American Society for Peripheral Nerve

Spring 2014   •   Volume 4, Issue 1

The Newsletters is a publication of the American Society for Peripheral Nerve. Views expressed by various authors are not necessarily those of the ASPN.

Editor:
Jonathan Isaacs, MD

Associate Editors:
Jonathan M. Winograd, MD
Brent M. Egeland, MD

American Society
for Peripheral Nerve

500 Cummings Center
Ste 4550
Beverly, MA 01915
contact@peripheralnerve.org
www.peripheralnerve.org

Future ASPN Meetings
2015 Annual Meeting
January 23-25, 2015
Atlantis
Paradise Island, Bahamas

2016 Annual Meeting
January 15-17, 2016
Westin Keirland Hotel
Scottsdale, Arizona

2017 Annual Meeting
January 13-15, 2017
Hilton Waikoloa Village
Waikoloa, Big Island, Hawaii
Message From The President

Spring is finally here. The flowers are blooming; the air is full of that wonderful fragrance of spring. Mother Nature is awakening from its winter slumber. You can feel the rebirth of nature in everything we see around us. Our society, ASPN, is no exception. This spring brings us a new awakening. The most wholesome thing about spring is its PROMISE; the anticipation of wonderful things to come. The same applies to our society. We are in the process of rejuvenating ourselves. And while we look forward to the future we don't forget our past. Actually we celebrate and embrace our past. Our foundation is strong. We are grateful to our founding pioneers who had the vision of starting a society totally dedicated to peripheral nerve research and clinical applications. We are also indebted to our past Presidents who took the mantle and served our society with dedication and commitment. Our challenge is to carry the torch and move forward with clear vision and determination to make our society stronger and more relevant.

Our last ASPN annual meeting in Hawaii was a huge success under the leadership of our past President Dr. Allan Belzberg and his program chair, Chris Novak, PT, PhD. We owe them both a debt of gratitude for doing such an outstanding job of skillfully mixing scientific basic science research and clinical applications. Thank you both. You are a tough act to follow.

Our society is in the midst of significant changes. Our management company has been changed to Professional Relations and Research Institute (PRRI). We can feel the winds of change as they sweep all the different facets of our organization. It is a sort of renaissance for our society. You will be able to see the effects of these changes in the months to come. ASPN leadership is working with administrative staff to design a new and contemporary logo for our society, which will help brand the ASPN a leading organization in peripheral nerve research and care. Details will be shared with the membership soon. Dr. Thomas Tung is spearheading this project. Please feel free to contact Dr. Tung if you have any ideas or thoughts about the prospects of the new design. We have already redesigned our website to make it more user friendly and comprehensive at the same time. We have added the new online membership application to the website and have streamlined the application process so it is easier for potential members to apply. We have also added the meeting abstracts to the website. Please take a few minutes to view the new and improved website: www.peripheralnerve.org.

A major challenge that small organizations like ours frequently face, is its ability to grow. We need to grow and we need to reach out to our colleagues who would not only benefit from joining our organization but would also enrich it. As you recall, at the past annual meeting I challenged our society members to recruit new members. If every one of us recruits even one member only, our society will grow in number and consequently in strength. The central office is ready to help the applicants and their sponsoring members to navigate through the application process.

One of the highlights of the annual meeting is our invited guest speakers. I am excited that our past President, Dr. Susan Mackinnon will be my guest speaker. Since we wanted our colleagues attending the AAHS meeting to enjoy Susan's lecture, AAHS President Dr. Mark Baratz and I have agreed to extend a combined invitation to Dr. Mackinnon to be our combined guest speaker for our two sister societies. Dr. Viterbo from Brazil will be our other invited guest speaker. I am looking forward to enlightening, provocative and stimulating talks from our two esteemed peripheral nerve surgery pioneers.

