The innervated gracilis musculocutaneous flap for total tongue reconstruction

A functional neotongue following total glossectomy requires both soft-tissue bulk and reconstruction of muscle function. We used innervated transverse gracilis musculocutaneous flaps to reconstruct total glossectomy defects in eight patients. The obturator nerve to the gracilis muscle was approximated to the hypoglossal nerve to reinnervate the gracilis muscle by using microsurgical technique. The cutaneous paddle of the gracilis flap easily supplies sufficient bulk to replace the total glossectomy defect. Follow-up of patients ranged from 3 to 47 months. All patients were able to resume oral feeding. Electromyographic studies performed on one patient showed reinnervation of the flap with active elevation of the posterior pharynx. Ultimately, seven patients died because of recurrence of their disease. The innervated gracilis musculocutaneous flap may benefit patients who have a total glossectomy by allowing them to achieve a more functional recovery.     

Forearm endurance training attenuates sympathetic nerve response to isometric handgrip in normal humans.

Recent evidence indicates that muscle ischemia and activation of the muscle chemoreflex are the principal stimuli to sympathetic nerve activity (SNA) during isometric exercise. We postulated that physical training would decrease muscle chemoreflex stimulation during isometric exercise and thereby attenuate the SNA response to exercise. We investigated the effects of 6 wk of unilateral handgrip endurance training on the responses to isometric handgrip (IHG: 33% of maximal voluntary contraction maintained for 2 min). In eight normal subjects the right arm underwent exercise training and the left arm sham training. We measured muscle SNA (peroneal nerve), heart rate, and blood pressure during IHG before vs. after endurance training (right arm) and sham training (left arm). Maximum work to fatigue (an index of training efficacy) was increased by 1,146% in the endurance-trained arm and by only 40% in the sham-trained arm. During isometric exercise of the right arm, SNA increased by 111 +/- 27% (SE) before training and by only 38 +/- 9% after training (P less than 0.05). Endurance training did not significantly affect the heart rate and blood pressure responses to IHG. We also measured the SNA response to 2 min of forearm ischemia after IHG in five subjects. Endurance training also attenuated the SNA response to postexercise forearm ischemia (P = 0.057). Sham training did not significantly affect the SNA responses to IHG or forearm ischemia. We conclude that endurance training decreases muscle chemoreflex stimulation during isometric exercise and thereby attenuates the sympathetic nerve response to IHG.     

Full-length phrenic nerve transfer by means of video-assisted thoracic surgery in treating brachial plexus avulsion injury

Phrenic nerve transfer has been widely used in treating brachial plexus avulsion injury. However, the present method crosses the thoracic part of the phrenic nerve, and nerve graft is needed, resulting in a long period of regeneration and partly irreversible muscle atrophy. We present our early experience of using video-assisted thoracic surgery to harvest a full length of phrenic nerve for transfer. Fifteen patients (mean age, 28 years) were treated. The thoracic part of the phrenic nerve was freed by means of video-assisted thoracic surgery and taken out of the thoracic cavity, and a full-length phrenic nerve was transferred to the musculocutaneous nerve to recover elbow flexion. The patients were followed. Another 29 patients with long-term follow-up who underwent traditional cervical phrenic nerve to musculocutaneous nerve transfer in our institute between 1994 and 1997 were selected. The period of newborn potential appearing in the biceps and the period for biceps to achieve M3 between two groups were compared. The operation was safe and no complications occurred. The additional length of phrenic nerve was 12.3 +/- 4.5 cm. Eleven patients received sufficient follow-up. Eight patients achieved biceps recovery to M3 (elbow flexion against gravity), and mean time was 198.8 +/- 36.0 days, much earlier than that of the traditional method (p < 0.01). Pulmonary function recovered to the preoperative level 9 months after operation. This new method is safe and minimally invasive. The result of full-length phrenic nerve transfer is much better than that of the traditional method. It obviously shortens the time required for nerve reinnervation, and offers a promising method for patients who have had a long interval from injury to operation and for forearm muscle reconstruction by phrenic nerve transferred to the median nerve or combined with free-muscle transfer.     

Shoulder defect correction with the island latissimus dorsi flap

Reconstruction of normal shoulder contour is possible utilizing a latissimus dorsi musculocutaneous flap at the end of a long neurovascular pedicle. The thoracodorsal vessels and their lateral divisions form the basis of the pedicle. The nerve in the pedicle is left intact if maintenance of muscle bulk is desired and sectioned if atrophy is preferred. The amount of muscle taken in conjunction with the skin island is determined by the nature of the defect to be corrected. The twin goals of a single-stage reconstruction and a satisfactory aesthetic result are achieved with this method.     

