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    Nerve Trauma

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    UjjawalShriwastav
    Peripheral nerve lesions can be purely sensory, purely motor, or mixed. Major peripheral nerves like the median and sciatic nerves contain motor, sensory and sympathetic fibers. Peripheral nerves are composed of fascicles surrounded by connective tissues. Nerve injuries are classified as neurapraxia, axonotmesis, or neurotmesis depending on the severity of axonal and connectural tissue damage. The diagnosis of peripheral nerve lesions is based on history and clinical examination. Surgical treatment involves primary repair, secondary repair using grafts, or neurolysis depending on the nature and timing of the injury. Nerve regeneration occurs at a rate of about 1mm per day, so the level of injury relative to target muscles impacts functional

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    Nerve Trauma

    Uploaded by

    UjjawalShriwastav
    31 views31 pages
    Peripheral nerve lesions can be purely sensory, purely motor, or mixed. Major peripheral nerves like the median and sciatic nerves contain motor, sensory and sympathetic fibers. Peripheral nerves are composed of fascicles surrounded by connective tissues. Nerve injuries are classified as neurapraxia, axonotmesis, or neurotmesis depending on the severity of axonal and connectural tissue damage. The diagnosis of peripheral nerve lesions is based on history and clinical examination. Surgical treatment involves primary repair, secondary repair using grafts, or neurolysis depending on the nature and timing of the injury. Nerve regeneration occurs at a rate of about 1mm per day, so the level of injury relative to target muscles impacts functional

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    THIS SLIDE IS ON PERIPHERAL NERVE LESIONS.

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    Peripheral nerve lesions can be purely sensory, purely motor, or mixed. Major peripheral nerves like the median and sciatic nerves contain motor, sensory and sympathetic fibers. Peripheral nerves are composed of fascicles surrounded by connective tissues. Nerve injuries are classified as neurapraxia, axonotmesis, or neurotmesis depending on the severity of axonal and connectural tissue damage. The diagnosis of peripheral nerve lesions is based on history and clinical examination. Surgical treatment involves primary repair, secondary repair using grafts, or neurolysis depending on the nature and timing of the injury. Nerve regeneration occurs at a rate of about 1mm per day, so the level of injury relative to target muscles impacts functional

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    31 views31 pages

    Nerve Trauma

    Uploaded by

    UjjawalShriwastav
    Peripheral nerve lesions can be purely sensory, purely motor, or mixed. Major peripheral nerves like the median and sciatic nerves contain motor, sensory and sympathetic fibers. Peripheral nerves are composed of fascicles surrounded by connective tissues. Nerve injuries are classified as neurapraxia, axonotmesis, or neurotmesis depending on the severity of axonal and connectural tissue damage. The diagnosis of peripheral nerve lesions is based on history and clinical examination. Surgical treatment involves primary repair, secondary repair using grafts, or neurolysis depending on the nature and timing of the injury. Nerve regeneration occurs at a rate of about 1mm per day, so the level of injury relative to target muscles impacts functional

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    © All Rights Reserved
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    of 31

    Peripheral Nerve Lesions

    Functional point of view


    Purely sensory nerves
    (e.g. anterior femoral cutaneus n., sural n. etc.)
    Purely motor nerves
    (e.g. deep branch of radial nerve at the forearm, deep branch
    of ulnar nerve at the hand)
    Mixed nerves (motor, sensory and sympathetic fibers).
    Majority of peripheral nerves (median, radial, ulnar, sciatic
    nerves)

    Anatomy
    Connective tissues
    of nerve trunks

    axon
    myelin

    epineurium

    interfascicular epineurium
    perineurium

    healthy nerve, myelin stain

    endoneurium

    The fascicle is the smallest nervous


    structure which can be sutured and
    anastomosed.
    An axon (single nerve fiber) or its
    endoneurium cannot be sutured

    Epineurectomy (Resection of epineurium)

    Interfascicular
    anastomoses

    Numerous interfascicular
    anastomoses.
    Constantly changing
    fascicular pattern during the
    course of nerve.
    Towards the periphery, the
    number of these
    anastomoses decrease.

    Clinical examination
    Motor deficit

    In the beginning: atrophy and paresis (reversible).


    If denervated for long (18 months): Degenerate
    (irreversible)
    Muscle fibers replaced by connective and fat tissue.
    Repair a severed motor nerve as early as possible.
    Sensory nerves: longer denervation periods supportable.

    Peripheral Nerve Vascularisation

    Two vascular systems:


    1. Extrinsic: epineural perifascicular
    2. Intrinsic: intrafascicular
    Numerous vascular anastomoses
    within and between the two systems.
    The risk of an ischaemic nerve lesion
    is very low during peripheral nerve
    surgery
    Within 8 days after nerve grafting, new vessels grow into the
    Nerve grafts from the surrounding tissue.

    Classification of nerve lesions


    (Seddon 1943)

    Neurapraxia:

    Axonal conduction impaired.

    But intact structure of axon and endoneurium.

