Well, good morning, everyone. A lot of very familiar faces out here, and thank you very much for coming and giving up your time today. We have some therapists in the room, residents, fellows, staff, and esteemed faculty. My name's Alex Shin. We're going to do a global perspective of management of panbrachial plexus injuries. The purpose of today's talk is really to give us a flavor of how to do things and what's going on globally. There's a really difficult problem that we have, because we try to compare the results of outcomes, and it's very, very difficult to do, especially in panbrachial plexus injuries. There are various traffic patterns in the world. If you're in Beijing, you're stuck in this traffic, or if you're in Chennai, you're stuck in this traffic. If you're in Minnesota, there is no traffic. But then, when you look at these traffic patterns and how people get injured, it can be very, very different from one region to another. Motorcycles have max speeds based on their engine and velocities, and the type of injuries in one area are very, very different than types of injuries in others. We also have the problem of comparing body mass index. This is that inpatient populations in various regions are not always reported and include the things and the factors that are listed here on the slide. One of the big things that we have is, how do we compare the outcomes of one group to a different group across the world? The purpose of this talk and this ICL is to understand the regional differences in patient demographics and injury patterns, to understand the differences in treatment philosophies, as well as the ability in trying to compare the outcomes respect to these differences. I have a wonderful panel, and unfortunately, because of the COVID restrictions, four of them will be on video, and then I have my partner, Rob Spinner, and then we'll do a little open dialogue. I give you a little reference. This is my COVID project. It's called the Operative Brachial Plexus Surgery that we wrote during COVID, since there was nothing else to do. It's a great reference when a lot of the authors are here in this audience, so please refer to that. Without further ado, I'm going to start with Jamie Bartelli, or Jaime Bartelli, and he will present his global perspective for Brazil. So let's get this going. Ladies and gentlemen, I will talk about my strategy, planning, and goals in the reconstruction of complete paralysis of the brachial plexus. We should define priorities because what is desirable is not sometimes achievable. We have a limitation of the technique and the knowledge about the reconstruction of peripheral nerve, and this is most important in the case of hand function reconstruction. We cannot waste lifetimes to reconstruct the hand because it's very difficult to achieve that goal. So my first priority is pain control, and the second priority, shoulder control, then elbow flexion, and finally, elbow extension. This means that pain control and elbow flexion, they are both addressed by root grafting. On the other hand, shoulder control and elbow extension are addressed by nerve transfer. Roots available for grafting brachial plexus is not rare. In my series, at least 7 in 70 to 80% of the cases, C5 is available for root grafting. The rate for C6 availability is lower, and it's in general from 35 to 40%. It's very important to examine your patient. Clinical exam is more important than image studies, and I'm relying in the examination of the scapula to determine if C5 or C6 are available for grafting, and I can tell you that the accuracy of this exam is around 80%. So this is the C5 protraction test, and this is the C6 protraction test. In the C6 protraction test, I ask the patient to touch the ceiling, and then I touch the scapula to see if there is forward motion. And just to remind you that tinoside is important. If the electricity goes to the arm and forearm, this is a sign of preservation of C5 root, and if it reaches the hand, this is a sign of C6 is available for grafting. Pain of brachial plexus trauma is present in 85% of the patients with complete paralysis. I don't think that pain is resulting from the afferentation, but it is a neuropathic on origin. It's very rare to have complete avulsion of the brachial plexus. In this image obtained when we did a drastotomy for pain relief, you can see examples of preserved roots here, here, and here. Another important data is that in the half of the patients, pain subsides immediately after surgery. Concerning elbow flexion reconstruction, it will be addressed by grafting, and if I have C5 and C6, I will graft the entire lateral cord, and eventually some axons can reach the median line. If only C5 is available for grafting, then I connect C5 directly to the muscle cutaneous in order to target my repeat. The reconstruction after root grafting is somehow good, because in 85% of my patients I could obtain M3 and M4 with full range of motion. After grafting the muscle cutaneous nerve, some sensation can be restored on the lateral side of the hand and forearm, so the lateral antebrachial cutaneous nerve. We don't need more than this, because hand function is very poor. In shoulder control, I address that by transferring the spinal accessory nerve to the suprascapular nerve, and in this schematic representation, I show you the incision in A is the one that I use for root grafting. On B, I use to dissect the suprascapular nerve and the accessory. Some patients have extended lesion of the suprascapular nerve, and we should have that in mind and should be ready to explore the suprascapular nerve in the entire trajectory until the suprascapular notch. So for exploring the suprascapular nerve trajectory, and especially in the suprascapular fossa, I do an osteotomy of the clavicle with a piece of bone attached to the trapezius muscle, and then I reach the suprascapular fossa and the ligament, transverse superior ligament, and then I release all the nerve and inspect for any distal lesion of the suprascapular nerve. And this here is by the end of the surgery when I reattach clavicle bone fragment with sutures. This is our interoperative images, showing you the transverse superior scapular ligament. Here it was divider, and here we have dissected the suprascapular nerve with the branch showing here to the supraspinatus. Through this approach, we can dissect the accessory nerve very distally, which enable us to connect directly this accessory nerve to the portion of the suprascapular nerve in the suprascapular fossa. 