Intraoperative radial nerve injury during coronary artery surgery – report of two cases

Background

Peripheral nerve injury and brachial plexopathy are known, though rare complications of coronary artery surgery. The ulnar nerve is most frequently affected, whereas radial nerve lesions are much less common accounting for only 3% of such intraoperative injuries.

Case presentations

Two 52- and 50-year-old men underwent coronary artery surgery. On the first postoperative day they both complained of wrist drop on the left. Neurological examination revealed a paresis of the wrist and finger extensor muscles (0/5), and the brachioradialis (4/5) with hypoaesthesia on the radial aspect of the dorsum of the left hand. Both biceps and triceps reflexes were normoactive, whereas the brachioradialis reflex was diminished on the left. Muscles innervated from the median and ulnar nerve, as well as all muscles above the elbow were unaffected. Electrophysiological studies were performed 3 weeks later, when muscle power of the affected muscles had already begun to improve. Nerve conduction studies and needle electromyography revealed a partial conduction block of the radial nerve along the spiral groove, motor axonal loss distal to the site of the lesion and moderate impairment in recruitment with fibrillation potentials in radial innervated muscles below the elbow and normal findings in triceps and deltoid. Electrophysiology data pointed towards a radial nerve injury in the spiral groove. We assume external compression as the causative factor. The only apparatus attached to the patients' left upper arm was the sternal retractor, used for dissection of the internal mammary artery. Both patients were overweight and lying on the operating table for a considerable time might have caused the compression of their left upper arm on the self retractor's supporting column which was fixed to the table rail 5 cm above the left elbow joint, in the site where the radial nerve is directly apposed to the humerus.

Conclusion

Although very uncommon, external compression due to the use of a self retractor during coronary artery surgery can affect – especially in obese subjects – the radial nerve within the spiral groove leading to paresis and should therefore be included in the list of possible mechanisms of radial nerve injury.     

A study of the relationship between blood flow and bacterial inoculation in musculocutaneous and fasciocutaneous flaps

Regional nutrient blood flow to musculocutaneous and fasciocutaneous flaps was studied in dogs using 15-microns radiolabeled microspheres, and correlations to bacterial inoculation into closed wound spaces were sought. During the 6-day study period, no differences were found between blood flow to noinoculated versus inoculated flaps. Comparisons of blood flow to the deep surfaces of the flaps showed that blood flow to muscle in musculocutaneous flaps increased rapidly during the first 24 hours and then plateaued, while that to subcutaneous tissue plus fascia in fasciocutaneous flaps demonstrated a gradual and steady increase. The most rapid decline in bacterial counts at the undersurface of both flaps occurred within 24 hours, dropping significantly lower within musculocutaneous flaps. In addition to such surface properties of muscle as tissue ingrowth, rapid early augmentation of muscle blood flow may be largely responsible for superior bacterial suppression observed beneath musculocutaneous flaps.     

Effect of high local temperature on reflex cutaneous vasodilation

We examined the effect of high local forearm skin temperature (Tloc) on reflex cutaneous vasodilator responses to elevated whole-body skin (Tsk) and internal temperatures. One forearm was locally warmed to 42 degrees C while the other was left at ambient conditions to determine if a high Tloc could attenuate or abolish reflex vasodilation. Forearm blood flow (FBF) was monitored in both arms, increases being indicative of increases in skin blood flow (SkBF). In one protocol, Tsk was raised to 39-40 degrees C 30 min after Tloc in one arm had been raised to 42 degrees C. In a second protocol, Tsk and Tloc were elevated simultaneously. In protocol 1, the locally warmed arm showed little or no change in blood flow in response to increasing Tsk and esophageal temperature (average rise = 0.76 +/- 1.18 ml X 100 ml-1 X min-1), whereas FBF in the normothermic arm rose by an average of 8.84 +/- 3.85 ml X 100 ml-1 X min-1. In protocol 2, FBF in the normothermic arm converged with that in the warmed arm in three of four cases but did not surpass it. We conclude that local warming to 42 degrees C for 35-55 min prevents reflex forearm cutaneous vasodilator responses to whole-body heat stress. The data strongly suggest that this attenuation is via reduction or abolition of basal tone in the cutaneous arteriolar smooth muscle and that at a Tloc of 42 degrees C a maximum forearm SkBF has been achieved. Implicit in this conclusion is that local warming has been applied for a duration sufficient to achieve a plateau in FBF.     

Brachial plexus injury.