Another major change that is taking place in our society is the change at the helm of our newsletter. I am very excited that my friend Dr. Jonathan Isaacs has accepted to be the Editor of the ASPN newsletter. I am certain that he will do a superb job. I have enjoyed editing the newsletter for several years and I am glad that someone as competent and dedicated as Jonathan has taken over that responsibility. I would ask each and every one of you to help him by submitting articles, tidbits, pearls of wisdom, opinions, book reviews or anything you would see relevant to our society and our members. He and I would really appreciate your input. So, go ahead and enjoy this fabulous spring. I will keep updating you on monthly basis. Please feel free to call me or email me at any time. I would definitely encourage and welcome your input.

Nash Naam
ASPN President
drnaam@handdocs.com

Editor’s Notes

After two years serving as Assistant Editor under Dr. Naam’s tutelage, I’m honored by his (and the ASPN leadership’s) faith in me to be able to maintain the high quality newsletters he has produced for our society over the last several years.

I see the ASPN newsletter as an opportunity to share noteworthy achievements and accomplishments of our members, keep members up-to-date on the governance of the ASPN, provide social depth to our group, and to fill in educational gaps. With the help of the staff of our new management company, Professional Relations and Research Institute (PRRI), the newsletter will continue to provide information regarding the organization, and we will continue the tradition of sharing pictures from our annual meetings. The Presidential Column is an important part of the newsletter that will continue as well. The areas I’d like to expand on will focus on filling in educational gaps. Case reports presented and commented on by some of the many experts we are lucky enough to have in our society are, I believe, an excellent way to share ideas and complex concepts. In this edition, I present two cases of my own. I am hopeful that others will share some of their difficult cases (both good and bad) so that we can all learn from them. Please feel free to contact me with suggested topics, your own cases (this can also be a good opportunity to get advice on your hard cases from the top experts in the field), and your own editorials.

ASPN 2014-2015 Executive Council Members
President
Nash H. Naam, MD
Effingham, IL

President-Elect
Thomas H. H. Tung, MD
Saint Louis, MO

Vice President
Martijn Malessy, MD, PhD
Leiden, Netherlands

Secretary
David L. Brown, MD
Ann Arbor, MI

Treasurer
Gregory H. Borschel, MD
Toronto, ON, Canada

Historian
Gedge D. Rosson, MD
Baltimore, MD
Past Presidents
Allan J. Belzberg, MD
Baltimore, MD

Robert Spinner, MD
Rochester, MN

Council Members-at-Large
Jonathan M. Winograd, MD
Boston, MA

Ida K. Fox, MD
St. Louis, MO

Lynda Yang, MD
Ann Arbor, MI
Difficult Brachial Plexus Case Presentation to ASPN Brachial Plexus Experts

Jonathan Isaacs, M.D.
Director, Upper Extremity and Peripheral Nerve Center
Chief, Division of Hand Surgery

Department of Orthopaedic Surgery
Virginia Commonwealth University
Richmond, Virginia

Commentary by:
Justin Brown, M.D.
Director of Neurosurgery Peripheral Nerve Program and Co-Director of the Center for Neurophysiology and Restorative Neurology
Associate Professor, Neurosurgery

University of California, San Diego Health System

Zhongyu John Li, M.D., Ph.D.
Associate Professor
Department of Orthopaedic Surgery
Wake Forest Baptist Medical Center
Winston-Salem, North Carolina

Glenn Gaston, M.D.
Chief of Hand Surgery
Orthocarolina Hand Fellowship Director

Carolinas Medical Center
Charlotte, North Carolina

Allan Belzberg, M.D., FRCSC
Director of the Peripheral Nerve Center
Associate Professor of Neurological Surgery

Johns Hopkins Medicine
Baltimore, Maryland

GP is a 56 yo RHD male initially presenting 5 weeks post injury, complaining of severe pain and loss of function in his left upper extremity. A 1-2 ton piece of metal fell on him at work (he worked as a foreman at a petroleum company) (worker’s compensation injury). Initial injuries included right ankle fracture, multiple left rib fractures, C7 left transverse process fracture, and left clavicle fracture all treated prior to presentation in our clinic.