90% of our patients recover at least 30 degrees of abduction. In general, the range of motion is at 60 degrees of abduction. Rarely external rotation can be restored. About elbow extension reconstruction, it is possible only when C6 and C5 are available for grafting. And my preferred nerve transfer is the use of the long thoracic, grafted on the thoracic wall, and connected to the branch of the radial nerve to the triceps, lung, and upper medial head. As I mentioned, for this nerve to be available for grafting, the division of the long thoracic nerve from C5 and C6 should be preserved. And this can be observed after electrical stimulation. Elbow extension is possible to be restored in at least 70% of our patients. Concerning finger flexion, this is a much more dramatic function to be restored. I have tried in a few patients, a two-stage surgery, I bravested the intercostal nerves, and then I connect with a nerve graft, and then I put the stump, the distal stump over the forearm. And a year later, I do a free foot service. I have observed some finger flexion reconstruction, but I'm not enthusiastic by this method. At this moment, I think we need more than what can be provided. Well that was Dr. Bertelli's experience, and so I want you to take out of that that he recommended number one priority was for pain, number two is that 70% to 80% of his patients have graftable roots. And so we'll take that, and then we're going to listen to Dr. Anil Bhatia, that is from India. Thank you, Dr. Shin, for having included my presentation in this symposium. My name is Anil Bhatia, and I practice at Pune in India. I have no financial conflict of interest to declare. In my practice, almost half my patients present with a complete paralysis from the shoulder to the fingers with a closed stretching injury to all five roots of the brachial plexus. When the flail condition persists for a month following the accident, a history of an injury with an impact faster than 30 kilometers per hour, a positive Horner sign, all three factors are sufficient justification to offer surgery at a month in my practice. I take care to confirm that the other skeletal injuries have been stabilized and the local tissues are supple before offering surgery. An MRI is useful if it confirms the presence of root avulsions at one or more levels, so that the indication for exploration and now reconstruction is justified. I have not found electrodiagnostic studies useful in deciding on surgery in my practice. Pressure at the posterior border of the stratum astroid in the posterior triangle should evoke paresthesia in the sensory territory of the upper roots for me to suspect that there is a ruptured root available in the neck. I also look for the movement of the inferior angle of the scapula when the patient attempts antipulsion, which I have found useful to detect preserved re-innervation of a portion of the serratus anterior. The Horner sign confirms the severity of the injury to the lower trunk at a proximal level. Exploration starts with identification of the phrenic nerve and evaluation of the roots at the foramina. Stimulation of the branch to the serratus would help confirm the quality of the root that has been found in the neck. Sectioning it just lateral to the branch to the serratus will reveal the quality of the fascicles and help us decide the utilization of that available root stump. I prefer to perform a single nerve reconstruction operation and the utilization of the available nerve donors depends upon the age of the patient and the delay since the accident. Since most of my patients have been referred to me within six months from the accident, it is the age which will decide on my strategy. In patients older than 35 years, results beyond the level of the elbow have not been very promising and I focus on restoration of control of the shoulder in the form of re-innervation of the rotator cuff and the pectoralis major and for restoration of elbow flexion against gravity. So, in this patient who had suffered an injury following a fall of a tree branch on his shoulder, the rotator cuff was innervated by the spinal accessory to suprascapular nerve transfer and the pectoralis major and the biceps were re-innervated using intercostals. A similar strategy was used in this patient who presented following a conveyor belt type of injury. The available C5 root stump was used to augment the ability of the patient to perform the shoulder function by grafting to the posterior cord. A de-rotation was started with the humerus and a wrist fusion helped improve the positioning space. In patient younger than 35 years however, I add an endeavour to restore innervation to the forearm flexors and automatically secondary procedures become necessary to augment the use of the recovered functions. So, in a case of all roots being avulsed, shoulder and elbow functions can be brought by nerve transfers whereas, the opposite C7 by direct repair via a pre-spinal root is used for restoration of forearm flexion. The elbow flexion came from intercostals, spinal accessory to suprascapular provided abduction and wrist and finger flexion is activated by a gesture from the opposite side because the contractive C7 direct repair has been performed. Here the humerus had been shortened by 3.5 centimetres. A de-rotation of the humerus helped improve the positioning space and a wrist fusion helped to augment the strength of the finger flexion so that the patient could reach the palm. The redundant FCU was transferred to the APB in order to improve the position of the thumb and the patient could carry this weight slung on the fingers with only a mild gesture on the opposite side. An identical strategy was employed in this patient with avulsion of all 5 roots. The rotator cuff re-innervation, elbow flexion and the contralateral C7 providing the finger flexion for the palm 0, the FCU has been transferred to improve the position of the thumb. How he uses this recovered function, it is entirely on the patient and they do not have a dedicated occupational therapist. If one ruptured root is found apart from the avulsion of the remaining 4 roots that can be bridged to the musculocutaneous for restoration of elbow flexion in which case the phrenic nerve becomes available for innervation of the triceps and the contralateral C7 is utilized for finger flexion. So, in this young boy, spinal accessory to suprascapular for the rotator cuff, the C5 was bridged distally to innervate the musculocutaneous and the vectoral nerves and the phrenic nerve was transferred to the posterior division of the lower trunk of the triceps. The nerve grafts were split to the vectoral and musculocutaneous nerves as I said earlier and the phrenic nerve was transferred to the posterior division of the lower trunk of the triceps. The nerve grafts were split to the vectoral and musculocutaneous nerves as I said earlier and the opposite C7 was brought to the anterior border of the sternum astroid for approximation direct approximation to the anterior division of the lower trunk. We provided this 40 degrees abduction, good elbow flexion from the C5 root and good wrist and finger flexion being activated by a mild gesture from the opposite side. So, the phrenic nerve to the posterior division of lower trunk provided some extrinsic extension. Following the derotational osteotomy of the humerus and the wrist fusion combined with the transfer of the trapezius and meris, the arm could be placed better in space and the patient could close and open the fist. When 2 roots are available, quite often the rotator cuff cannot be removed because of the quality of the suprascapular nerve in which case the spinal accessory can be bridged to the musculocutaneous. The other nerve transfers for would be the phrenic to the posterior