Clin Plastic Surg 30 (2003) 109 126
Pathophysiology of nerve injury
Sergio P. Maggi, MD, James B. Lowe III, MD, MBA,
Susan E. Mackinnon, MD*
Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, Suite 17424 East Pavilion,
One Barnes-Jewish Hospital Plaza, St. Louis, MO 63110, USA
Anatomy
Connective tissue
A normal myelinated nerve is represented in Fig. 1,
which demonstrates the extensive connective tissue
that makes up the major component of the nerve and
provides the scaffolding for the axons and their
Schwann cells. Early studies of peripheral nerve anat-
omy delineated much of the fundamental architecture.
Key and Retzius [1] detailed the subdivision of epi-
neurium, perineurium, and endoneurium. The loose
areolar tissue external to the epineurium is termed the
mesoneurium. It is continuous with the epineurium
and is critical to the longitudinal excursion of pe-
ripheral nerves. Millesi [2] stressed the importance of
the mesoneurium in aiding the movement of the nerve
in its surrounding tissue bed. Millesi [3] has shown that
the median nerve moves up to 9.6 mm with wrist
flexion and slightly less with extension. Wilgis and
Murphy [4] demonstrated that the median and ulnar
nerves glide longitudinally approximately 7.3 mm and
9.8 mm, respectively, with elbow flexion. Nerve
excursion is critical in normal physical activity, and
chronic nerve compression or associated fibrosis may
significantly impair the ability of a nerve to glide,
resulting in pain or discomfort.
The outer sheath of the nerve is the external
epineurium and is composed primarily of collagen
and elastic fibers. The internal epineurium is the
* Corresponding author.
E-mail address: mackinnons@msnotes.wustl.edu
(S.E. Mackinnon).
0094-1298/03/$ see front matter D 2003, Elsevier Science (USA). All rights reserved.
doi:10.1016/S0094-1298(02)00101-3
structure that invests the fascicles, which are com-
posed of myelinated and unmyelinated nerve fibers
[5]. Fascicles vary in quantity and in size; much of
the variety depends on the anatomic level and posi-
tion of the peripheral nerve. Fascicular anatomy of a
peripheral nerve can consist of a single fascicle
(monofascicular), few fascicles (oligofascicular), or
many fascicles (polyfascicular) (Fig. 2).
Each fascicle is encircled by the connective tissue
known as perineurium. The cellular make-up of the
perineurium consists of collagen fibrils dispersed
among perineural cells [6]. The perineural layer is a
major site for selective permeability because of the
tight junctions that form between adjacent perineural
cells. Surrounding each individual axon is a loose
gelatinous collagen matrix called the endoneurium
[7]. Although the endoneurial tissue has some tensile
strength, the perineurium provides the peripheral nerve
with most of its tensile strength and elasticity [8].
The volume and quality of intra- and extraneural
connective tissue varies among different nerves and
within the same nerve at different levels and anatomic
sites [5]. For instance, superficial nerves have been
shown to have substantial increases in connective
tissue as they cross joint surfaces. The sciatic nerve
has been shown to consist of approximately 87%
connective tissue as it crosses the hip, which may be
the result of a local reaction to repetitive strain or as a
protective mechanism of nature [5].
Neural topography
In the more proximal aspects of the extremities,
there is a significant plexus formation between the
fascicles, but the sensory and motor topography is
110 S.P. Maggi et al. / Clin Plastic Surg 30 (2003) 109126
Fig. 1. Diagrammatic representation of the cross-section of a normal peripheral nerve demonstrating the connective tissue and
nerve tissue components. (Adapted from Mackinnon SE, Dellon AL. Surgery of the peripheral nerve. New York: Thieme, 1988.
p. 36; with permission.)
specific. In the distal aspects of the extremity, the
plexus formation between fascicles is far less exten-
sive. Sunderland [9] reported that the internal topog-
raphy of peripheral nerves became increasingly more
organized as they progressed distally (Fig. 3).
Jabaley [10] has shown that nerve fascicles have
Fig. 2. Schematic diagram of the three types of fascicular
patterns: monofascicular (left top), oligofascicular (center
top), and polyfascicular (right top). Below are schematic
examples of unmyelinated (left) and myelinated axons (right).
A single Schwann cell can envelop multiple unmyelinated
axons or concentrically wrap its cell membrane around an
axon to form a myelinated fiber. (From Winagrad J,
Mackinnon S. Peripheral nerve injuries: repair and recon-
struction. In: Mathis S, Hentz VR, editors. Plastic surgery.
Philadelphia: Elsevier and Saunders; 2003; with permission.)
significantly fewer interfascicular connections, or
plexus formation, distally as compared with prox-
imally in the extremity.
Jabaley [10] demonstrated that the recurrent motor
branch of the median nerve can be readily dissected
without plexus formation for approximately 70 mm,
and the anterior interosseous nerve at the level of the
medial humeral epicondyle can be separated prox-
imally approximately 60 mm. The development of
more functionally distinct fascicles in distal periph-
eral nerves allows a more extensive surgical dissec-
tion via internal neurolysis and provides a variety of
reconstructive options (Fig. 4). Therefore, an under-
standing of the anatomical patterns and topography of
different peripheral nerves is an essential component
to peripheral nerve surgery [11].
