do this, but there are a lot of people that work very hard in this section. The history section is not a joint section. It is a section completely devoted to the AANS and its history and to the history of neurosurgery and to the history of neuroscience and to the history of medicine as it pertains to neuroscience. So we're a small section, but we're a very devoted section. And so I'd like to have the officers stand up, and that's Chris Slofer, who is our past chair, who is an officer, Dr. Teo Daghi, who is here, who is our chair elect, well, secretary treasurer right now, and then Dr. Presa Giacomo, who is the chair elect, who then these people then become the chair, the chair elect, and the, well, the secretary treasurer is one of Dr. Scholder's faculty members, Mike Scholder from New Jersey, and then I'll be the past chair. So I want to thank these three people really are the ones that make things go here. So we've had a tremendous time in New Orleans because everything that we've done has been very applicable to New Orleans. On our Rangashere Memorial Lecture dinner night was a really fascinating history into the structure of the Charity Hospital system of Louisiana, and I don't know if you know about that history, but it is unique to Louisiana, and we heard a little bit about its founding, about its long history, and about its evolution, and with an emphasis on the big charity hospital, the one here in New Orleans, by Dr. Durant, who is a sociology professor, an emeritus at Louisiana State University, and now at Jackson State University. Excuse me. So in that vein, we wanted to have one of our luminaries talk to us, somebody who has been an institution in neurosurgery in our specialty, and somebody who is intimately knowledgeable and informed and experienced in Louisiana, and who is probably the person, if you think peripheral nerve, you think David Klein. And Dr. Klein has also been a very active member of our history section. He often comments on papers that are given, on presentations, and you sort of sit back and you have a new perspective on what has been presented to you. You have a lengthy perspective on this. So we decided that we wanted Dr. Klein to come back to Louisiana. I don't know if he really comes back. He's in North Carolina right now. But Dr. Klein is not only one of our institutions in neurosurgery, as a Boyd professor and emeritus chair of neurosurgery at the LSU Health Science Center, but Dr. Klein has been a prominent, perhaps the most prominent figure in peripheral nerve surgery and education and knowledge of post-war time, of combat injuries, of these sorts of things. He's experienced at Walter Reed and carrying that through to New Orleans. And I know from going through residency and as a young staff member and then as a more senior person, Dr. Klein is the person who we think of when we think of peripheral nerve and the AANS and neurosurgery. Also, Dr. Klein is not only a neurosurgeon, but he's a person who has given vast amount of hours back in terms of service in and around his hometown of Boone, North Carolina. So we couldn't think of anybody better to speak to us in New Orleans and to speak about his journey of 40 years here in Louisiana and about his career than Dr. David Klein and to award him with the Sir Victor Horsley Lectureship in the History of Neurosurgery. So I would appreciate if you would give him a round of acclamation. And we look forward in a couple seconds to hear his talk. Thank you. Sorry about that. Digital SLR. Thank you. Got it? All right. Thanks. Let me just move my computer and you'll be ready to go. Okay. So this is active. This is not active for you. Well, thank you, Mark Pruel. And I'm very happy to hear that your wife is doing better after an auto accident. You've been back and forth to Arizona several times. And I thank Dr. Daughey and Jim. Thank you. Thank all the history people for having me. It's a distinct honor. I'm going to start this by just a word about Victor Horsley, who I and many people view as the modern father of neurosurgery. And keep in mind, I'm quite retired, and I hope you remember that during this lecture. And does that make me a better history speaker or one that's worse? I don't know. Some days I think it's not so red hot, but some days I think it's pretty nifty to be retired. Horsley's contributions. And he lived just 60 years. Cerebral localization. That's what he's well known for. And he worked with a variety of neurologists and basic scientists in that area. He removed the first spinal cord tumor by a laminectomy. And he was involved with Clark on the first stereotaxic instrument, the Horsley-Clark stereotaxic instrument. Although many said it was mainly Clark who devised it. Horsley brought it into play with experimental animals. He was an experimentalist. And he was a vivisectionist. He believed in experimental work on animals. In my area, I was interested in finding out that he was one of the first people to have