Effects of exosomes from mesenchymal stem cells on functional recovery of a patient with total radial nerve injury: A pilot study

BACKGROUND Peripheral nerve injury can result in significant clinical complications that have uncertain prognoses.Currently,there is a lack of effective pharmacological interventions for nerve damage,despite the existence of several small compounds,Despite the objective of achieving full functional restoration by surgical intervention,the persistent challenge of inadequate functional recovery remains a significant concern in the context of peripheral nerve injuries.AIM To examine the impact of exosomes on the process of functional recovery following a complete radial nerve damage.METHODS A male individual,aged 24,who is right-hand dominant and an immigrant,arrived with an injury caused by a knife assault.The cut is located on the left arm,specifically below the elbow.The neurological examination and electrodiagnostic testing reveal evidence of left radial nerve damage.The sural autograft was utilized for repair,followed by the application of 1 mL of mesenchymal stem cell-derived exosome,comprising 5 billion microvesicles.This exosome was split into four equal volumes of 0.25 mL each and delivered microsurgically to both the proximal and distal stumps using the subepineural pathway.The patient was subjected to a period of 180 d during which they had neurological examination and electrodiagnostic testing.RESULTS The duration of the patient’s follow-up period was 180 d.An increasing Tinel’s sign and sensory-motor recovery were detected even at the 10th wk following nerve grafting.Upon the conclusion of the 6-mo post-treatment period,an evaluation was conducted to measure the extent of improvement in motor and sensory functions of the nerve.This assessment was based on the British Medical Research Council scale and the Mackinnon-Dellon scale.The results indicated that the level of improvement in motor function was classified as M5,denoting an excellent outcome.Additionally,the level of improvement in sensory function was classified as S3+,indicating a good outcome.It is noteworthy that these assessments were conducted in the absence of physical therapy.At the 10th wk post-injury,despite the persistence of substantial axonal damage,the nerve exhibited indications of nerve re-innervation as evidenced by control electromyography(EMG).In contrast to the preceding.EMG analysis revealed a significant electrophysiological enhancement in the EMG conducted at the 6th-mo follow-up,indicating ongoing regeneration.CONCLUSION Enhanced comprehension of the neurobiological ramifications associated with peripheral nerve damage,as well as the experimental and therapy approaches delineated in this investigation,holds the potential to catalyze future clinical progress.

Human umbilical cord mesenchymal stem cell-loaded amniotic membrane for the repair of radial nerve injury

In this study, we loaded human umbilical cord mesenchymal stem cells onto human amniotic membrane with epithelial cells to prepare nerve conduits, i.e., a relatively closed nerve regeneration chamber. After neurolysis, the injured radial nerve was enwrapped with the prepared nerve conduit, which was fixed to the epineurium by sutures, with the cell on the inner surface of the conduit. Simultaneously, a 1.0 mL aliquot of human umbilical cord mesenchymal stem cell suspension was injected into the distal and proximal ends of the injured radial nerve with 1.0 cm intervals. A total of 1.75 x 107 cells were seeded on the amniotic membrane. In the control group, patients received only neurolysis. At 12 weeks after cell transplantation, more than 80% of patients exhibited obvious improvements in muscular strength, and touch and pain sensations. In contrast, these improvements were observed only in 55-65% of control patients. At 8 and 12 weeks, muscular electrophysiological function in the region dominated by the injured radial nerve was significantly better in the transplantation group than the control group. After cell transplantation, no immunological rejections were observed. These findings suggest that human umbilical cord mesenchymal stem cell-loaded amniotic membrane can be used for the repair of radial nerve injury.

Ultrasonographic reference values for assessing normal radial nerve ultrasonography in the normal population

High-resolution ultrasound has been used recently to characterize median and ulnar nerves, but is seldom used to characterize radial nerves. The radial nerve is more frequently involved in en- trapment syndromes than the ulnar and median nerves. However, the reference standard for normal radial nerves has not been established. Thus, this study measured the cross-sectional areas of radial nerves of 200 healthy male or female volunteers, aged 18 to 75, using high-resolution ultrasound. The results showed that mean cross-sectional areas of radial nerves at 4 cm upon the lateral epicondyle of the humerus and mid-humerus （midpoint between the elbow crease and axilla） were 5.14± 1.24 and 5.08 ± 1.23 mm2, respectively. The age and the dominant side did not affect the results, but the above-mentioned cross-sectional areas were larger in males （5.31± 1.25 and 5.19 ±1.23 mm2） than in females （4.93 ± 1.21 and 4.93 ± 1.23 mm2, respectively）. In addition, the cross-sectional areas of radial nerves were positively correlated with height and weight （r = 0.38, 0.36, respectively, both P 〈 0.05）. These data provide basic clinical data for the use of high-resolution ultrasound for the future diagnosis, treatment, and prognostic evalua- tion of peripheral neuropathies.