Blood supply
The blood supply to peripheral nerves occurs via
an intrinsic and extrinsic system. The intrinsic system
circulates within the epineural sheath, and the
extrinsic circulation is derived from small vessels
outside of the nerve. These vessels can enter the
nerve via one of three patterns: segmental with no
dominant pedicle, one dominant pedicle coursing
longitudinally with the nerve, and multiple dominant
pedicles along the length of the nerve [12] (Fig. 5).
The external vessels enter the mesoneurium and
communicate with the epineurial space via the vasa
nervorum. At this junction, a plexus formation devel-
ops and runs longitudinally within the perineurial
 S.P. Maggi et al. / Clin Plastic Surg 30 (2003) 109126
Fig. 3. Sunderlands classic reconstruction of the internal
topography of a peripheral nerve with marked plexus
formation. (From Sunderland S. Nerves and nerve injuries.
Edinburgh: Churchill Livingstone; 1978; with permission.)
space. This plexus enters the endoneurium at an
oblique angle to anastomose with the intrinsic cir-
culation that surrounds each nerve fascicle. This
junction is a site of potential circulatory compromise
with increase in endoneurial pressure.
Many studies have shown that peripheral nerves
have a well-developed intrinsic blood supply [13 15].
Breidenbach [12] used radioactive microspheres in the
111
rabbit sciatic nerve model to evaluate intraneural
blood flow. He demonstrated that a peripheral nerve
could be raised independent of its extrinsic inflow
without evidence of ischemic damage. He demonstrat-
ed that a nerve receiving flow from only one extrinsic
blood vessel maintains perfusion over a diameter/
length ratio of 1:45 without evidence of ischemic
changes. This knowledge is useful when a peripheral
nerve needs to be extensively mobilized (eg, submus-
cular transposition of the ulnar nerve) and supports the
theory of a robust and hardy intrinsic vascular system.
Blood-nerve barrier
A barrier system exists in the peripheral nerve that
is an extension of the blood-brain barrier. The blood-
nerve barrier is composed of the internal layers of the
perineurial sheath and the tight junction of the endo-
thelial cells of the endoneurial microvessels. These
tight junctions regulate the intraneural environment
and provide a level of immunologic protection. Smith
et al [16] showed that the blood-nerve barrier is not
functional before 13 days of life because clefts are
present between the endothelial cells. After 16 days,
these clefts are replaced by tight junctions, resulting
in a blood-nerve barrier.
Nerve injury can result in a breakdown in the
blood-nerve barrier at the level of the microvessels,
resulting in an increase in pressure within the fascicle.
The lack of a lymphatic circulation within the endo-
neurial space and subsequent unresolved edema
within the compartment can interfere with the micro-
circulation of the fascicles [17]. Leaking capillaries
within the endoneurium permits the eventual accu-
mulation of fluid and proteins. As the pressure rises
within the endoneurial space, a mini compartment
syndrome can develop, resulting in ischemic damage
to that portion of the nerve.
Nerve fibers
The basic neural structure is made up of axons and
their accompanying Schwann cells. Nerve fibers are
myelinated or unmyelinated. Sensory and motor
nerves contain both types of fibers in a ratio of
4 unmyelinated to 1 myelinated. Unmyelinated fibers
constitute 75% of cutaneous nerves and 50% of motor
nerves. They are composed of several axons encircled
by a single Schwann cell. In most cases, unmyelinated
axons are small, with diameters averaging 0.15 to
2.0 mm. The axons of myelinated nerve fibers are
individually enveloped by a single Schwann cell
(Fig. 6). Histologically, the myelinated fiber consists
of a center core of cytoplasm (axoplasm) surrounded
112 S.P. Maggi et al. / Clin Plastic Surg 30 (2003) 109126

Fig. 4. (A) A cadaver dissection demonstrating the internal fascicles of the median nerve with the hand to the right of the page.
(B) A closer view of the intraneural topography at the proximal arm above the elbow showing marked plexus formation between
fascicles. (C) A closer view of the intraneural topography just distal to the elbow with less plexus formation. (D) A closer view of
the intraneural topography at the wrist where little to no plexus formation exists. (From Mackinnon SE, Dellon AL. Surgery of
the peripheral nerve. New York: Thieme, 1988. p. 7 8; with permission.)

by a confluent membrane (axolemma) that is further
surrounded by the Schwann cells laminar myelin
sheath. The Schwann cells act as specialized satellite
cells that can be identified definitively at the electro-
microscopic level by their double basement membrane
[18,19].
At the junction between adjacent Schwann cells,
the axolemma becomes exposed at a gap known as
the node of Ranvier. This gap is where sodium
channels cluster and are found regularly along the
axon. The nodes of Ranvier aide in the propagation of
the depolarizing action potentials along the length of
 S.P. Maggi et al. / Clin Plastic Surg 30 (2003) 109126
Fig. 4 (continued ).
the nerve. The myelinated portions of the axon act as
insulated areas that accelerate axonal conduction as
the depolarization wave jumps from node to node.
This is referred to as saltatory conduction, and it
increases the speed of transmission more than would
be accomplished by simply increasing axonal di-
ameter. Unmyelinated fibers are able to propagate
electrical impulses at speeds of 2 to 2.5 m/s. Myeli-
nated fibers, by contrast, propagate impulses at
speeds ranging from 3 to 150 m/s [20,21].
