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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

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Peripheral nerve injury l.jpg

Peripheral Nerve Injury

Neurosurgeon

Yoon Seung-Hwan


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Anatomy

  • Connective tissue

    - major tissue componant

    - epineurium, perineurium, endoneurium

  • Nerve tissue

    - axon, schwann cell


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Peripheral Nerve Injury

  • Acute injury

  • Chronic injury

    (entrapment neuropathy)


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Classification


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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


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Axontmetic

  • axon continuity is disrupted

  • fascicular integrity is maintained

  • Wallerian degeneration occurs


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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


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Factor s for Decision Making

  • Age

  • Segment between injury and end organ

  • Gap of injury

  • Mechanism of injury

  • Severity of injury

  • Presence of pain


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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


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Acute Denervation

Fibrillation potentials and

positive sharp waves


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Regeneration

Long duration, small amplitude

polyphasic motor unit potentials


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Diagnosis

Clinical Signs

  • Motor function

  • Tinel’s sign

    positive-sensory function

    negative(after 4-6weeks)-total interruption

  • Sweating-sympathetic fiber

  • Sensory function


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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.


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Diagnosis

Electrophysiological Tests

  • EMG

  • SNAP

  • SSEP

  • Intraoperative NAP


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EMG

SNAP


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SSEP


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Intraoperative NAP


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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


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Treatment

Time of Operation

  • Open injury

    Early intervention

    Delayed intervention

  • Closed injury

    Delayed intervention


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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


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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.


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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


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Epineural Repair


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Fascicular Repair


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Nerve Graft

# leading cause of failure of nerve graft

  • Inadequate resection

  • Distraction of repair site


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Postoperative Care

  • Neurolysis : 수술직후부터 운동시작

  • End-to-end repair :3주 이상 고정

    6주까지 서서히 운동

  • Graft:좀 더 일찍 운동 허용

    과도한 관절운동은 피한다


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Injured Peripheral Nerve


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Evaluation of Closed Injury


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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


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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.


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Chronic Injuries of Peripheral Nerves by Entrapment

  • Pain

  • Paresthesia

  • Loss of function


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Pathophysiology of Entrapment

  • Direct compression

    segmental demyelination

    wallerian degeneration(distal)

  • Ischemia

    swelling of nerve

    microcompartment SD


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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


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Treatment

Surgical Indications

  • Failed conservative tx

  • Typical clinical finding

    with electrodiagnostic data

  • Severe

    sensory loss

    muscle atrophy

    motor weakness


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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


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scalene anterior

and medius M.


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Carpal Tunnel Syndrome


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thenal atrophy


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Entrapment of Radial Nerve


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Entrapment of Ulnar Nerve

- Cubital tunnel

- Guyon’s canal


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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


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Meralgia Paresthesia

Lateral femoral cutaneous nerve injury (L1-2)


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Tarsal Tunnel Syndrome


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