MILITARY MEDICINE, 183, 9/10:e434, 2018

Combat Injury of the Sciatic Nerve – An Institutional Experience

CPT Patrick E. Jones, MC USA*∥; CPT R. Michael Meyer, MC USA‡¶; Walter J. Faillace, MD†‡;
Mark E. Landau, MD§; MAJ Jonathan K. Smith, MC USA§; CDR Patricia L. McKay, MC USN*‡;
LTC Leon J. Nesti, MC USA‡

ABSTRACT Introduction: Combat injury of the sciatic nerve tends to be severe with variable but often profound
consequences, is often associated with widespread soft tissue and bone injuries, significant neurologic impairment,
severe neuropathic pain, and a prolonged recovery time. There is little contemporary data that describes the treatment

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and outcome of this significant military acquired peripheral nerve injury. We describe our institution’s experience treat-
ing patients with combat-acquired sciatic nerve injury in the recent Iraq and Afghanistan wars. Materials and Methods:
IRB approval was obtained, and a retrospective review was performed of the records of 5,137 combat-related extremity
injuries between June 2007 and June 2015 to identify patients with combat-acquired sciatic nerve injury without trau-
matic amputation of the injured leg. The most common mechanisms of injury were gunshot wound to the upper thigh
or pelvis, followed by blast injury. Thirteen patients were identified that underwent sciatic nerve exploration and repair.
Nine patients had nerve repair using long-length acellular cadaveric allografts. Five patients underwent nerve surgery
within 30 d of injury and eight had surgery on a delayed basis. The postoperative follow-up period was at least 2 yr.
Results: Reduction of neuropathic pain was significant, 7/10 points on the 11-point pain intensity numerical rating
scale. Eight patients displayed electrodiagnostic evidence of reinnervation distal to the injury zone; however, functional
recovery was poor, as only 3 of 10 patients had detectable motor units distal to the knee, and recovery was only in tib-
ial nerve innervated muscles. There were no serious surgical complications, in particular, wound infection or graft
rejection associated with long-length cadaver allograft placement. Conclusion: Early surgery to repair sciatic nerve injury
possibly promotes significant pain reduction, reduces narcotic usage and facilitates a long rehabilitation process. Allograft
nerve placement is not associated with serious complications. A follow-up period longer than 3 yr would be required and is
ongoing to assess the efficacy of our treatment of patients with combat-acquired sciatic nerve injury.

INTRODUCTION
Combat-related peripheral nerve injuries (PNI) present exceed-
ingly complex challenges for surgeons. The nerve injuries
result from penetrating mechanisms such as gunshot wounds,
blast fragments, or bone fractures associated with high-energy
skeletal insult that cause nerve transection, stretch or shear (Fig.
1A–D). These nerve injuries are typically associated with local
*Department of Orthopedic Surgery, Walter Reed National Military
Medical Center, 8901 Rockville Pike, Bethesda, MD 20889.
†Department of Neurosurgery, Walter Reed National Military Medical
Center, 8901 Rockville Pike, Bethesda, MD 20889.
‡Department of Surgery, Uniformed Services University of the Health
Sciences, 8901 Rockville Pike, Bethesda, MD 20889.
§Department of Neurology, Walter Reed National Military Medical
Center, 8901 Rockville Pike, Bethesda, MD 20889.
∥Department of Surgery, United States Naval Hospital, Kuwae, Chatan,
Nakagami District, Okinawa Prefecture 904-0103, Japan.
¶Department of Neurological Surgery, University of Washington, 325
9th Ave, Seattle, WA 98104.
The views expressed in this presentation are those of the authors and do
not reflect the official policy of the Department of the Army/Navy/Air
Force, Department of Defense, U.S. Government, Walter Reed National
Military Medical Center, or the Uniformed Services University of the
Health Sciences. The identification of specific products does not constitute
endorsement or implied endorsement on the part of the authors, Department
of Defense, or any component agency.
doi: 10.1093/milmed/usy030
© Association of Military Surgeons of the United States 2018. All rights
reserved. For permissions, please e-mail: journals.permissions@oup.com.
and systemic vascular compromise, bone and soft tissue dam-
age.14,15 Several studies have demonstrated a relatively high
prevalence of sciatic nerve injury, with very poor outcomes fol-
lowing surgical repair.16,18,19 Electrodiagnostic testing, mag-
netic resonance imaging, and ultrasound enhance the clinical
evaluation with physiological and anatomic information that
determine extent and localization of the nerve injury (Fig. 1,
1–6).21 These tests may facilitate decisions regarding the timing
of surgical intervention post-trauma, as well as the specific
approaches; however, whether they assist in long-term outcome
is not completely known. This overall experience underscores
the need for a continued effort to investigate the management
of sciatic nerve injury.
The best functional outcomes following surgery for PNI are
in cases of partially injured nerves that undergo external neuro-
lysis for decompression, or after direct end-to-end suture of a
clean cut severed nerve. This is rarely the case in combat-
related PNI, as large nerve gaps are often present and repair
often requires nerve grafting or tubulization.3,20 A nerve graft is
recommended over tubulization when the nerve gap is longer
than 3 cm.20 Sural nerve autograft has been the gold standard
for peripheral nerve reconstruction,3 but harvesting sufficient
sural nerve autograft to span and connect a wide caliber nerve
such as the sciatic nerve has been challenging and relatively
ineffective.11 Alternatively, processed decellularized freeze-
dried cadaveric allografts can be used. These allografts have
good nerve regeneration potential, are not in limited supply, and

