Phrenic nerve neurotization utilizing the spinal accessory nerve: technical note with potential application in patients with high cervical quadriplegia

Tubbs, R. Shane; Pearson, Blake; Loukas, Marios; Shokouhi, Ghaffar; Shoja, Mohammadali Mohajel; Oakes, W. Jerry

doi:10.1007/s00381-008-0650-4

Cited by 17 publications

(8 citation statements)

References 18 publications

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“…The spinal accessory nerve (SAN) has been shown to be a possible donor nerve for anastomosis with the PN to restore physiological respiration. 9,28,29,31 However, the SAN does not have spontaneous discharge, and an external electronic pacing has to be provided. Spontaneous discharge from a donor nerve is important for restoration of spontaneous respiratory function.…”

Section: Discussionmentioning

confidence: 99%

“…Spinal accessory nerve (SAN) and PN anastomosis has been shown to be a possible way to restore the respiratory movement of the diaphragm. 9,28,29,31 Our previous study showed that vagus nerve (VN) to PN anastomosis could partially improve respiratory function in rabbits that had been subjected to unilateral PN transection. 30 Nevertheless, there are drawbacks to using the VN for anastomosis to the PN, even though the VN contains some fibers that produce efferent discharges synchronous with the PN.…”

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confidence: 99%

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Recovery of respiratory function and autonomic diaphragm movement following unilateral recurrent laryngeal nerve to phrenic nerve anastomosis in rabbits

Wen

Han²,

Guo³

et al. 2018

Journal of Neurosurgery: Spine

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OBJECTIVERespiratory dysfunction is the leading cause of mortality following upper cervical spinal cord injury (SCI). The authors’ previous study suggested that vagus nerve (VN) and phrenic nerve (PN) anastomosis could partially improve respiratory function in rabbits that had been subjected to PN transection. As a branch of the VN and a motor fiber–dominated nerve, the recurrent laryngeal nerve (RLN) seems a better choice to anastomose with the PN for respiratory function restoration after upper cervical SCI. This study was designed to determine whether RLN-PN anastomosis could restore the respiratory function after upper cervical SCI in rabbits.METHODSTwelve male New Zealand rabbits were randomly divided into 3 groups: 1) sham group (no injury), 2) transection group (right RLN and PN were transected), and 3) bridge group (transected right RLN and PN were immediately anastomosed). Spontaneous discharges of the RLN and PN were compared using a bio-signal collection system. RLN and PN cross sections were stained for acetylcholinesterase (AChE), and the numbers of motor fibers were compared. Three months after the initial surgical procedures, the movement of the diaphragm was assessed using a digital subtraction angiography (DSA) system, and discharges from the right diaphragm muscle were recorded. Toluidine blue staining, electron microscopy, and staining for AChE were used to assess whether motor fibers from the RLN regenerated into the PN, and sections of diaphragm were examined after AChE staining to assess the motor endplates.RESULTSBoth the RLN and PN exhibited highly rhythmic discharges, synchronized with respiration, and most fibers in the RLN and PN were found to be motor fibers. Numerous myelinated fibers were observed in anastomosed PN using toluidine blue staining and electron microscopy. Staining for AChE showed that those regenerated fibers had typical characteristics of motor fibers, and motor endplates with typical morphological characteristics were observed in the diaphragm. Reestablished rhythmic contraction of the hemidiaphragm was directly observed using the DSA system, and rhythmic spontaneous discharge was recorded from the reinnervated hemidiaphragm using the bio-signal collection system.CONCLUSIONSMotor fibers from the RLN could regenerate into the PN after end-to-end anastomosis and reinnervate the denervated hemidiaphragm in rabbits. Those regenerated motor fibers restored rhythmic and autonomic movement of the paralyzed diaphragm. These results suggest that the RLN is an optimal donor nerve to anastomose with the PN in order to reestablish the autonomic movement of paralyzed diaphragms after high-level SCI.