division of the lower trunk for the triceps and the C5, the available root stumps being directly approximated to the lower trunk for forearm flexion. Like in this case, who presented at 4 months from the accident with the flail of a limb, the untreated fracture of the upper end of the humerus dissuaded me from attempting the innervation of the rotator cuff. The spinal accessory was bridged to the musculocutaneous, phrenic to the posterior division of the lower trunk and the available root stumps for the finger flexion, elbow flexion, elbow extension and wrist and finger flexion were restored. All of it became much better utilized following a fusion of the shoulder and of the wrist combined with the flexor capillaris to ABB transfer. When the injury is distal to the origin of the suprascapular nerve, the rotator cuff is already innervated, in which case the available root stumps can be used for the medial cord and nerve transverse can be used for the biceps and triceps, like in this case the intercostals were used for the biceps, spinal nexus were bridged with the radial branches to the triceps and the upper trunk was bridged to the medial cord. This is the integrity of the upper trunk to the neck, none of the other roots could be visualized there, there are ruptured divisions, ruptured cords in the deltoid region, the spinal nexus was bridged by neografts to the radial branches to triceps, the anterior and posterior divisions of the upper trunk were bridged to the medial cord using neograft cables, intercostals had been transferred to the musculoputaneous, so the shoulder abduction had been triggered already, intercostals are probably in the musculoputaneous, whereas the neografting from the root stumps has probably increased in finger flexion, the long head of triceps was reinnervated using the spinal nexus in the neografting. Following the wrist fusion, the position of the limb improved and the strength of the finger flexion improved. Best to conclude, I prefer to operate at a month following the accident in the presence of a positive Horner sign and a flail of a limb. Nerve transfers have given consistent results for restoration of control at the shoulder and elbow which frees the opposite C 7 or the available ipsilateral root stumps for re-nervation of the finger flexion occasionally and ipsilateral root stump is utilized for elbow flexion. Thank you all for your attention. That was Dr. Bhatia's experience. So we went from Brazil to India and in India where Dr. Bhatia practices, he prefers the use of the contralateral C 7 in the technique that was described by Shu Feng Wang to restore elbow flexion hand function and uses humeral shortening as well as the phrenic nerve for finger extension and triceps extension. So now we're going to move over to Taiwan and Dr. Liu will give us his approach in the Taiwanese patient population. Good afternoon. My name is Johnny Liu. I'm a plastic surgeon in Changi Memorial Hospital in Taiwan and I'm very honored to be a part of this prestigious panel. I want to thank Dr. Shin for giving me this opportunity to present our Changi experience. Unfortunately I can't be there so I apologize for not being able to attend in SSH. This is a very interesting panel and I'm very happy to introduce Taiwan. Taiwan is definitely one of the smallest countries in the world but the population size, it's about number 57 but at the same time, looking at all these countries from 50 to 62 here, Taiwan is one of the smallest area for a country size but definitely one of the more highly dense population dense countries in the whole world. And because of that, you know, our country is a small country. Our average BMI is, you know, definitely less than 25. So for the age between 19 to 44, it's about 24.5 and 23 respectively. We have a national health insurance that's very affordable, traveling is easy, easy access for patients to go from the north to the south. There's always, there's direct referral from surgeons anywhere from the country. There's no need for primary care position and the rehabilitation is very convenient in our country. And I think the number one cause of trauma is motorcycles or some people call it mopeds. And being such a dense country easily leads to accidents. And so many of our patients come with complete total paralysis and there's lack of shoulder, elbow or wrist or finger movement. And so how do we approach this? So our strategy here is to always explore the brachial plexus and then to look for donor nerves. And that includes the ruptured spinal nerves. And also looking for other donors such as the phrenic nerve, the spinal accessory nerve. But we believe that we should be very flexible in your choice of donor and how it goes to your recipients. And location is the number one priority when you're trying to design how your donor nerve goes to your recipients. Does it go there via nerve transfer, does it reach via nerve grafting or do you use functioning free muscle? And the recipient choice is very important. Obviously for panplexus it's very difficult because there's multiple areas that needs to be—multiple functions that needs to be re-innervated. But the focus should still be on shoulder, elbow flexion and some form of finger movement. And for us the functioning free muscle is used more as a backup. So we definitely want to preserve a donor nerve and the recipient vessels in case there is a problem with one of the functions that are re-innervated. And so it's number one, when you're dissecting the neck it's always important to, when you're looking at the spinal nerves, is it ruptured or evulsed because it can affect your surgical planning. And so for us if it's evulsed it means that it's not a good stomp, you can't really nerve graft it. But if it's a usable stomp and it's a good quality it changes your strategy. And we look at—in a series that—this was written by a radiologist where they looked at the C5 and the strategy they have used for the past 10 years has been to use the MRI to determine the healthiness of the roots. And they look at the rootlets inside and they devised a classification system looking at the rootlets, the ventral or the dorsal, and then to help us determine the quality of the rupture. And it has really identified these false positives that look like ruptured roots but it turned out to be bad roots. And so this really helps us to determine beforehand what we can do with the strategy. And in a study that we collaborated with Mayo Clinic and Dr. Shin, we looked at 200 consecutive panplexus patients. This is 100 from each center and we only looked at the demographic, the mechanism, and nerve root without the outcomes. And it was a very interesting study where we could kind of compare between the two centers. And aside from the body mass index being drastically different between the two centers and also the mechanism of injury, here we found that the rate of total root abulsion was 62 percent in the Mayo Clinic and about 44 percent in Shingon. And the percentage of ruptured roots is only available in 33 percent in the Mayo Group and in 56 percent in Shingon, which even though they're significantly different, they're also