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 Combat Injury of the Sciatic Nerve

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FIGURE 1. High-energy fractures such as (A) and (C) subtrochanteric and (B) and (D) diaphyseal femur fractures are commonly associated with
traumatic sciatic nerve injury (A and B are pre-reduction/fixation, C and D are postoperative). Magnetic resonance imaging may be used to evaluate
the 1 and 2 normal architecture of the sciatic nerve as well as 3 and 4 fascicular disruption and 5 and 6 distal stump neuroma (all are T1 weighted axial
sequence images). Normal fascicles are hyper-attenuating “dots” within the iso- to slightly hypo-attenuating sciatic nerve that is indicated by the white
arrows. At the point of fascicle disruption the hyper-attenuating dots can no longer be appreciated, and at the point of neuroma formation the overall
diameter of the sciatic nerve is increased, with the neuroma itself appearing as a large and mixed attenuation area that does not appear to preserve the
organized architecture of the nerve.

are readily available for surgical implantation.4,7 The high inci-
dence of associated multiple extremity injuries and amputations
unique to military patients renders many donor sites unaccept-
able, providing further support for using allograft material as a
practical graft alternative. Allograft use also diminishes potential
donor site morbidity such as loss of sensation, wound infection,
dehiscence, and postoperative painful donor site neuroma.
Following PNI, up to 6 mo of observation prior to nerve
repair may be accepted to allow for spontaneous proximal axo-
nal sprouting and reinnervation. Seimienow et al20 question
this approach. Cautious watchful waiting will not be beneficial
in instances of nerve discontinuity. Furthermore, the supporting
Schwann cells required for axonal regeneration and the motor
endplates necessary for muscle reinnervation can be expected
to degenerate by 18–24 mo. In rat models, delay in repair
beyond 3 mo of PNI is associated with a decline in the number
of viable Schwann cells and subsequent regenerated axons at
the injury site.3,6,8,10,22
The purpose this retrospective study is to provide early out-
come data following surgical repair of the sciatic nerve in
patients injured during Operation Iraqi Freedom and Operation
Enduring Freedom, hopefully to assist in the management of
these patients and to possibly inspire further development in
this area of military medicine.
METHODS
Our research protocol was submitted, reviewed, and approved
after administrative, scientific, and ethical review by the
Department of Research Programs and the Walter Reed National
Military Medical Center Institutional Review Board (Research
Project IRBNET # 402914-1).
Patient Selection
The inpatient and outpatient medical records, operative reports,
radiologic and clinical photographs of all patients treated for
sciatic nerve injuries between June 2007 and June 2017 treated
at the Walter Reed Army Medical Center in Silver Spring,
Maryland or the National Naval Medical Center in Bethesda,
Maryland or the now merged Walter Reed National Military
Medical Center in Bethesda, Maryland were retrospectively
reviewed. We identified 13 patients who sustained sciatic nerve
injury as a result of combat wounds that did not have a trau-
matic amputation of the injured leg.
Data on patient age, sex, mechanism of injury, time from
injury to nerve surgery, self-reported pain, narcotic and neuro-
pathic pharmaceutical usage, and size of the nerve defect at
time of surgery were recorded. All patients had documentation
of preoperative clinical and electrophysiological assessments.