Radial nerve recovery following closed nailing of humeral shaft fractures without radial nerve exploration: A retrospective study

BACKGROUND Radial nerve palsy due to humeral shaft fracture is the most common peripheral nerve injury associated with long bone fractures.An antegrade nailing surgical technique is becoming popular for the fixation of these fractures with minimal invasiveness.We analyzed nerve recovery in patients with humeral shaft fracture and radial nerve palsy treated with humeral nail fixation without nerve exploration.AIM To assess the radial nerve recovery rate and time from humeral shaft fracture with surgical treatment using close nailing.METHODS We retrospectively collected data of patients who underwent undergone surgical nail fixation for humeral shaft fractures between October 1,2016,and March 31,2020.Subsequently,we analyzed the primary or secondary radial nerve palsy recovery rate and radial nerve motor function recovery time.RESULTS The study included 70 patients who underwent surgical treatment for closed-or Gustilo type I open humeral shaft fractures using a nail fixation technique without radial nerve exploration.The patients suffered from primary(n=5)and secondary(n=5)radial nerve palsy.A 100%radial nerve recovery rate was achieved.The mean recovery time was 4.3 mo.CONCLUSION The study results indicate full recovery of radial nerve palsies from humeral shaft fracture using close nailing treatment.Surgeons need not be concerned about the occurrence of permanent nerve palsies.

Ultrasound-guided needle release plus corticosteroid injection of superficial radial nerve:A case report

BACKGROUND The radial nerve(RN)splits into two main branches at the elbow:The superficial branch of RN(SBRN)and the deep branch of RN.The SBRN can be easily damaged in acute trauma due to its superficial feature.CASE SUMMARY A 55-year-old male patient injured his right wrist 10 mo ago.Debridement,suturing and bandaging were performed in the emergency room.Six months after the scar had healed,he felt numbness and tingling in the dorsal surface of the thumb of the right hand.So the surgery of resection and SBRN anastomosis were performed.The pathological findings showed it as traumatic neuroma.Four months after surgery,the patient felt numbness and tingling in the right dorsal surface of the thumb again.The tenderness was marked in the operated area.Ultrasound indicated that the SBRN was adhered to the surrounding tissue.The patient refused further surgical treatment and underwent ultrasound-guided needle release plus corticosteroid injection of the SBRN.Four weeks later,the tenderness in the surgical area was reduced by 70%,the numbness in the dorsal surface of the thumb of the right hand was reduced by 40%and the nerve swelling evaluated by ultrasound was reduced.Four months passed,he did not feel any numbness or tingling sensation of his right wrist.This is the first report of ultrasound-guided needle release plus corticosteroid injection of the SBRN.CONCLUSION Ultrasound can evaluate the condition of the RN,and the relationship with surrounding tissues.Ultrasound-guided needle release plus corticosteroid injection is an effective and safe treatment for SBRN adhesion.

The Radial Nerve Entrapment in Pediatric Extension-Type Supracondylar Humeral Fractures. About Two Cases Reports

Radial nerve injuries in displaced extension-type supracondylar humeral fractures in children are well known. Entrapment in fracture of radial nerve is uncommon and rarely evocated in literature. We report two similar cases in the mechanism of injury, the clinical findings and the treatment and propose therapeutic guidelines.

Treatment of posterior interosseous nerve entrapment syndrome with ultrasound-guided hydrodissection:A case report

BACKGROUND Posterior interosseous nerve(PIN)entrapment syndrome is one of the causes of weakness and pain of the arm muscles,which is prone to missed diagnosis and misdiagnosis in clinic practice.This paper reports a case of PIN entrapment syndrome,with PIN injury indicated by electrophysiology.Musculoskeletal ultrasound was applied to identify that the entrapment point was located at the inlet of the Frohse arch and the outlet of the supinator muscle.Treatment with ultrasound-guided nerve hydrodissection was performed on the entrapment point,which significantly improved the symptoms.Ultrasound-guided nerve hydrodissection is an effective therapeutic method for PIN entrapment syndrome.CASE SUMMARY A male patient,35 years old,worked as an automobile mechanic.He felt slightly weak extension activity of his right fingers 2 years ago but sought no treatment.Later,the symptoms gradually became aggravated and led to finger drop,particularly severe in the right middle finger,accompanied by supination weakness of the right forearm.Neural electrophysiological examination showed that the patient had partial PIN injury of the right radius.Musculoskeletal ultrasound examination indicated PIN entrapment at the inlet of the Frohse arch and the outlet of the supinator muscle.Therefore,PIN entrapment syndrome was diagnosed.After treatment with ultrasound-guided nerve hydrodissection around the entrapment point,the dorsiflexion weakness of the right hand was significantly improved compared with before treatment.CONCLUSION Ultrasound-guided hydrodissection is efficacious for PIN entrapment syndrome,with high clinical value and great application prospects.