reportedly lower than what has been reported in literature from other centers. So using that, our priorities are always to reinnervate the elbow flexion. These are adenine nerves. We use the vascularized adenine nerve graft or we can use the intercostal nerve. And then next comes the shoulder movement and finger movement. And again for finger, we use the vascularized adenine nerve graft and we can use the ipsilateral C5 or the contralateral C7. For shoulder movement and also elbow extension, we are more flexible and we determine, you know, we can use the phrenic, which we often use. We can also use the roots. We can also use the hypoglossal, but we do tend to preserve the spinal accessory nerve for future function. One of the studies that Dr. Pertelli had published in 2010 and also a subsequent study from Dr. Skowarski was that, you know, they believe that when you do a graft and the graft is the distal palpation site that's closer to the target muscle, it can have effect on the final strength index, even at the expense of extending your nerve graft. And that is actually something that we do believe in, you know, but we do believe in extending the nerve graft length so that you can reach your targets faster, but we also believe in using the vascularized nerve graft rather than the traditional sternal nerve graft. And the reason is it's easy. You're able to extend abundant axons from your roots with survival of the important glial cells such as Schwann cells and preserve the structure, but at the same time, you know, provide nutrition to your entire nerve graft. And so having this direct profusion of nerve graft at day one, you know, you can have very vascularized tissues at both ends of the nerve graft and you can see this easy bleeding from the nerve graft. And so the vascularized nerve graft is our vascularized nerve graft of choice. Certainly it has been, the superior ulnar collateral artery has been the more common choice as the innervating, as the profusing artery, but for us, when we dissect, you know, looking at the whole length of the ulnar nerve graft, ulnar nerve, you can see that the ulnar artery is more centrally placed. And also given this larger caliber compared to the superior ulnar collateral, we believe that it can nourish this entire nerve better and we harvest it as a free nerve graft, as you can see here. And you can see how where the ulnar artery is located right in the middle of the ulnar nerve, being able to innervate both sides. And so this is how we would inset, given that if we have a very good C5 route that's been previously proven by the MRI and we decide where our target goes to, you know, having harvesting both sides, both branches of the ulnar nerve, we'll hook it up to the ipsilateral transverse cervical artery, an EJV. This is kind of the course where it is. You see the proximal stump, and then see the course where you place this underneath the clavicle, underneath the P major and the P minor to reach your distal targets. It allows you to have really good elbow flexion, strong, you know, at ease, more than M3, in this case it was M4 for sure, and then to have a finger flexion, have some form that is able to go against resistance. And with our way of using the phrenic nerve to innervate the scapular nerve, we can see good lateral superduction, abduction, also anterior flexion of the elbow and some form of posterior extension of the shoulder. At the same time, with that strong elbow flexion comes with good forearm supination. If the bicep is successfully innervated, you can see this ease of moving the elbow. Again, you can see this patient really able to mobilize the elbow with some form of elbow extension with gravity assistance. And then more important, the finger movement with the grip of objects, so you can see good movement of both thumb and the finger flexion, and if it comes, is able to grip an object with sufficient strength, able to do some form of supination and pronation, and be able to grip objects such as holding a water bottle, and to be able to drink. And here, being able to perform daily activities, something such as eating ice cream, holding a phone, apologize for the music, being able to play a guitar, and then be able to ride a bike with stability. But not all cases are like that. Not all cases have the ability to have a good root on the obstacle lateral side. And in approximately 40% of our cases come across with a total root avulsion. And so what do we do? Our strategy is to use the contralateral C7, again, using the vascularized ulnar nerve graft, hook up to the median nerve, but then preference is to use the intercostals to join the muscle cutaneous nerve. But a systematic review from Dr. Chung, reporting 2015, cites sensory abnormalities existing and at the same time, heavy motor deficits in the triceps. But please recognize that when you use the contralateral side, even though patients do compare some form of numbness in the index or maybe in the middle finger or in the thumb, it acts as an alarm. And when the injured side is indeed, the sensory does recover, when they touch objects, our left hand or the healthy side acts as that alarm that triggers, if it's from danger, from heat, from pain. And so it's at the same time, you could see that these patients have good movements of their shoulder, good movements of their elbow, able to—good elbow extension, again, with good grip, no loss of grip, and able to do that good elbow extension. And that is really predominantly our—given our past publications, we have shown that despite some form of sensory disturbance, it is justified in these cases. And so again, in the contralateral C7 case, we would hook this up to the distal median nerve, have some form of finger flexion along with sensory reinnervation or sensory recovery, and then have that good median nerve, even with a very extended long nerve gap, still being able to show some finger flexion and some movement. But in cases where the grip is not strong enough, you can definitely use the functioning free muscle and have the median nerve, the distal median nerve with its branches innervate this functioning free muscle, and then to restore, as you see here, some form of finger flexion. We have—for outcome measures, we have used—collaborated with the Michigan—with Dr. Chong and Dr. Brown and Dr. Lydia Yang from Michigan, using a device that they have used, accelerometer, to calculate the time per day to detect movement that the injured limb is used, and also the vector magnitude of the injured limb. So we looked at 29 patients, and this is usually the traditional way of how we would present the outcomes. But here, it's shown here, the injured limb is used more than 50% of the time compared to the healthy limb, which is exceptional in our eyes and our perspectives. The magnitude definitely is less, 0.3, but as long as it can assist the patient into using this limb, it's very important, and it's important to recognize here that there is no significant correlation found between the time of the use of the limb with the traditional outcomes, and patients with contralateral C7 did not fare worse than the patients that had extralateral