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14th Triennial Congress of the International Federation of Societies for Surgery of the Hand (IFSSH), 11th Triennial Congress of the International Federation of Societies for Hand Therapy (IFSHT)

17.06. - 21.06.2019, Berlin

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Oberlin technique assisted with intraoperative nerve recording

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  • presenting/speaker Joaquim Casanas - Traumaunit, Centro Medico Teknon, Sant Cugat del Valles, Spain
  • Manuel Llusa - Traumaunit, Centro Medico Teknon, Hospital Clínic de Barcelona, Departamento de Anatomía y Embriología Humana, UB, Sant Cugat del Valles, Spain
  • Isabel Fernandez Conejero - Traumaunit, Centro Medico Teknon, Sant Cugat del Valles, Spain
  • M. Rosa Morro - Traumaunit, Centro Medico Teknon, Hospital Clínic de Barcelona, Departamento de Anatomía y Embriología Humana, UB, Sant Cugat del Valles, Spain

International Federation of Societies for Surgery of the Hand. International Federation of Societies for Hand Therapy. 14th Triennial Congress of the International Federation of Societies for Surgery of the Hand (IFSSH), 11th Triennial Congress of the International Federation of Societies for Hand Therapy (IFSHT), 11th Triennial Congress of the International Federation of Societies for Hand Therapy (IFSHT). Berlin, 17.-21.06.2019. Düsseldorf: German Medical Science GMS Publishing House; 2020. DocIFSSH19-1107

doi: 10.3205/19ifssh1221, urn:nbn:de:0183-19ifssh12217

Published: February 6, 2020

© 2020 Casanas et al.
This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 License. See license information at http://creativecommons.org/licenses/by/4.0/.

Outline

Text

Objectives/Interrogation: Fascicles identification to optimize nerve transfer is usually an issue during surgery. Anatomic fascicular variability is frequent. Potential of each fascicle is of at most importance to decide which one must be transferred. Intraoperative nerve recording (NAP) and CMAP evaluation guide us to choose the best option for nerve transfer surgeries.

Methods: Oberlin procedure has been performed under intraoperative nerve recording to evaluate which is the best fascicule to be harvested and CMAP in intrinsic and extrinsic muscle obtained. From 2007 to 2013, 36 patients (34 male, 2 female), ages ranges from 17 to 55 has been treated using this method.

Adequate stimulator, recorder, intramuscular needles and settings for multiple channel electromiograph is necessary. Careful intraneural dissection to split fascicles of ulnar nerve and low stimulus intensity is crucial to apply this technique properly.

CMAP technique on FCU, hypothenar and first dorsal interosseous muscle were done to record proper fascicle donor. At the same time, we identified and measured NAP of the selected fascicle to optimize results of Oberlin nerve transfer. Activity in the biceps branch was also recorded to decide end-to-side (ETS) or reverse end-to-side (RETS) suture.

Results and Conclusions: Although is decribed motor fascicles for FCU must be elevated from anteroexternal area of ulnar nerve, we have found just 58% motor nerves are coming from this area, 25% from posteroexternal and 16% from anteroexternal. Reinnervation appears between 3 and 8 months, 91% ETS sutures were performed and 9% RETS sutures in cases we detected some nerve conduction in the biceps motor branch.

We consider CMAP above 500mV in FCU and NAP fascicle greater than 100 mV is necessary to obtain good results. NAP lower than 50 mV get poor results.

Final muscular strength range from 3/5 to 4+/5. We have no failure in any case in terms of EMG reinnervation, however, the amount of NAP transfered is related to clinical results.

So, we can conclude that not all proper fascicles are in the anteroexternal axial section of ulnar nerve and intraoperative nerve recording give us relevant information to localize it, such as measurement of the amount of axonal charge transferred which is correlated with clinical results.