Sciatic Fascicular Transfers to Restore Leg Function in Patients with Acute Flaccid Myelitis
Elspeth J R Hill, MD PhD MRes, Washington University School of Medicine, St Louis, MO, Jana Dengler, MD, Washington University School of Medicine, St. Louis, MO and Amy M Moore, MD, Department of Surgery, Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, Saint Louis, MO
Introduction: Acute Flaccid Myelitis (AFM) is a devastating paralytic condition affecting previously healthy children. Although much remains unknown about its pathology, the disease attacks the anterior horn cell causing lower motor neuron injury in unpredictable patterns, with proximal muscles more severely affected. It often leaves children with mixed upper and lower extremity paralysis and ventilator-dependent. Recovery patterns are also highly varied. Here, we present results of sciatic fascicular nerve transfers to restore knee flexion, knee extension and hip abduction and stabilization.
Materials & Methods: A retrospective case series of 6 consecutive patients with AFM diagnosed in 2018 treated with sciatic fascicular nerve transfers from April to July 2019 are presented. History, physical examination and electrodiagnostics determined suitability for nerve transfers. Sciatic fascicles were identified intra-operatively, and redundant donor fascicles confirmed using intra-operative nerve stimulation. Each patient had a unique pattern of deficit requiring tailored transfers, often with final fascicular transfer plan determined based on intra-operative stimulation.
Results: Patients undergoing transfers ranged 1 to 10 years of age. Time of nerve transfer from initial illness ranged from 5 to 10 months. 14 sciatic fascicular nerve transfers were undertaken in 8 limbs of 6 patients. Intra-operative stimulation confirmed functioning donor fascicles. Of the 14 sciatic donor fascicles, 7 were peroneal fascicles for toe extension, 2 were peroneal fascicles for foot eversion, and 6 were tibial fascicles for toe flexion. The most suitable target for transfer was also identified using intra-operative stimulation. Of the 14 recipient nerves transferred, 4 went to biceps femoris, 2 to semitendinosus, 4 to vastus medialis, 3 to vastus lateralis, and 2 to superior gluteal nerves. Of the 8 limbs that were operated on, all underwent concomitant superior and inferior gluteal nerve decompression, sciatic nerve decompression at the sciatic notch, and femoral nerve decompression. No patients had downgraded function post-operatively, 3 have early improvement in motor function, and the remainder have inadequate follow up at the present time. Outcome data collection is ongoing and will be presented.
Conclusions: Sciatic fascicular nerve transfers are an exciting new option for children afflicted with AFM, with early outcomes extremely promising. Ongoing clinical and basic science research is needed to optimize treatment for this complex disorder.
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