donors. So these are all very important data telling us that our strategy does help our patients. And so this is our strategy, where we prepare. We look at the history, the imaging, the surgical expiration, telling us what donors we can use, how—telling us what recipients to reiterate, and to actually have a strategy or a plan to decide what we do, and then actual execution of it, and have a really decent, long-term follow-up where—to look at the outcomes, and if it doesn't work out, you can always have extra donors that you can use as a backup, and so that it can really help these patients. So in conclusion, I just wanted to hone in this message, is that good things take time. Not all patients have good outcomes, that is for sure, but you do your best at anything, even the smallest little things, you know, even this little flicker of finger flexion that is seen post-op eight months can still tell you that you're doing something right and giving them hope. You're giving your patients hope. So I just wanted to say thank you so much for this. Well, that was Dr. Liu from Taiwan, and it's interesting, their use of Contrail C7, in addition to their workup and their philosophies, are a little bit different, especially with the use of vascularized ulnar nerve grafts. Our last video comes from England, so we've now gone from Brazil to India to—from to Asia to the U.K., and Dominic Powers will give us his perspective on how they do things in England. Many thanks for the invitation to join you in San Francisco. Unfortunately, due to COVID restrictions, I'm not able to travel from the U.K. My name's Dominic Power. I'm a consultant hand and peripheral nerve surgeon and lead for the Birmingham Brachial Plexus and Peripheral Nerve Injury Service, and this is a talk about the U.K. perspective on the management of pound plexus injuries. So the U.K. has a population approaching 67 million, and there's a cluster in the south around London and also within the Midlands, and Birmingham is located centrally within the country, with an immediate population of 2.5 million, a wider connovation catchment of 5 million, and for brachial plexus injuries, somewhere between 7 and 10 million. The University Hospital Birmingham NHS Foundation Trust consists of four hospitals, with the flagship, the Queen Elizabeth Hospital, a major trauma center. It has 125 critical care beds on a single floor, around 1,200 beds, and 48 operating theaters. It's also the Royal Center for Defense Medicine. It's home to the Birmingham Hand Center, with 14 consultants, and the regional brachial plexus and peripheral nerve injury service, with five consultants. It's difficult to estimate the number of brachial plexus injuries in the U.K. Historical estimates were around 500 cases, with 350 close to clavicular injuries. We estimate currently around 0.75 per 100,000 incidents, but there are increasing numbers of low energy fractures and dislocations around the shoulder girdle associated with infraclavicular injuries, and increasing numbers of penetrating trauma with stab and gunshot wounds. The challenges in collecting data in the U.K. are there is no mandatory central reporting. The Trauma Audit Research Network collects some data, but isolated brachial plexus injuries will be missed. There is no specific service designation outside of Scotland, and as a result of this, historical provision of services has sprung up at multiple sites, based on the needs of the local population and the interests of the treating surgeons. One trend is that we're seeing more patients survive with complex injuries of polytrauma, an increasing age at presentation, and an increasing proportion of plexus injuries. Many of these patients have developed comorbidities, and also have a high BMI, which creates challenges for treatment and for rehabilitation. The U.K. is served for the adult population by a number of centres. The most historic centre is at the Royal National Orthopaedic Hospital in London, the Peripheral Heart Injuries Unit. This has three consultants. Scotland has three consultants in Glasgow, and there's a Welsh unit in Swansea in South Wales in Purple with two consultants. Birmingham is the largest unit with five consultants, and the Midlands is served by several other units where surgeons are locally placed who have an interest in brachial plexus injuries. In the U.K., there's an initiative called Getting It Right First Time, and this is about taking rare, complex, and specialist services and centralising them to try and improve outcomes. In Scotland, there's already a nationally commissioned service, but this doesn't exist for the rest of the U.K. for brachial plexus injuries, and because of financial constraints, it's challenging to develop local services. The current NHS funding model is that most of the money is held with the primary care physician, and groups of these physicians will buy services from secondary care or commission services through clinical commissioning groups. It's very difficult to innovate and to allow new services to develop and receive the financial remuneration that they deserve, and as a result, historic trends mean that income for complex services such as brachial plexus are extremely limited, and because the numbers are small, they're not high on the agenda for revision. As such, to give you an example, the total package of care from referral, outpatient consultation, investigations, surgery, inpatient management, drugs, discharge, outpatient therapy, and all outpatient appointments is featured here in dollars. The cost for brachial plexus attracts around $3,000 currently. A single nerve transfer, I managed to get recognized locally, and gains around $3,500, but if we were to undertake a quad transfer, considering more intensive in terms of theater resources and rehabilitation, then we get the same amount of money. Tendon transfers for a complex patient around $2,000, a functioning pre-muscle around $17,000, and a contralateral C7, just $2,500. And as a benchmark, an allograft reconstruction of a 15 millimeter defect in a digital nerve gains around $1,500 of income, which doesn't even cover the cost of the allograft. So within this constraint, it's very difficult to establish and develop services and make the necessary business cases for investment. So Birmingham is the center for defense medicine with a need for treating injured military personnel. The Hand Center was established, as we said, in 2003, and I commenced brachial plexus services in 2006. There was local designation as a regional peripheral nerve injury service in 2010. We established the Birmingham Nerve Fellowship Program in 2014, and we gradually expanded with the increasing volume of work from the region, with growth up to five consultants by 2021. We have three therapists with an interest in nerve surgery, a lead hemotherapist, clinical neurophysiologist who supports the service, an active research program, and we have one main nerve clinic per week with five consultants, but additional clinics for seeing new patients with a total of seven and a half clinics per week, plus an MDT meeting. We see on average around two to three superclavicular