LUCIANO HENRIQUE LOPES FORONI
Projetos de Pesquisa
Unidades Organizacionais
Instituto de Psiquiatria, Hospital das Clínicas, Faculdade de Medicina - Médico
Instituto Central, Hospital das Clínicas, Faculdade de Medicina - Médico
LIM/45 - Laboratório de Fisiopatologia Neurocirúrgica, Hospital das Clínicas, Faculdade de Medicina
Instituto Central, Hospital das Clínicas, Faculdade de Medicina - Médico
LIM/45 - Laboratório de Fisiopatologia Neurocirúrgica, Hospital das Clínicas, Faculdade de Medicina
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- Nerve transfers for acute flaccid myelitis: a case series(2021) HEISE, C. O.; OLIVEIRA, A. J. de; BHERING, T.; MARTINS, R. S.; STERMAN-NETO, H.; FORONI, L.; SIQUEIRA, M. G.Background Acute flaccid myelitis (AFM) syndrome consists of loss of lower motor neurons following a viral infection, with preserved sensory function. It usually affects the upper limbs asymmetrically, with proximal more than distal muscle involvement. Methods Five cases were surgically treated with nerve transfers: spinal accessory to suprascapular nerve transfer (4 patients), branch of radial nerve to axillary nerve transfer (Somsak's procedure) (2 patients), and transfer of a fascicle of the ulnar nerve to the motor branch to the biceps (Oberlin's procedure) (1 patient). Results Motor improvement was seen in three cases. Widespread motor involvement was associated with poor outcome. Conclusion This small series of cases reinforces that nerve transfers are a reliable option for treatment of selected children with AFM.
- A Prospective Study Comparing Single and Double Fascicular Transfer to Restore Elbow Flexion After Brachial Plexus Injury(2013) MARTINS, Roberto Sergio; SIQUEIRA, Mario Gilberto; HEISE, Carlos Otto; FORONI, Luciano; TEIXEIRA, Manoel JacobsenBACKGROUND: The recovery of elbow flexion in upper brachial plexus injury can be achieved by the reinnervation of the biceps muscle (single reinnervation), but concomitant restoration of brachialis and biceps function (double reinnervation) has been recommended to improve elbow flexion strength. OBJECTIVE: To prospectively compare morbidity and outcomes of single or double muscle reinnervation in restoring elbow flexion following incomplete injury to the brachial plexus. METHODS: Forty consecutive patients were prospectively submitted to single or double muscle reinnervation. Elbow flexion strength was evaluated with a push-and-pull dynamometer 12 months after surgery. Hand morbidity related to the procedures was evaluated by the Semmes-Weinstein monofilaments test, quantification of static 2-point discrimination, and measurements of handgrip and lateral pinch strength in serial evaluations up to the final follow-up. RESULTS: Similar results for the strength of elbow flexion were observed in both groups. A worsening of sensibility, measured by using Semmes-Weinstein monofilaments, was identified in 8 patients, all of whom showed recovery during follow-up. No worsening of 2-point discrimination was observed. A decrease in handgrip and lateral pinch strength was identified in 8 and 9 patients, respectively, which improved during follow-up. There was no difference between the groups in the incidence of hand motor morbidity parameters. CONCLUSION: The strength of elbow flexion did not differ significantly between the groups treated with single or double muscle reinnervation. Deterioration of handgrip, lateral pinch strength, and sensibility measured by using Semmes-Weinstein monofilaments, was temporary, resulting in low morbidity for both techniques.
- Distal nerve transfer versus supraclavicular nerve grafting: comparison of elbow flexion outcome in neonatal brachial plexus palsy with C5-C7 involvement(2017) HEISE, Carlos O.; SIQUEIRA, Mario G.; MARTINS, Roberto S.; FORONI, Luciano H.; STERMAN-NETO, HugoPurpose Ulnar and median nerve transfers to arm muscles have been used to recover elbow flexion in infants with neonatal brachial plexus palsy, but there is no direct outcome comparison with the classical supraclavicular nerve grafting approach. Methods We retrospectively analyzed patients with C5-C7 neonatal brachial plexus palsy submitted to nerve surgery and recorded elbow flexion recovery using the active movement scale (0-7) at 12 and 24 months after surgery. We compared 13 patients submitted to supraclavicular nerve grafting with 21 patients submitted to distal ulnar or median nerve transfer to biceps motor branch. We considered elbow flexion scores of 6 or 7 as good results. Results The mean elbow flexion score and the proportion of good results were better using distal nerve transfers than supraclavicular grafting at 12 months (p < 0.01), but not at 24 months. Two patients with failed supraclavicular nerve grafting at 12 months showed good elbow flexion recovery after ulnar nerve transfers. Conclusion Distal nerve transfers provided faster elbow flexion recovery than supraclavicular nerve grafting, but there was no significant difference in the outcome after 24 months of surgery. Patients with failed supraclavicular grafting operated early can still benefit from late distal nerve transfers. Supraclavicular nerve grafting should remain as the first line surgical treatment for children with neonatal brachial plexus palsy.