MILITARY MEDICINE, Vol. 183, September/October 2018 e435

 Combat Injury of the Sciatic Nerve

Time from Injury to Surgery Surgical Nerve Grafting Techniques

The date of injury was retrieved from the hospital medical
records or the “in theater” (war zone) medical records. The date
of the nerve surgery was defined as the date when definitive
treatment of the nerve injury was performed. The time between
the date of injury and date of nerve surgery was calculated and
reported in days.
Calculation of Narcotic Use
All narcotic use was converted to oxycodone (the most com-
Surgery was performed with the patient in prone position with
the knees and hips flexed to approximately 15 degrees (Fig.
2A). Intraoperative electro-physiologic monitoring was per-
formed to record compound muscle action potentials and nerve
action potential (NAP) across regions of injured nerve. If after
the initial external neurolysis a NAP could be recorded, then no
further intervention was taken. If no NAP was recorded, then
further external and internal neurolysis was performed, and fas-
cicular stimulation with NAP recording was repeated. If NAPs
were present in a fascicle then no further action was taken. If

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mon narcotic used in our patient population) use in milligrams
per day using a narcotic conversion calculator (Simplicity
GmbH, Therwil, Switzerland).17 Direct comparisons of oxyco-
done requirements were then made for study patients, and the
percentage change over time per patient was calculated. We
documented changes in narcotic use 6 mo after surgery to allow
time for equilibration of pain regimens. A multidisciplinary
Pain Team managed multi-trauma patients with complex pain
medication requirements.
no fascicular NAPs were present, then serial axial cuts of the
fascicle were made until normal fascicular architecture was
appreciated at both the proximal and distal ends of the injured
section. If the nerve was transected, then serial axial cuts of the
proximal and distal stump neuromas were made until the nor-
mal fascicular architecture was appreciated. The remaining
nerve gap was then measured and if the remaining nerve ends
could be approximated with no tension then an end-to-end
repair was performed. If direct approximation of the nerve ends

FIGURE 2. (A) An extensive infra-gluteal incision is used to gain exposure deep to the gluteal sling in high sciatic nerve injuries. (B) In this patient, a
proximal sciatic nerve transection was found with stump neuromas at of both the common sciatic and tibial and peroneal components, represented by the
white S, T, and P, respectively. The (C) proximal and (D) distal stump neuromas are resected to healthy appearing fascicular architecture.

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 Combat Injury of the Sciatic Nerve

was not possible without tension, then the nerve was grafted
with ipsilateral sural nerve autograft, or processed decellular-
ized freeze-dried cadaver allograft (Avance Nerve Graft,
AxoGen Co., Alachua, FL, USA). Grafts were secured using 8-
0 nylon and coaptation sites were wrapped with AxoGuard
Nerve Protector (Cook Biotech Inc, West Lafayette, IN, USA).
Evaluation of Pain
We evaluated pain generated by the nerve injury with an
emphasis on neuropathic pain, as this was the most disabling
mechanisms of injury were gunshot wound (9 of 13, 69%) fol-
lowed by improvised explosive device (IED) blast (2 of 13,
12%), and rocket propelled grenade (RPG) or missile blast (2
of 13, 12%). Nearly all patients had additional injuries. Sixty
percent had ipsilateral femoral bone shaft or neck fractures,
seven (54%) of those injured by gunshot wound received multi-
ple gunshot wounds to other parts of their body, two patients
(12%) had contralateral lower extremity amputation, and two
patients (12%) had major arterial injuries (Table I).
Time from Injury to Nerve Surgery