written about nerve vinerverum. This is nerves that innervate the epineurial level of the epineurium in major nerves. He described the motor function of cranial nerves one through three, which a lot of people felt at that time they didn't do anything motor-wise. And he talked about other substitutions to restore nerve function. He was a wonderful person to describe and to utilize experiments, to work on his principles. And of course, the anti-vivisectionists came after him tooth and nail. His election in the Royal College of Medicine was based on his work with absence of the thyroid or disease of the thyroid causing myxedema and eliminating rabies in Great Britain by quarantine all dogs that came into the country for at least six months before permitting them full-time residence. His devotion to the country was so great that when he lost a lot of his patients because of his stance against alcoholism, which was vibrant and outspoken, and because of his vivisectionist activities with experimental animals, he went back into the army and he got posted first to Egypt and then to Mesopotamia. In Mesopotamia, he was dealing with temperatures as high as 110. And his supervisors said, get out of the sun, stop working. He said, no, because only alcoholics die of heat stroke. And obviously, I'm not an alcoholic. Guess what he died of at the relatively young age, even for those time, of 60 years. I found this in the book about Montreal Neurologic Institute. And to the left, playing our lecture named person, playing him, is Webb Haymaker, who went on to do many, many things for our government. And then to his right is William Gibson, who helped found the college, one of the colleges at Oxford and another Oxford in England. And this is Hewling Jackson Day because, of course, that's what our speaker, our honoree, Sir Victor Horsley, took off from. I mean, he took off from Hewling Jackson's work and extended it for pre-motor strip, post-motor strip, and other areas in the brain. And they're in costume, and they have angel wings. You don't see Mr. Gibson so well portraying Hewling Jackson, but it's back there. And they've come down to earth in Montreal for this Hewling Jackson Day to perform. And okay, so he was in huge great regard, not only in America, many other countries, but even in Canada. Well, I should point out, right to begin with, this talk has been given before because, after all, I'm now 83 and almost 84. So it's been given to the Neurosurgical Society of America. It's been given to the North American Peripheral Nerve Society, and at several institutions where I've been a visiting professor. And I told Michael Schilder that, and I think Jim Goodrich, and I certainly told Rebecca Marchi, the scientific director for the ANS, but they still wanted to have me. So here it is. It's after World War II. We've had SEDN, and we've had neuropraxia, axonotomesis, and neurotomesis. We've had a trial with nerve grafts, which did not go well with World War II war-wounded soldiers. But along comes a chap by the name of Sidney Sunderland from Melbourne, and he served with the Australian Army, even though he was not fully trained in neurosurgery, helping the neurosurgeon do nerve cases. And what were his contributions? Well, of course, he pointed out the true nature of the interior of nerve and its fascicular structure, and how they change positions level to level, and also how they interrelated. And here's a view of fascicles dissected out, microsurgical epineurium removed, and it looks like they're totally linear structures. They're not. They're changing position relative to one another down the course of the nerve, and they're also trading off small branches as well as the major branches. He was very interested in the interior anatomy, the epineurium, the interfascicular epineurium, the perineurium around each fascicle, and eventually the endoneurium around the motor fibers and the larger sensory fibers, but not around all fibers. And he used this as well as Seddon's grading system to break it down, and I concentrate on this because this is so important to things we do today. Okay, he agreed. There's a concussion-like injury to nerve where conduction is temporarily stopped, and so you can't transmit from here. Oh, boy. I'm trying to get that from here to there. There's a blocking conduction, and you can't, by stimulating here, make muscle contract. But if you stimulate down here, muscle contracts. It's reversible. Anywhere in hours to three days. Some people say a week or two. It's a favorable lesion because the internal structure other than the axon is not affected. But then how about grade two, which Seddon would call axonotomesis, where axonal continuity is stopped, and so, of course, conduction from here distally stops, but down here after 72 hours, you can't stimulate the axons and get function. Up to 72 hours, you can, but they degenerate. They undergo Wallerian degeneration, and there's some distortion, not