Christian Heinen

Brachial plexus injuries are challenging conditions. Over the past decades, nerve transfer surgery has progressively evolved from proximal nerve reconstruction toward selective distal neurotization strategies, considerably expanding the possibilities for functional restoration. As the number of described donor–recipient combinations has increased, the literature has become increasingly fragmented, often focusing on isolated techniques or specific functional targets. The aim of the present study was to provide a comprehensive state-of-the-art overview of currently available motor nerve transfer strategies for upper-limb reinnervation in BPI. A literature review was conducted according to PRISMA guidelines using PubMed/MEDLINE, Embase, Cochrane Library, Scopus, and Web of Science databases. Studies concerning motor nerve transfers for upper-limb reconstruction were systematically reviewed and categorized according to recipient nerve and functional target, including shoulder function, scapular stabilization, elbow flexion and extension, wrist and finger extension, wrist and finger flexion, intrinsic hand function, and extraplexal donor nerve reconstruction. A total of 250 studies met the inclusion criteria. Both intraplexal and extraplexal donor strategies were identified for most reconstructive targets. Intraplexal distal nerve transfers currently represent the preferred approach whenever feasible because of shorter reinnervation distances and more predictable outcomes. Extraplexal donors, including the spinal accessory, intercostal, contralateral C7, and phrenic nerves, remain essential in complete BPIs and root avulsion injuries. Despite substantial advances, restoration of intrinsic hand function and reliable distal reinnervation remain major reconstructive challenges. Motor nerve transfers represent an increasingly versatile and function-oriented reconstructive strategy that should be tailored to the individual injury pattern, available donor nerves, and functional priorities.

Zusammenfassung Der intraoperative Ultraschall (IOUS), ggf. als „contrast-enhanced intraoperative ultrasound“ (CE-IOUS), ist ein vielseitiges Instrument der chirurgischen Entscheidungsfindung. Er verbessert die intraoperative Orientierung, ermöglicht eine präzise Resektionsführung und trägt zur Vermeidung von Komplikationen und Folgeeingriffen bei. In Deutschland wird IOUS bislang jedoch nur selektiv eingesetzt – häufig durch nicht-operativ tätige Disziplinen. Dies ist in bestimmten Konstellationen sinnvoll, stößt jedoch an Grenzen, sobald die Bildgebung unmittelbar in die chirurgische Handlung einfließt. Der klinische Nutzen des IOUS ist in mehreren Fachgebieten – insbesondere der Leberchirurgie, Neurochirurgie und operativen Senologie – gut belegt. Dennoch fehlt bislang eine systematische Verankerung in der chirurgischen Ausbildung, im klinischen Alltag und in den Leitlinien. In der Viszeralchirurgie verfügen bislang nur wenige Operateure über eigene IOUS-Erfahrung. In anderen Bereichen wie der Gefäß- oder Transplantationschirurgie gehört der Einsatz bereits zum Standard, jedoch ohne dass dieser durch randomisierte Studien abgesichert wäre. Die DEGUM als führende Fachgesellschaft für Ultraschall in der Medizin spricht sich daher für eine breitere und strukturierte Integration des IOUS in der operativen Medizin aus. Sie bietet praxisnahe Weiterbildungsformate in Modulform an, fördert wissenschaftliche Projekte und setzt sich in der Leitlinienarbeit dafür ein, bestehende Evidenz sichtbar und zukünftige nutzbar zu machen. Ziel ist es, IOUS als festen Bestandteil qualitätsgesicherter chirurgischer Versorgung zu etablieren – interdisziplinär kooperativ, aber mit eigener sonographischer Kompetenz auf operativer Seite. Daher empfiehlt die DEGUM die Anwendung von IOUS zur Kontrolle und Steuerung bei Tumorresektionen, zur Navigation bei anatomisch unklaren Situs, zur Beurteilung von Gefäßanastomosen bzw. der Organperfusion und zur erweiterten Diagnostik, insbesondere in der Leberchirurgie, ggf. unter ergänzendem Einsatz von Kontrastmittelsonographie.