Axons originate from their corresponding cell
bodies, which are located in the spinal cord, dorsal
Fig. 5. The blood supply of a peripheral nerve classified into
three patterns. (Left) Segmental supply with no dominant
pedicle. (Center) A single dominant pedicle running
longitudinally. (Right) Multiple dominant pedicles. (From
Winagrad J, Mackinnon S. Peripheral nerve injuries: repair
and reconstruction. In: Mathis S, Hentz VR, editors. Plastic
surgery. Philadelphia: Elsevier and Saunders; 2003;
with permission.)
113
root ganglion, and autonomic ganglia. Sensory nerve
fibers originate from the cell bodies in the dorsal root
ganglia and join other spinal nerves to connect with
sensory end organs. Motor nerve fibers (along with
presynaptic sympathetic ganglia) arise from the
anterior horn of the spinal cord and terminate at the
neuromuscular junction in the muscle. The presynap-
tic sympathetic ganglia send their axons out to the
postsynaptic sympathetic ganglia in the periphery,
which then go on to innervate blood vessels, skin,
and hair follicles.
The majority of a neurons cytoplasm is included
in the volume of the axon [22]. Duckers [22,23]
analogy is pertinent: If the central cell body were
the height of an average man, its axon would be one
or two inches in width and would extend more than
two miles. The diameter of nerve fibers correlates
with the velocity of transmission and function. Nerve
fibers have been classified by variation in diameter
and speed. Group A fibers are the largest and fastest
conducting fibers. They are mostly myelinated
and take pulses in efferent and afferent directions.
Group B fibers contain myelinated autonomic and
preganglionic efferent fibers. Group C fibers are the
smallest and slowest. They are usually nonmyelinated
and serve in the transmission of thermoreceptive and
interoceptive signals.
Axoplasmic transport
Axoplasmic transport can be divided bidirection-
ally into an antegrade and retrograde system. The
transport process occurs via fast or slow transport in
the antegrade direction and via a fast system in the
retrograde direction. Axoplasmic transport maintains
114 S.P. Maggi et al. / Clin Plastic Surg 30 (2003) 109126

Fig. 6. Transverse section (uranyl acetate and lead citrate, 13,000) demonstrating a Schwann cell nucleus with an associated
double basement membrane.

the structure of the nerve and provides the functional
capacity of neurotransmitters. Axonal transport is
energy dependent and can be disturbed by systemic
derangements and direct nerve injury. In 1941, it was
noted that the poliovirus infections used retrograde
axonal transport to reach the anterior motor horn [24].
Subsequent work by Droz and Leblond [25], using
labeled amino acids, determined that the antegrade
transport of neurotransmitter vesicles along the nerve
occurred at a rate of 1 and 1.5 mm per day.
Slow antegrade flow (1 to 6 mm per day) is used
for the transport of major neural building blocks such
as actin, tubulin, and other components of micro-
tubules and microfilaments. Materials synthesized at
the cell body that have a functional role at the
terminal axon, such as neurotransmitters, are moved

Fig. 7. An electron microscopy (uranyl acetate and lead citrate, 9895) of a peripheral nerve after injury demonstrating the
process of regeneration and degeneration occurring simultaneously in the distal stump. (Right) A classic regenerating unit
containing myelinated and unmyelinated fibers surrounded by perineurium. (Left) The unit demonstrates evidence of Wallerian
degeneration with myelin debris. (From Mackinnon SE, Dellon AL. Surgery of the peripheral nerve. New York: Thieme, 1988.
p. 18; with permission.)
 S.P. Maggi et al. / Clin Plastic Surg 30 (2003) 109126 115

at a rapid antegrade rate of up to 410 mm/d. Ret-
rograde transport remains constant at 240 mm/d. It
allows the return of spent neurotransmitter vesicles
and neurotrophic factors for recycling [21,26 29].
Basic response to nerve injury
In 1850, Waller [30] described changes in the
distal segment of the hypoglossal nerve of the frog
after transection; these changes later became known
as Wallerian degeneration. His microscopic examina-
tion of the changes that occur to the cell body and
axon after nerve transection demonstrated evidence
of distal degeneration. He also described the genera-
tion of neural tissue from the end of the proximal
stump, which was later referred to as the out-
growth theory. Further investigation by Ramon y
Cajal [31] established that nerve regeneration ema-
nated as an outgrowth from the proximal stump of the
severed axon (Fig. 7).
The transection of a peripheral nerve initiates a
cascade of events (Fig. 8). The changes occur in the
cell body, at the site of injury, and in the proximal and
distal segments of the axon. After a central axono-
tomy, the cell nucleus migrates toward the periphery
of the cell body, and neuronal chromatolysis occurs.
An increase in cellular volume occurs as the cell
increases the production of RNA and associated
regenerative enzymes. The cellular RNA production
and overall metabolism increases at 4 days after
injury, with a peak at 20 days [23,32].