A 28-year-old man shot himself in the left posterior triangle of the neck with a shotgun. At the initial operation secondary repair of the resultant brachial plexus injury was decided upon in view of the difficulty in assessing lesions in continuity at this point after injury. The patient had total brachial plexus palsy. Nine weeks after the injury sensory and motor function were returning and the only element of the brachial plexus not showing evidence of nerve fibre continuity was the musculocutaneous nerve. Sural nerve autografts were sutured between the trimmed proximal and distal stumps of this nerve. By 4 months after the injury there was further improvement in both sensory and motor function, and by 18 months there was sensation in the autonomous zones of both median and ulnar nerves and good return of muscle power.     

FGF negatively regulates muscle membrane extension in Caenorhabditis elegans

Striated muscles from Drosophila and several vertebrates extend plasma membrane to facilitate the formation of the neuromuscular junction (NMJ) during development. However, the regulation of these membrane extensions is poorly understood. In C. elegans, the body wall muscles (BWMs) also have plasma membrane extensions called muscle arms that are guided to the motor axons where they form the postsynaptic element of the NMJ. To investigate the regulation of muscle membrane extension, we screened 871 genes by RNAi for ectopic muscle membrane extensions (EMEs) in C. elegans. We discovered that an FGF pathway, including let-756(FGF), egl-15(FGF receptor), sem-5(GRB2) and other genes negatively regulates plasma membrane extension from muscles. Although compromised FGF pathway activity results in EMEs, hyperactivity of the pathway disrupts larval muscle arm extension, a phenotype we call muscle arm extension defective or MAD. We show that expression of egl-15 and sem-5 in the BWMs are each necessary and sufficient to prevent EMEs. Furthermore, we demonstrate that let-756 expression from any one of several tissues can rescue the EMEs of let-756 mutants, suggesting that LET-756 does not guide muscle membrane extensions. Our screen also revealed that loss-of-function in laminin and integrin components results in both MADs and EMEs, the latter of which are suppressed by hyperactive FGF signaling. Our data are consistent with a model in which integrins and laminins are needed for directed muscle arm extension to the nerve cords, while FGF signaling provides a general mechanism to regulate muscle membrane extension.     

Patterns of motor activity in the isolated nerve cord of the octopus arm

The extremely flexible octopus arm provides a unique opportunity for studying movement control in a highly redundant motor system. We describe a novel preparation that allows analysis of the peripheral nervous system of the octopus arm and its interaction with the muscular and mechanosensory elements of the arm's intrinsic muscular system. First we examined the synaptic responses in muscle fibers to identify the motor pathways from the axial nerve cord of the arm to the surrounding musculature. We show that the motor axons project to the muscles via nerve roots originating laterally from the arm nerve cord. The motor field of each nerve is limited to the region where the nerve enters the arm musculature. The same roots also carry afferent mechanosensory information from the intrinsic muscle to the axial nerve cord. Next, we characterized the pattern of activity generated in the dorsal roots by electrically stimulating the axial nerve cord. The evoked activity, although far reaching and long lasting, cannot alone account for the arm extension movements generated by similar electrical stimulation. The mismatch between patterns of activity in the isolated cord and in an intact arm may stem from the involvement of mechanosensory feedback in natural arm extension.     

The brachial plexus in the squirrel monkey (Saimiri sciureus)

Based on the statistical data obtained from 37 squirrel monkeys, the standard type of the brachial plexus was determined. Each of the superior (C6, normally also C5), middle (C7), and inferior (C8 and T1, rarely with rudimentary T2) trunks gives off the anterior and posterior divisions. The lateral cord composed of the superior and the middle anterior divisions usually breaks up immediately into the musculocutaneous nerve and the lateral root of the median nerve. The medial cord (generally the peripheral extension of the inferior anterior division itself) terminates in the ulnar nerve and in the medial root of the median nerve. The dorsal cord formed by the union of the 3 posterior divisons extends peripherally as the radial nerve; the axillary nerve arises before the union of the 3 posterior divisons is completed. The frequently encountered aberrant connecting branches, the musculocutaneous nerve tending to separate from the plexus, and the long lateral root of the median nerve characterize the feature of the plexus.The data were compared with previous findings about the plexus of other primates.This investigation was conducted during the tenure of a postdoctoral fellowship in the Department of Anatomy, UCLA School of Medicine, Los Angeles, California, U.S.A.     

An extended approach for the vascular pedicle of the lateral arm free flap.