injuries per month, and that includes pamplexus injuries. We see about three to four infraclavicular injuries per month, including the low energy cleaning humoral dislocations. Around 40% of our injuries are panplexus and the distribution is motorcycle RTCs with then motor vehicle collisions, pedestrian RTCs and falls making up the remainder. But we are seeing increasing numbers of open brachial plexus injury with stab wounds and gunshot wounds and cases come not only from our own major trauma centre locally but also from regional hospitals and I estimate we've operated around 200 cases of brachial plexus injury over the last 11 years. In terms of our process of assessment we rely on a trauma CT or a clinical survey of the affected limb to rule out concomitant injuries that may otherwise be missed due to the paralysis and lack of sensation. We don't undertake any routine fluoroscopy to check the integrity and function of the phrenic nerve, we no longer use the phrenic nerve as a donor. The majority of our patients will have an MRI of the brachial plexus with special sequences developed locally which are very reliable at picking up avulsions. We'll do angiography if there's a suspicion of a vascular injury and unfortunately some patients particularly with infracavicular injuries with complex fractures and dislocations may now be stented primarily and that can delay open surgical intervention. CTA plus minus invasive angiography is necessary prior to functioning muscle transfers and typically we'd use the functioning precocillus. And the majority of our patients have sequential neurophysiology but if it's an early presentation of a pump plexus injury which meets our requirements of at least one complete nerve root suspected of ulcerative rupture, we would undertake urgent surgical exploration at the first available opportunity and we wouldn't wait for neurophysiology. So in terms of some of the specific questions that have been raised, acute referrals would ideally explore within four weeks and this would be if there are no other complications or polytrauma that precludes that surgery timeline. Delayed referrals would go on the next available appointments and we may consider neurophysiology if there's some uncertainty regarding any renovation or retained function. Late referrals we may undertake surgery for pain, for salvage, for primary functioning pre-muscles and for later shoulder arthrodesis. And if a C5 route is available, the way we assess this is we can inspect the plate and debride it serially but we don't tend to use somatosensory evoked potentials in our unit. Reconstruction priorities are elbow flexion followed by extension, finger flexion, shoulder stability and wrist stability. If C5 is available, my preferred technique is C5 to the anterior division of the upper trunk, intercostal nerves to triceps, preserving the spinal accessory nerve for a free muscle transfer, the biceps for elbow flexion and finger flexion to augment any recovery that's come through the C5 transfer and then shoulder arthrodesis plus or minus wrist arthrodesis later. If there are plant plexus evulsions, spinal accessory into the musculocutaneous nerve with graft, intercostals to triceps, lateral intercostals plus the supraclavicular nerves onto the medial nerve with graft sensation, I have in the past used a cross-pectoral transfer to try and get some other function within the upper shoulder girdle rather than go to C7 and then later we would plan a shoulder arthrodesis once the elbow flexion commences plus or minus the wrist arthrodesis. Contrast to C7 I used historically with the vascular zone, the nerve graft into the medial nerve but the results are poor for motor and so I don't use it currently but I'm more interested in how this can be used for more proximal innovation within the brachial plexus. However, my experience of discussing this with patients is many are unwilling to consider it. I use the phrenic nerve historically in patients with no chest injury, no respiratory disease and I haven't used it for around five years. Chrysalis is the preferred functioning free muscle and it's used to augment a weak elbow flexor while in reconstruction or as a primary case when grafting is not possible. Root-root plantation is not possible in our unit. Amputation is rare but a patient request and we currently don't have myoelectric prosthesis, robotics or exoskeletons available but we would consider targeted muscle renovation for signals in a funder patient referred through specialist commissioning. Pain management is also a priority but we use functional renovation strategies, neuralitis medications, multi-professional support for patients together with charity support, counseling, cognitive behavioral therapy and rarely refer patients for spinal cord stimulation. We have a six-phase rehabilitation program for nerve injuries with overlapping stages, preoperative education, protection after a nerve transfer or graft, prevention, maximizing passive motion and joint while we're waiting for renovation, a power phase where we augment any recovery within a nerve transfer by recruiting the donor, a plasticity phase where patients learn to separate donor and recipient functions and then purpose where we tailor the function to the patient's requirements. In terms of outcome assessments we use the British Medical Research Council but the grade four is extremely poor as it covers the majority of outcomes and so we use a four minus four and four plus depending on the percentage of the other side. We measure the range of motion, any sensation using SEMS, Weinstein monofilaments and my preferred prom is a BRAT score or brachial plexus assessment tool. We've just completed a large study called the combined study which is core outcome measures in brachial plexus injury evaluation and this has developed a three-tier core outcome data set which is about to be published and the first tier includes things like Medical Research Council grade of muscle function and the BRAT tool but then there are other things that can be measured in select cases. I use a present pain intensity scale, a FAS pain scale and a pain diary where necessary particularly monitoring the response to surgery. My future perspectives, well I think we need improved data capture with perhaps a national registry in the UK. We could also move towards an international registry sharing outcomes and standardizing outcomes but the challenge has been historical papers do not have a standardized approach to reporting and the patient groups and needs can be very different. I think in the UK we need national service designation with specialist commissioning status to allow us to develop services. We need to integrate other services that provide ancillary support such as pain, psychology, rehabilitation, prosthetics and implantable stimulators. I'd like to see under the UK National Institute for Health Research funded research evaluating the cost-effectiveness of surgery, myoelectric prosthetics, exoskeletons and robotics and improved pharmacological and non-pharmacological pain management strategies and most importantly we need to standardize the way we report