Anatomic location of the first dorsal extensor compartment for surgical De-Quervain’s tenosynovitis release:A cadaveric study

BACKGROUND De-Quervain’s tenosynovitis is a disorder arising from the compression and irritation of the first dorsal extensor compartment of the wrist.Patients who fail conservative treatment modalities are candidates for surgical release.However,risks with surgery include damage to the superficial radial nerve and an incomplete release due to inadequate dissection.Currently,there is a paucity of literature demonstrating the exact anatomic location of the first dorsal extensor compartment in reference to surface anatomy.Thus,this cadaveric study was performed to determine the exact location of the first extensor compartment and to devise a reliable surgical incision to prevent complications.AIM To describe the location of the first dorsal compartment in relation to bony surface landmarks to create replicable surgical incisions.METHODS Six cadaveric forearms,including four left and two right forearm specimens were dissected.Dissections were performed by a single fellowship trained upper extremity orthopaedic surgeon.Distance of the first dorsal compartment from landmarks such as Lister’s tubercle,the wrist crease,and the radial styloid were calculated.Other variables studied included the presence of the superficial radial nerve overlying the first dorsal compartment,additional compartment subsheaths,number of abductor pollicis longus(APL)tendon slips,and the presence of a pseudo-retinaculum.RESULTS Distance from the radial most aspect of the wrist crease to the extensor retinaculum was 5.14 mm±0.80 mm.The distance from Lister’s tubercle to the distal aspect of the extensor retinaculum was 13.37 mm±2.94 mm.Lister’s tubercle to the start of the first dorsal compartment was 18.43 mm±2.01 mm.The radial styloid to the initial aspect of the extensor retinaculum measured 2.98 mm±0.99 mm.The retinaculum length longitudinally on average was 26.82 mm±3.34 mm.Four cadaveric forearms had separate extensor pollicis brevis compartments.The average number of APL tendon slips was three.A pseudo-retinaculum was present in four cadavers.Two cadavers had a superficial radial nerve that crossed over the first dorsal compartment and retinaculum proximally(7.03 mm and 13.36 mm).CONCLUSION An incision that measures 3 mm proximal from the radial styloid,2 cm radial from Lister’s tubercle,and 5 mm proximal from the radial wrist crease will safely place surgeons at the first dorsal compartment.

Nerve transfer helps repair brachial plexus injury by increasing cerebral cortical plasticity

In the treatment of brachial plexus injury, nerves that are functionally less important are transferred onto the distal ends of damaged crucial nerves to help recover neuromuscular function in the target region. For example, intercostal nerves are transferred onto axillary nerves, and accessory nerves are transferred onto suprascapular nerves, the phrenic nerve is transferred onto the musculocutaneous nerves, and the contralateral C7 nerve is transferred onto the median or radial nerves. Nerve transfer has become a major method for reconstructing the brachial plexus after avulsion injury. Many experiments have shown that nerve transfers for treatment of brachial plexus injury can help reconstruct cerebral cortical function and increase cortical plasticity. In this review article, we summarize the recent progress in the use of diverse nerve transfer methods for the repair of brachial plexus injury, and we discuss the impact of nerve transfer on cerebral cortical plasticity after brachial plexus injury.

Evaluation of nerve transfer options for treating total brachial plexus avulsion injury： a retrospective study of 73 participants

Despite recent great progress in diagnosis and microsurgical repair, the prognosis in total brachial plexus-avulsion injury remains unfavorable.Insufficient number of donors and unreasonable use of donor nerves might be key factors. To identify an optimal treatment strategy for this condition, we conducted a retrospective review. Seventy-three patients with total brachial plexus avulsion injury were followed up for an average of 7.3 years. Our analysis demonstrated no significant difference in elbow-flexion recovery between phrenic nerve-transfer （25 cases）, phrenic nerve-graft （19 cases）, intercostal nerve （17 cases）, or contralateral C7-transfer （12 cases） groups. Restoration of shoulder function was attempted through anterior accessory nerve （27 cases）, posterior accessory nerve （10 cases）, intercostal nerve （5 cases）, or accessory ＋ intercostal nerve transfer （31 cases）. Accessory nerve ＋ intercostal nerve transfer was the most effective method. A significantly greater amount of elbow extension was observed in patients with intercostal nerve transfer （25 cases） than in those with contralateral C7 transfer （10 cases）. Recovery of median nerve function was noticeably better for those who received entire contralateral C7 transfer （33 cases） than for those who received partial contralateral C7 transfer （40 cases）. Wrist and finger extension were reconstructed by intercostal nerve transfer （31 cases）. Overall, the recommended surgical treatment for total brachial plexus-avulsion injury is phrenic nerve transfer for elbow flexion, accessory nerve ＋ intercostal nerve transfer for shoulder function, intercostal nerves transfer for elbow extension, entire contralateral C7 transfer for median nerve function, and intercostal nerve transfer for finger extension. The trial was registered at Clinical-Trials.gov （identifier： NCT03166033）.