always very marked, of the endoneurial envelope around the nerve and perhaps even a little bit of the perineural structure. But he recognized very importantly that there's a grade three injury where not only is axonal continuity loss and endoneurial continuity pretty severely involved, but this is a lesion that has, in some patients, the potential for regrowth, regeneration, return of function. Both of these definitely do. How about grade three? Yes, and we don't know what those numbers are, but they can be surprisingly large. Only grade four, where there was a lot of destruction, not only of interfacicular epineurium, but epineurium itself, even though the nerve is in continuity, this one does not regenerate. Well, it does. It regenerates thousands and thousands of axons, but they tend to be fine. They tend to be poorly myelinated, and they have great trouble getting back to where they started out. They get lost in the interfacicular epineurium. They get lost more distally when they try to go to their end inputs, whether it be muscle or sensory. And then the obvious sudden lesion, the nerve is in half. So why were these changes important? Well, because by World War II and all the data that came out from it, even taking all the missile wounds, all the gunshot wounds, 70 percent of those that were serious, that took away function, still left the nerve in gross continuity. Only 30 percent put it apart. And guess what? That's sort of how it works with us in civilian practice. Okay. So the major advances, I think, since the 60s were the development of interfacicular graphs, because this is what Hanno Malese took advantage of, the Sunderland work. And he began to run the graphs from fascicle to fascicle, or groups of fascicles to groups of fascicles, to go into the nerve to place those graphs, not put them to the bare face of the proximal stump and back to the bare face of the distal stump. And I guess the development of intraoperative electrophysiology, and this is embarrassing to even mention because I think we're responsible for some of that, methods to safely remove most neural sheath tumors, nerve transfers, as well as direct repair for many stretch injuries, certainly expansion of surgical procedures for brachial plexus lesions, and renewed interest in many different repair techniques, such as intubation, and all that's come about since World War II, and aided and abetted by what happened in Korea, by what happened in Vietnam, what even happened in Iraq and Afghanistan. So wars, always for nerve, have played a big role. Well, here's the Malese technique. Weather the lesions apart, and you're trimming back at three weeks, so you know how far to trim back to get to healthy tissue, but you're left with a gap that you can't easily make up with minimal tension or a lesion in continuity that doesn't transmit a compound nerve action potential and needs to be resected, and you're left with a gap. So, you dissect out the fascicles and groups, and you do an interfascicular repair, fascicle to fascicle. And the epineurium and the scar, of course, has been resected, and oftentimes just two sutures are all that's necessary to get the grafts together, or some people use fiber and clot. Well, here's, you know, an injury to the brachial plexus. It was a gunshot wound in a Bosnian boy who loved to play outside, and his parents knew when the air raid siren stopped going off that it was okay if you waited 15 minutes to go outside. He did, and a shell came down and caught the upper trunk of the brachial plexus. So you're looking to 5 and 6. Here's 5, there's 6, there's upper trunk. Here are the branches of upper trunk, suprascapular nerve, posterior division, anterior division. There's C7, the middle trunk. And so we operated on him at four months, and we recorded, couldn't get anything through, so interfascicular grafts were placed in. And similar things for years have been used for stretch injuries where there's a viable nerve root stump, oftentimes C5, because C5, if you analyze large numbers of stretch injuries to the brachial plexus, it's only a volstance in 5% of patients, and sometimes it's 6, but not as often as 5. So in this case, it was 5 and 6. So grafts are going from viable stumps down to the trunk, upper trunk, and where they go to, C7 recorded a positive response, so only was cleaned up, not resected. So who's responsible for those interfascicular grafts? Well, I guess in a way you could say Seddon and all the people who worked with nerve during World War II, they all recognized the need to make up space and room, and they all tried their hand at it, but here's the man from Australia who made it feasible with the interfascicular grafts, and he just died, I guess, a year and a half ago. And that's his wife. He was married to a plastic surgeon, and he was a plastic surgeon himself. And a gentleman. We didn't always agree. We had some pretty vociferous arguments at meetings, because he sort of felt everything