We present an extension of the surgical approach for harvesting the lateral upper arm free flap by which an additional 6 to 8 cm of pedicle length may be gained. First, the flap is raised by the standard lateral approach. Then, by proceeding proximally and posteriorly, the triceps muscle is split between its lateral and long heads to expose the entire length of the profunda brachii vessels in the spiral groove. A tunnel is developed beneath the lateral head of the triceps, and the flap or its pedicle is delivered through this. We describe the surgical technique and present details of a dissection study on 25 fresh cadaver limbs. The nerve branches to the lateral head of the triceps, which are close to the vessels of the flap, are highly variable in number and location. When unusually short and distally placed, they are at risk of damage, but damage can be avoided if the tunnel is not unduly widened. We present our early clinical experience in 10 consecutive cases using the extended-pedicle lateral arm flap. The free pedicle length in this series ranged from 8 to 13 cm. The maximum flap size was 5 x 19 cm. All cases were successful, although one required reoperation for venous thrombosis. Although postoperative testing of upper arm muscle function showed some weakness and impaired endurance, this was found equally in the surgically disturbed triceps and in the untouched elbow flexors and thus could not be attributed to motor nerve damage to the triceps muscle.     

Macrocystic schwannoma in the seventh cervical nerve.

We have recently treated a case of asymptomatic macrocystic schwannoma discovered between the left neck and the supraclavicular fossa. The tumor, originating from the left seventh cervical nerve, was extirpated. Nearly 70 percent of the tumor area showed macrocyst with transparent fluid collection. The tumor was diagnosed as macrocystic schwannoma histopathologically. Schwannoma is often associated with small cysts but rarely with macrocysts. Because schwannoma is a benign tumor, partial resection against an attempt at total removal resulting in progressive neurologic deficits is recommended. In general, schwannoma does not present any apparent symptoms at an early stage, because it occurs and progresses very slowly. Schwannoma originating at the spinal nerve root has been called a dumbbell-shaped tumor because of its characteristic shape on MRI and cystogram images. We recently have treated a case of dumbbell-shaped tumor that was an asymptomatic macrocystic schwannoma in the seventh cervical nerve.     

A case of Cushing's syndrome associated with possible adrenomedullary hyperplasia

A 57-year-old male, who had been suffered from hypertension and diabetes mellitus for 10 years, was admitted to the hospital because of thirst, lassitude and muscle wasting. On admission, his urinary excretion of 17-OHCS and plasma cortisol levels were elevated without diurnal variations. Plasma ACTH levels were found to be very low with repeated determinations. Dexamethasone suppression test, 2 mg 4 times a day orally for 2 days, showed no changes in plasma cortisol levels and only a mild reduction in urinary 17-OHCS excretion. Estimation of urinary catecholamines showed an increase only in norepinephrine. Abdominal computerized tomography and radionuclide scanning of adrenal glands with 131I-adosterol demonstrated a well-defined adrenal mass in the left side without apparent changes in the right side. 131I-metaiodobenzylguanidine scintigraphy was negative. At surgery, his left adrenal medulla was found to be hypertrophic in addition to the cortical tumor. The left adrenal gland was also removed. After surgery, excretion of urinary catecholamines fell to nearly the normal range and he was discharged without insulin and antihypertensive drugs. Microscopically, the cortical tumor is an adenoma consisting of lipid laden cells and eosinophilic compact cells. Medullary cells were distinctly hyperplastic in appearance and many of the cells were extensively vacuolated, suggesting an active functional status. The present report describes a patient with Cushing's syndrome who showed increased urinary catecholamine excretion due to the possible coexistence of adrenal medullary hyperplasia. As far as we know, this is the first case of Cushing's syndrome with this abnormality.     

A stimulating nerve cuff for chronic in vivo measurements of torque produced about the ankle in the mouse

Specific muscle training and chronic contractilemeasurements are difficult in rodents, especially in the mouse. Theprimary reason for this is the lack of a means for stimulating themotor nerve that does not damage the nerve and that permitsreproducible measurements of contractility. In this paper, we describeprocedures for the construction and implantation of a stimulating nervecuff for use on the mouse common peroneal nerve. We demonstrate that nerve cuff implantation success rates can be high (i.e., 75-93%), as determined from measurements of maximal isometric torque produced bythe anterior crural muscles. Isometric torque production is notadversely affected by the nerve cuff because the torque produced matches that observed in our established percutaneous stimulation model. We also demonstrate that use of the nerve cuff for stimulation is compatible with electromyographic measurements made on the tibialisanterior muscle, with no sign of stimulation artifact in theelectromyographic signal.

