Peripheral Nerve Injury

Neurosurgeon Yoon Seung-Hwan

Anatomy
Connective tissue - major tissue componant - epineurium, perineurium, endoneurium

Nerve tissue
- axon, schwann cell

Peripheral Nerve Injury

Acute injury

Chronic injury (entrapment neuropathy)

Classification

Neuropraxia
the mildest form, reversible conduction block loss of function, which persists for hours or days direct mechanical compression, ischemia, mild burn trauma or stretch

Axontmetic
axon continuity is disrupted fascicular integrity is maintained Wallerian degeneration occurs

Neurotmesis
laceration from sharp or blunt forces the only important consideration is the timing of repair acute repair or more bluntly lacerated nerves are repaired 3-4 weeks

Factor s for Decision Making

Age
Segment between injury and end organ

Gap of injury
Mechanism of injury Severity of injury Presence of pain

Axonal Regeneration
Initial delay to the distal stump : 1-2 week delay Growth rate 1mm/day, 1 inch/month Terminal delay several weeks-several months
Recovery within 6 weeks good prognosis

Acute Denervation

Fibrillation potentials and positive sharp waves

Regeneration

Long duration, small amplitude polyphasic motor unit potentials

Diagnosis
Clinical Signs
Motor function Tinels sign positive-sensory function negative(after 4-6weeks)-total interruption Sweating-sympathetic fiber Sensory function

Tinels sign
advancing along the anatomical distribution of the nerve, particularly if it is does so at the expected rate of nerve regeneration, then this provides evidence of ongoing regeneration.

Diagnosis
Electrophysiological Tests
EMG

SNAP
SSEP

Intraoperative NAP

EMG

SNAP

SSEP

Intraoperative NAP

Muscle Atrophy
24 month rule
- 2 muscle scar tissue () Muscle atrophy start : post-injury 1 month

peak : 3rd - 4th month

Segment between injury and end organ

Treatment
Time of Operation
Open injury

Early intervention
Delayed intervention

Closed injury
Delayed intervention

Early Intervention
Enlarging hematoma/aneurysmal sac
Predisposing to Volkmanns ischemic contracture Severe noncausalsic pain SD Injury to N. in areas of potential entrapment Simple, clean lacerating injury

Delayed Intervention
2-3 months after injury No clinical or substantial recovery 1. . 2. .

3. Epineurium .
4. .

Operations
Neurolysis : internal/external Nerve repair end-to-end repair : epineural/fascicular autologous graft : sural N. Neurotization intercostal N./accessory N./cervical plexus within 1 year Muscle and tendon transfer

Epineural Repair

Fascicular Repair

Nerve Graft

# leading cause of failure of nerve graft Inadequate resection Distraction of repair site

Postoperative Care
Neurolysis : End-to-end repair : 3

6
Graft :

Injured Peripheral Nerve

Evaluation of Closed Injury

Conclusions
1. Immediate primary repair in sharp injuries with suspected transsection of nerve Immediate repair is especially important for brachial plexus and sciatic nerve transsections because delay leads not only to retraction but also to severe scaring Bluntly transsected nerve best repaired after a delay of several weeks. 2. A focally injured nerve should be explored if no functional return within 8-10 weeks 3. Decision - making as to whether neurolysis or resection & repair in a lesion in gross continuity based on intraoperative electrophysiological evaluation

Conclusions
4. Split repair with usually graft - lesion in continuity partial function or undergoing partial regeneration 5. Careful patient selection for operation - plexus involved 6. Nerve anastomosis failure inadequate resectin of scarred nerve ends nerve suture distration 7. A good end result requiring rehabilitation from onset of treatment. Prevention of disuse, relief of pain, predicting probable end results of operative procedures.

Chronic Injuries of Peripheral Nerves by Entrapment

Pain Paresthesia Loss of function

Pathophysiology of Entrapment
Direct compression segmental demyelination wallerian degeneration(distal) Ischemia swelling of nerve microcompartment SD

Treatment
Conservative Tx
Indications not long history mild-moderate, intermittent reversible cause pregnancy, oral contraceptive, endocrine abnormalities(DM), type writer Method nonsteroidal anti-inflammatory drugs splint

Treatment
Surgical Indications
Failed conservative tx Typical clinical finding

with electrodiagnostic data

Severe sensory loss muscle atrophy motor weakness

Entrapment of Thoracic Outlet

- Cervial rib or anomalous transverse process of C7
- Fibromuscular bands or scalene muscle abnomality

- X-ray - NCV & EMG

- Angiography vascular anomaly

Tx : Supraclavicular approach
- Best op. management

scalene anterior and medius M.

Carpal Tunnel Syndrome

thenal atrophy

Entrapment of Radial Nerve

Entrapment of Ulnar Nerve

- Cubital tunnel - Guyons canal

Motor Deficit of Ulnar Nerve

Bediction posture : clawing of ring & small finger Froments sign : weakness of adductor pollicis, there will be flexion
of the interphalangeal joint of the thumb because of substitution of the median innervated flexior pollicus longus for a weak adductor pollicis

Meralgia Paresthesia
Lateral femoral
cutaneous nerve injury (L1-2)

Tarsal Tunnel Syndrome