that needed repair should be done in this way, at least in the early years. And our data would suggest, well, even though you have some tension, if you can get a direct repair, it's always going to do better than putting in two suture lines and putting in grafts. He disagreed with that, because he developed a wonderful technique for making up length and taking all tension, or what he felt was all tension, away from repairs. So, you know, the big thing that World War II taught us from the wonderful chapters by J.C. White, Frank Nolson, the chair at Duke, and many others, is you can't tell by looking at a lesion in continuity whether it's going to do well or not do well. Here's one that's knobby firm and irregular, but when you section into it and did neurohistology, you got very patterned, very longitudinally oriented axons with early myelination. Here's one that looks modeled and good, looks like some bruising or abnormality here. When you sectioned into it, it was disordered axons of smaller size, and in a later specimen, not only smaller size, but poorer myelination. Here's how a stretch injury commonly looks at the operating table. So where do you operate? What do you take out? How do you repair there? Here's phrenic nerve, and there's the branch to the subclavius, and there's seven, and there is a lower trunk fed by eight and one. Well, one thing you can do is put on electrodes, record, and see what's transmitting or not. If it's preganglionic, you'll get very fast-conducting high responses. If it's either severely damaged at a central level, at a root level, and or more distally at spinal nerve to trunk, you're going to get flat traces. So you can section back, and if you don't find good anatomy, then you can begin to think about grafts and or doing transfers more distally. Here's an infraclavicular lesion that had very severe loss, not only in lateral cord, but posterior cord, but some sparing of medial cord, and that posterior cord looks bad, but it transmitted at five months, and so didn't need to be resected, whereas lateral cord did, and needed grafts, and medial cord, we knew ahead of time, was spared. And another situation like that, an infraclavicular gunshot wound where a lot of this looks bad, but some of it could be winnowed out, could be saved by intraoperative electrophysiology, and this is how it's done with small hook electrodes for larger nerves. This would be a size, stimulation, and recording. We use tripolar for stimulation, Lee Hippel taught us that, bipolar for recording, and different sizes for different nerves, and we use an EMG machine, because any EMG machine made in the last quarter century will basically have what you need, will have stimulus artifact suppression settings, will have differential amplifiers, and moreover, on the stimulus side, when you hook it up to a stimulus isolation unit, will have stimuli that can be very brief, not long, like you would use in the physiologic laboratory to get nerve function. It's important that you're using brief shocks, because longer shocks will pick out fine fibers and give you a response, but the short-duration shocks will be preferential for moderate-sized or large-sized fibers, and that's what you want to know about. So here's it being put to work in another stretch injury, and here we've already dissected out 5-6 upper trunk, and we're recording from 7 to middle trunk, and that had a response, and there were lead-outs in this case from both 5 and 6, because it was a C5-6, and in 15% of 5-6 lesions, when we studied hundreds and hundreds of avulsions, we found that in 15% C7 was involved, even though the pattern was all loss of supraspinatus, loss of deltoid, loss of biceps, loss of brachioradialis, weak supination. No hint of triceps weakness, no hint of C7 going to wrist or wrist weakness or finger extension weakness. Why is that? Because oftentimes C7, though, was still a contributor, particularly to what C6 did, so it was important to assess that. So you can see here an example of how that type of thinking was put to work. There's 5, and here's accessory nerve, which we use going to suprascapular nerve. The lead-out here was only from C6 that was usable, so when we did our recordings, it was either pre- and postganglionic or preganglionic at all R1, R2, R3, and R4 now. It looked bad, but when we stimulated here and recorded there, it had a response, so only a neuralysis was done. So C6 divisions, they were all flat, and we turned out when we sectioned back, we had a usable stump. Well, that argues against, maybe a little bit, transfers, but even better, as we'll talk about briefly later, transfers plus direct prayer do 15% better than either transfers or direct repair. We use this technology to study the ulnar nerve, an ulnar entrapment at the elbow, and I thank resident John Reeves for some of this data, and also Dan Kim and Gabe Tender, but we would record operatively at the table a proximal response and then see what