The severity of injury and its proximity to the cell
body influence the degree of neural cell death. The
more proximal the injury is to the cell body, the more
neuronal cell damage occurs. Ygge et al [33] studied
the transection of the rat sciatic nerve and found a

Fig. 8. Schematic diagram of the neural response to axotomy. (A) The normal-appearing cell body of the neuron after a
conceptual scalpel cut in a single axon. Muscle tissue of the end organ also appears normal. (B) Chromatolysis occurs from
nuclear eccentricity, nucleolar swelling, and dissolution of Nissl bodies. The process of Wallerian degeneration begins in the
axon distal to the injury as the denervated muscle begins to atrophy. (C) Histologic evidence of chromatolysis remains in
the neuron as the axon forms a growth cone. Further atrophy of the end-organ muscle occurs. (D) The histologic appearance of
the cell body returns to normal over time. Remaining fibers are pruned down to one as the partially fibrosed muscular end organ
becomes successfully reinnervated. (From Winagrad J, Mackinnon S. Peripheral nerve injuries: repair and reconstruction.
In: Mathis S, Hentz VR, editors. Plastic surgery. Philadelphia: Elsevier and Saunders; 2003; with permission.)
116 S.P. Maggi et al. / Clin Plastic Surg 30 (2003) 109126
27% neuronal loss after a proximal injury versus a
7% loss after a distal nerve injury. Similarly, they
found that the more severe the injury, the more
proximal the extent of injury.
Neuronal survival after axonal injury is age
related. It is generally appreciated that younger chil-
dren have superior functional recovery than adults. In
a 15-year clinical study, Barrios and de Pablos [34]
found that children recovered better than adults after
peripheral nerve injury. However, there is evidence
that a susceptibility to neuronal apoptosis exists in the
neonatal period [35]. In a sciatic nerve transection
model, when comparing a 6- versus 22-day-old ani-
mals, significantly greater motoneuron death was
found in the younger group. It has been shown that
the retrograde release of trophic factors from the target
tissue is important for the survival of embryonic
motoneurons [36]. Motoneurons early in the neonatal
period are particularly dependent on growth factors
[35]. Administration of nerve growth factor, ciliary
neurotrophic factor, and neurotrophin-4/5 rescued a
significant number (up to 30%) of motoneurons after
sciatic nerve axotomy in 2- to 5-day-old mice. The
administration of insulin-like growth factor, brain-
derived neurotrophic factor, and neurotropin-3 res-
cued the majority of axotomized motoneurons [37].
After injury, Schwann cells proliferate and migrate
as Schwann cell columns (bands of Bungner). The
Schwann cell alters its phenotype and becomes non-
myelinating, with stimulation transforming from a
quiescent state to one of high mitotic activity and
growth factor production [38]. Basement membrane
components and cellular adhesion molecule produc-
tion increases. This activity of the Schwann cells
enables peripheral growth cone elongation. When
Schwann cell migration is blocked by cytotoxins,
regeneration does not occur [39,40].
Site of injury
Within 24 hours at the site of a peripheral nerve
injury, a single axon produces multiple axonal
sprouts, forming a regenerating unit [41] (Fig. 9).
At the tip of these sprouts is a growth cone that has an
affinity for the fibronectin and laminin of the
Schwann cell basal lamina. Via contact guidance,
filopodia in the growth cone explore the distal envi-
ronment for the appropriate physical substrate
[42 44]. The regeneration proceeds along the neural
tube to reconstitute the axon at a rate between 1 to
4 mm per day. Without successful elongation, a
neuroma forms. With successful reinnervation of the
end organ, the number of axonal sprouts is modulated
over a period of months to years [45].
Distal to the axonotomy site, the nerve segment
undergoes Wallerian degeneration. After transection,
Schwann cell proliferation and myelin breakdown
plays a prominent role. The Schwann cells and
macrophages dispose of the axonal debris that forms
with degeneration. Although the endoneurium and
basement membrane remain essentially intact, the
neural tube that forms eventually collapses as the
myelin and axonal contents are digested. The process
continues until the axons neural contents are fully
resorbed, at which point the neural tube becomes
replaced by Schwann cells and macrophages. The
proliferative cells then organize into columns and
form the bands of Bungner [46].
Although histologically similar to the Wallerian
degeneration, axonal degeneration is more limited in
the proximal segment. Depending on the severity of
injury, the impact is often limited to one or a few of
the nodes of Ranvier along the proximal segment
[47,48]. The changes that occur in the proximal
segment are referred to as traumatic degeneration.
In a sufficiently severe injury, in terms of energy and
proximity, the degeneration can result in death of the
cell body.
Contact guidance and neurotropism
In 1905, Ramon y Cajal [31] popularized the
notion of chemical agents attracting nerve sprouts
from the proximal stump of a peripheral nerve after
injury. This concept was refined and became known
as neurotropism, or directional guidance, by chemo-
tactic factors. In 1944, Weiss and Taylor [49] dem-
onstrated that neuroregeneration across short nerve
gaps did not seem to be related to an attraction by the
distal stump, the proximal stump, or any other neuro-
tropic effect. They proposed a mechanism of regen-
eration based on contact guidance. In a series of
Y-shaped artery experiments, they showed that
. . .in no cases were the regenerating nerves attracted
towards the peripheral nerve fragment but the fiber
stream divided itself more or less evenly regardless of
the kind of destination awaiting them [49]. How-
ever, these results were influenced by an immuno-
logic reaction to the aortic allografts (Fig. 10).