Past medical history remarkable for heart disease (s/p six vessel bypass), high blood pressure, and diabetes.

Medications included hydrochlorothiazide, amlodipine, amiodarone, metformin, and neurontin. He is unable to tolerate any narcotic medication (an observation tested and proven accurate multiple times during our interaction with him).

Pertinent physical findings: mild distress, obese, + Horner’s syndrome, shoulder appears slightly subluxed; no obvious atrophy; moderate hand and shoulder stiffness, 5/5 trapezial, 3/5 elbow flexion, 1/5 deltoid, 4/5 rhomboids; o/w 0/5 throughout. Decreased sensation along lateral aspect of brachium and reports some sensation along radial aspect of forearm (and medial aspect of proximal brachium);

Radiographs (Fig 1): midshaft clavicle fracture healed with callus, bayonetting, and 1cm shortening; Glenohumoral joint subluxed 50%; MRI of plexus does not reveal any discrete structures

Initial impression: significant brachial plexus injury with possible lower root avulsion but some retained upper plexus elements in an obese male with substantial co-morbidities

Initial plan: therapy to improve shoulder and hand stiffness; MRI of c-spine to evaluate for root avulsion; new EMG/NCS of upper extremity

-will maximize Neurontin dosing at 900mg TID and add Tramadol

Commentary:

JB: Given the Horner’s and C7 TP fracture, very high likelihood that he has suffered avulsions. If the MRI does not clearly define what is and is not avulsed, I like to use the old fashioned CT myelogram. It is still usually better than some of the best MRI sequences.

8 weeks post injury:

Pain becoming more of complaint (described as burning, tingling, radiating into fingers).

NCS: no conduction in ulna nerve

MRI- done in open MRI (worker’s compensation insisted on setting up study) - poor quality

Impression: no conduction in ulna nerve suggests that roots not avulsed (if roots avulsed, the cell bodies of sensory nerves in lower plexus would still be in continuity—only separated from spinal cord; though the person would be insensate, the NCS would demonstrate functioning nerve tissue)

Plan: need MRI of adequate quality; will repeat but start planning surgical exploration at 3-4 months post injury

Commentary:

JB: I would trust the imaging over the NCS. There can certainly be injury to the roots in the post-ganglionic region of the nerve root even if it is avulsed. I think preserved NCS are sensitive, but not specific. Get that myelogram and operate earlier if the avulsion is present

3 mos post injury:

-regaining some weak elbow extension; still struggling with pain

- New MRI suggesting C7-T1 avulsion (Fig 2)

PE: shoulder, hand, and wrist getting stiffer (70 degrees of shoulder abduction and fingers passively only 3 cm from palm); atrophy now noted diffusely in hand

5/5 trapezial, 5/5 rhomboids, 5/5 serratus anterior, 4-/5 shoulder abduction, 4-/5 external rotation, 5-/5 internal rotation, 1/5 brachiothoracic pinch (cannot tell which muscle contracting), 5-/5 elbow flexion, 1/5 elbow extension, 5-/5 supination; 0/5 pronation, wrist and finger motion

sensation only in lateral aspect of brachium and forearm

no obvious Tinel’s

Impression: preservation of upper plexus with probably lower trunk avulsion; triceps may be coming from upper plexus; some potential for pec recovery; has potential of median nerve sensory recovery; overall poor prognosis for other spontaneous recovery Plan: will explore to confirm avulsion injury of C7 primarily (will look at lower plexus though even rupture at this level with poor prognosis); will consider spinal accessory to radial nerve branch to triceps; if able to restore elbow control, would consider fusing wrist for assist hand; intercostals not considered an option due to severe left chest trauma and patients habitus (obese) and significant co-morbidities

Commentary:

