Member Highlight:
Dr. Nash Naam, ASPN Past President, Honored as EDN Citizen of the Year!
![]() |
Member Highlight:
Dr. Nash Naam, ASPN Past President, Honored as EDN Citizen of the Year!
![]() |
![]() |
David L. Brown, MD ASPN President |
Avoiding Bias and Providing Value to Members
The Michigan winter has finally given way directly to summer, and we are enjoying record heat here in Ann Arbor. Similarly, our ASPN Executive Council is heating things up with several new initiatives, and our Program Committee is putting the finishing touches on the agenda for the 2019 Meeting in Palm Desert with AAHS and ASRM. I would like to share some of the details with you:
ASPN Travelling Fellowship
Applications have been solicited for the Inaugural ASPN Travelling Fellowship, which will provide a stipend to a junior member of the Society, in order to facilitate learning new clinical and/or laboratory techniques from others around the world. Fundraising efforts are currently underway, led by Shai Rozen, Rob Hagan and myself, in order to make this Fund self-sustaining. Please consider donating to this auspicious program. Look for an announcement of the awardee in the near future, as well as their presentation at our Annual Meeting.
ASPN Committees
One of my commitments as President is to strengthen and broaden the engagement of our Committees. Thanks to efforts by Greg Borschel as President-Elect, we have a robust roster of Chairpersons and members. Notable highlights include:
Ad-Hoc Committee Conflict of Interest
There is a healthy interplay between science and industry. Maintaining a balance between the two should be the goal of responsible medical societies. In recent years, the medical community has begun to take steps to identify and document conflicts that may introduce bias in the reporting and interpretation of scientific information. Admirable efforts are currently underway by ASPS and other organizations to define and mitigate bias in their executive leadership, and in sanctioned presentations to their members. It is a goal of our Executive Committee to position ASPN at the forefront of this movement.
Amy Moore is helping to spearhead this new committee, which is charged with examining the influence of industry-associated bias in our Society, to take initial steps to eliminate such influence from our Annual Meeting, and protect our Society from bias within its leadership.
2019 Annual Meeting
Our Program Committee, led by Catherine Curtin, is putting the finishing touches on what is shaping up to be a fantastic meeting. As usual, coordination with sister societies AAHS and ASRM has been a priority. Invited speakers include Ann Compton, and perhaps a break-out Yoga session led by Susan Mackinnon!
Shai Rozen has put together a second-annual Nerve 101 afternoon course, centered on practice development, restoration of function and treatment of pain. Last year's course was a big hit, and along with the Posters and Drinks session, was a highlight of the meeting.
Tax-Exempt Status
ASPN is currently in the process of converting from a 501c6 tax exempt organization to a 501c3 charitable, organization. This will position us to be able to offer the benefits of tax-deductible donations to incentivize giving toward valuable programs such as our new Travelling Fellowship.
Administration
PRRI continues to do an excellent job of keeping ASPN on track and helping us to grow. We are indebted to Sarah Boardman and her staff for their hard work and fantastic organizational skills.
Leadership
Nominations are currently being accepted for leadership positions in our Society. Please consider donating your time, energy and ideas to help make ASPN one of the premier nerve groups in the world!
I am proud of our Society, and appreciate the opportunity to do what I can to ensure its growth and prosperity this year. Please reach out to me at davbrown@umich.edu with any comments or suggestions.
David
Current Concepts in Spinal Accessory Nerve Injury
Hollie A. Power, MD FRCSC
Susan E. Mackinnon, MD FACS
Division of Plastic and Reconstructive Surgery
Washington University School of Medicine, St. Louis, MO
Spinal accessory nerve (SAN) injury is an uncommon cause of shoulder dysfunction. Injury most often occurs following surgery in the posterior cervical triangle, with a risk of 3-10% in cervical lymph node biopsy.1 These procedures are frequently done with the use of paralytic medications (including local anesthesia) and without loupe magnification. The small accessory branch supplying the upper trapezius is often spared and thus the injury may go unrecognized for a prolonged period, resulting in delayed referral.
Patients often present with complaints of shoulder pain, fatigability and difficulty with overhead activity. Female patients may complain of their bra strap sliding off the affected shoulder. The upper trapezius contributes to shoulder shrug while the middle and lower trapezius contribute to shoulder abduction and scapula stabilization. Examination of the patient's unclothed back is critical to allow bilateral comparison. Varying degrees of scapular dyskinesis or winging are observed with shoulder abduction and resisted external rotation (‘flip test’),1 depending on compensation by the rhomboids and levator scapulae. This is differentiated from long thoracic nerve palsy, where winging is elicited with shoulder flexion maneuvers. Over time patients will develop compensatory movement patterns and a skilled therapist is needed to guide them in the perioperative period.2
Electromyography should include the upper, middle and lower trapezius. If no motor unit potentials are detected, then surgical exploration is indicated. In patients referred late, the presence of active denervation on EMG (i.e. fibrillations, positive sharp waves) reassures the surgeon that reinnervation of the trapezius is still possible.