    Axonotmesis:
    Degeneration of endoneurial tube (axon and endoneurium).
    Nerve conduction slowed
    or abolished.
    Perineurium and endoneurium
    intact.
    Examples: Nerve entrapment syndromes (carpal tunnel syndrome)
    Radial nerve compression after fracture of humerus

    Neurotmesis:
    Total nerve transection

    Degeneration ad Regeneration

    Axonotmesis and Neurotmesis :


    Degeneration of the axons distal to the lesion.
    Only empty endoneurial tubes survive: Wallerian Degeneration.
    Following Axonotmesis: Regenerating axons find their proper
    endoneurial tubes.
    Following Neurotmesis: Regenerating axons do not or do rarely find
    back into their original endoneurial tubes.

    Sciatic nerve neuroma 36 year after


    leg amputation at thigh level

    Normal (regular structure of


    myelinated nerve fibers)

    Neuroma

    Regeneration
    (so.called mini-fascicles)

    Muscle Denervation

    Atrophy:
    Reversible
    Decreased diameter of muscle
    fibers.
    Degeneration:
    Irreversible
    Muscle replaced by fat and
    connective tissue

    A muscle denervated for 18 months


    will degenerate .

    Degeneration

    The diagnosis of a peripheral nerve lesion


    depends primarily on
    a precise history
    and
    an exact clinical examination

    Additional technical examinations :


    often superfluous.

    Traumatic nerve lesions


    Open Injury

    Sharp nerve transection

    No loss of nerve substance. If possible Primary (immediate) nerve repair.

    Traumatic nerve lesions

    Open injury

    Nerve laceration

    Nerve ends rugged and contused.


    Some loss of nerve substance.
    Usually, repaired by using a nerve graft

    Traumatic nerve lesions

    Indirect lesions

    Usually, a stretch-contusion injury.


    Example: radial nerve paresis after fracture of humerus.
    Frequently, the lesion extends over long distance.
    Recovery difficult.

    Traumatic nerve lesions

    Ischaemic lesion

    Median nerve, forearm

    Interruption of the arterial flow secondary to a


    Volkmanns ischaemic contracture

    Avulsion of cervical roots

    A forceful traction on the arm can lead to an avulsion of cervical


    roots from the spinal cord.
    Frequently seen in motorcycle accident

    Surgery

    Sharp nerve transection


    by piece of glass
    Immediate (primary)
    nerve suture

    Surgery

    Lacerations and contusions are repaired 2 3 weeks after injury by an early


    secondary repair.

    If the nerve cannot be repaired end-to-end without tension, an interfascicular


    graft interposed between the nerve stumps.

    2 3 weeks after surgery, the nerve suture is stable.


    The region of surgery should be immobilised for 3 weeks.
    Physiotherapy.

    Radial n.

    callus

    Radial n.

    Fracture of the
    humerus
    No neurological
    deficit
    immediately
    after the injury
    Some weeks
    later:
    progressive
    radial nerve
    paresis

    Removal of callus, external neurolysis and


    epineurectomy of radial nerve.

    Surgical strategy
    Open Injury with sharp nerve transection (glass, knife)
    and immediate neurologic deficit.
    Examination: clinical only, nothing else
    Differential diagnosis: none
    Treatment: surgical.
    Primary (immediate) nerve repair or
    Early secondary nerve repair after 2 3 weeks

    Surgical strategy
    Open Injury with nerve laceration and immediate
    neurologic deficit.
    Examination: clinical only, nothing else
    Differential diagnosis: none
    Treatment: surgical
    Early secondary nerve repair after 2 3 weeks,
    or whenever possible

    Surgical strategy
    Closed lesion and immediate neurologic deficit.
    Frequently, the nerve recovers spontaneously.
    Regular clinical examinations (every month)
    If there is no spontaneous functional improvement after
    4 months: surgery.

    Surgical strategy
    Closed lesion, initially no neurologic deficit, but later
    progressive neurologic deficit:

    Operation early after start of deficit.

    Iatrogenic nerve lesion:


    Judgement is often difficult (lack of precise information
    about original surgery).
    If there is no spontaneous improvement after 4 months:
    surgical exploration.

    Nerve Regeneration
    A muscle which has been without innervation for 18
    months has practically no chance to recover.
    Period of denervation: period between injury and the
    arrival of regenerating axons at the surface of the muscle
    fibers.
    After re-establishment of the motor endplates the muscle
    itself must recover, too. This needs several months.

    The axons regenerate at 1 mm / day


    (3 cm /month)

    In case of a lesion 60 cm proximal to the target muscle:

    Muscle degenerated at the arrival of regenerating axons


    even if nerve repaired immediately after the trauma.
    It makes no sense to repair an ulnar nerve lesion at the
    brachial plexus level.
    Intrinsic muscles of the hand degenerated at the arrival of
    regenerating axons. The distance between site of injury and
    target muscles is > 60 cm).

    Nerve Regeneration
    Discrepancy between the nerve regeneration seen by
    electromyography and the functional (useful) recovery or
    improvement.
    After surgery, EMG proof of arrival of axons at the most
    distal muscles in 95 % of cases.
    However, on clinical examination : muscle power either
    good or moderate in 61 % only.

    Nerve Regeneration
    Prognostic factors for the result of nerve repair
    (suture or grafting)
    Factors outside the our influence
    Nerve injured (motor, sensory, mixed)
    Level of lesion (proximal distal)
    Accompanying lesion (fractures etc.)
    Age of patient
    Factors which we can influence
    Delay between injury and surgery
    Surgical technique

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