happened to it as we approached the olecranial notch, and that's where it began to reduce, and it really reduced across the notch area and had very delayed conduction. So it was initially very bad here, but got worse coming down here, but there were only eight cases in 367 instances where we did this that the compression was distal to the olecranial notch. So I know our colleagues in orthopedics and plastic surgery talk lots about having to go down there and release the nerve. The main pathology, which fit with what we were looking at, seemed to be within the olecranial notch, and so that worries me a little bit about just doing exposure of the nerve, not doing a neuralysis through that area, but large series seem to support that in the milder cases of ulnar entrapment, so we'll leave that go. This was also taken to thoracic outlet cases, and here's a Gilead Sumner hand with small needle electrodes placed in T1 for stimulation and recording from distal lower trunk and divisions of lower trunk from C7 to middle trunk, C8 to lower trunk. You can see the conductions began to go down when we got down here in C8 to lower trunk, and they were particularly bad here, T1 to lower trunk. So not only the amplitude, but the conduction velocity, and this was fine needle electrodes over four centimeters or sometimes less. Now thanks to Mike Lusk, Tom Donner, Ran Voorhees, some of my visiting fellows like Raj Mittal, Rob Spinner, and Eric Zager, we did tackle neural sheath tumors, and like had been described before, there are nerve fibers that are somewhat compressed, stretched, and cloak a lot of the tumors, especially schwannomas, but also neurofibromas. But if you went to the trouble to stimulate and record from what went directly into the tumor or directly and indirectly came back out, you found that those were flat traces, and when you looked at the histology of those entry and exit places, it was very rudimentary, almost embryonic axonal population, very fine fibers, very poor myelination, and that permitted section here, section there, and taking out the tumor as a mass. And actually this is a neurofibroma involving the ulnar nerve at the level of the elbow. And neurofibromas before this study, which was published in the Journal of Neurosurgery, before they were felt to be non-resectable, now we know that solitary ones and better than 80% are resectable as long as you do the neurophysiology. Now, do you need to record across them? Of course not. You mainly stimulate something like this and see if it goes to important motor function, in this case, and intrinsics, and maybe the flexor profundus to the little finger and ring finger. That's all you need to know because if you lose a little sensory in the ulnar distribution, it's not as big a problem. Now, were you doing this tumor in the median? Recording across may be more important because the median has some very important sensory fibers in it. If you're doing the perineal with a tumor in it, no. What do you care whether there's some sensory loss? I mean, I always care, don't believe me, on the top of the foot, but you do care whether you can lift the foot, so the motor is important. You're doing the tibial just like the median. Yes, you're going to have to assess what you're moving away from the tumor to see whether it conducts and how big that is before you section it. But even neurofibromas, they'll have more than the schwannomas do. They'll have two or three, sometimes four, although rarely four, entry and exit fascicles that need to be taken to get the tumor out in toto. You know, we did go over this, and that really eventually led to the tumor story, but it also led to the story about Gilead-Sunderhand, and we started to do this on thoracic outlet problems that had some mild neurologic abnormalities, and we did find abnormalities, but I had to retire pretty much at the age of 75. I just couldn't sustain the long operations. And I needed to, because I had wanted to retire at 70, but I retired at 75 because Katrina. I stayed on longer. Is that somebody saying my time is up? Because my phone is going off. So there's the tumor, and there is another neurofibroma being totally worked out. Here's the schwannoma paradigm with one going in and one out. Here's the neurofibroma with multiple going in. You record from the ones that you can move away from the tumor, and for what goes in and goes out, you get a flat trace. So most neurofibromas can be excised with little or no disc. There are certainly exceptions to that, because sometimes there'll be one or more fascicles going into the center of the tumor, and certainly plexiform neurofibromas. You can't do that way. Sometimes total excision may cure the tumor but hurt the patient, and that's bad. You've got to remember that. So you have to be prepared for total excision or repair if needed. Always, always don't be so proud to neglect the need from vascular general, cardiovascular, or even orthopedic surgeon or our