterior and posterior divisions of C7 nerves were positively correlated with that measured during surgery (anterior division, r = 0.94, p < .01; posterior division, r = 0.92, p < .01). High agreement was found between MRI-measured and intra-surgery measured length of anterior and posterior divisions of C7 nerve by BLAD-ALTMAN analysis. Ultrasonography could feasibly image supraclavicular C7 nerve and recognize small variant branches derived from middle trunk of C7 nerve root, which could be dissected intra-operatively and confirmed by electromyography during the procedure of contralateral C7 nerve transfer.

Conclusion: CUBE-STIR MRI had advantages for the imaging of the brachial plexus and measurement of the length of root-trunk-anterior/posterior divisions of C7 nerve. The clinical role of ultrasonography may be a simple way of evaluating general condition of C7 nerve and provide guidelines for contralateral C7 nerve transfer surgery.
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http://dx.doi.org/10.1080/02688697.2019.1584661DOI Listing
March 2019

C7 transfer in a posterior intradural approach for treating hemiplegic upper-limbs: hypothesis and a cadaver feasibility study.

Br J Neurosurg 2019 Aug 25;33(4):413-417. Epub 2019 Jan 25.

a Department of Hand Surgery, Huashan Hospital, Shanghai Medical College, Fudan University , Shanghai , China.

Contralateral C7 nerve root transfer surgery has been successfully applied to rescue motor function of a hemiplegic upper extremity in patients with central neurological injury. This surgical technique is challenging, and limited anatomical space makes it difficult to manipulate tissues and may lead to higher complication rates. The authors hypothesis a new surgical route in which cervical nerve roots of both donor and recipient sides are exposed from a posterior intradural approach and neurorrhaphy is performed easily and clearly. The feasibility of this operation is tested in a cadaver model. A fresh cadaver was placed prone. After a standard midline incision and extensive cervical laminectomy, the dura and arachnoid were widely opened, and the spinal nerve roots of C6, C7, and C8 were exposed bilaterally. Nerve grafting was attempted between pairs of donor and recipient nerve roots on contralateral sides of the spinal cord. After completion of neurorrhaphy, the dura was closed. Precise neurorrhaphy could be performed intradurally between posterior and anterior nerve roots of C7 on both sides. Multiple anastomoses of C7 to various nerve roots on the contralateral side could also be performed within the same surgical field with an interposition nerve graft. The posterior intradural repair idea affords many advantages, the pathway is shorter and more straightforward, which provides more access to multiple nerve roots repair in one surgical field, and is more familiar to many neurosurgeons and spine surgeons. It may potentially be adapted for clinical use.
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http://dx.doi.org/10.1080/02688697.2018.1552754DOI Listing
August 2019

Contralateral Lumbar to Sacral Nerve Rerouting for Hemiplegic Patients After Stroke: A Clinical Pilot Study.

World Neurosurg 2019 Jan 26;121:12-18. Epub 2018 Sep 26.

Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, China; Department of Hand and Upper Extremity Surgery, Jing'an District Central Hospital, Shanghai, China; Limb Function Reconstruction Center, Jing'an District Central Hospital, Shanghai, China; National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China; Key Laboratory of Hand Reconstruction, Ministry of Health, Shanghai, China; Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, China; State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, China. Electronic address:

Background: Spasticity and muscle weakness are common severe neurologic sequelae after stroke. Contralateral peripheral neurotization has been applied successfully to promote motor function of the hemiplegic upper extremity in patients with central neurological injury. To our knowledge, we present the first report of contralateral lumbar to sacral nerve transfer for the lower extremities in hemiplegic patients after stroke.

Case Description: Two patients were enrolled in the study. The first patient is a 57-year-old man who experienced permanent muscle weakness in his left leg after a right cerebral infarction. The second patient is a 42-year-old man who had spasticity and hemiplegia in both upper and lower limbs on the right side 32 months after a left cerebral hemorrhage. Both patients underwent contralateral lumbar-to-sacral nerve rerouting to improve lower-limb motor function. Twenty months after surgery, both patients experienced significant improvement in ambulatory status.

