Peripheral nerve injury l.jpg
Sponsored Links
This presentation is the property of its rightful owner.
1 / 48

Peripheral Nerve Injury PowerPoint PPT Presentation


  • 955 Views
  • Updated On :
  • Presentation posted in: General

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).

Download Presentation

Peripheral Nerve Injury

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript


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

  • Tinel’s sign

    positive-sensory function

    negative(after 4-6weeks)-total interruption

  • Sweating-sympathetic fiber

  • Sensory function


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.


Diagnosis

Electrophysiological Tests

  • EMG

  • SNAP

  • SSEP

  • Intraoperative NAP


EMG

SNAP


SSEP


Intraoperative NAP


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


Treatment

Time of Operation

  • Open injury

    Early intervention

    Delayed intervention

  • Closed injury

    Delayed 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

  • 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

  • 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 : 수술직후부터 운동시작

  • End-to-end repair :3주 이상 고정

    6주까지 서서히 운동

  • Graft:좀 더 일찍 운동 허용

    과도한 관절운동은 피한다


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.

  • 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 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.


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

  • 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


scalene anterior

and medius M.


Carpal Tunnel Syndrome


thenal atrophy


Entrapment of Radial Nerve


Entrapment of Ulnar Nerve

- Cubital tunnel

- Guyon’s canal


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


Meralgia Paresthesia

Lateral femoral cutaneous nerve injury (L1-2)


Tarsal Tunnel Syndrome


  • Login