Primary Repair and Nerve Grafting
When possible, primary repair of the SAN should be performed. However, delayed presentation often makes tension-free repair impossible and a nerve graft must be used. The distal stump of the SAN is readily identified at the anterior border of the trapezius. This can be facilitated by incising the distal trapezius attachment at the clavicle and dissecting along its deep surface. The standard anatomy atlas underestimates the plexiform anatomy of the SAN and care must be taken not to inadvertently divide branches. Identification of the proximal stump can be challenging as it requires dissection through scar and the nerve may have retracted under the sternocleidomastoid muscle. Techniques for primary repair and grafting are well-described.1,3
In 156 patients with SAN injury following lymph node biopsy, direct repair resulted in better recovery than grafting, and results were better in patients presenting by 3-6 months.1 Tubbs et al. (2018) increased the length of the SAN an average of 4.5cm by dividing its proximal contributions from C2 in a cadaver model.4 This technique may facilitate primary repair of the SAN, although its feasibility in patients is yet to be demonstrated.
Nerve Transfers
Nerve transfer is indicated when the proximal stump is not available (e.g. proximal injury, radiation, fibrosis). This has several advantages, including moving the dissection to unaltered tissue planes and coaptation closer to the motor end plates. Numerous donors have been described, including the pectoral nerves5-7 and a triceps fascicle from the posterior division of the upper trunk.8 Unlike conventional distal nerve transfers, these donors require intra-plexal dissection. C2-3 donors have also been described, but with poor outcomes.1,3
Pectoral Fascicle to Spinal Accessory Nerve Transfer
The pectoral fascicles are harvested via standard supraclavicular approach to the brachial plexus. There is controversy regarding the preferred donor. The lateral pectoral fascicle is easily identified arising from the anterior division of the upper trunk. It has more myelinated fibres (2637±839) compared to the middle pectoral fascicle (1784±445), although both are a suitable match for the SAN in terms of size and number of nerve fibres (~1300).6,9 The middle pectoral fascicle is isolated from the anterior division of the middle trunk, and thus requires mobilization and retraction of the upper trunk. Both donors have sufficient length to allow tension-free coaptation to the SAN. The literature is currently limited to case reports, but all patients had less pain and restoration of shoulder abduction.5-7,10 No issues with donor site morbidity have been reported.
A case presentation and surgical technique video are available at passioeducation.com.11
Triceps Fascicle to Spinal Accessory Nerve Transfer
The triceps transfer is performed via the supraclavicular approach as above. A triceps (± deltoid) fascicle is isolated from the posterior division of the upper trunk and dissected distally to allow tension-free coaptation to the SAN. Nerve stimulation is used to confirm adequate residual function of the axillary and radial-innervated muscles. Cambon-Binder et al. (2018) reported their experience with this nerve transfer in 11 patients with an average 2 year follow-up.8 Ten patients achieved trapezius MRC grade >4 and normal scapular kinematics were restored in 7 patients. The current series did not detect any triceps or deltoid weakness at final follow-up, but the possibility of down-grading critical function (even temporarily) warrants consideration.
Conclusions
A number of iatrogenic injuries to the SAN could be prevented by avoiding paralysis, using loupe magnification and a nerve stimulator during procedures in the posterior cervical triangle. Shoulder examination in the postoperative period must go beyond gross assessment of shoulder shrug. Early recognition and referral of these injuries is critical to optimize outcomes in this patient population. Patients referred late have often developed compensatory motion patterns that may be difficult to overcome despite reinnervation of the trapezius. Primary repair of the SAN should be performed when possible. Several nerve transfers have been described and show promising outcomes, although current patient series are small.
Corresponding Author:
Hollie A. Power, MD FRCSC
Division of Plastic and Reconstructive Surgery
Washington University School of Medicine
Campus Box 8238, 1150 NW Tower
660 S. Euclid Avenue
St. Louis, MO 63110
E-mail: hpower@ualberta.ca
Disclosures: none
References
Electrodiagnostic Testing in SCI
Ida K. Fox, MD
Division of Plastic and Reconstructive Surgery
Washington University School of Medicine, St. Louis, MO
Recently, there has been interest in the use of nerve transfer surgery to restore function in cervical level spinal cord injury (SCI). People with mid-cervical level SCI may have shoulder, elbow and some wrist function but no extrinsic or intrinsic hand function. Nerve transfers such as the supinator branch to posterior interosseous nerve (PIN) (supinator to PIN) and brachialis branch to AIN and flexor digitorum superficialis (FDS) branches of the median nerve (brachialis to AIN/FDS) may be used to restore some hand opening and closing function, respectively1-6.
Although electromyography (EMG) and functional electrical stimulation may help predict the integrity of the lower motor neuron (LMN) in cervical SCI, we have been using nerve conduction studies (NCS) to obtain quantitative information about the integrity of the LMN. We find that our NCS results can be used to predict the quality of neuromuscular stimulation intraoperatively. The results of intraoperative stimulation are then used to make a final decision about the appropriate recipient nerve branches.