Conclusions: Although long-term follow-up and a randomized controlled trial are required, this study demonstrates the safety and possible benefits of contralateral lumbar-to-sacral nerve transfer for hemiplegic patients after stroke. This novel surgical approach could provide a new means for lower-limb motor functional recovery.
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http://dx.doi.org/10.1016/j.wneu.2018.09.118DOI Listing
January 2019

Comparative effects of implanted electrodes with differing contact patterns on peripheral nerve regeneration and functional recovery.

Neurosci Res 2019 Aug 17;145:22-29. Epub 2018 Aug 17.

Department of Hand Surgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, 200040, China; Department of Hand and Upper Extremity Surgery, Jing'an District Central Hospital, Shanghai, 200040, China. Electronic address:

Electrical stimulation could enhance nerve regeneration and functional recovery. The objective of this study was to evaluate the regenerative effects of implanted electrodes with different contacts in resected sciatic nerve. Sciatic nerve resection and microsurgical repair models were established and randomly divided into four groups (point contact, 1/4 circle contact; whole-circle contact; no electrodes as control). Electrical stimulation was performed and electrophysiological, morphological and histological exams (of the sciatic nerve and muscle) were conducted at 4 and 10 weeks post-implantation. Point and 1/4 circle contact groups showed significantly higher scores in the sciatic functional index (SFI), increased amplitude of compound muscle action potential (AMP) and motor nerve conduction velocity (MNCV) compared to the control group at both 4 and 10 weeks post-implantation. Point and 1/4 circle contact morphologically promoted sciatic nerve regeneration and reduced muscular atrophy with less mechanical injury to the nerve trunk observed compared with the whole-circle contact group at both 4 and 10 weeks post-implantation. Electrodes with point and 1/4 circle contacts represented an alternatively portable and effective method of electrical stimulation to facilitate injured sciatic nerve regeneration and reduce subsequent muscular atrophy, which might offer a promising approach for treating peripheral nerve injuries.
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http://dx.doi.org/10.1016/j.neures.2018.08.007DOI Listing
August 2019

Contralateral C7 to C7 nerve root transfer in reconstruction for treatment of total brachial plexus palsy: anatomical basis and preliminary clinical results.

J Neurosurg Spine 2018 Nov;29(5):491-499

1Department of Hand Surgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China.

OBJECTIVEContralateral C7 (CC7) nerve root has been used as a donor nerve for targeted neurotization in the treatment of total brachial plexus palsy (TBPP). The authors aimed to study the contribution of C7 to the innervation of specific upper-limb muscles and to explore the utility of C7 nerve root as a recipient nerve in the management of TBPP.METHODSThis was a 2-part investigation. 1) Anatomical study: the C7 nerve root was dissected and its individual branches were traced to the muscles in 5 embalmed adult cadavers bilaterally. 2) Clinical series: 6 patients with TBPP underwent CC7 nerve transfer to the middle trunk of the injured side. Outcomes were evaluated with the modified Medical Research Council scale and electromyography studies.RESULTSIn the anatomical study there were consistent and predominantly C7-derived nerve fibers in the lateral pectoral, thoracodorsal, and radial nerves. There was a minor contribution from C7 to the long thoracic nerve. The average distance from the C7 nerve root to the lateral pectoral nerve entry point of the pectoralis major was the shortest, at 10.3 ± 1.4 cm. In the clinical series the patients had been followed for a mean time of 30.8 ± 5.3 months postoperatively. At the latest follow-up, 5 of 6 patients regained M3 or higher power for shoulder adduction and elbow extension. Two patients regained M3 wrist extension. All regained some wrist and finger extension, but muscle strength was poor. Compound muscle action potentials were recorded from the pectoralis major at a mean follow-up of 6.7 ± 0.8 months; from the latissimus dorsi at 9.3 ± 1.4 months; from the triceps at 11.5 ± 1.4 months; from the wrist extensors at 17.2 ± 1.5 months; from the flexor carpi radialis at 17.0 ± 1.1 months; and from the digital extensors at 22.8 ± 2.0 months. The average sensory recovery of the index finger was S2. Transient paresthesia in the hand on the donor side, which resolved within 6 months postoperatively, was reported by all patients.CONCLUSIONSThe C7 nerve root contributes consistently to the lateral pectoral nerve, the thoracodorsal nerve, and long head of the triceps branch of the radial nerve. CC7 to C7 nerve transfer is a reconstructive option in the overall management plan for TBPP. It was safe and effective in restoring shoulder adduction and elbow extension in this patient series. However, recoveries of wrist and finger extensions are poor.
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http://dx.doi.org/10.3171/2018.3.SPINE171251DOI Listing
November 2018

Brachialis muscle transfer for reconstructing digital flexion after brachial plexus injury or forearm injury.

J Hand Surg Eur Vol 2018 Mar 13;43(3):259-268. Epub 2017 Sep 13.

1 Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, China.

Restoration of digital flexion after brachial plexus injury or forearm injury has been a great challenge for hand surgeons. Nerve transfer and forearm donor muscle transfer surgeries are not always feasible. The present study aimed at evaluating the effectiveness of restoring digital flexion by brachialis muscle transfer. Ten lower brachial plexus- or forearm-injured patients were enrolled. After at least 12 months following surgery, the middle-finger-to-palm distance was less than 2.5 cm in six patients. In the other four patients with less satisfactory results, secondary tenolysis surgery was performed and the middle-finger-to-palm distances were reduced to 2.0-4.0 cm. The average grasp strength was 20 ± 4 kg. Elbow flexion was not adversely affected. In conclusion, brachialis muscle transfer is an effective method for reconstructing digital flexion, not only in lower brachial plexus injury, but also in forearm injury patients.

Level Of Evidence: IV.
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http://dx.doi.org/10.1177/1753193417730656DOI Listing
March 2018

Local and Extensive Neuroplasticity in Carpal Tunnel Syndrome: A Resting-State fMRI Study.

Neurorehabil Neural Repair 2017 Oct-Nov;31(10-11):898-909. Epub 2017 Aug 26.

1 Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, China.

Carpal tunnel syndrome (CTS) is a most common peripheral nerve entrapment neuropathy characterized by sensorimotor deficits in median nerve innervated digits. Block-design task-related functional magnetic resonance imaging (fMRI) studies have been used to investigate CTS-related neuroplasticity in the primary somatosensory cortices. However, considering the persistence of digital paresthesia syndrome caused by median nerve entrapment, spontaneous neuronal activity might provide a better understanding of CTS-related neuroplasticity, which remains unexplored. The present study aimed to investigate both local and extensive spontaneous neuronal activities with resting-state fMRI. A total of 28 bilateral CTS patients and 24 normal controls were recruited, and metrics, including amplitude of low-frequency fluctuation (ALFF) and voxel-wise functional connectivity (FC), were used to explore synaptic activity at different spatial scales. Correlations with clinical measures were further investigated by linear regression. Decreased amplitudes of low-frequency fluctuation were observed in the bilateral primary sensory cortex (SI) and secondary sensory cortex (SII) in CTS patients (AlphaSim corrected P < .05). This was found to be negatively related to the sensory thresholds of corresponding median nerve innervated fingers. In the voxel-wise FC analysis, with predefined seed regions of interest in the bilateral SI and primary motor cortex, we observed decreased interhemispheric and increased intrahemispheric FC. Additionally, both interhemispheric and intrahemispheric FC were found to be significantly correlated with the mean ALFF.
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http://dx.doi.org/10.1177/1545968317723749DOI Listing
July 2018

Electrophysiological evidence for pre-attention information processing improvement in patients with central hemiplegic after peripheral nerve rewiring: a pilot study.

Sci Rep 2017 07 31;7(1):6888. Epub 2017 Jul 31.

Department of Hand Surgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China.