Investigation of the effectiveness of LI4, LI10, LR3 and ST36 acupoints electroacupuncture in radialis and ulnaris nervus injuries

Background:Radial and ulnar nervus injuries are among the most common peripheral nerve injuries in veterinary medicine.In this study,it was aimed to evaluate electroacupuncture applications in radialis and ulnaris nervus injuries.Methods:New Zealand rabbits were used in the study.Rabbits were divided into treatment groups and control groups.The treatment groups included the acute nerve injury group and the chronic nerve injury group.The control groups included the positive control group(damaged but no treatment),and the negative control group(no damage but with electroacupuncture).Hegu(LI4),Shousanli(LI10),Taichong(LR3)and Zusanli(ST36)acupoints were used for electroacupuncture applications.During the treatment period,clinical examinations of the rabbits were performed.Results:The deep pain sensation and resistance to the applied pulling force in the legs of the rabbits in the treatment groups(both acute nerve injury group and the chronic nerve injury group)were statistically significantly increased(P˂0.001 for all).Again,the rabbits in the treatment groups were found to be in a better condition than the positive control group in terms of using their legs while walking and using their claws,and there was a statistically significant difference(P˂0.001 for all).Electroacupuncture is an effective treatment for both acute and chronic nerve injuries,as well as being more effective in acute cases than in chronic cases.Conclusion:Electroacupuncture based on LI4,LI10,LR3 and ST36 acupoints is an effective treatment in rabbits’radial and ulnar nervus injuries.

Cell proliferation and apoptosis in optic nerve and brain integration centers of adult trout Oncorhynchus mykiss after optic nerve injury

Fishes have remarkable ability to effectively rebuild the structure of nerve cells and nerve fibers after central nervous system injury.However,the underlying mechanism is poorly understood.In order to address this issue,we investigated the proliferation and apoptosis of cells in contralateral and ipsilateral optic nerves,after stab wound injury to the eye of an adult trout Oncorhynchus mykiss.Heterogenous population of proliferating cells was investigated at 1 week after injury.TUNEL labeling gave a qualitative and quantitative assessment of apoptosis in the cells of optic nerve of trout 2 days after injury.After optic nerve injury,apoptotic response was investigated,and mass patterns of cell migration were found.The maximal concentration of apoptotic bodies was detected in the areas of mass clumps of cells.It is probably indicative of massive cell death in the area of high phagocytic activity of macrophages/microglia.At 1 week after optic nerve injury,we observed nerve cell proliferation in the trout brain integration centers：the cerebellum and the optic tectum.In the optic tectum,proliferating cell nuclear antigen（PCNA）-immunopositive radial glia-like cells were identified.Proliferative activity of nerve cells was detected in the dorsal proliferative（matrix） area of the cerebellum and in parenchymal cells of the molecular and granular layers whereas local clusters of undifferentiated cells which formed neurogenic niches were observed in both the optic tectum and cerebellum after optic nerve injury.In vitro analysis of brain cells of trout showed that suspension cells compared with monolayer cells retain higher proliferative activity,as evidenced by PCNA immunolabeling.Phase contrast observation showed mitosis in individual cells and the formation of neurospheres which gradually increased during 1–4 days of culture.The present findings suggest that trout can be used as a novel model for studying neuronal regeneration.

Derotational osteotomy and internal fixation of a 180°malrotated humerus:A case report

BACKGROUND Humeral shaft fractures are relatively common in adults.Rotational malalignment is reported as one complication but severe rotational deformity of the humerus is extremely rare.To our knowledge,only three cases of symptomatic humeral malrotation have been reported.There are sparse literature reports of humeral reconstruction correction.CASE SUMMARY We present a case of extreme rotational deformity of the humerus(180°)after humeral shaft fracture.The patient complained of pain and difficulties with activities of daily living.In addition,she found the deformity cosmetically unacceptable.Therefore,she was searching for surgical correction.Neurolysis of the radial nerve followed by derotational osteotomy of the humerus and internal fixation were performed.Postoperatively,the patient demonstrated transient iatrogenic radial nerve palsy which recovered completely during postoperative follow-up.The Disabilities of the Arm,Shoulder,and Hand score improved from 55 preoperatively to 16 at the final 2-year follow-up.CONCLUSION Single-stage radial neurolysis,derotational osteotomy and stable fixation is a feasible option to improve anatomic and functional problems of severely malrotated humeral shaft fractures.