Name:
10.3171/2022.10.FOCVID22100
Description:
10.3171/2022.10.FOCVID22100
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/2630c868-74bf-47f5-84c7-3221375cd93e/thumbnails/2630c868-74bf-47f5-84c7-3221375cd93e.jpg
Duration:
T00H08M57S
Embed URL:
https://stream.cadmore.media/player/2630c868-74bf-47f5-84c7-3221375cd93e
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/2630c868-74bf-47f5-84c7-3221375cd93e/5. 22-100.mp4?sv=2019-02-02&sr=c&sig=B93YAaTvQoRhIFJCXAyRwqdUqK6oI4kZaIdxLKUi4dQ%3D&st=2024-11-26T11%3A27%3A34Z&se=2024-11-26T13%3A32%3A34Z&sp=r
Upload Date:
2022-11-17T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
[MUSIC PLAYING]
SPEAKER: In this video, we demonstrate the operative techniques for the Oberlin procedure to restore function for C5-6 palsy after posterior cervical spine surgery. Postoperative C5-6 palsies can occur in 5% to 10% of cases after cervical spine surgery. Nerve transfer has been shown to restore function for those with persistent weakness in retrospective case series. In one such series, nine of 10 treated patients had recovery in biceps and deltoid function at last follow-up.
SPEAKER: Possible nerve transfers include spinal accessory to suprascapular nerve transfer, triceps branch of the radial nerve to axillary nerve transfer, as well as single or double fascicular transfer from the ulnar and/or median nerve to the biceps and/or brachialis motor branches of the musculocutaneous nerve, which is known as the Oberlin procedure. The patient is a 55-year-old right-handed male, who initially presented with a one year history of gait instability, subjective right lower extremity weakness, dysesthesias in the bilateral feet, and intermittent radiculopathy in the bilateral upper extremities, most notably in the C6 distribution.
SPEAKER: On examination, he had subtle hand intrinsic weakness bilaterally, hyperreflexia in all four extremities, and abnormal tandem gait, concerning for cervical spondylotic myelopathy. Imaging studies demonstrated multi-levels degenerative changes resulting in cervical stenosis between C3 to 6 with evidence of cord signal change. Given evidence of partial ossification of the posterior longitudinal ligament, he was counseled against multilevel anterior cervical discectomy infusion, and ultimately underwent C3 to 6 laminectomy and posterior fusion.
SPEAKER: Postoperative imaging studies are shown here, demonstrating successful decompression and stabilization. Postoperatively, the patient reported that his radiculopathy and gait had significantly improved, however, he developed bilateral upper extremity weakness in the C5-6 distribution over a period of days. His right deltoid was 2/5. His left deltoid was 1/5.
SPEAKER: And bilateral biceps were 2/5, with weakness also noted in the left supra and infraspinatus. The patient was followed closely with both serial neurological examinations and electrodiagnostic studies averaging every three months. And he was noted to have spontaneous recovery of function to near-full strength in all affected muscle groups of the right upper extremity by 10 months. Electromyography study demonstrated motor unit potentials in the left biceps, but he still could not achieve anti-gravity function.
SPEAKER: At 12 months, in the left upper extremity, his supra and infraspinatus were 4/5. His deltoid was 3/5, and he's able to achieve adequate shoulder abduction. He still exhibited weakness in the biceps, 2/5, but was able to flex at the elbow in a neutral position predominantly through the use of his brachoradialis.
SPEAKER: The patient was offered an Oberlin procedure on the left side to improve elbow flexion and supination in the setting of good hand function, via an ulnar nerve to musculocutaneous nerve transfer. While nerve transfer for improvement of shoulder abduction were considered, including radial to axillary nerve transfer, and spinal accessory to suprascapular nerve transfer, the authors do not believe that patients with at least anti-gravity function are appropriate candidates for these additional transfers.
SPEAKER: However, these options are often used in conjunction with the Oberlin transfer when patients do have severe shoulder abduction and/or external rotation weakness following posterior cervical decompression surgery. The patient was taken to the operating room and the left medial arm was marked. After general endotracheal anesthesia was induced, the patient was positioned supine on the operating table with the left arm abducted and externally rotated onto a hand table.
SPEAKER: A linear incision was marked overlying the neurovascular bundle between the atrophied biceps and the triceps muscle. The skin was infiltrated with local anesthetic and an incision was opened with a number 15 blade. Dissection then proceeded through the subcutaneous tissues and fascia to the neurovascular bundle. The medial antebrachial cutaneous nerve and medial cutaneous nerve of the forearm were identified and protected.
SPEAKER: Exposure continued medially where the ulnar nerve was identified and neurolized with good response to stimulation. Just lateral to the brachial artery, the median nerve was then identified, also with good response to stimulation. Next, the interval between the atrophied biceps and brachialis muscles were explored to identify the musculocutaneous nerve.
SPEAKER: These nerves were dissected and encircled with vessel loops. The proximal branch of the musculocutaneous nerve was then isolated and neurolized and encircled with the vessel loop. There is minimal electrical response to stimulation of this branch as expected from his preoperative examination. The operating microscope was brought into the field and microsurgical technique was used to open the epineurium of the ulnar nerve.
SPEAKER: An internal neurolysis was performed of the ulnar nerve with stimulation of fascicles. We identified one fascicle that provided a response, mainly in the flexor carpi ulnaris, more so than in hand function at very low current.
SPEAKER: This fascicle was gently dissected from the remaining ulnar nerve fascicles using microsurgical technique, and was isolated with the vessel loop so that it could be dissected distally for a significant distance. The biceps branch of the musculocutaneous nerve was then sectioned proximally, and brought downward and medially toward the ulnar nerve.
SPEAKER: The selected ulnar nerve fascicle was transacted distally and was brought towards the biceps branch.
SPEAKER: The fascicular nerve repair was then performed using a single interrupted suture of 8 0 nylon with no tension at the suture line.
SPEAKER: There was a good size match and good apposition of the nerve ends. The repair site was covered with fibrin glue. The wound was then irrigated with saline, and meticulous hemostasis was obtained. The incision was then closed in anatomic layers using interrupted 3 0 absorbable sutures, and a running 3 0 subcuticular suture for the skin closure.
SPEAKER: A dry, sterile dressing was placed. A compressive wrap was applied, and a sling was placed on the arm. The patient was extubated, and taken to the recovery room postoperatively in satisfactory condition. The patient kept his arm in a sling until his postoperative visit at three weeks to avoid disruption of the co-optation.
SPEAKER: His incision had healed well. He reported minimal pain at the incision, but had mild anterior forearm numbness. He has follow-ups scheduled at six months postoperatively as well as at nine months for repeat electromyography and nerve conduction studies to monitor the outcome of this nerve transfer.
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