Central neurologic injury (CNI) causes dysfunctions not only in limbs but also in cognitive ability. We applied a novel peripheral nerve rewiring (PNR) surgical procedure to restore limb function. Here, we conducted a prospective study to develop estimates for the extent of preattentive processes to cognitive function changes in CNI patients after PNR. Auditory mismatch negativity (MMN) was measured in CNI patients who received the PNR surgery plus conventional rehabilitation treatment. During the 2-year follow-up, the MMN was enhanced with increased amplitude in the PNR plus rehabilitation group compared to the rehabilitation-only group as the experiment progressed, and progressive improvement in behavioural examination tests was also observed. Furthermore, we found a significant correlation between the changes in Fugl-Meyer assessment scale scores and in MMN amplitudes. These results suggested that PNR could affect the efficiency of pre-attention information processing synchronously with the recovery of motor function in the paralyzed arm of the in chronic CNI patients. Such electroencephalographic measures might provide a biological approach with which to distinguish patient subgroups after surgery, and the change in MMN may serve as an objective auxiliary index, indicating the degree of motor recovery and brain cognitive function.
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http://dx.doi.org/10.1038/s41598-017-07263-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5537276PMC
July 2017

Contralateral peripheral neurotization for a hemiplegic hindlimb after central neurological injury.

J Neurosurg 2018 01 24;128(1):304-311. Epub 2017 Mar 24.

Departments of1Hand and Upper Extremity Surgery and.

OBJECTIVE Contralateral peripheral neurotization surgery has been successfully applied to rescue motor function of the hemiplegic upper extremity in patients with central neurological injury (CNI). It may contribute to strengthened neural pathways between the contralesional cortex and paretic limbs. However, the effect of this surgery in the lower extremities remains unknown. In the present study the authors explored the effectiveness and safety of contralateral peripheral neurotization in treating a hemiplegic lower extremity following CNI in adult rats. METHODS Controlled cortical impact (CCI) was performed on the hindlimb motor cortex of 36 adult Sprague-Dawley rats to create severe unilateral traumatic brain injury models. These CCI rats were randomly divided into 3 groups. At 1 month post-CCI, the experimental group (Group 1, 12 rats) underwent contralateral L-6 to L-6 transfer, 1 control group (Group 2, 12 rats) underwent bilateral L-6 nerve transection, and another control group (Group 3, 12 rats) underwent an L-6 laminectomy without injuring the L-6 nerves. Bilateral L-6 nerve transection rats without CCI (Group 4, 12 rats) and naïve rats (Group 5, 12 rats) were used as 2 additional control groups. Beam and ladder rung walking tests and CatWalk gait analysis were performed in each rat at baseline and at 0.5, 1, 2, 4, 6, 8, and 10 months to detect the skilled walking functions and gait parameters of both hindlimbs. Histological and electromyography studies were used at the final followup to verify establishment of the traumatic brain injury model and regeneration of the L6-L6 neural pathway. RESULTS In behavioral tests, comparable motor injury in the paretic hindlimbs was observed after CCI in Groups 1-3. Group 1 started to show significantly lower slip and error rates in the beam and ladder rung walking tests than Groups 2 and 3 at 6 months post-CCI (p < 0.05). In the CatWalk analysis, Group 1 also showed a higher mean intensity and swing speed after 8 months post-CCI and a longer stride length after 6 months post-CCI than Groups 2 and 3 (p < 0.05). Transection of L-6 resulted in transient skilled walking impairment in the intact hindlimbs in Groups 1 and 2 (compared with Group 3) and in the bilateral hindlimbs in Group 4 (compared with Group 5). All recovered to baseline level within 2 months. Histological study of the rat brains verified comparable injured volumes among Groups 1-3 at final examinations, and electromyography and toluidine blue staining indicated successful regeneration of the L6-L6 neural pathways in Group 1. CONCLUSIONS Contralateral L-6 neurotization could be a promising and safe surgical approach for improving motor recovery of the hemiplegic hindlimb after unilateral CNI in adult rats. Further investigations are needed before extrapolating the present conclusions to humans.
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http://dx.doi.org/10.3171/2016.4.JNS152046DOI Listing
January 2018

Enhancement of Contralesional Motor Control Promotes Locomotor Recovery after Unilateral Brain Lesion.

Sci Rep 2016 Jan 6;6:18784. Epub 2016 Jan 6.

Department of Hand Surgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China.