JB: I would skip plexus exploration. Likelihood of getting regeneration to the forearm from grafting at the plexus is not great, and sounds like we have good evidence that things are avulsed. We don’t want to downgrade what is preserved. I would be inclined to assess with EMG what the innervation is like to the remaining muscles. Poorly innervated muscle groups (few large MUPs) are not good donors for nerve transfers, but can be okay for tendon transfers

Surgery (4 mos post injury)

C7, C8, T1 avulsion confirmed; Triceps contracted and Brachioradialis contracted with stimulation; Spinal Accessory Nerve transferred to long head of triceps with 30cm sural nerve graft (hoping to allow continued recovery of part of triceps vs potential innervation from transfer);

May be able to use Brachioradialis for transfer to wrist extensor down the road (though would work better if elbow extension restored)

Commentary:

JB: If long head of triceps contracted, would skip the transfer. If it clearly has no MUPs, would be more inclined to use intercostals to neurotize it and avoid the long graft. I like the brachioradialis plan. I would be inclined to use additional transfers at this stage, or shortly hereafter. Inventory potential donors (brachialis, supinator)

5 mos post injury

Triceps improved to 2-3/5; may have trace wrist extension; pain much worse

-will add Elavil and TENS unit (still can’t tolerate narcotics)

6mos post injury

Pain getting worse; now w/ periscapular and trapezial spasms

Respond temporarily to injections (lidocaine); will try lododerm patches and continue therapy

Commentary:

JB: Have therapy assess his shoulder and scapular dynamics. Does he need bracing. Is he on Neurontin/lyrica? Is pain management involved??

6 and 7 mos post injury:

pain still the main issue; wrist extension 3/5

Plan: continue current treatment for pain despite suboptimal response; suggest that we consider distal nerve transfers using branches either from BR or supinator to AIN or wrist flexor (wrist extension recovering)

Must get worker’s comp approval for change in plan (which we get at 9 mos post injury; we consider this at the edge of window of opportunity so continue back to OR)

Commentary:

JB: BR likely a poor axon donor. Would not use this for a nerve transfer, but preserve this for tendon transfer at a later date when it reaches its full strength. Supinator is a great thought, but again would check it with EMG to assess its innervation. I would skip wrist flexor as a target. If you would like to maintain wrist movement and avoid a fusion, extension is your priority.

Surgery (10mos post injury)

Transferred two branches of supinator: to AIN and branch to FCR; BR branch considered too proximal considering time since injury but supinator branches only a few inches from targets)

Commentary:

JB: See above. Supinator is a great thought for donor, but I would be very selective with targets as it is not strong even in a healthy patient.

12 mos post injury:

no change in exam (maintains supination strength); pain predominates discussions; now with severe insomnia

Plan: has not tolerated Elavil; will try over the counter sleep aids

Commentary:

JB: Time for a trial of spinal cord stimulation.

14 mos post injury

no change in exam; switched to Lyrica with slight improvement in pain though prolonged course clearly taking toll; patient reports marriage falling apart, breaks down into tears during interview;

Plan- referral for consideration of spinal stimulator

15 mos post injury

1/5 FCR contraction; wrist extension seems improved to about 3-4/5; no other significant change; pain is all he wants to talk about

What to do now?

At this point, close to 18 mos post injury, patient has functional elbow flexion and shoulder abduction, weak elbow extension and wrist extension, still with insensate hand, but with severe debilitating pain; when we discuss further options (like a special brace to allow return to fishing which he had been passionate about), he reports that he can’t even ride in a car to get to the river; he is clearly depressed and in constant and consuming pain; our interventions to date have made no difference in his function and may have made him worse (Brachioradialis no longer contracting since our exploration of that nerve though we did not take it; Trapezial spasms may be a result of weakening after harvest of spinal accessory though we took distal to initial muscle innervation).

Legend:

Fig 1. Radiograph showing left shoulder with early subluxation

 

Fig 2. MRI showing avulsed left nerve root.