BACKGROUND: In the first part of this report, the European Association of Neurosurgical Societies' section of peripheral nerve surgery presented a systematic literature review and consensus statements on anatomy, classification, and diagnosis of thoracic outlet syndrome (TOS) along with a subclassification system of neurogenic TOS (nTOS). Because of the lack of level 1 evidence, especially regarding the management of nTOS, we now add a consensus statement on nTOS treatment among experienced neurosurgeons. OBJECTIVE: To document consensus and controversy on nTOS management, with emphasis on timing and types of surgical and nonsurgical nTOS treatment, and to support patient counseling and clinical decision-making within the neurosurgical community. METHODS: The literature available on PubMed/MEDLINE was systematically searched on February 13, 2021, and yielded 2853 results. Screening and classification of abstracts was performed. In an online meeting that was held on December 16, 2021, 14 recommendations on nTOS management were developed and refined in a group process according to the Delphi consensus method. RESULTS: Five RCTs reported on management strategies in nTOS. Three prospective observational studies present outcomes after therapeutic interventions. Fourteen statements on nonsurgical nTOS treatment, timing, and type of surgical therapy were developed. Within our expert group, the agreement rate was high with a mean of 97.8% (± 0.04) for each statement, ranging between 86.7% and 100%. CONCLUSION: Our work may help to improve clinical decision-making among the neurosurgical community and may guide nonspecialized or inexperienced neurosurgeons with initial patient management before patient referral to a specialized center.

Verletzungen des Plexus brachialis können verheerende Folgen haben. Die Ursachen reichen von Unfällen über ärztliche Komplikationen bis hin zu Geburtstraumata (diese sind nicht Gegenstand dieses Artikels). Liegt ein hochgradiger Schaden vor, kann durch eine operative Nervenrekonstruktionen zuverlässig ein gutes Ergebnis erreicht werden. Prognostisch entscheidend ist, möglichst rasch die Diagnose zu sichern und die Patient*innen in spezialisierten Zentren für Armplexusverletzungen vorzustellen. Die Komplexität der APV erfordert eine multidisziplinäre Versorgung (u. a. Neurologie/Radiologie/Nervenchirurgie/Plastische und Unfallchirurgie/Schmerz- und Rehamediziner) der Betroffenen. Article published online: 07 June 2022 © 2022. Thieme. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

BACKGROUND: Although numerous articles have been published not only on the classification of thoracic outlet syndrome (TOS) but also on diagnostic standards, timing, and type of surgical intervention, there still remains some controversy because of the lack of level 1 evidence. So far, attempts to generate uniform reporting standards have not yielded conclusive results. OBJECTIVE: To systematically review the body of evidence and reach a consensus among neurosurgeons experienced in TOS regarding anatomy, diagnosis, and classification. METHODS: A systematic literature search on PubMed/MEDLINE was performed on February 13, 2021, yielding 2853 results. Abstracts were screened and classified. Recommendations were developed in a meeting held online on February 10, 2021, and refined according to the Delphi consensus method. RESULTS: Six randomized controlled trials (on surgical, conservative, and injection therapies), 4 “guideline” articles (on imaging and reporting standards), 5 observational studies (on diagnostics, hierarchic designs of physiotherapy vs surgery, and quality of life outcomes), and 6 meta-analyses were identified. The European Association of Neurosurgical Societies’ section of peripheral nerve surgery established 18 statements regarding anatomy, diagnosis, and classification of TOS with agreement levels of 98.4 % (±3.0). CONCLUSION: Because of the lack of level 1 evidence, consensus statements on anatomy, diagnosis, and classification of TOS from experts of the section of peripheral nerve surgery of the European Association of Neurosurgical Societies were developed with the Delphi method. Further work on reporting standards, prospective data collections, therapy, and long-term outcome is necessary.

BACKGROUND. Proximal lesions of the sciatic nerve are often difficult to diagnose and to treat properly. In particular, if there are posttraumatic or po