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component. Neuropathic pain was defined as burning paresthe-
sias (dysesthesias), electric shocks, hyperalgesia, and allodynia.
Self-reported patient pain scores were recorded using the 11-
point pain intensity numeric rating scale (PI-NRS)5 during pre-
operative encounters and postoperative assessments for each
patient, and reported as a preoperative pain score and 6-wk
postoperative pain score.
A bimodal distribution was noted whereby six patients under-
went nerve exploration and repair less than 30 d from injury
(range 12–30 d), and seven patients had nerve surgery at a sig-
nificantly later time (mean 373 d, range 159–1142 d). These
two groups were thenceforth referred to as the early treatment
and late treatment group, respectively (Table I).

Determination of Graft Rejection Findings at the Time of Surgery

The patients who received cadaver allografts were monitored
for potential graft rejection. The presence of fever, skin rash
and/or erythema, onset of increasing local pain, or wound
drainage were all noted during postoperative clinical exams as
indicators of potential graft rejection.
Outcome Assessments
Each patient had multiple neurological assessments of motor
and sensory deficits and at least one repeat electrodiagnostic
electromyography/nerve conduction (EMG/NCS) study 6 mo
after surgery. Patients were followed-up for a 3-yr minimum
postoperative period.
RESULTS
Selected Patients
Thirteen patients underwent surgical exploration of a combat-
acquired sciatic nerve injury. The mean patient age was 28 yr
with a range of 19–48 yr. All patients were men. The predominant
A. Four patients had a neuroma-in-continuity with no record-
able NAP distal to the lesion. In three, following external
and internal neurolysis, NAPs were recorded and no further
action was taken. The fourth had a neuroma-in-continuity
in a portion of the peroneal division, and no NAP was
recordable following internal and external neurolysis.
These non-conducting fascicles were resected and an inter-
fascicular graft with processed decellularized allograft
nerve was placed.
B. The other nine patients had transected sciatic nerves
exhibiting stump neuromas of either or both the peroneal
or tibial components (Fig. 2B). In these nerves, the
stump neuromas were resected until normal appearing
fascicles were exposed (Fig. 2C and D). An end-to-end
nerve repair was possible in one patient. The remainder
had nerve gap repair with multiple interfascicular nerve
grafts using either decellularized allograft nerve or sural
nerve autograft (Fig. 3A and B). The mean length of the
nerve gap after debridement of the retracted, scarred nerve
was 6.2 cm, with a maximum of 7 cm.

TABLE I. Injury Characteristics

Patient Number Mechanism of Injury Time from Injury to Surgery (D) Nerve Defect After Debridement
1 Missile blast 17 5 cm
2 IED blast 1,142 No defect
3 RPG blast 16 5 cm
4 GSW 245 6 cm
5 GSW 446 7 cm
6 IED blast 384 No defect
7 GSW 241 7 cm
8 GSW 332 No defect
9 GSW 251 6 cm
10 GSW 159 6 cm
11 GSW 30 7 cm
12 GSW 20 7 cm
13 GSW 28 6 cm

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 Combat Injury of the Sciatic Nerve

Pain
Twelve patients had severe neuropathic pain necessitating com-
binations of oral analgesic medications, topical analgesics, and
non-pharmacological interventions (desensitization and cogni-
tive). The average postoperative pain reduction on the PI-NRS
scale was seven points (a reduction of two points or a reduction
of approximately 30% in the PI-NRS is a clinically important
difference). Two patients reported no change in pain and one
reported an increase. Among patients with gunshot wounds,
the early nerve surgery group had a mean 5-point pain reduc-
tion (range 3–8), while the late group had a mean reduction of
reduction in narcotic use compared with 82% for the late nerve
surgery group (Table II).
Graft Rejection and Complications
No patients with cadaveric allografts developed deep wound
infection, graft infection, or need for further surgery. The reop-
eration rate was 0%. Three patients had minor complications.
One reported increased pain after surgery with an increase of
two points on the PI-NRS scale 6 wk postoperatively. At the
6-mo postoperative evaluation, the pain was reduced to a mini-