There have been controversies on the contribution of contralesional hemispheric compensation to functional recovery of the upper extremity after a unilateral brain lesion. Some studies have demonstrated that contralesional hemispheric compensation may be an important recovery mechanism. However, in many cases where the hemispheric lesion is large, this form of compensation is relatively limited, potentially due to insufficient connections from the contralesional hemisphere to the paralyzed side. Here, we used a new procedure to increase the effect of contralesional hemispheric compensation by surgically crossing a peripheral nerve at the neck in rats, which may provide a substantial increase in connections between the contralesional hemisphere and the paralyzed limb. This surgical procedure, named cross-neck C7-C7 nerve transfer, involves cutting the C7 nerve on the healthy side and transferring it to the C7 nerve on the paretic side. Intracortical microstimulation, Micro-PET and histological analysis were employed to explore the cortical changes in contralesional hemisphere and to reveal its correlation with behavioral recovery. These results showed that the contralesional hemispheric compensation was markedly strengthened and significantly related to behavioral improvements. The findings also revealed a feasible and effective way to maximize the potential of one hemisphere in controlling both limbs.
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http://dx.doi.org/10.1038/srep18784DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4702126PMC
January 2016

Contralateral peripheral neurotization for hemiplegic upper extremity after central neurologic injury.

Neurosurgery 2015 Feb;76(2):187-95; discussion 195

‡Department of Hand Surgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; ¶Department of Hand and Upper Extremity Surgery, Jing'an District Central Hospital, Shanghai, China; §State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, China.

Background: Central neurological injury (CNI) is a major contributor to physical disability that affects both adults and children all over the world. The main sequelae of chronic stage CNI are spasticity, paresis of specific muscles, and poor selective motor control. Here, we apply the concept of contralateral peripheral neurotization in spasticity releasing and motor function restoration of the affected upper extremity.

Objective: A clinical investigation was performed to verify the clinical efficacy of contralateral C7 neurotization for rescuing the affected upper extremity after CNI.

Methods: In the present study, 6 adult hemiplegia patients received the nerve transfer surgery of contralateral C7 to C7 of the affected side. Another 6 patients with matched pathological and demographic status were assigned to the control group that received rehabilitation only. During the 2-year follow-up, muscle strength of bilateral upper extremities was assessed. The Modified Ashworth Scale and Fugl-Meyer Assessment Scale were used for evaluating spasticity and functional use of the affected upper extremity, respectively.

Results: Both flexor spasticity release and motor functional improvements were observed in the affected upper extremity in all 6 patients who had surgery. The muscle strength of the extensor muscles and the motor control of the affected upper extremity improved significantly. There was no permanent loss of sensorimotor function of the unaffected upper extremity.

Conclusion: This contralateral C7 neurotization approach may open a door to promote functional recovery of upper extremity paralysis after CNI.
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http://dx.doi.org/10.1227/NEU.0000000000000590DOI Listing
February 2015

Deactivation of distant pain-related regions induced by 20-day rTMS: a case study of one-week pain relief for long-term intractable deafferentation pain.

Pain Physician 2014 Jan-Feb;17(1):E99-105

Department of Hand Surgery, Hua-Shan Hspital, Shanghai Medical College, Fudan University, Shanghai, China.

Background: Deafferentation pain secondary to brachial plexus avulsion, spinal cord injury, and other peripheral nerve injuries is often refractory to conventional treatments. Stimulation of the primary motor cortex (M1) has been proven to be an effective treatment for intractable deafferentation pain. The mechanisms underlying the attenuation of deafferentation pain by motor cortex stimulation remain hypothetical.

Objectives: The purpose of this case report is to: (1) summarize a case in which a patient suffering chronic intractable deafferentation pain for 25 years underwent rTMS treatment over M1, (2) describe the evidence from PET imaging, and (3) reveal a possible relief mechanism with cortical plasticity.

Study Design: Case report.

Setting: University hospital.

Results: This patient had successful pain control with no transient or lasting side effects. The pain relief remained stable for at least one week. At the end of the 20-day procedure, pain relief was obtained according to the Visual Analog Scale (VAS) (-34.6%) and the McGill Pain Questionnaire (MPQ) (-31.6%). In the PET/CT scans, the glucose metabolism was significantly reduced contralaterally to the pain side in the anterior cingulate cortex (ACC), insula, and caudate nucleus. There was no statistically significant difference in any other cortical area.