competitors, because you may need their help. You may need to divide that clavicle and need to have it put back together better than you can do it. You may need a vessel found that's bleeding that you can't stop that will need repair. And on and on we can go. You know my colleague of 36 years, and we did research together. We published together from the University of Toronto, Alan Hudson. Many things he taught me was about the need to involve other specialists and not to have so much pride to push ahead and think you could do everything together. Here he is at the wedding. Well, it's the second wedding. It's a remarriage. No, not the remarriage. That's the wrong term. It's a second go-around for my oldest daughter. Can you believe that? So that's how old we both were at this time. And he was kind enough to come. And I've been to the weddings of all of his children and all of his major events until his 80th birthday, which we were on the road to Lenore, North Carolina when that was occurring, so couldn't do that. But this picture also shows you the effect of floodwaters on photographs. And this is a polaroid photograph, and usually polaroids were immune to that chemical process, whatever it was in floodwaters. But Alan always said, look, you're going down a white big, big river or big, big stream. You may be at the helm, but you need all these other people to help you, and that's an important lesson. Aaron Filler and Michelle Cleo taught us about the usefulness of the new MRI components. They're very useful for tumors, occasionally for entrapments, occasionally for thoracic outlet problems. In most institutions, they're not as substituted as yet, but they're getting close to it. For a myelogram followed by a CT for severe stretch injuries, particularly flail arms. But a lot of the people that have the newer MRIs say they do just as well with that as a CT myelogram. Sometimes plain x-rays help, and that's because they'll show Parrot's beak, humeral condyle, and extra structure. So here's 5'6", and this is a normal nerve root exit on both sides. And this is a CT myelogram. Here's one that's abnormal. Here's a plain x-ray that showed this extension of the C7 lateral process, and this patient had compression of the lower elements of the brachial plexus, particularly 8 and 1. So there's the Parrot beaking that you can see. And sometimes if you have patients with TOS-like symptoms and you find that, well, more likely if you operate then, particularly if you decompress the plexus. It's not the bone that does it. It's the displacement of the ligaments and the muscle coming off. In this case, the deep scalene coming off an elongated C7 process or an extra rib, a cervical rib. So this is what I alluded to earlier. We looked at 1,040 spinal nerves in 208 patients with flail arms. 407 had inoperable proximal spinal nerve injuries, but these were the levels they were at. C7, C8, T1, 35% of cases. C7 and C8, 35%. Well, repairs at those levels, even if you had something to put in there, would not be so good. Knee transfers, tendon, or other. Various other combinations, including C6, 20%. Only 10% had avulsion of 5. I think I mentioned 4% or 5% because that's the newer figure when you have a flail arm, where everything else is out. So usually can find something to hook to. And my contention is, yes, I love the distal transfers, the Oberlin and the medial pectoral transfers and what they've done, and the accessory to suprascapular nerve. So what do we do? Where direct repair of one or more roots is possible, we can get a grade 3 or better result. And that's with the LSU system. LSU system, different from MRC. MRC is just contraction against gravity. And most muscles, that's not worth much. In the LSU system, it's contraction against gravity and some pressure. So with biceps, that makes a big difference. For shoulder abduction, that makes a big difference. Where transfers were added to repair of one or more roots, LSU grade 3 or better came up, at least 5%. Where only transfers were possible when you took all the things that you were neglecting by just concentrating on the biceps or on the deltoid, all the other things, like supination, like contribution into triceps, like latissimus dorsi, when you took all those things into account, the grades dropped to 30%. So I think the story for me, and I guess I'm too late to really prove this, although some of our results of pants over vests, which is doing both direct repair and transfers, are now available in the literature but probably not in a big enough study. But here's a flail arm. So how do you dissect this out? Well, eventually it had accessory to suprascapular nerve. We threw in descending cervical plexus. We were able to bring grafts out from C5 and bring it down into some of the upper trunk divisions. We weren't able to use C6, C7, 8, or 1. So we used intercostal nerve, and we would split the musculocutaneous. Part would be there for what came down from above. Part