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2.8 points (range 2–8) (Table II). Two patients had spinal cord
stimulators placed prior to surgery. Following nerve surgery,
the stimulator was removed in one patient, and turned off in
the other.
mal level and he was no longer taking narcotic pain medica-
tions. Another patient had an initial unexplained increase in
narcotic use that subsequently resolved. One patient developed
a superficial cellulitis that resolved after a short course of oral
antimicrobial.

Narcotic Usage Electrodiagnostics

The mean oxycodone (or equivalent) narcotic usage decreased
from 127 mg (range 0-960 mg) preoperatively to 21.5 mg
(range 0-188 mg) daily 6 mo postoperatively. Six patients were
not taking any narcotics 6 mo postoperatively. Of those with
gunshot wounds, the early nerve surgery patients had a 90%
Ten of 13 patients obtained EMG/NCS studies at least 6 mo
after surgery. Eight of 10 patients demonstrated electromyo-
graphic evidence of tibial and peroneal nerve reinnervation dis-
tal to the injury site; only three had detectable motor unit
potentials distal to the knee, all in tibial nerve innervated

FIGURE 3. The segmental nerve defect is addressed with (A) an interfascicular repair of the (s) sciatic nerve proper and (t) tibial and (p) peroneal divi-
sions using processed, decellularized allograft nerve (thin white arrow) and (B) the coaptation sites are reinforced with collagen nerve wraps (white block
arrows).

TABLE II. Pain Scores

Days from Injury to Surgery Preoperative NRS-11 Score Postoperative (6 wks) NRS-11 Score Narcotic Usage at 6 mo
Early less than 31 d (N = 5) 8 range 10–6 2.2 range 4–0 90% reduction
Standard greater than 150 d (N = 8) 5.9 range 9–1 4.3 range 7–1 50% reductiona
GSW patients only
Early less than 31 d (N = 3) 8.3 3.3 90% reduction
Standard greater than 150 d (N = 6) 4 3 82.5% reduction

Pain outcome.
a
Four patients were not taking narcotics preoperatively, one of these patients was taking narcotics at 6 mo after surgery.