outcomes internationally and perhaps a wider adoption of the combined recommendations when it becomes published later this year. Many thanks for asking me to talk and I hope working together we can all strive to improve the outcomes for our brachial plexus patients. Well now we heard the UK's options and the real interesting thing in the United Kingdom is the finances actually drive what can be done and I didn't recognize that until Dr. Powers really mentioned that. My last speaker is Dr. Rob Spinner and I asked Rob to or Dr. Spinner not to prepare slides but I wanted him to come up to the podium and we're going to kind of go through some questions with him and use the videos that we heard to compare and contrast different things to our patients that we see in Rochester, Minnesota. So Dr. Spinner why don't you come up. So I think the first question I'd like to ask Dr. Spinner is what is the typical patient that we see in Rochester? Well hearing the global perspective I think it's important to make a few general comments and I think the first one is it's a global pandemic. Just like what we're suffering with here but we all have our geographic challenges whether it was the financial or patient related ones or in the states legal ones. So I think if you divide what we're talking about I would say the best resource was wasn't Dr. Shin's book but it's actually a nice paper he put together in the European Hand Journal which really summarizes sort of this symposium in advance. So I think if you divide what we're talking about is sort of the old man in the sea. It's the patient and the mechanism and then the physician surgeon and the philosophies expectations. Then I think you can really get a grasp on what Dr. Shin is getting at here. So if we look at now the patient the first thing is is to understand that all patients aren't created equally and all pan plexus injuries aren't the same and I think our data from Mayo is completely tertiary care. So firstly pan plexus injuries are a large significant percentage of our practice and they're not just pan plexus injuries they're the worst of the worst because in reality the c56 where other people are doing nerve transfers those are getting done in the communities or in smaller hospitals. The ones that are coming to us are not just the pan plexus but they're the heavy BMI heavy high impact speed kinetic energy severity injury severity scale all the sort. So our typical patient not just has the pan plexus but also comes with severe pain and then three four weeks of hospitalization three four weeks of rehab related to the head injury spinal cord injury lung injuries all of which we then have to take into account into our algorithm because not only that our patients expect to be normal which no one here talked about. It's our patients are a little different than other patients in other countries the expectation is you know it's the old joke there when am I going to play piano again and they have a pan plexus with severe pain. So I think to summarize sort of the other people I agree with what everyone sees ours are worse and we talk about sort of the trifecta which would be the pan plexus phrenic nerve out spinal accessory out and then the expectations for normal right and we all laugh but that's what comes to our clinic. So Rob how do you approach our or Dr. Spinner how do you approach our patients what diagnostic tools you give them or to figure out what they have and what do you typically offer them in terms of reconstructive surgery. So like everyone else I think the pre-op evaluation is history physical exam EMG and then imaging. We've used CT myelogram even though we have advanced high resolution imaging we still like the CT myelogram. So I think that's standard part I think the difference with our approach versus several of our other colleagues is we do rely heavily on intraoperative monitoring. I think the last comment by the UK speaker you know you can't judge a book by its cover. So looking at a nerve root in fact I used to joke that the easiest dissections were the pan brachial plexus pre-evulsive injuries the evulsive injuries pre-ganglionic because many times the nerve root looks beautiful because the injuries in the spinal cord it's ripped out so your dissection is easy. So the easiest dissections sometimes are the pan plexal pre-ganglionic ones. So for us while stimulation and seeing a little twitch helps but it really doesn't guide you need SSCPs and MEPs. And I think that's one difference than other groups. I think the other one relates now from patient to operative and surgery is what we've talked about with the availability of c5. So again you know here we're in evolution just like everyone else and it's very difficult to predict the future. So we've gone through different algorithms over the years and it's important to evolve. So I think Dr. Shin has looked at our c7s and our hemi c7s were abysmal. Now you can't compare hemi c7 to full c7 but the point is is in America in our society where our patient comes with their lawyer or at least mentions the name of their lawyer you have to worry about really c7 in America. It's a different patient but the hemi c7s didn't work and the question is is we just took our loss. We learned from it moved on because there are three ways to get hand function which is really the pivotal algorithm point is when you see a patient in our practice it's here's what we can offer you. Do you want the rudimentary hand function that many people get or some people get because I think the best of the best pictures are being shown here and I think a lot of you would say is that useful and our last speaker was talking about whether or not it would be cost effective right that was his last slide and I would say if you showed that to the UK government the little bit of hand function that's not going to be cost effective. Just like they're making difficult decisions and discussions about people getting dialysis or even IVF they've made tough choices because of their geography. So I think for hand function three ways to get there it's c7 whole which we've decided we weren't going to do the full and the hemi didn't work. Extended phrenic well all you have to do is have one patient with a bad outcome with that and then you have a lifetime of problems. So in our early stages we had one patient who was with developed ARDS and was difficult to get off the vent. Related to the BMI which at that point people weren't talking about and we're timid about going back and I would say in yesterday's clinic I saw a 60 year old man who has a phrenic nerve dysfunction from Parsonage-Turner syndrome and is severely symptomatic and I would say that's a difficult thing for us to swallow now voluntarily in America. And the third thing is what we've done which others have talked about is using free muscle transfer. So if you take Joy's study from 15 years ago with double transfer the double technique probably isn't as easy to pull off in America because again if you count the operations you know you're between this fusion and that fusion and then using this as a backup some of those patients with the shortening they were up to