would be there for the intercostal nerve. And of course you can't do an Oberlin on this patient because the ulnar nerve doesn't work, nor does the medial pectoral nerve. If you don't believe in the Oberlin, rather do that work. So that's how the thinking has evolved up until now, I guess on my part, but I'd have to honestly say 2008 when I really retired. So an important study neglected by many. Oh, sharp injuries. Okay. Hanno, I wish you were here to see this. Operative plexus cases. Okay. Sharp transection. What happened to them? If we got them in time and it involved 83 plexus elements, none had neuralysis, of course the nerves were apart. We were able to get end-to-end suture, which I call primary suture, because we were able to get it within 72 hours. 25 of 31 elements came back to LSU grade 3 or better. Secondary suture did pretty well. Two-thirds, 8 of 12. Secondary grafts fell off, but 21 of 40 still came back to grade 3. So 54 of 83. Now blunt transection, there were 23 patients involving 61 elements, and of course neuralysis would not suffice, so we did get a few end-to-end repairs. They did fairly well. 60 percent came back. Grafts a little better than half came back. That's the overall take-up. But a wonderful group of people to operate on, eh? Here's a guy sawing a log with his still, I hope, saw, and he hits an embedded spike in that trunk, and it comes back and hits him in the supraclavicular area. Here's a lady bartender in the French Quarter. So be careful, gang, when you go into the French Quarter. And she was trying to calm down a recalcitrant patron who probably had too much to drink, and he broke his beer bottle and put her into her supraclavicular area. This is on the left side, so there's the phrenic nerve, clavicle down here, trap up this way, and the severance was here, was here, and we were able to convince vascular surgery, hey, you've done an angiogram, it's negative, you know? Why are you going to take her to the operating room? We need to take her to the operating room, because now is the time to repair this plexus. And fortunately they exceeded, because they had enough experience with the terrible Dr. Klein and his shouting matches, so they let us do it. And guess what? We could get an end-to-end repair, and this was done on the third day after that beer bottle hit her supraclavicular area. And this is a great group, because, you know, when you look at 71 patients with brachial plexus lacerations, sharp lacerations, looking at it element by element, no matter what, the bad elements folded in with good elements, 54 of 83 came back to at least grade 3 blunts, not so good, a little less than half, but overall totals were very, very good. So here's the cases, 20, 28, so almost a match, group 20, I mean, I'm sorry, in continuity, and that's the other lesson we learned. And I used to talk to Hanno about this all the time. How do you know that it's not going to regrow? Well, you don't if you go in acutely, no matter how clever you are. But by a little time, in particular if you're willing to use operative recordings, you'll know, and in this group of 20, with some degree of incontinuity involving 57 elements, having neuralysis, 24 of 26, a 94% take rate came back. But that's only if you're willing to go to the trouble to do this type of thing. 7 of 9 with secondary suture, and 17 of 22 with grafts, pretty favorable category, despite the severity of this injury. So when direct repair of one or more roots is possible, for the plexus, that's the way we go. We've already gone through that, and we've already gone through that. So what is left here? Well, some important things. Intubation of nerve, and we have to owe a lot to Simon Archibald. Now with Integra, as one of their scientific officers, he did the first studies in primate, with intubation, and many others, Lee Dillon, Rob Spinner, Raj Mithal, many others have been involved too. Works best for small distal sensory nerves, and larger nerves with small gaps, especially sharp transections. And really, if the gap gets over an inch or more, probably not a good procedure. Needed is further development of what's implanted in the tube to make them better. And this is a modified collagen, and here shows you some of the substrate of how the growth is coming from proximal to distal in the tube, and filling in that gap which gets filled with blood and serum. Okay, less certain innovations. Endocyte coaptation, called babysitting, you know. Yeah, you get some growth that way, putting a divided nerve into the side of an intact nerve. But the problem is, it's not very robust growth. And as a result, the people doing this are now making multiple windows in the intact nerve. Would you like to be doing that in the ulnar nerve for a median that's transected that you don't think you can repair? I don't think so. I won't. So maybe things will get better, but the babysitting is a disappointment, as is the side-to-side. Yes, you get axons, but