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 Combat Injury of the Sciatic Nerve
muscles. No patients demonstrated reinnervation of the tibialis
anterior muscle (peroneal nerve innervation).
Functional Recovery
No patient had regained full strength or meaningful functional
recovery distal to the knee joint in the 2 or more yr follow-up
period. Dorsiflexion strength remained 0/5 (MRC scale) in all.
One patient had an elective trans-tibial amputation 3 yr later to
facilitate ambulation.
DISCUSSION
In a recent study of 100 British military patients that described
261 total peripheral nerve injuries, Birch et al1 observed that
two of the three most commonly injured peripheral nerves were
the tibial and peroneal divisions of the sciatic nerve. Eighteen
of the 261 peripheral nerve injuries were deemed to have poor
outcomes defined as persistent and severe pain, failure of
regeneration, and atrophy of innervated muscle groups at a
mean follow up of 28.4 mo. Eleven of the 18 poor outcomes
occurred in patients with injuries to one or both divisions of the
sciatic nerve, with the peroneal nerve demonstrating the worst
recovery. Three other large recent studies also demonstrated a
poor prognosis for peroneal nerve injury.16,18,19 These findings
are akin to our observations.
In our study, 8 of 10 patients displayed electrophysiological
evidence of new motor unit action potentials in muscles that
were undetectable prior to neurolysis or grafting. This highly
supports the utility of surgical techniques in assisting axonal
sprouting and muscle reinnervation. Unfortunately, the degree
of reinnervation was significantly less than what was necessary
for improved neurological function. Notably, no patient ever
demonstrated clinical dorsiflexion after surgical intervention
with persistent 0/5 strength. Furthermore, there was never any
sub-clinical, electrophysiological evidence of reinnervation of
the tibialis anterior muscle. This was true even with reinnerva-
tion of the gastrocnemius muscle after a graft reconstruction in
patients with complete transection of the tibial nerve portion of
the sciatic nerve. Therefore, the distance required for axonal
regrowth insufficiently explains why the tibialis anterior muscle
is particularly resistant to reinnervation. Some patients subse-
quently underwent tendon transfers, and one elected to undergo
a trans-tibial amputation due to persistent neurological deficits,
precluding further axonal growth and longer term observations.
In 1998, Kline et al13 noted significant recovery in the pero-
neal division of 36% of patients needing suture or graft repairs
for sciatic nerve injuries. In a 2004 follow-up study by the same
group, surgical outcome data following sciatic nerve injuries
were reported for thigh level versus buttock level localizations.12
In the patients with gunshot wounds who required either direct
epineural suture repair or sural nerve graft, good recovery in the
tibial and peroneal components was 60% and 20%, respectively
with buttock level lesions, and 86% and 50% with thigh-level
lesions. Though modest, these results are significantly better
MILITARY MEDICINE, Vol. 183, September/October 2018
compared with ours. The mechanisms of injury were likely
more severe in our population, to include the gunshot wounds
and explosions by powerful military-grade weaponry, and sev-
eral other sites of bodily injury. All of our patients had preop-
erative electrodiagnostic EMG/NCS studies demonstrating
complete absence of motor unit potentials in the tibialis ante-
rior muscle. The other reports noted the use of electrodiagnos-
tics, but did not report the data, and therefore it is possible that
some of those patients may have had some preservation of
peroneal nerve fibers preoperatively. Our cohort included only
those with complete axonotmesis or neurotmesis. The differ-
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ences in surgical techniques, to include the use of allograft as
opposed to sural nerve autograph, cannot be discounted.
Our findings demonstrate that surgery on the sciatic nerve to
resect painful neuromas and repair the injured nerve with long
length processed decellularized allograft is a safe and an effica-
cious means of reducing pain. Eleven of 12 patients with severe
preoperative pain experienced significant reduction on the PI-
NRS scale (the 0 to 10 scale that is routinely used in most clini-
cal settings in the United States, with 0 being no pain and 10
being the worst pain that the patient has ever experienced or
could imagine), with reduction of narcotic usage irrespective of
whether they underwent early or late surgery. This is consistent
with a previously completed study of combat-acquired nerve
injuries that demonstrated great pain relief after neurolysis or
nerve grafting in 83% of patients.1 A paper describing combat-
associated sciatic nerve repairs in Iran noted neuropathic pain
in less than 10% of patients, a marked difference from our
experience.9 We wish to promote the viewpoint that early sur-
gery to repair an injured sciatic nerve for the goal of achieving
significant pain reduction should be an important, independent
variable when considering the timing of surgery, as pain reduc-
tion promotes rehabilitation and patient well-being. It should be
noted that this interpretation is somewhat limited given that or
study is observational and we do not have a non-surgical con-
trol group, as well as the complexity of pain management in
these patients who all had numerous other injuries and were
often taking other agents that may affect pain (e.g., gabapentin).
While the correlation is clear in our series of patients, this prin-