Additional work in the ensuing decades has
expanded our understanding of the directional guid-
ance of the regenerating axons. It is believed that that
a motor axon sprouts into a regenerating unit that
contains many axons. After axonotomy, the pioneer
motor axons initially regenerate along motor or sen-
sory Schwann cell tubes. Upon the recognition of a
motor cell tube, the leading motor axon signals back
to the cell body. This results in further communication
Fig. 9. Light microscopy (Toluidine blue, 655) demonstrating a nerve at different levels of a peripheral nerve injury. (A) Well-
myelinated fibers in the proximal aspect. (B) Distal to the nerve injury, Wallerian degeneration is noted with areas of myelin
debris. (C) Each nerve fiber will eventually sprout into a regeneration unit.
118 S.P. Maggi et al. / Clin Plastic Surg 30 (2003) 109126

Fig. 10. Schematic diagrams representing four theories of mechanisms of neuronal regeneration. (A) Operative alignment:
Microsurgical technique is used to reapproximate severed nerve endings, thus determining direction. (B) Contact guidance:
Recognition of the appropriate microenvironment guides the regenerating neuron toward the correct distal stump.
(C) Neurotropism: Guidance of the regenerating axon toward the correct distal nerve stump is accomplished by a gradient of
dissolved substances at the molecular level. (D) Neurotropism: Trophic support is supplied to regenerating axons that connect
with appropriate distal nerve stumps. Axons that incorrectly connect undergo degeneration. (From Winagrad J, Mackinnon S.
Peripheral nerve injuries: repair and reconstruction. In: Mathis S, Hentz VR, editors. Plastic surgery. Philadelphia: Elsevier and
Saunders; 2003; with permission.)

to the other motor axons within the regenerating unit

Fig. 11. Schematic diagram representing the concept of
preferential motor regeneration after an axonotomy down a
sensory or motor Schwann cell tube. (A) After the nerve is
transected, the nerve fibers sprout into regenerating units.
(B) The motor axons that regenerate into inappropriate
sensory cell tubes do not preferentially mature. (C) The
motor axons, however, are not specifically pruned away.
to preferentially regenerate within that specific motor
Schwann cell tube. Once the motor axons arrive at the
distal muscle target, the motor axons mature, and
those that regenerate toward sensory targets do not
preferentially mature. However, motor axons that
regenerate into inappropriate Schwann cell tubes are
not specifically pruned away, as was previously
thought. This phenomenon is known as preferential
motor regeneration [40,50] (Fig. 11).
There is evidence to support the concepts of
contact guidance and neurotropism. Cellular adhesion
molecules (CAMs) have been found to be upregu-
lated in the distal nerve end after axotomy by the
Schwann cell. They include glycoprotein L1, neural
cell adhesion molecule (N-CAM), and N-cadherin
[51]. The expression of L1 and N-CAM is a con-
sequence of the Schwann cells transition from a
myelinated to an unmyelinated state [52]. Williams
[11] has affirmed the significance of an organized
longitudinal fibrin matrix in a model of nerve regen-
eration. He demonstrated that axons elongate more
effectively along a longitudinally oriented neural
 S.P. Maggi et al. / Clin Plastic Surg 30 (2003) 109126
matrix than through a randomly oriented fibrin matrix
or in a matrix free chamber. This further supported
the role of the extracellular environment as a scaffold
for the advancing regenerating nerve units.
The term neurotropism implies an ability to
stimulate nerve maturation. Neurotrophins that par-
ticipate in neural regeneration include nerve growth
factor (NGF), brain-derived neurotrophic factor,
neurotrophin 3, neurotropin-4/5, epidermal growth
factor, insulin-like growth factor I and II, and glial-
derived neurotrophic factor [51,53]. These factors are
primarily produced by Schwann cells, which are
known to become activated in the response to neural
injury. Neurotrophins bind to specialized high-affin-
ity tyrosine kinase receptors and to p75, a low-affinity
NGF receptor [53]. Their role in neural regeneration
is by indirectly acting on the Schwann cells by
stimulating migration and adhesion to axonal projec-
tions. Through this mechanism, they play a key role
in the progression of the axonal growth cone. Despite
all these intricate mechanisms that are initiated,
retrograde labeling indicates that up to 51% of the
nerve fibers form inappropriate connections after
significant nerve injury [54].
Nerve repair (end-to-side)
End-to-side neurorrhaphy, or latero-terminal neuro-
rrhaphy, is the method of nerve repair whereby the
distal end of a severed nerve is attached to the side of
an uninjured nerve. In 1903, Balance [55] reported the
first use of the end-to-side neurorrhaphy for the
treatment of a facial palsy by the suturing of the distal
end of the facial nerve laterally into the spinal acces-
sory nerve. This concept was reintroduced in 1991
by Viterbo et al in animal and human studies [56].
Viterbo et al demonstrated in a rat study evidence of
axonal ingrowth and the conduction of electrical
impulses from a healthy nerve into the distal segment
of a severed nerve after an end-to-side repair. Histo-
logic evaluation distal to the repair site showed func-
tional axonal regrowth and muscular reinnervation.