seldom enough to make the function of what you're trying to get back to work. And maybe it's all you can do, so it's worth doing. Don't misunderstand me, but don't expect a whole lot. MRI to detect regeneration. Yes, you're seeing with the newer tractotomy studies wonderful displays of early axonal regeneration. But keep in mind that the worst lesion in continuity you'll ever encounter in your life as a neurosurgeon or a nerve surgeon will have thousands and thousands of axons there. It's how mature they are, where they're going, and where they wind up. And no amount of tractotomy so far done within the early weeks or months after a nerve injury is going to tell you, don't operate, it's going to get better. Or maybe you better operate. No. Ultrasound for entrapments. I think that's been good. I should really take that out of the less certain category and really applaud it, because I think with injuries at least it's going to show you whether the nerve is a part. And you're not going to make the nerve that's a part better by waiting on it, not in the human. Maybe in the rat, or maybe in the gerbil, or maybe in the hamster, or maybe in the rabbit, but not in the human. So a lot of opinions and anecdotal experience with some case reports needed as well-graded and evaluated outcomes in greater numbers of patients. Here to stay, nerve transfer for plexus and some peripheral lesions. I love some of Susan McKinnon's newer things for more distal nerve injuries. I worry a little bit, again, about whether you're focusing on what's felt important, but ignoring all the other things that that nerve does by just picking out a transfer for what you think is important. But it's an advance, and certainly the Oberlin is advanced. And use of medial pectoral, in our experience, was very good. I'd like to think operative NAP recordings are here to stay. Maybe someone will develop something better. I hope they do, because it's sort of a pain in the neck to have to do that. MRI for tumors and some entrapments, yes. Methods to bridge gaps, that's going to be our future. And the person picked out by General Ireland during World War II, who was a Michigan neuroanatomist, that's what he devoted all of his research to during World War II. Methods to make up gaps, because he had already concluded, even though he wasn't an M.D., that looking at the literature, looking about what he knew about the biology of nerve and the histology of nerve, you know, the things apart could usually be put back. But the other lesions couldn't without loss of a good deal of length. And so he devoted all of the experiments done at Michigan and farmed out to, I think, five other places in America. And some very famous early neurosurgeons and other surgeons involved with nerve were involved in that study. So Sir Sidney Sunderland, he pointed out before he died, okay, here's histology on a nerve graft, and this is the distal stump. So some of the axons several centimeters below the second suture site have gotten there, and some of them are pretty robust looking. Now, they're not like we'd have them bigger and better myelinated, but a lot of them are still extra fascicular. And that's because what occurs at that injury site is not only loss of length but secondary scar, particularly in blunt injuries, particularly when there's any element of stretch, and that can go up and down the nerve. And so methods need to be devised to take that into account and continue research in this area. I had meant to mention, and I will mention, you know, my wonderful people at LSU. You know, I had, over the years, 80 fellows who came and spent time, and my own residents who were long-suffering because they wanted to do brain, they wanted to do spinal cord. But I got some of them interested. You know, like Dan Kim. You know, couldn't have done without him. I got Alan Hudson, who was, I think, wavering, but he got a Canadian FRCS fellowship and chose to come. And really, I learned more from Alan than I taught him. I had Susan McKinnon, a few years after Alan Hudson. I had the plastic hand surgeon, who was one of the first to do closed carpal tunnel release. I had people from other disciplines and other countries, as well as our own country, and I'm very proud of that, and I'm very thankful to them, because a lot of what I've talked about, they did, not me. Thank you very much. APPLAUSE There are some people here that, there's no reason that they should be here. Look at the foremost neurobiologist and neuroanatomist and neuro-everything from England is sitting right there, and what could I have said that he didn't know about, and many others in the audience. So, Annie Dubisson from Belgium and many others involved in nerves, so I apologize to you, but it's been fun to do it again. Thank you.

Dr. David Klein

peripheral nerve surgery

neurosurgery advancements

AANS

neuroscience history

Charity Hospital system

Sir Victor Horsley

interfacial graph techniques

nerve repair