Limitations: Single case of a patient with long-term intractable deafferentation pain having a PET study.

Conclusion: This study implies that a single session of 20 Hz rTMS over the motor cortex could reduce the pain level in patients suffering from long-term, intractable deafferentation pain. The stimulation of the M1 induces deactivation in the ACC, insula, and caudate nucleus. The changes in these pain-related regions may mirror an adaptive mechanism to pain relief after rTMS treatment.
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September 2014

Arthroscopic distal metaphyseal ulnar shortening osteotomy for ulnar impaction syndrome: a different technique.

J Hand Surg Am 2013 Nov;38(11):2257-62

Department of Hand Surgery of Huashan Hospital, Shanghai Medical College of Fudan University, Shanghai, People's Republic of China; Department of Hand and Upper Extremity Surgery of Jingan District Center Hospital, Shanghai, People's Republic of China; State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, People's Republic of China.

Ulnar impaction syndrome generally occurs with positive ulnar variance. The solution to the problem is to unload the ulnocarpal joint. Effective surgical options include diaphyseal ulnar shortening osteotomy, open wafer osteotomy, and arthroscopic wafer osteotomy. Recently, Slade and Gillon described an open procedure of ulnar shortening in the osteochondral region of the ulnar head. The procedure minimizes the risk of hemarthrosis and does not require hardware removal, which are problems with other surgical options. This article introduces a new arthroscopic technique of distal metaphyseal ulnar shortening osteotomy for ulnar impaction syndrome. This technique offers the advantages of minimizing surgical injury to the dorsal capsule of the distal radoulnar joint and so protects its stability.
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http://dx.doi.org/10.1016/j.jhsa.2013.08.108DOI Listing
November 2013

Long-term ongoing cortical remodeling after contralateral C-7 nerve transfer.

J Neurosurg 2013 Apr 1;118(4):725-9. Epub 2013 Feb 1.

Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, China.

Object: Contralateral C-7 nerve transfer was developed for the treatment of patients with brachial plexus avulsion injury (BPAI). In the surgical procedure the affected recipient nerve is connected to the ipsilateral motor cortex, and the dramatic peripheral alteration may trigger extensive cortical reorganization. However, little is known about the long-term results after such specific nerve transfers. The purpose of this study was to investigate the long-term cortical adaptive plasticity after BPAI and contralateral C-7 nerve transfer.

Methods: In this study, 9 healthy male volunteers and 5 male patients who suffered from right-sided BPAI and had undergone contralateral C-7-transfer more than 5 years earlier were included. Functional MRI studies were used for the investigation of long-term cerebral plasticity.

Results: The neuroimaging results suggested that the ongoing cortical remodeling process after contralateral C-7 nerve transfer could last for a long period; at least for 5 years. The motor control of the reinnervated limb may finally transfer from the ipsilateral to the contralateral hemisphere exclusively, instead of the bilateral neural network activation.

Conclusions: The authors believe that the cortical remodeling may last for a long period after peripheral rearrangement and that the successful cortical transfer is the foundation of the independent motor recovery.
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http://dx.doi.org/10.3171/2012.12.JNS12207DOI Listing
April 2013

Long-term observation of respiratory function after unilateral phrenic nerve and multiple intercostal nerve transfer for avulsed brachial plexus injury.

Neurosurgery 2012 Apr;70(4):796-801; discussion 801

Department of Hand Surgery, Hua-Shan Hospital, Shanghai Medical College, Fudan University, Shanghai, China.

Background: Phrenic nerve transfer (PNT) or multiple intercostal nerve transfer (MIT) alone are reported to have no significant impact on pulmonary function in the short or medium term, but it has rarely been reported whether the combination of PNT-MIT could influence respiratory function in the long term.

Objective: Respiratory function was evaluated after PNT and PNT-MIT 7 to 19 years (mean, 10 years) postoperatively.

Methods: Twenty-three adult patients with brachial plexus avulsion injuries who underwent PNT-MIT were compared with 19 corresponding patients who underwent PNT. Pulmonary function testings, phrenic nerve conduction study, and chest fluoroscopy were performed. In the PNT-MIT group, further investigation was performed on the effect of the number of transferred intercostal nerves and the timing of MIT.

