Surgical Options and Outcomes for Acute Flaccid Myelitis
Sameer H Halani, MD, MSc1, Amy Kite, MD1 and Jonathan Cheng, MD2, (1)UT Southwestern, Dallas, TX, (2)Plastic Surgery, UT Southwestern, Dallas, TX
Acute Flaccid Myelitis (AFM) is a newly re-defined polio-like process affecting anterior horn cells, leading to lower motor neuron paralysis with preserved sensation. Persistent limb weakness in AFM presents as a brachial plexus-type deficit with few non-surgical interventions. Nerve, tendon, and free muscle transfers have been recognized as viable reconstructive options. We report our center's experience with surgical management of AFM, which is the largest known series reported since the CDC's new definition of the disease. Our hope is to help guide treatment going forward.
Materials and Methods
We performed a retrospective review for our tertiary Peripheral Nerve Center from 2009-2018, and identified patients who met diagnostic criteria for AFM. Data were collected for: demographics, motor deficits upon presentation, surgical interventions, and post-operative functional recovery. Our primary endpoint of interest was overall functional recovery.
Of the 24 AFM patients referred to our Center, 9 were deemed surgical candidates and had 19 total operations. For surgical candidates, median age at disease onset was 6y (range, 10 months - 13 years); median time to presentation after onset was 8.2 months (range, 5.3 months - 11.7 years).
Deficits of surgical candidates were in: upper extremity (n=6); lower extremity (n=2); and mixed upper/lower extremity (n=1). Unilateral deficits were present in 7, and bilateral deficits in 2. Functional deficits were noted with: intrinsic palsy (n=3), pronation (n=2), finger flexion at FDS/FDP (n=2), foot drop (n=2), elbow extension (n=1), elbow flexion (n=1), and shoulder abduction (n=1).
The most commonly performed procedures were: nerve transfers (n=14), tendon transfers or re-routing (n = 13), free functional muscle transfer (n = 2) and nerve decompression (n=1). Operative intervention was generally delayed (median, 10.9 months after symptom onset; range, 7.9 months to 145.8 months). Median clinical follow-up time was 26.3 months post-operative (range, 3.7 months to 108.6 months).
All 9 patients had significant improvement and regained function in their affected limbs.
AFM is a newly re-defined disease process which may leave patients with severe disability despite prompt non-surgical management. Nerve, tendon, and free muscle transfers can be excellent reconstructive options after AFM and are noted to improve functionality for these severely affected patients. Surgery is typically delayed to allow sufficient time for identification of persistent deficits following spontaneous but frequently incomplete recovery. Surgical decision-making including patient selection, surgery timing, procedure selection, and reconstructive staging will be discussed.
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