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Section: Discussionmentioning

confidence: 99%

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confidence: 99%

Recovery of respiratory function and autonomic diaphragm movement following unilateral recurrent laryngeal nerve to phrenic nerve anastomosis in rabbits

Wen

Han²,

Guo³

et al. 2018

Journal of Neurosurgery: Spine

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“…The posterior approach could even allow the accessory nerve to be harvested for use in neurotization procedures involving the radial nerve branches to the triceps brachii muscle, and the axillary nerve at its exit from the quadrangular space (Vathana et al, ; Tubbs et al, a). A recent cadaveric feasibility study by Tubbs et al () showed that the accessory nerve would be feasible for use in neurotization of the phrenic nerve in patients with high cervical quadriplegia (Tubbs et al, ). Additionally, Tubbs et al () have shown that the accessory nerve in the posterior cervical triangle can be lengthening in order to use it for neurotization procedures more distally.…”

Section: Surgerymentioning

confidence: 99%

The Accessory Nerve: A Comprehensive Review of its Anatomy, Development, Variations, Landmarks and Clinical Considerations

Johal

Iwanaga

Tubbs

et al. 2018

The Anatomical Record

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The accessory nerve continues to be a topic of much discussion regarding its exact function and in particular to its cranial roots. Recently, various surgical procedures have been devised that repurpose the accessory nerve (e.g., lengthening procedures, contralateral neurotization procedures). Currently, we continue to learn and have much to learn about this lower cranial nerve. Anat Rec, 2018. © 2018 Wiley Periodicals, Inc.

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“…Restoration of the diaphragm by anastomosing the SAN with the phrenic nerve has been reported in animal and cadaver studies. 9,12 In the animal models, the transferred SAN could effectively pace the diaphragm; however, no clinical application has been reported. Based on our case study, the procedure led to satisfactory results: 6 months after the operation, partial improvements in the motion of the diaphragm were observed, and the patient's lung function, especially the tidal volume, could fulfill the demands of his daily life.…”

Section: Clinical Effectsmentioning

confidence: 99%

Functional restoration of the paralyzed diaphragm in high cervical quadriplegia via phrenic nerve neurotization utilizing the functional spinal accessory nerve

Yang

Zhang

et al. 2011

SPI

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The authors report a case of functional improvement of the paralyzed diaphragm in high cervical quadriplegia via phrenic nerve neurotization using a functional spinal accessory nerve. Complete spinal cord injury at the C-2 level was diagnosed in a 44-year-old man. Left diaphragm activity was decreased, and the right diaphragm was completely paralyzed. When the level of metabolism or activity (for example, fever, sitting, or speech) slightly increased, dyspnea occurred. The patient underwent neurotization of the right phrenic nerve with the trapezius branch of the right spinal accessory nerve at 11 months postinjury. Four weeks after surgery, training of the synchronous activities of the trapezius muscle and inspiration was conducted. Six months after surgery, motion was observed in the previously paralyzed right diaphragm. The lung function evaluation indicated improvements in vital capacity and tidal volume. This patient was able to sit in a wheelchair and conduct outdoor activities without assisted ventilation 12 months after surgery.

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Phrenic nerve neurotization utilizing the spinal accessory nerve: technical note with potential application in patients with high cervical quadriplegia

Cited by 17 publications

References 18 publications

Recovery of respiratory function and autonomic diaphragm movement following unilateral recurrent laryngeal nerve to phrenic nerve anastomosis in rabbits

Recovery of respiratory function and autonomic diaphragm movement following unilateral recurrent laryngeal nerve to phrenic nerve anastomosis in rabbits

The Accessory Nerve: A Comprehensive Review of its Anatomy, Development, Variations, Landmarks and Clinical Considerations

Functional restoration of the paralyzed diaphragm in high cervical quadriplegia via phrenic nerve neurotization utilizing the functional spinal accessory nerve

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