- Fascicular Anatomy of the Musculocutaneous Nerve in Its Origin in Lateral Cord. Could It Be Used for Better Surgical Results?(2021) FORONI, Luciano; OLIVEIRA, Adilson Jose Manuel de; SIQUEIRA, Mario Gilberto; MARTINS, Roberto Sergio; HEISE, Carlos OttoBACKGROUND: Though anatomy of the brachial plexus is well known, its fascicular anatomy is still a challenge. In case of themusculocutaneous nerve (MCN), the position of the motor branches at its terminations is well known; however, their position in the lateral cord has been rarely investigated. OBJECTIVE: To describe the position of motor branches of the MCN at its origin in the lateral cord. METHODS: The MCN of 26 adult nonfixed cadavers was dissected from its terminal branches in the medial aspect of the arm to its origin from the lateral cord of the brachial plexus (from distal to proximal) on the right side, removed, and fixed. Intraneural longitudinal fascicular dissectionwas performed using microsurgical techniques, withmeticulous removal of connective tissue and subsequent identification and tracking of fibers of each MCN branch. RESULTS: At the origin of the nerve, biceps and brachialis muscle fiberswere concentrated in the lateral portion of the nerve (100%), and the sensory fiberswere preferentially located in the medial portion (78%). CONCLUSION: At its origin, the lateral portion of the MCN is the best location to coapt. donor nerves in order to improve motor results.
- The nerve to the levator scapulae muscle as donor in brachial plexus surgery: an anatomical study and case series(2021) MARTINS, Roberto Sergio; SIQUEIRA, Mario Gilberto; HEISE, Carlos Otto; FORONI, Luciano; NETO, Hugo Sterman; TEIXEIRA, Manoel JacobsenOBJECTIVE Nerve transfers are commonly used in treating complete injuries of the brachial plexus, but donor nerves are limited and preferentially directed toward the recovery of elbow flexion and shoulder abduction. The aims of this study were to characterize the anatomical parameters for identifying the nerve to the levator scapulae muscle (LSN) in brachial plexus surgery, to evaluate the feasibility of transferring this branch to the suprascapular nerve (SSN) or lateral pectoral nerve (LPN), and to present the results from a surgical series. METHODS Supra- and infraclavicular exposure of the brachial plexus was performed on 20 fresh human cadavers in order to measure different anatomical parameters for identification of the LSN. Next, an anatomical and histomorphometric evaluation of the feasibility of transferring this branch to the SSN and LPN was made. Lastly, the effectiveness of the LSN-LPN transfer was evaluated among 10 patients by quantifying their arm adduction strength. RESULTS The LSN was identified in 95% of the cadaveric specimens. A direct coaptation of the LSN and SSN was possible in 45% of the specimens (n = 9) but not between the LSN and LPN in any of the specimens. Comparison of axonal counts among the three nerves did not show any significant difference. Good results from reinnervation of the major pectoral muscle (Medical Research Council grade >= 3) were observed in 70% (n = 7) of the patients who had undergone LSN to LPN transfer. CONCLUSIONS The LSN is consistently identified through a supraclavicular approach to the brachial plexus, and its transfer to supply the functions of the SSN and LPN is anatomically viable. Good results from an LSN-LPN transfer are observed in most patients, even if long nerve grafts need to be used.
- Outcomes from primary surgical reconstruction of neonatal brachial plexus palsy in 104 children(2019) SIQUEIRA, Mario G.; HEISE, Carlos Otto; ALENCAR, Gustavo C.; MARTINS, Roberto S.; FORONI, LucianoPurposeThe outcome from microsurgical reconstruction of neonatal brachial plexus palsy (NBPP) varies, and comparison between different series is difficult, given the differences in preoperative evaluation, surgical strategies, and outcome analysis. To evaluate our results, we reviewed a series of children who underwent surgical treatment in a period of 14years.MethodsWe made a retrospective review of 104 cases in which microsurgical repair of the brachial plexus was performed. Strength was graded using the Active Movement Scale. Whenever possible, upper palsies underwent surgery 4 to 6months after birth and total lesions around 3months. The lesions were repaired, according to the type of injury: neurolysis, nerve grafting, nerve transfer, or a combination of techniques. The children were followed for at least 24months.ResultsThe majority of cases were complete lesions (56/53.8%). Erb's palsy was present in 10 cases (9.6%), and 39 infants (37.5%) presented an extended Erb's palsy. The surgical techniques applied were neurolysis (10.5%), nerve grafts (25.9%), nerve transfers (34.6%), and a combination of grafts and transfers (30.7%). The final outcome was considered poor in 41.3% of the cases, good in 34.3%, and excellent in 24%. A functional result (good plus excellent) was achieved in 58.3% of the cases.ConclusionsThere is no consensus regarding strategies for treatment of NBPP. Our surgical outcomes indicated a good general result comparing with the literature. However, our results were lower than the best results reported. Maybe the explanation is our much higher number of total palsy cases (53.8% vs. 25% in the literature).