Results: In the PNT-MIT group, forced vital capacity, forced expiratory volume in one second, and total lung capacity were 73.69%, 72.04%, and 74.81% of predicted values without significant differences from the PNT group. Diaphragmatic paralysis permanently existed with 1 to 1.5 intercostal spaces (ICSs) elevation and near 1 ICS reduced excursion. There was no statistical difference between the PNT and PNT-MIT groups. Furthermore, 3 and 4 intercostal nerves transferred resulted in no further decrease in pulmonary function test results than 2 intercostal nerves. No significant difference was found when PNT and MIT were performed at the same stage or with an interval.

Conclusion: PNT-MIT did not result in additional impairment in respiratory function in adult patients compared with PNT alone. It is safe to transfer 2 to 4 intercostal nerves at 1 to 2 months delay after PNT.
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http://dx.doi.org/10.1227/NEU.0b013e3181f74139DOI Listing
April 2012

Phrenic nerve transfer for elbow flexion and intercostal nerve transfer for elbow extension.

J Hand Surg Am 2010 Aug 8;35(8):1304-9. Epub 2010 Jul 8.

Department of Hand Surgery, Hua-Shan Hospital, Shanghai Medical College, Fudan University, Shanghai, China.

Purpose: To explore long-term recovery of elbow flexion and extension after transferring the phrenic nerve and intercostal nerves, respectively, in adults with global brachial plexus avulsion injuries.

Methods: Seven adults with global brachial plexus avulsion injuries had the phrenic nerve transferred to the musculocutaneous nerve (or to the anterior division of upper trunk) and intercostal nerves transferred to the triceps branch of the radial nerve at our hospital 7 to 12 years ago. The results of elbow motor strength testing using the Medical Research Council grading scale, and electrodiagnostic findings using electromyogram examinations, were studied retrospectively. Pulmonary function tests were also performed at final visits.

Results: Functional elbow flexion was obtained in most of the 7 cases (M2, 1; M3, 3; M4, 2; and M5, 1) but elbow extension was absent or insufficient in all subjects (M0, 1; M1, 3; and M2, 3). Electrical results showed successful biceps reinnervation in 6 patients and successful triceps reinnervation in 5. No patient experienced breathing problems, and pulmonary function results were within normal range.

Conclusions: In the long term, after brachial plexus avulsion injury in most patients who underwent both phrenic nerve and intercostal nerve transfer to achieve elbow flexion and extension eventually obtained satisfactory elbow flexion but poor elbow extension. We recommend against transferring the intercostal nerves to the triceps branch of radial nerve in conjunction with primary phrenic to musculocutaneous nerve transfer.

Type Of Study/level Of Evidence: Therapeutic IV.
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http://dx.doi.org/10.1016/j.jhsa.2010.04.006DOI Listing
August 2010

Hand prehension recovery after brachial plexus avulsion injury by performing a full-length phrenic nerve transfer via endoscopic thoracic surgery.

J Neurosurg 2008 Jun;108(6):1215-9

Department of Hand Surgery, Hua-Shan Hospital, Shanghai Medical College, Shanghai, PR China.

Object: The functional recovery of hand prehension after complete brachial plexus avulsion injury (BPAI) remains an unsolved problem. The authors conducted a prospective study to elucidate a new method of resolving this injury.

Methods: Three patients with BPAI underwent a new procedure during which the full-length phrenic nerve was transferred to the medial root of the median nerve via endoscopic thoracic surgery support. All 3 patients were followed up for a postoperative period of > 3 years.

Results: The power of the palmaris longus, flexor pollicis longus, and the flexor digitorum muscles of all 4 fingers reached Grade 3-4/5, and no symptoms of respiratory insufficiency occurred.

Conclusions: Neurotization of the phrenic nerve to the medial root of the median nerve via endoscopic thoracic surgery is a feasible means of early hand prehension recovery after complete BPAI.
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http://dx.doi.org/10.3171/JNS/2008/108/6/1215DOI Listing
June 2008
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