Commentary:

JB: I thought we had no wrist extension. This is great news! Regarding pain, he may need referral to a center that is good with the DREZ, but again an assessment of the scapular kinematics and what is the course of his pain would be a priority. We should work hard on the wrist extension and treat the hand like a tetraplegic. Consider a thumb CMC fusion, House intrinsic balance for MP flexion and IP extension at D2-4. Then you could think about using brachialis to power FDPs as described by Bertelli versus just driving passive grasp from his wrist extension.

ZL: Lower brachial plexus injury remains a major challenge to nerve surgeons. This patient poses even more problem for his neuropathic pain management with his intolerance to narcotics and his worker comp status. A multi- disciplinary pain management approach is necessary for this type of patients. Early therapy emphasizes pain modalities, joint range of motion maintenance and strengthening. Oral medications include a combination of tricyclics, anticonvulsants, lyrica and NSAID. Counseling with a psychologist is also beneficial and is an important part of the management as patients are often depressed.

Although this patient’s clinical presentations clearly consist with a lower brachial plexus avulsion injury, we would also wait for about 3-6 months to observe the recovery of the upper plexus and its innervated muscles before proceeding for surgery. We need to know which nerves/muscles could be considered as a potential donor for transfer. The majority of lower plexus injury patients will recover some wrist extension. Pronator teres (C6, 7) and supinator (C5, 6) are usually functioning. We prefer distal nerve transfers without a proximal exploration for this type of injury since the results of proximal lower brachial plexus reconstruction are universally poor. Our current transfer strategy includes - pronator teres branch to the anterior interosseous nerve (AIN) for thumb/finger flexion and the supinator branch to the posterior interosseous branch (PIN) for thumb/ finger extension. The brachialis branch to AIN transfer as describe by Gu, et al. would be considered if the pronator branch is not suitable as in this patient. This patient is only 6 months out from his distal nerve transfer. It is too early to determine whether the transfer is a success. Based on our experience and as reported by Dong et al and Bertelli et al., 9-12 months is the typical time to see some early signs of muscle function recovery after transfer.

GG: The authors have made a valiant effort for a difficult problem. Those who care for brachial plexus patients regularly all go through the same frustrations and failures that the authors present. I think this case really highlights an under-reported and under-discussed problem: the emotional and psychological impact of this injury. While most studies focus on range of motion and strength, there is no question the psychological toll on the patient drives outcomes as much as any intervention we perform.

To that end, all of our patients are referred to a clinical psychologist at the time of presentation and pain specialists if there is any excessive pain. Treating these patients certainly involves treating the entire patient (physical and emotional well being).

As for a treatment plan at this time, once the psychological and pain control issues have been maximally improved I would consider the following algorithmic approach:

  1. Trialing an en-abler or similar custom brace with terminal device. If this is effective a prosthetist may can add adaptations for ADL’s

  2. To me based on the description, he doesn’t sound like a good operative candidate at present; however, if that changed I would consider biceps to FDP for hook grasp, a House type intrinsic balancing procedure, LABCN to median sensory for some sensation, later possible free gracilis for wrist extension if overpowered by the biceps transfer.

  3. Lastly, amputation has a role in some patients. This is always a decision driven by direct patient interactions and discussion, but in the right patient who has had severe distal pain and functionless hand after numerous surgeries (especially if complains of the “weight of the useless arm”) it would be considered.
AB: Thank you for presenting this very sad and challenging case. The patient has not only a sever brachial plexus injury, but also serious co-morbidities.

In an adult case with middle and lower trunk avulsion injury, I have not been impressed with regaining function from nerve transfers over the natural history. We have used brachialis to AIN with minimal success and this has not been a transfer that has provided good “functional” recovery. In this case, I would wonder if secondary surgery with tendon transfer will afford the best outcome. I will defer to our hand surgeons.

There is some discussion about the NCV not indicating avulsion. This is not correct. When there is an absent motor and a normal SNAP then there is preganglionic lesion. When the SNAP and motor are absent, this does not rule out an avulsion as there is often a stretch injury distal to the DRG in addition to the avulsion. In the latter situation, as in this case, one must pay more attention to the imaging. In this case the avulsion injury was clear and perhaps surgical intervention could have been performed earlier. The transfer of spinal accessory to a distal target such as the triceps (in this case) or biceps, in our hands, has not been useful unless performed early in the process.

