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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).

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peripheral nerve injury

Peripheral Nerve Injury

Neurosurgeon

Yoon Seung-Hwan

anatomy
Anatomy
  • Connective tissue

- major tissue componant

- epineurium, perineurium, endoneurium

  • Nerve tissue

- axon, schwann cell

peripheral nerve injury4
Peripheral Nerve Injury
  • Acute injury
  • Chronic injury

(entrapment neuropathy)

neuropraxia
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
Axontmetic
  • axon continuity is disrupted
  • fascicular integrity is maintained
  • Wallerian degeneration occurs
neurotmesis
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
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
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

slide11

Acute Denervation

Fibrillation potentials and

positive sharp waves

slide12

Regeneration

Long duration, small amplitude

polyphasic motor unit potentials

clinical signs

Diagnosis

Clinical Signs
  • Motor function
  • Tinel’s sign

positive-sensory function

negative(after 4-6weeks)-total interruption

  • Sweating-sympathetic fiber
  • Sensory function
tinel s sign
Tinel’s 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.
electrophysiological tests

Diagnosis

Electrophysiological Tests
  • EMG
  • SNAP
  • SSEP
  • Intraoperative NAP
slide16

EMG

SNAP

muscle atrophy
Muscle Atrophy
  • 24 month rule

- 2년 이상 지속 시 muscle scar tissue로 대치되기 때문 에 (비가역변화) 회복불가

  • Muscle atrophy

start : post-injury 1 month

peak : 3rd - 4th month

  • Segment between injury and end organ
time of operation

Treatment

Time of Operation
  • Open injury

Early intervention

Delayed intervention

  • Closed injury

Delayed intervention

early intervention
Early Intervention
  • Enlarging hematoma/aneurysmal sac
  • Predisposing to Volkmann’s ischemic contracture
  • Severe noncausalsic pain SD
  • Injury to N. in areas of potential entrapment
  • Simple, clean lacerating injury
delayed intervention
Delayed Intervention
  • 2-3 months after injury
  • No clinical or substantial recovery
  • 장점

1. 손상범위를 정확히 알 수 있다.

2. 동반손상의 치유로 감염을 줄인다.

3. Epineurium이 두꺼워져 봉합이 쉽다.

4. 계획수술로 정확한 수술이 가능하다.

operations
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
slide26

Nerve Graft

# leading cause of failure of nerve graft

  • Inadequate resection
  • Distraction of repair site
postoperative care
Postoperative Care
  • Neurolysis : 수술직후부터 운동시작
  • End-to-end repair : 3주 이상 고정

6주까지 서서히 운동

  • Graft : 좀 더 일찍 운동 허용

과도한 관절운동은 피한다

conclusions
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.

  • 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

slide31

Conclusions

4. Split repair with usually graft - lesion in continuity가 partial function or undergoing partial regeneration

5. Careful patient selection for operation

- 특히 plexus involved 시

6. Nerve anastomosis 의 failure 주원인은

① inadequate resectin of scarred nerve ends

② 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.

pathophysiology of entrapment
Pathophysiology of Entrapment
  • Direct compression

segmental demyelination

wallerian degeneration(distal)

  • Ischemia

swelling of nerve

microcompartment SD

conservative tx

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

surgical indications

Treatment

Surgical Indications
  • Failed conservative tx
  • Typical clinical finding

with electrodiagnostic data

  • Severe

sensory loss

muscle atrophy

motor weakness

slide36

Entrapment of Thoracic Outlet

  • 원 인

- Cervial rib or anomalous transverse process of C7

- Fibromuscular bands or scalene muscle abnomality

  • 진 단

- X-ray

- NCV & EMG

- Angiography – vascular anomaly

  • Tx : Supraclavicular approach

- Best op. management

slide37

scalene anterior

and medius M.

slide43

Entrapment of Ulnar Nerve

- Cubital tunnel

- Guyon’s canal

slide44

Motor Deficit of Ulnar Nerve

  • Bediction posture : clawing of ring & small finger
  • Froment’s 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
slide47

Meralgia Paresthesia

Lateral femoral cutaneous nerve injury (L1-2)

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