Our understanding of the regeneration process
after an end-to-side neurorrhaphy is evolving. Un-
injured sensory axons sprout de novo; however,
whether or not motor axons have the same ability
without an initiating local injury is debated [57].
Tarasidis et al [58] demonstrated an inferior recovery
of motor nerve function when comparing end-to-side
versus the end-to-end technique between posterior
tibial and peroneal nerves in the rat at 16 weeks.
Retrograde labeling showed that the vast majority of
fibers regenerating from the proximal segment of the
nerve were sensory. Noah et al [59] recommended the
119
severance of the perineurium, or an epineurial
window, for improved axonal regeneration when
performing an end-to-side repair. They found the
highest axonal counts when a perineurial window or
partial neurectomy was performed [59]. Dvali and
Hunter have recently demonstrated that motor axons
sprout across an end-to-side repair if the donor nerve
is crushed above the repair site, which suggests a
different mechanism for sensory versus motor sprout-
ing (unpublished observation).
Distal receptors
Once denervated, the muscle fibers undergo a
process of atrophy. In 1944, Bowden and Guttmann
[60] performed 140 muscle biopsies on Seddons
patients and identified progressive atrophy and fibrosis
in the first 3 years after denervation. Mammalian
striated muscle after denervation has been shown lose
80% to 90% of its cross-sectional area with no loss of
fiber numbers [5,61]. Additional studies indicated this
process begins within 1 week of denervation [62]. In
cross-sectional analysis, the normally eccentric nu-
cleus of the muscle cell migrates centrally, creating
the target cells found in denervated muscle [63,64].
Within 3 months of denervation, particularly if this is
accompanied by lack of activity or movement, inter-
stitial fibrosis replaces the muscle. By 2 to 3 years, the
muscle seems to be essentially replaced by scar tissue
or fat [63].
Reinnervation at the neuromuscular junction is
dependent on the timely arrival of axonal regenera-
tion in the region of the neuromuscular junction. The
absolute time of denervation in which reinnervation is
not possible is not known, but it is likely to occur
after a 12-month period. Experimental evidence
shows that an extended period from injury to repair
further worsens the degree of ultimate recovery [65].
Age also plays a profound role in the ability for
muscles to recover after denervation. Age-related
decreases in muscle mass, force, power, and endur-
ance are in part due to selective denervation of fast-
twitch fibers. The reinnervation of denervated muscle
fibers in old animals is not as successful as that seen
in young animals [66 68].
Sensory organs
The end organ for sensory fibers consists of one of
variety of specialized structures: Pacinian or Meiss-
ners corpuscles, Merkel cells, or free nerve endings
(Fig. 12). Pacinian corpuscles receive a single axon
terminal and are less likely to be reinnervated [69,70].
Alternatively, other mechanoreceptors, such as the
120 S.P. Maggi et al. / Clin Plastic Surg 30 (2003) 109126
Fig. 12. Distal glabrous human skin. MC, Meissner
corpuscle; MD, Merkel cell-neurite complex; PC, Pacinian
corpuscle; SG, sweat gland; SD, sweat duct. (Modified from
Mackinnon SE, Dellon AL. Surgery of the peripheral nerve.
New York: Thieme, 1988. p. 26; with permission.)
Meissners corpuscles, Merkel cells, or Ruffini end-
ings, have demonstrated a better ability to be reinner-
vated [69]. Unlike with muscle injury, sensibility may
be recovered many years after a nerve injury [71].
Clinical classification of nerve injury
In 1941, Cohen introduced a classification to
describe the injury to peripheral nerves: neurapraxia,
axonotmesis, and neurotmesis. In the early 1940s,
Seddon [72,73] examined 650 patients with pe-
ripheral nerve injuries and popularized Cohens clas-
sification system. In 1951, Sunderland [74] expanded
upon the classification system by defining five dis-
tinct degrees of nerve injury; this is the classification
system that is commonly used today. Sunderlands
third- and fourth-degree injuries were included as
extensions of axonotmesis and neurotmesis, respec-
tively, in the original classification used by Seddon.
In 1988, Mackinnon coined the term 6th degree
injury, which was defined as a mixed injury involv-
ing different combinations of injuries [75] (Fig. 13).
A first-degree peripheral nerve injury (neuro-
praxia) shows recovery within the first 3 months. A
second-degree injury (axonotmesis) fully recovers;
this occurs at the rate of 1 inch per month. A third-
degree injury demonstrates incomplete recovery with
the same time course as an axonotmetic type injury.
A fourth-degree injury is in continuity, but, like the
transected fifth-degree injury, it will not recover. A
sixth-degree injury demonstrates a variety of recov-
ery patterns based on the pattern and involvement of
the injury.
First-degree injury, neurapraxia
The fundamental basis of a first-degree injury is
a conduction block with preservation of anatomical
Fig. 13. Schematic diagram representing the six classes of
nerve injury. A healthy fascicle is represented where the
blood supply of the nerve enters via the mesoneurium.
Continuing clockwise, Neurapraxia (I) or loss of axonal
myelin is shown. Axonotmesis (II) or second-degree injury
is depicted in the next fascicle where loss of myelin and
axon has occurred without damage to the endoneurium. The
two fascicles (III) depict a third-degree injury. A fourth-
degree injury (IV) is shown with damage to all portions of
the nerve except for the epineurium. Fifth-degree injury or
neurotmesis (V) is defined as complete nerve transection.