Pain is the predominant debilitating factor. It has not been clearly described to allow a determination if the pain is due to the avulsion, musculoskeletal issues or neurotic pain from partial nerve injury. I will assume this to be avulsion related pain with crushing pain in the hand. This pain, when severe, is often refractory to medications. Dorsal column stimulation is unlikely to work as in avulsion there is no dorsal column to stimulate. Deep brain stimulation and frontal cortical stimulation are options with moderate results. DREZ lesioning is an option for the patient and even with the comorbidities, the benefits will greatly outweigh the risks. This will likely bring the pain under control and allow for better rehabilitation, in a truly holistic manner. It is one of my favorite surgical procedures in terms of impact on quality of life.

Again, thank you for presenting this case and I look forward to reading how various people would manage it. There is certainly more than one way to repair a plexus.

Case Discussion - Atypical Tetraplegic Patient

Jonathan Isaacs, M.D.
(with expert commentary by Ida Fox, M.D.)

As the concept of nerve transfers in lieu of tendon transfers for tetraplegic patients gains momentum, I recently encountered a patient that on the surface seemed like an excellent candidate. Though I had seen this topic presented at several meetings over the last couple of years and had read some of the literature on the topic, I became quickly overwhelmed as I examined and counseled this young man. There are interesting consideratons with this presentation and his diagnosis when considering nerve transfers to restore function.

He is 22 years old right hand dominant male presenting 16 months out from idiopathic transverse myelitis at around the c6 level. Though at the initial onset, he was completely paralyzed from the neck down, he has regained some upper extremity function. Over the last few months he has noted continued improvement in strength of his shoulders (Fig 1) and elbow flexion but minimal function in his forearms and hands(Fig 2). He has spasticity for which he receives botox injections. He presents for possible tendon transfers.


Fig. 1

Fig. 2

His past medical history is remarkable for diabetes and high blood pressure (he does take insulin, baclofen, and lyrica)

PE: in an electric wheelchair;
He seems fairly symmetrical in his motor exam though slightly stronger on the left than the right:

  R L
Trapezius 5 5
External Rotation 3 4
Pecs 3 3+
Deltoid (ant) 3 4
Deltoid (mid) 4 4
Deltoid (post) 4 4
 
Pronator Teres 1 1
Triceps 0 0
Elbow Flexion 4 4
Supination 4 4
ECRL 3- 3+
ECRB 0 0

Everything else 0

Assessment-
IC Grade 2 bilaterally. Limited options for tendon transfers but could offer Brachioradialis to Flexor Pollicis Longus and CMC fusion to improve pinch. Nerve transfer options could potentially include Posterior Branch of Axillary Nerve to Triceps Branch of Radial Nerve and Motor Branch of Brachialis to AIN.

Important unanswered questions include: 1) Are nerve transfers an option in patients with transverse myelitis? 2) has this patient’s final deficits evolved fully? 3) are triceps, FDP, FPL innervated/nonfunctional or have these muscles undergone denervation atrophy because their lower motor neurons were affected as part of the condition/disease process?

Expert Opinion:
Ida Fox, M.D.
Assistant Professor of Plastic Surgery
Washington University School of Medicine in Saint Louis

This is a fascinating and challenging case of transverse myelitis that pushes the boundaries of all the areas that we at the ASPN try and think of as we evaluate and treat patients.

It demands an understanding of both peripheral (PNS) and central (CNS) nervous system pathophysiology and expected outcomes with and without intervention.

Although nerve transfers are being described for use in patients with cervical spinal cord injury (SCI) or tetraplegia, the challenges in cases of transverse myelitis are even more daunting.