     

Changes in the spectral power and coherence of the EEG alpha rhythm in humans performing grasp efforts by the right and left arm

We compared changes in the EEG indices in healthy dextral volunteers performing static force grasps by the arm. Three test modes were used: (i) performance of two successive grasps by the dominant (right) arm (test A), (ii) performance of two successive grasps by the subdominant (left) arm (test B), and (iii) performance of the grasps first by the right arm and then by the left arm (test C). Fourteen, six, and nine persons took part in tests A–C, respectively. In the course of grasps performed by the right and left arms, bilateral increases in synchronization within the alpha 1 and alpha 2 ranges were frequently observed in occipital regions in both the first and repeated grasps (P < 0.05). Consecutive grasps by the right arm were accompanied by clear desynchronization in a few anterior and central leads. Alpha 2 desynchronization was observed in both realizations of the left-arm grasps (test B) performed by some subjects, but intragroup modifications were not significant in this case. The coherence coefficients of the alpha 2 rhythm in most cases increased for symmetric leads from the right and left hemispheres in the course of grasps by both the right and left hands. The effect of intensification of interhemisphere links was manifested in the anterior and central cortical regions; this fact showed that interhemisphere interaction increases in the course of the static effort. Changes in the coherence coefficients for the alpha 2 range in the performance of the grasp efforts by the right arm and the left arm were most clear in the posterotemporal (P = 0.02), parietal (P = 0.05), and anterofrontal (P = 0.06) lead pairs. Thus, we demonstrated the dependence between the side of performance of the muscle effort in the mode close to isometric and lateralization of the EEG modifications. Neirofiziologiya/Neurophysiology, Vol. 38, No. 3, pp. 235–238, May–June, 2006.     

Trigeminal nerve: the possible origin of substance p-nergic response in isolated rabbit iris sphincter muscle

We determined the effects of trigeminal nerve denervation on the noncholinergic, nonadrenergic response to electrical transmural stimulation of the isolated rabbit iris sphincter muscle. The left ophthalmic nerve (first branch of the trigeminal nerve) was cut at the intracranial, peripheral site of the trigeminal ganglion and five to ten days later, the iris sphincter muscle isolated from the left eye (operated side) was found to produce a fast cholinergic contraction in response to electrical transmural stimulation and there was no evidence of noncholinergic, nonadrenergic contractions. On the other hand, in the iris sphincter muscle isolated from the right eye (control side), electrical transmural stimulation produced both cholinergic and noncholinergic, nonadrenergic contractile responses. Capsaicin and bradykinin produced noncholinergic, nonadrenergic contractile responses in the muscle from the control side, while in the iris sphincter from the trigeminally denervated eye there was no such response to application of these drugs. Exogenous substance P (SP) and carbachol produced a strong contractile response in both the trigeminally innervated and denervated sphincter muscles. Somatostatin, vasoactive intestinal polypeptide (VIP) and enkephalin were without effects. These observations suggest that the noncholinergic, nonadrenergic responses to electrical transmural stimulation are derived from the trigeminal nerve and that the mediator involved is probably SP or a related peptide.     

Effects of lower body negative pressure on sympathetic discharge to leg muscles in humans

Recent studies indicate that nonhypotensive orthostatic stress in humans causes reflex vasoconstriction in the forearm but not in the calf. We used microelectrode recordings of muscle sympathetic nerve activity (MSNA) from the peroneal nerve in conscious humans to determine if unloading of cardiac baroreceptors during nonhypotensive lower body negative pressure (LBNP) increases sympathetic discharge to the leg muscles. LBNP from -5 to -15 mmHg had no effect on arterial pressure or heart rate but caused graded decreases in central venous pressure and corresponding large increases in peroneal MSNA. Total MSNA (burst frequency X mean burst amplitude) increased by 61 +/- 22% (P less than 0.05 vs. control) during LBNP at only -5 mmHg and rose progressively to a value that was 149 +/- 29% greater than control during LBNP at -15 mmHg (P less than 0.05). The major new conclusion is that nonhypotensive LBNP is a potent stimulus to muscle sympathetic outflow in the leg as well as the arm. During orthostatic stress in humans, the cardiac baroreflex appears to trigger a mass sympathetic discharge to the skeletal muscles in all of the extremities.     

The arterial supply of the muscle biceps brachii

The bicipital arteries (Rami bicipitales) were classified according to the part of the muscle they supply, to the artery from which they originate and to their relative position to the median, musculocutaneous and ulnar nerves. The maximal density of bicipital arteries can be found in the middle of the upper arm and slightly distal to the greater tubercle.