No recovery is possible without microsurgical repair. A
mixed nerve injury, or sixth-degree injury, is a combination
of various degrees of nerve injury and is referred to as
neuroma in-continuity. (From Winagrad J, Mackinnon S.
Peripheral nerve injuries: repair and reconstruction. In:
Mathis S, Hentz VR, editors. Plastic surgery. Philadelphia:
Elsevier and Saunders; 2003; with permission.)
 S.P. Maggi et al. / Clin Plastic Surg 30 (2003) 109126
continuity. Although recovery is complete, the time
required varies from days to 3 months. There is no
nerve regeneration involved in the recovery, and
there is no advancing Tinel sign because there is
no axonal involvement. Histologically, at most, de-
myelination is noted. Examples of first-degree inju-
ries include tourniquet palsy or a similar type of
localized pressure palsy. In early nerve entrapments,
the degree of injury is a first-degree injury with a
partial electrical conduction block with prolonged la-
tency measurements.
Second-degree injury, axonotmesis
In second-degree injuries, the endoneurium and
perineurium remain intact. A Tinel sign is present and
can be traced distally as axonal regeneration occurs.
Disintegration of the axon and all the associated
changes, collectively referred to as Wallerian degen-
eration, occur below the site of the injury. The general
arrangement of the axon sheaths and the remaining
structures comprising the nerve are preserved, as is
the integrity of the endoneural tube. Because nerve
recovery depends on the regrowth of the axon,
structures typically recover in the anatomic order,
and the preservation of the endoneural tubes ensures
complete restoration of the original pattern of in-
nervation. Nerve recovery should be complete.
Third-degree injury
The structure pattern of third-degree injury
involves endoneurial scarring and disorganization
within the fascicles. The endoneural tube is disrupted,
resulting in erroneous alignment of the regenerating
axonal fibers. Regeneration progresses through a
component of scar tissue within the endoneurium,
thus limiting the regenerating fibers ability to make
contact with distal receptors or end organs.
The rate of recovery after a third-degree injury
occurs as expected in axonotmesis, at approximately
1 inch per month. An advancing Tinel sign demon-
strates the level of regeneration, but the degree of
recovery will not be complete. If the fascicle contains
sensory and motor fibers, then a mismatch of motor
and sensory fibers can occur, leading to a poorer
functional result.
Fourth-degree injury
A fourth-degree injury is a condition in which the
nerve is physically in continuity, but regeneration
does not occur across scar block. A Tinel sign is
found at the level of the injury but does not advance
121
because regeneration is blocked by scar tissue. As in
second- and third-degree injuries, Wallarian degen-
eration takes place in the nerve distal to the injury. If
recovery is to occur, then surgical intervention with
nerve repair, nerve grafting, or conduit technique is
necessary. These injuries are typically the result of a
severe stretch, traction, crush, cautery injury, or
nerve injection.
Fifth-degree injury, neurotmesis
The fundamental basis of a fifth-degree injury is
severance of the nerve trunk. Recovery is not possible
without a microsurgical repair. Although these inju-
ries can occur through a severe stretch and resulting
avulsion, they are more commonly associated with
penetrating trauma.
Sixth-degree injury
In 1988, Mackinnon used the term sixth-degree
injury, neuroma-in-continuity to describe a mixed
nerve injury [75]. She illustrated how the pattern of
recovery is mixed respective to the varying degree of
injury (I, II, III, IV, V). Partial recovery does occur in
fascicles with a third-degree injury, and complete
recovery takes place in the fascicles that have a first-
or second-degree injury. No recovery is seen in
fascicles with fourth- or fifth-degree injury patterns.
In this injury, some fascicles may be normal.
The sixth-degree injury is in many ways the most
surgically challenging. There is a significant potential
for underestimating the overall injury due to limited
recovery in the less injured portions of the nerve. A
careful assessment and correlation of the observed
recovery pattern and fascicular anatomy is indicated.
Similarly, careful surgical technique with microinter-
nal neurolysis allows for fascicular separation and
individual reconstruction of the fourth- and fifth-
degree injuries without injury to the other fascicles.
Compression neuropathy
The pathology found in chronic nerve compres-
sion can span the entire range of the nerve injury. In
the early stages, nerve compression may be associ-
ated with the breakdown in the blood-nerve barrier. It
is followed by subperineurial edema with fibrosis and
subsequently localized segmental demyelination. Dif-
fuse demyelination and eventually Wallerian degen-
eration of the nerve fibers occurs in advanced stages.
These changes are dependent on the amount and
extent of the compressive forces (Fig. 14).
122 S.P. Maggi et al. / Clin Plastic Surg 30 (2003) 109126

Fig. 14. Schematic diagram outlining the pathogenesis of nerve compression. The initial changes involve the blood-nerve barrier
with endoneurial and subperineurial edema secondary to subperineurial edema. Next, changes involve the connective tissue
layers that demonstrate increased perineurial and epineurial thickening. Localized nerve fiber changes occur, with some fascicles
appearing normal and others demonstrating localized areas of demyelination of the large fibers. Unmyelinated fibers show
evidence of regeneration with a new population of small unmyelinated fibers. The central fascicles or the central fibers are
usually spared, and progressive compression results in diffuse injury of the myelinated and unmyelinated fibers. (Adapted from
Mackinnon SE, Dellon AL. Surgery of the peripheral nerve. New York: Thieme, 1988. p. 42; with permission.)

Nerves with more connective tissue and fewer
fascicles may be better protected and undergo neural
changes slower than nerves with less connective
tissue [76]. Similarly, fascicles located closer to the
predominant compression undergo changes sooner
than other more distantly located fascicles. Organized
fibrosis in the subperineurial space results in the
formation of Renault bodies that often occur at sites
where the nerve crosses a joint. This is believed to be
related to repetitive movement and traction occurring
across joints.
Various methods have been described to recreate
or induce acute or chronic compression in a periph-
eral nerve. Rydevik et al [77] used a rabbit tibial
nerve to examine the effect of graded compression on
the intraneural blood flow. They found that external
pressures of 20 mm Hg caused a reduction in venule
blood flow, 30 mm Hg resulted in an inhibition of
axonal transport, and 80 mm Hg caused a complete
cessation of intraneural blood flow [77].
The impact of prolonged nerve compression on
function has also been examined. In a rat model, the
effects of various pressures (10, 30, and 80 mm Hg)
over different durations (4 hours to 28 days) were
studied [78]. Within hours, subperineurial edema,
inflammation, and the formation of fibrin deposits
were reported; within days, fibrous tissue prolifera-
tion was present; and fibrosis was seen by 28 days.
At higher pressures, (80 mm Hg), axonal damage
was evident.
In 1973, Upton and McComas [79] introduced the
double crush hypothesis. They hypothesized that
 S.P. Maggi et al. / Clin Plastic Surg 30 (2003) 109126
proximally located nerve compression could cause
distal sites to become susceptible to compression.
The authors associated a high incidence of carpal
and cubital tunnel syndromes with associated cervical
root lesions. Summation of compression along the
nerve can lead to changes in axoplasmic flow with
subsequent pathology. The concept of double or mul-
tiple crush has a clinical relevance in patients who
demonstrate multiple levels of nerve compression.
Failure to recognize this possible condition results in
a failure to relieve the patients underlying pathology.
Systemic disease, such as diabetes, thyroid dis-
ease, alcoholism, and various arthritic states, can
result in peripheral neuropathies and lead to enhanced
susceptibility of nerve compression. Dellon et al [80]
have demonstrated that, in the streptozocin model, the
diabetic nerve is more susceptible to compression. It
seems that glucose enters the nerve directly (because
there is no blood-nerve barrier to glucose), causing
endoneurial edema. The glucose is then metabolized
to hydrophilic polyols, which pull additional water
into the endoneurial space. The resulting edema leads
to increased endoneurial fluid pressure and prog-
resses to myelin changes. It seems that anything that
could alter axoplasmic physiology could render the
nerve more susceptible to developing a compression
neuropathy and act as a crush.
Vibration can also result in peripheral neuropathy.
A number of studies have shown the association of
vibratory exposure with the development of periph-
eral neuropathy [81 84]. The histologic changes
associated with this type of exposure are much like
those seen in compression neuropathy, with the
development of intraneural edema, demyelination,
and eventual axonal loss [85]. Epidemiologic investi-
gations have found a strong association between
vibratory exposure and the development of compres-
sion at the carpal tunnel [86].
Improvements in neuroregeneration
Recently, an enhancement in neuroregeneration
with the use of FK506 has been shown after nerve
crush, transection, repair, and nerve grafting. Al-
though the exact mechanism of this action is unclear,
it seems that its beneficial effects are enhanced at
higher doses or with immunosuppressive doses
[87 90]. It also seems that the beneficial effects of
FK506 are seen even when its administration is
delayed [91].
Al-Majed et al [50] have recently shown the
application of direct nerve stimulation to increase
peripheral never regeneration. It is believed that
123
electrical stimulation of the decompressed nerve is
beneficial by resulting in a more synchronous regen-
eration. Nicolaidis and Williams [92] presented
some promising work on the usefulness of continu-
ous electrical stimulation via implantable electrodes
in deinnervated muscle. In a study of 15 patients
with peripheral nerve injuries of the upper extrem-
ities, the authors demonstrated improved functional-
ity in all cases with extended stimulation (range of
127 to 346 days).
Summary
The response to nerve injury is a complex and
often poorly understood mechanism. An in-depth and
current command of the relevant neuroanatomy, clas-
sifications systems, and responses to injury and
regeneration are critical to current clinical success.
Continued progress must be made in our current
understanding of these varied physiologic mecha-
nisms of neuro-regeneration if any significant prog-
ress in clinical treatments or outcome is to be
expected in the future. Reconstructive surgeons have
in many ways maximized the technical aspects of
peripheral nerve repair. However, advances in func-
tional recovery may be seen with improvements in
sensory and motor rehabilitation after peripheral
nerve surgery and with a combined understanding
of the neurobiology and neurophysiology of nerve
injury and regeneration.
Acknowledgments
We thank DA Hunter, research assistant, Wash-
ington University School of Medicine, St. Louis,
for his contribution to the electron and light micros-
copy images.
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