Confirming the integrity of the LMN in late presenting individuals with SCI, is a critical first step to determining candidacy for late nerve transfers in this setting7. Individuals with a more extensive zone of LMN injury will not be candidates for late nerve transfer as the muscle will be terminally denervated (as is seen in all peripheral nerve and brachial plexus injury).
We have specifically focused on the value of the compound muscle action potential (CMAP) amplitude across the recipient (or recipient surrogate) segments. Typically, we find if the CMAP amplitude is non-recordable, then late nerve transfer is not possible. For the supinator to PIN, we focus on the radial CMAP amplitude across the EIP to forearm segment. For the brachialis to AIN/FDS, we focus on the median CMAP amplitude across the wrist to abductor pollicis brevis (APB) segment. If the CMAP amplitudes across these segments are normal, we generally find that the intraoperative stimulation of the recipient PIN or AIN/FDS musculature is excellent.
The exact role of electrodiagnostic and other preoperative testing is unclear and the ultimate utility and outcomes of nerve transfers in the setting of SCI is under investigation. However, this preliminary attempt to quantitate the quality of the LMN's at the level of the potential nerve transfer recipients has helped us discuss surgical candidacy with people considering nerve transfer surgery in SCI. These types of non-recordable CMAP amplitudes in those presenting >12-18 months post-SCI, should prompt consideration for alternative treatment, such as tendon transfer surgery.
This information includes the nerve conduction study and electromyography information that we most commonly obtain when considering a variety of nerve transfer procedures in the setting of cervical spinal cord injury.
2019 Annual Meeting Abstract Submission Deadline July 8, 2018!
Download author instructions and submit your abstract by Sunday, July 8, 2018 to be considered for the 2019 Annual Meeting program in Palm Desert, California!
What to Expect:
2019 ASPN Annual Meeting
![]() Catherine Curtin, MD |
![]() Kristen Davidge, MD |
Happy Spring! We the program chairs are putting together a fantastic program for next year's ASPN meeting in Palm Springs. We are planning a new exciting learning format using videos from some of the masters. We also are tackling some of the challenging topics in nerve: Sensation, we want that too! What should you do with that lower extremity nerve injury? How can you get an innovation into practice? We also want to leave time for all of us to meet, mingle, exchange ideas and cheer for next year's super bowl game. We look forward to seeing you next year.
Catherine Curtin, MD
Program Committee Chair, 2019
Kristen Davidge, MD
Program Committee Co-Chair, 2019
Nerve 101 Update from the ASPN
Education Committee
![]() Shai Rozen, MD Education Committee Chair |
Last year was the first year for the Peripheral Nerve 101 course, designed with the intention to present the multiple basic science and clinical facets of peripheral nerve surgery, concentrating on restoration of sensation, function, and the treatment of pain in all areas of the body. The course was a tremendous success but we asked many of you, to provide input on topics you would like to hear about in the future. The one common theme noted by residents, junior, and mid-level faculty alike, was that they wanted to hear about and also discuss the practical aspects of practice building, strategies on effective communications with physicians from other specialties, pearls in management and work flow, and how to deal with diverse and occasionally difficult patients and clinical dilemmas. In addition, many attendees asked to leave sufficient time for an open discussion with the faculty.
In the spirit of these ideas, this year the 101 Course will include an expert faculty who will share their experiences, trials and tribulations, failures and successes, and suggested solutions and future thoughts in a diverse range of topics including restoration of sensation in the extremities, cornea, and other areas, treatment of functional deficits seen in facial palsy patients, brachial plexus injuries, and more, as well as treatment of a diverse group of common and less common pain scenarios. This course will end with sufficient time and an open stage for discussion between faculty and participants to discuss any subject including difficult cases, practice building strategies, and any other subject of interest to the audience and faculty.
We look forward seeing you in this year's course and await great talks followed by an engaging and passionate discussion for everyone.
Shai Rozen, MD
Education Committee Chair
Sign Up for the NEW ASPN
Mentorship Program!
You are invited to sign up for the inaugural year of the ASPN Mentorship Program! The Mentorship Program pairs established members of the peripheral nerve community with young faculty, fellows, and residents to provide them with the unique opportunity to gain experience from seasoned veterans.
The Mentorship Program will be a 1-year time commitment for both mentors and mentees. Recommended activities for the 1-year period include meeting at the 2019 ASPN Annual Meeting, phone and email exchanges throughout the year, and connecting at affiliated meetings when possible. Reminders are sent throughout the year to encourage regular communication between mentors and mentees.
To participate as a mentor or mentee, complete the online application. Submit your application by July 1, 2018 to participate in upcoming cycle.
The ASPN ad hoc mentorship committee will match mentors and mentees and contact all parties accordingly by July 1, 2018 so that pairs can plan to meet in Palm Desert at the ASPN 2019 Annual Meeting.
Thank you for your participation!
Important Societal Links: