Age	45 years
Gender	Male
Diagnosis	Posttraumatic paraplegia at L1 level

Summary:

The patient was exposed to trauma 3 months ago with subsequent burst fracture of L1 body with paraplegia at that level. The patient was operated elsewhere and fusion was attempted and for unknown reasons the device was removed after 5 days and the patient was left unable even to set down, for the mobile fracture and progressing infection. The patient was treated for 3 months for the infection and was sent to Al-Shmaisani hospital. 28-01-2004, the old incision was refreshed and skeletonization of D10 down to L3 was performed , exposing during that the postganglionic parts of the roots after removal of the intertransverse ligaments above them. Corporectomy of L1 was performed with the aid of drilling. The dura was exposed 3 cm above and below the affected level. The dural sac was seen to be completely transected . Sural nerve grafts were harvested from both legs and a cross anastomosis was performed between the proximal Th11 and L2 distal parts both sides. There was a small piece of sural graft left and used to anastomose the right Th12 with one of the running roots of the cauda equina. After then, using Luque fixation, fusion was performed between D10 down to L3.

Anatomical considerations:

The spinal dura mater is the external layer ,which surround the spinal cord and outgoing spinal roots . The dura reaches the sacral region and the filum durae materis spinalis becoming adherent with the periosteum of the coccygeal bone. The outgoing roots are engulfed by the dural sheet down to the intervertebral foramina

Muscles of the Lower limbs:

The muscles can be divided into four major groups: 1. Muscles of the pelvico-femural group. 2.Muscles of the femur. 3: Muscles of the knee joint. 4: Muscles of the foot. Special muscles to the pelvic girdle are not considered, since the pelvic girdle is rigid. The muscles of the lower limbs have the nerve supply through the lumbar and sacral plexuses.
Muscles of the pelvico-femural group:
These muscles take origin from the pelvic girdle and anchor the femur, so as to perform motion to the hip joint to all possible rotations. These muscles are divided into anterior, posterior and medial groups.
The anterior group: Flexing the hip joint, they are attached to the lesser trochanter. Iliopsoas ( psoas major, m.iliacus and minor psoas)
1. Iliopsoas muscle has two heads , psoas major originating from the lateral walls of bodies and intervertebral structures of the 12th dorsal vertebral body, down to the 4th lumbar body, including the transverse processes of these bodies. The muscle fibers continue down and in slight lateral direction, becoming united with iliac muscle, which take origin from the iliac fossa, and the anterior and inferior iliac spines In the groove between the tow heads running the femoral nerve. The iliopsoas muscle running anterior to the hip joint , passing the lacuna musculorum of the inguinal canal. The muscle including flexing the hip joint , can flex the pelvis and the trunk anteriorly , in case of keeping the legs fixed. The innervation is from L2-4 roots through the lumbar plexus.
2. Psoas minor: Not in all people can be seen, it is laying above the iliopsoas muscle, transforming to iliac fascia , anchoring to the iliopubic eminence. It stretches the iliac fascia and flex the lumbar spine. The innervation is from L1-2 roots through the lumbar plexus.
The posterior group: Extensors, rotators and adductors of the hip joint, they are attached to the greater trochanter and its surrounding area. In this group the following muscles: m.gluteus maximus, m.gluteus medius, m.tensor fasciae latae, m. gluteus minimus, m. piriformis, m. obturatorius, mm. gemelli, m. quadratus femoris and m. obturatorius externus.
1. Gluteus maximus: A massive muscle taking origin from the outer surface of the iliac bones , the thoraco-lumbar fascia , lateral aspects of the sacrum and coccygeum and sacrotuberal ligament, going down. The anterior part of the muscle transforming to wide ligament, running around the lateral aspect of the major trochanter continue in the form of iliotibial tact. The posterior part of the muscle anchor to the gluteal tuber of the femur. In addition to hip extension, it rotate the hip laterally. With tension it keep pelvic and trunk balance. The innervation is from L5-S1 roots through the sacral plexus.
2: Gluteus medius: Originate from the outer layer of the iliac bone with point of fixation to the lateral surface of the greater trochanter, near its tip. During contraction it abduct the hip. The anterior part of the muscle, when contracting in isolation, rotate the femur inside, but the posterior part , rotate outside. In standing position, during its contraction, it bends the pelvis to its side. The innervation is from L4-S1 roots through the sacral plexus.
3:Tensor fasciae latae: Anterior to the gluteus medius at the lateral surface of the thigh, between two sheets, which unify to form the iliotibial tact, which anchor to the lateral epicondyle of the tibial bone. During contraction, it flexes the hip and knee joints and outer rotation of the last. The innervation is from L4-S1 roots through the sacral plexus.
4:Gluteus minimus: Below the gluteus medius, originate from the outer surface of the iliac bone to be attached to the anterior aspect of the greater trochanter. Functioning the same as gluteus medius. The innervation is from L4-S1 roots through the sacral plexus.
5.Piriform muscle: Originate from the pelvic side of the sacrum, lateral to the sacral foramen. It cross the major ischiadic foramen from the pelvic cavity horizontally , posterior to the hip joint to be attached to the greater trochanter. It rotate the femur outside and to lesser degree abducting it. With legs fixed, it rotate the pelvis to its side and anteriorly. The innervation is from S1-2 roots through the sacral plexus.
6.Internal obturator muscle: originate from the boundaries of the obturator foramen and membrane, encircling the minor ischiadic foramen, to be attached to the trochanteric fossa of the femur. Parallel to the ligament of the internal obturator muscle after emergence from the pelvic cavity, the two gemelli muscles also attach the fossa trochanterica . These muscles rotate the femur outside. The innervation is from L4-S2 roots through the sacral plexus.
7.
The medial group: Adducting the hip joint, except gracilis muscle, which is attached to the tibia, they are attached to linea aspera femoris. In this group the following muscles: M. pectineus, m. adductor longus , m. adductor brevis, m. adductor magnus and gracilis muscle.