ciple should cautiously be applied to the larger population of
patients with combat-related peripheral nerve injuries.
In our study, the possibility of surgical placebo bias in con-
trolling pain cannot be discounted. However, the overall long-
term reduction of pain months after surgery, in addition to the
near-term benefits supports a genuine effect of surgery. There
is also the potential that pain may have subsided independent
of surgical intervention with passage of time from injury.
Though possible, we observed that the late surgical group of
gunshot wound patients in addition to the early group, still had
persistent pain up until the surgical intervention, and both also
had marked postoperative reductions in pain and decreased nar-
cotic use. Neuropathic pain in severe PNI can be disabling,
interfere with rehabilitation, and be irresponsive to pharmaco-
logical and other pain management techniques. Thus surgical
e439
 Combat Injury of the Sciatic Nerve
intervention for the indication of pain control alone may be
appropriate.
In this series of sciatic nerve injury, 71% of the injuries
occurred from gunshot wounds, in contrast to previous combat-
related studies, where a blast mechanism was causative in 63%
of all nerve injuries.1 In a series of 353 sciatic nerve injuries
sustained over a greater than 30-yr period in a civilian popula-
tion, approximately 22% (79/353) were attributed to gunshot
wounds.12 The wide disparity in injury rate and functional
effect of penetrating trauma between military and civilian
patients underscores the need to report the management and
challenges of sciatic nerve injury.
The primary method to bridge a long nerve gap in our
patients was to use commercially available processed decellu-
larized freeze-dried human cadaver allografts. This practice
mitigated the possibility of donor nerve graft site morbidity,
and decreased surgical operative time as no additional time was
taken to harvest autograft. While the use of sural nerve auto-
graft is still considered the “gold standard” in the treatment of
segmental nerve defects and was offered to our patients, it was
not always possible or desirable in our patient population, as
some patients sustained multiple traumatic injuries to all four
extremities, and in some patients one or more amputations ren-
dered autograft donor sites inappropriate for use. In addition,
some patients elected to have the processed decellularized allo-
graft used over autograft in anticipation of no further neurologi-
cal deficit or complications. Recent studies demonstrated
equivalence of processed decellularized allograft versus auto-
graft to bridge short segment nerve injury,2,4 which further sup-
ported using longer length (greater than 5 cm) decellularized
autograft. The supply of varied 1–5 mm diameter decellularized
processed allograft nerve allowed us to provide an equivalent
caliber match to the repaired nerve fascicles, this match poten-
tially increases the number of axons able to cross the segmental
defect. The decellularized processed allograft nerve also main-
tains many of the ultrastructural components of the native
nerve, mitigating the Wallerian degeneration process and dele-
terious consequences of scar tissue in the defect area (Fig. 3C
and D). Processed decellularized allograft nerve is deemed to
be an acceptable alternative toward repairing segmental defects
of large caliber nerves.
There are several limitations of our study. It was comprised
of a relatively small patient population, the form was a retro-
spective review, and there were no controls. The follow-up
period was relatively short, namely 2 yr minimum; and it may
require several more years to adequately assess long-term out-
come. The most notable outcomes from this study were noted
within 2 yr, in that nerve repair with long length processed
decellularized freeze-dried cadaver allograft is safe, and
markedly diminishes pain and improves management. These
findings may facilitate decisions in civilian practice, where gun-
shot wounds are more likely to be of lower intensity, have less
soft tissue destruction, and are more amenable to early surgical
repair.
e440
CONCLUSIONS
Traditionally, observation periods up to 6 mo following PNI
are suggested prior to nerve repair to account for potential
spontaneous reinnervation. However, during this observational
period patients may suffer from severe neuropathic pain. We
have demonstrated that the repair of combat-acquired sciatic
nerve injury performed early after injury is likely a safe and
efficacious means of reducing pain, despite no definitive
improvement in motor strength. The high likelihood for signifi-
cant pain reduction represents an important variable in the for-
mulation of surgical decision, and may negate the traditional
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role of waiting 6 mo. Long length processed decellularized
allograft use is safe, without serious complications, reduces
donor site morbidity, and is practical in patients with multiple
limb injuries.
PRESENTATIONS
Portions of this work were presented in abstract and poster forum at the annual
meeting of the Congress of Neurological Surgeons, Section of Disorders of the
Spine and Peripheral Nerves, New Orleans, LA, USA, September 2015;
American Society for Peripheral Nerve Annual Meeting, Paradise Island,
Bahamas, January 2015; Society of Military Orthopedic Surgeons 56th Annual
Meeting, Scottsdale, AZ, USA, December 2014.
ACKNOWLEDGMENTS
We thank the support staff of the Walter Reed National Military Medical
Center, Bethesda, MD, USA and the Peripheral Nerve Clinic staff for their assis-
tance in performing this study.
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