In this case of a patient who is 16 months out from the primary process, understanding of the zone of injury is critical. Additional electrodiagnostic testing with nerve conduction studies to examine the integrity of the C8/T1 motor unit might be helpful.

Observation of patterns of upper extremity use and adaptive patterns is often helpful in determining further priorities of care. Tenodesis effect may be providing some hand function if the wrist extension is strong enough. In that case brachioradialis may be used as a tendon transfer to restore some thumb function. If not, it might be used to restore stronger wrist extension and subsequent tenodesis hand function.

If the electrodiagnostic studies show relative preservation of the C8/T1 motor unit, a nerve transfer may be possible even at this late date. Unfortunately, however, cases of transverse myelitis often involve a more extensive zone of injury that, at 16 months out might preclude the use of nerve transfers. Previously reported successful cases of use of nerve transfer for transverse myelitis have been completed within months of the primary process.

Plan:
With patient showing continued improvement in shoulder recovery over the last couple of months, we will watch him for 6 more weeks to make sure that he shows no further signs of recovery. Pending evidence that he has truly plateaued, we will obtain a NCS (which we had not previously obtained) looking specifically at the C8/T1 motor unit. The NCS will evaluate if the Sensory Nerve Action Potentials (SNAP) and Compound Muscle Action Potentials (CMAP) are present in the median and ulnar nerve as tested by APB and FDI. If both are present then we assume that the muscles such as FPL and FDP may be intact. If CMAPs are not present using these “surrogates” then we have to assume that the lower motor neurons are involved in the disease process and at 16 months muscle reinnervation is not recoverable. Thus, patient counseling will include the possibility that nerve transfers may not be possible. We will prioritize avoidance of down grading current function and preserving the possibility of tendon transfers if nerve transfers not possible.

Legend

Fig 1. Patient exhibits strong but not normal shoulder abduction.
Fig 2. Patient exhibits wrist extension though it is easily “broken” by examiner.
2014 ASPN Annual Meeting Photo Highlights

The 2014 Annual Meeting in Kauai, Hawaii was full of valuable educational exchanges, excellent talks and presentations, and time with family and friends.

25 New Members for Election in 2015!

Earlier in the year, President Nash Naam informed the membership that in 2014 the Society would undertake a membership campaign to recruit new members to the ASPN for increased collaboration, and to foster development and knowledge exchange. His challenge to the membership is to recruit at least 25 new members in 2014!

THANK YOU!!!

To all the members who recruited new candidates for membership. So far, we have 21 applications in process. Our goal is 25. We still need your help.

Please utilize your peripheral nerve and nerve regeneration contacts and educate them on the value of the ASPN and the ability to enhance one’s practice by becoming a member. Inform your colleagues that ASPN membership benefits include access to research grant funding, significantly reduced registration rates for ASPN Annual Meetings which are held in warm, family-friendly locations each January, opportunities to hold office and serve on ASPN committees, complimentary access to the Plastic Surgery Education Network (PSEN), and access to the ASPN newsletter. New applicants should visit the ASPN website to review membership categories and complete an online application.

New ASPN Office Address and Redesigned ASPN Website

As of February 1, 2014, the American Society for Peripheral Nerve has a new address:

ASPN Administrative Office
500 Cummings Center, Ste 4550
Beverly, MA 01915

The Society’s Website and Technical Exhibits Committee has recently overseen a redesign of the ASPN website. The newly designed website is now available at http://peripheralnerve.org. A few exciting additions you may wish to explore include the online membership applications and list of membership benefits, Annual Meeting information, and FAQ section. Please browse the redesigned website at your leisure and feel free to provide feedback and recommendations to admin@peripheralnerve.org.

Grant Opportunities for ASPN Members

The ASPN co-sponsors a Combined Research Grant with the Plastic Surgery Foundation. The ASPN/PSF Combined Pilot Research Grant is intended to fund a research project that will advance the scientific knowledge and clinical practice of peripheral nerve surgery. This grant is worth up to $10,000 and it can be used for consumables or personnel costs in support of a research project. The ASPN co-sponsors one such grant per year. To be eligible, one of the applicants must be an ASPN member. ASPN members from any training background are encouraged to apply, including basic scientists, therapists, and surgeons of any discipline.