six operations as I counted them. That's not really tolerable in many people's practice. So Dr. Shin and Dr. Bishop about 10 years ago started a single stage free muscle transfer which is our go-to procedure. So if you think about our algorithm it's everyone gets explored, everyone gets monitored, and then we look for C5 and look for other nerves. Rarely do we find them and that's different than other people. The injury is worse and it's related to lots of things including the injury and the weight of the patient. If we patient wants hand function then anything from C5 goes to shoulder and then inner costals are doubly neurotized. We believe that the elbow flexion is the main priority so even when we have none or two we try two routes available which is really rare we try to use two sources for elbow flexion and it's two different ways. So it's a native biceps and and the gracilis and for the people who go for hand function it's using the free muscle for finger flexion extended and then getting some triceps from spinal accessory and then if C5 is available using that for shoulder and then doing some sensory innerization using the inner costals. I would say the other difference that really people haven't talked about is pain. So in Bertelli's talk and his premise and philosophy is that it comes from C5. Our patients all talk about this crushing sensation in usually it's related to their horners C8 and T1. So again that's a distinct different than any neurosurgeon in this country. Our patients come in with crushing hand pain which wouldn't be C5 and it's not postganglionic. That's preganglionic avulsive pain and that's one of the bigger drivers in our patients and it's seldom talked about in our Asian colleague literature. So Rob we have about five minutes left. I'm going to ask you for like maybe a one or two minute summary of what you think the future needs especially globally and then if there's any questions from the floor we'll take those in the last couple of minutes. Well it's like Yogi Berra it's hard to predict the future. Hard to predict the future especially when it's in the future whatever his quote was but the point is is I don't know. I wouldn't I don't want to be negative because I think if you divide things again into technical and technological I think a lot of the technical advances have been made. So if you look at nerve grafts we really haven't come very far in the last 30 years since Hanoma Lacey. So somebody was advocating nerve grafts for hand function. That doesn't work very well. So we know that. So even if you graft a high ulnar nerve in the axilla the results are poor and that's why we're looking for other nerve transfers. So to graft lower trunk in adult patients without humeral shortening is destined to failure most of the time. Nerve transfers I think the aggressive ones have been tried. I was hoping for re-implantation at the spinal cord. So I don't think we're going to get there and as a neurosurgeon I thought that was going to be the way of the future. Getting patients early and then replanting. The distance is too long. So then if the technical things have all been tried then what are you left with? Well are we going biologic? Well if anyone has a good graduate student I would say there's a Nobel Prize for your PhD student and all they have to do he or she is go from one inch a month to two inches a month and that will be a Nobel Prize. So if you have some time this weekend you can do that. That's all we need to do and that would revolutionize what we would do and it would save the country billions of dollars. I don't see that in the next 10 years. I do think the myoelectrics and I think some of those in the brain interfaces are exciting. I don't think robotics are going to change things and I think yeah I agree with outcomes and I agree with the pain management. Unfortunately I think in this population it's a little bit more sobering than the contributions many of our colleagues at this meeting have made for the upper trunks which many of us aren't seeing as many of because other people are doing them. Well thank you Rob. Any questions from the floor? Awesome. Perfect. Oh please question. So the question is what is the proposal for using long thoracic nerve for shoulder function as a nerve transfer? Well so I think again if you think about the basic anatomy of the long thoracic most of it comes from six and seven. Very little comes from five. So if I'm telling you in our population that we see where they're usually pre-ganglionic, long thoracic is rarely, rarely available. So for us that's not an option and if it just has some trace of innervation from c7 then it's a or c6 or wherever it's coming from it's a party trick. It's not going to be useful in our patients but again I think that's the difference between Bertelli saying you know he has 70 to 80 percent and he's published 87 percent of c5s. We don't have that and other people don't seem to have that. Question? to experience seemingly very honest, respectful Well, I'll start with that. Peter Stern told me one time, your ego is not your amigo. And if you really, really think about that, there's a little bit too much ego in peripheral nerve. And one of the things that I've been very blessed with, with two partners, Dr. Spinner and Dr. Bishops, that when I examine somebody and I think they might hit a grade four plus, I have two eyes coming in saying, are you kidding? That's like a grade two. And so we have to be very honest with ourselves first. And then you have to understand the geographic area that your patients come from. And one of the highlights of this program was to show patients in Taiwan are very different from the patients in UK, are very different than the patients in Brazil, and you have to just try to take all these principles and then apply them. And I'll have Rob, if you want to add anything else to that. So I would just say stick with the basics, which is, unfortunately, this is a life changing injury. We're so sorry. I want to play piano. I never played it. So I want normal hand function. Unfortunately, no one in the world can get you that. And then think about what your priority is. Would it be useful for you to have really strong elbow flexion? Well, we can prioritize it. Shoulder, we can get you a little bit. Hand is really difficult. Is it worth it for you to either for us to try to get you some very basic rudimentary hand function? Is that going to be useful? Because I would say a bunch of those videos, as you saw as well as I, that's not very useful. It's an amazing accomplishment. But is it useful? So again, if you just tell your patient, you know, we're going to get you the best elbow flexion and shoulder, a little is a lot to those with nothing. One more question from Dr. Horry-Clifton. practice That's a very, very good point. And with that, I thank you for coming here to be first educated and understand the global perspectives and have a great day and a very safe meeting.

panplexus injuries

global perspective

patient demographics

treatment approaches

severe injuries

diagnostic tools

nerve function

surgical reconstruction

pain management

outcome reporting