- Functional outcome of spinal accessory nerve transfer to the suprascapular nerve to restore shoulder function: Results in upper and complete traumatic brachial plexus palsy in adults(2019) SIQUEIRA, Mario G.; MARTINS, Roberto S.; SOLLA, Davi; FAGLIONI, Wilson; FORONI, Luciano; HEISE, Carlos O.Background: Shoulder stability, abduction and external rotation are vital for the performance of usual daily tasks. Aims: To compare the functional outcomes in the shoulder following spinal accessory to suprascapular nerve transfer (SASNT). Patients and Methods: Comparison of the outcome of adult patients with upper traumatic brachial plexus palsy undergoing SASNT with patients with complete palsy submitted to the same procedure. Statistical Analysis: Ranges of motion were compared via the Mann-Whitney U test. The percentages of patients with a favorable outcome were compared by the chi-square test. All tests were two-tailed and P values <0.05 were considered statistically significant. Results: SASNT was performed in 76 patients: 23 cases (30.2%) of upper-plexus injuries and 53 cases (69.7%) of complete brachial plexus palsy. Good shoulder abduction was achieved in 15 patients (65.2%) with upper plexus palsy and a good external rotation in 5 (21.7%). In those patients with a good recovery, the average range of motion (ROM) was 53 degrees for shoulder abduction and 71.2 degrees for external rotation. Thirty-six patients (67.9%) with complete palsy had a good shoulder abduction recovery with 30.7 degrees of average ROM, but only 3 patients (5.6%) recovered a good shoulder external rotation with 68.3 degrees of average ROM. There was no statistical difference for the abduction outcome, but the external rotation outcome was superior in the upper plexus palsy group. Conclusion: SASNT is a consistent procedure to achieve functional recovery of shoulder abduction after a partial or complete plexus injury, but the outcomes of external rotation were quite disappointing in both the groups.
- Morbidity following sural nerve harvesting: A prospective study(2012) MARTINS, Roberto S.; BARBOSA, Rafael A.; SIQUEIRA, Mario G.; SOARES, Matheus S.; HEISE, Carlos Otto; FORONI, Luciano; TEIXEIRA, Manoel J.Objective: To evaluate donor site morbidity following sural nerve harvesting, with special attention to the recovery of sensory loss. Methods: We prospectively followed 38 subjects who underwent sural nerve harvest, including two with bilateral nerve excision. Symptoms related to sural nerve excision were evaluated and demarcation of the area with reduced touch sensation was quantified. Assessments were performed periodically up to 1 year after surgery and the results of different sensory evaluations were compared. Results: A significant reduction of sensory deficit was identified between consecutive evaluations (p < 0.05). Decreases of 26.85%, 20.69% and 24.29% were observed 3, 6 and 12 months after surgery, respectively. Shock-like pain (7.5%), stabbing pain (7.5%), and numbness (5%) were the most frequently reported symptoms. All symptoms were brief and resolved spontaneously 3-6 months after surgery. Conclusion: Sural nerve harvest can be performed with acceptable morbidity. When present, symptoms resolve between the third and sixth month after surgery and a significant reduction of sensory loss in the area innervated by the sural nerve was observed during the first year of follow-up.
- Diagnostic accuracy of imaging studies for diagnosing root avulsions in post-traumatic upper brachial plexus traction injuries in adults(2020) BORDALO-RODRIGUES, Marcelo; SIQUEIRA, Mario G.; KURIMORI, Ceci O.; CARNEIRO, Ana Carolina R.; MARTINS, Roberto S.; FORONI, Luciano; OLIVEIRA, Adilson J. M.; SOLLA, Davi J. F.Background There is no consensus about which type of imaging study, computed tomography myelography (CTM) or magnetic resonance imaging (MRI), provides better information concerning root avulsion in adult brachial plexus injuries. Methods Patients with upper brachial plexus traumatic injuries underwent both CTM and MRI and surgical exploration. The imaging studies were analyzed by two independent radiologists and the data were compared with the intraoperative findings. The statistical analysis was based on dichotomous classification of the nerve roots (normal or altered). The interobserver agreement was assessed using Cohen's Kappa. The accuracy of CTM and MRI in comparison with the intraoperative findings was evaluated using the same methodology. Results Fifty-two adult patients were included. CTM tended to yield slightly higher percentages of alterations than MRI The interobserver agreement was better on CTM than on MRI for all nerve roots: C5, 0.9960 (strong) vs. 0.145 (poor); C6, 0.970 (strong) vs. 0.788 (substantial); C7, 0.969 (strong) vs. 0.848 (strong). The accuracy regarding the intraoperative findings was also higher on CTM (moderate, kappa 0.40-0.59) than on MRI (minimal, kappa 0.20-0.39) for all nerve roots. Accordingly, the overall percentage concordance (both normal or both altered) was superior in the CTM evaluation (approx. 70-75% vs. 60-65%). CTM was superior for both sensitivity and specificity at all nerve roots. Conclusion CTM had greater interobserver agreement and higher diagnostic accuracy than MRI in adult patients with root avulsions due to brachial plexus injury.
bookPart Hipertensão Intracraniana(2012) FORONI, Luciano Henrique Lopes; PINTO, Fernando Campos Gomes