For further information please visit http://www.thepsf.org/research/psf-grant-funding/combined-research-grant.htm

Nicholas Langhals, MD at the University of Michigan was awarded the 2013 ASPN/PSF Combine Pilot Research Grant with his grant entitled, “Biosignal Insulators in Regeneration Peripheral Nerve Interfaces”.

Project Description: There are over 1.7 million people within the United States currently suffering from some type of limb loss, and this number continues to grow by 185,000 each year. Typical upper extremity replacement limbs are passive prosthetic devices and provide little functional recovery beyond basic grasping. Newer prostheses that add additional control through using muscle activity of the patient’s remaining muscle groups increase the utility of these replacement limbs. The current state of the art treatment allows subjects to have the greatest restoration of function through targeted reinnervation of muscle groups using nerve from the amputated limb. However, these devices have limited control options for prostheses with multiple degrees of freedom and are generally difficult to master.

We have developed a regenerative peripheral nerve interface (RPNI) that creates a biologically robust and functional connection to the nerve in an amputated limb through the use of a graft of free muscle tissue. The graft is then sutured to the severed residual nerve, and electrodes are affixed allowing signals to be recorded from the nerve (epineural electrode), or the muscle (epimysial electrode). These electrophysiological signals are then used for control of a replacement robotic arm.

We propose to quantify the effect of neuromuscular amplification in regenerative peripheral nerve interfaces.

Using a rodent model developed within our research group, we will quantify the information content that can be recorded by using a neuromuscular “amplifier”. Nerve signals will be sampled after they have been “amplified” by the muscle, thereby providing a higher signal-to-noise ratio without signal loss from electrode encapsulation and tissue trauma from direct epineural electrode placement. Further, the use of epimysial electrodes should increase the overall long-term stability of the interface, compared to current methods utilizing penetrating electrodes either in the nerve or muscle.

Invitation to the 2015 ASPN Annual Meeting

On behalf of the organizing committee, I am delighted to invite all of you to the 25th Anniversary Meeting of the American Society for Peripheral Nerve. The meeting will be held at the Atlantis Resort on Paradise Island, Bahamas, January 23-25, 2015. Abstracts are accepted until Sunday, July 13, 2014 at http://peripheralnerve.org/meeting/. We are celebrating this milestone by holding a number of special events, including an ASPN Founders and Past Presidents' Panel, a special International Panel, and several unique instructional courses.

This meeting promises be the most highly-coordinated yet, with programming specially tailored to the needs of our members in conjunction with our sister societies, the AAHS and ASRM. On Friday morning we will showcase a program coordinated with AAHS, including a workshop on nerve transfers, six combined instructional courses, and the AAHS/ASPN Joint Invited Speaker -- our very own Susan Mackinnon. On Saturday we will enjoy six combined AAHS/ASPN/ASRM instructional courses, followed by panel on affordable health care and our role in the transition. The Joint Presidential Keynote Lecture will be delivered by noted technology expert and author Ramez Naam. Sunday will include six more instructional courses specifically designed for ASPN attendees, followed by the ASRM/ASPN panel on free functioning muscle transfers in brachial plexus injuries, followed by a combined ASRM/ASPN paper session. Fausto Viterbo will provide a special International Guest Lecture, followed by Nash Naam's Presidential Address on "The Power of Touch." We will also feature an expanded venue for interactive poster sessions with special Caribbean libations and flair.

We will continue our tradition of focusing on programming during the day and adjourning early to enjoy the fabulous Bahamian outdoors. See you in the Bahamas!

Gregory H. Borschel, MD, FAAP, FACS
2015 ASPN Program Chair

American Society for Peripheral Nerve
500 Cummings Center, Suite 4400, Beverly, MA 01915
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