	Common picture of the muscular system , demonstrating the minimal role of the muscles of the thoracic spine in locomotion. View from behind Common picture of the muscular system , demonstrating the minimal role of the muscles of the thoracic spine in locomotion. View from anterior. The dermatomal map of the spinal cord innervation. View from behind The dermatomal map of the spinal cord innervation. View from anterior

Indications for surgery:

Complete paraplegia below the level of D8, since the targeted healthy roots are above the lesion and below Th3 postganglionic roots. The more inferior level the better the outcome and the higher are less promising.
Young age below the 45 years, since recovery and positive results will take effect after 3-6 years with vigorous physiotherapy.
Absence of mental disorders and full desire of the patient to walk, even with braces, orthoses or with crutches.
Understanding , that this procedure is not related to his micturition and defecation problems and it is intended to the ability to make his musculoskeletal system for walking active after several years.
Since it is hard to estimate the neurological outcome in the immediate posttraumatic period, these procedures are undertaken not earlier than 8-12 months after injury.
Since for locomotion the L1-down to S1 roots are important, the patient needs donors from his matching with high grade of matching of the neural grafts, after using the maximum of his own sources. The more roots supplied , the better the outcome.

Legal aspects:

1. Since the selection of the patients, in this stage of implementation of such new surgery, confined to completely paralyzed patients, they will loose nothing. In the contrary, every positive result will be noticeable, comparing to the zero functionality, obtained by EMG and ECS performed before surgery. The jeopardized dorsal nerves, must be taken after the emergence of the rami albicans and gresium to avoid sympathetic system dysfunction. Check for diaphragmatic breathing pattern should be studied, to avoid possible breathing difficulties in the long run.

2. The donors must be completely matching the patient, since there is no urgency in performing such surgery. This avoid the patient the protocol of aggressive chemotherapy and its sequences, which is a high price to such a situation.

3. The donors lose minimal, since the sural graft for more than 100 years is taken as routine in other surgeries. The only visible scar of the incision will be noticed and no functional deficit will arise from such, old applied procedure.

References:

Prives M.G., Lisenkov N.K., Bushkovich V.I., Anatomia cheloveka 1974. Leningrad -Meditsina.USSR.

To my knowledge, it is the first operation performed using the postganglionic roots in paraplegia , using sural grafts to improve the regenerating outcome of the neurological state of the patient . From this preliminary experience, it became evident, that there must be at least 10-16 sural grafts to complete the task. It means that there must be nerve graft donor bank to make this mission possible.It is too early to predict the outcome of such procedures, but it is known for more than 100 years that grafts giving results when performed at the postganglionic peripheral nervous system. It is now clear that such procedure can make the paraplegic (walk) , if the lesion is below the mid-dorsal level. This fact will open new dimensions in the surgical treatment of paraplegia.

More than 10 months, the surgical activity came to hold, due to lack of donors and the need to promote the idea, for what I have yet no time. For that reason, I strongly appreciate the involvement of other neurosurgeons to make the project come to common practise. Another time, I am not a seeker for authorities or patents.

There are a lot of tasks, which can be achieved, with the creation of nerve graft bank, and many problems waiting to be resolved after then.

There is one idea evolving in mind, but still lacking theoretical acceptance : using cross anastamosis between the upper and lower roots in relation to lesion .

24. January 2005 00:33:11