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NERVE LESIONS

Lesion: a structural change in a body


part due to injury or disease.
signs and symptoms of a nerve lesion
are directly correlated to the function of
the nerve

DEFINITIONS
Neurapraxi a = segmental demyel i nati on
Local injury may distort/disrupt the myelin sheath
locally, resulting in focal demyelination. =>
temporary conduction block
Sheath is restored locally


Wal l eri an degenerati on
Occurs distal to lesion site = loss of conduction
Accompanied by corresponding muscle atrophy
followed by removal by macrophages and recycling of
myelin-derived material
RESPONSES TO INJURY
CLASSIFICATION OF
NERVE LESIONS
Incomplete/complete
Complete when all neurons traversing the
injured segment are disrupted
Incomplete when not all neurons are disrupted,
sparing of distal motor/sensory function
BY SEVERITY
A system of classifying severity
With regard to axon
SUNDERLAND CLASSIFICATION SYSTEM
First degree
(Neuropraxia)
Reversible conduction block Recover in hours to
weeks
No need surgical
intervention
Second degree Loss of continuity to axons No need surgical
intervention
Third degree Damage to axons and surrounding
structures
Recovery variable
Fourth degree Damage to axons, scarring
prevents nerve regeneration
Surgery with nerve
grafting needed
Fifth degree Usually in laceration/stretch
injuries: nerve divided into 2
Same as above
NB: some sources include sixth degree-
mixed patterns of injury
Affects management of injury
ABOUT THE CLASSIFICATION
By how they damage nerves:
Those which cause anoxic anoxia
CO, cyanide
Those which cause demyelination
Lead, trimethyl tin, thallium
Those which damage peripheral neurons
Usually from chronic exposure
e.g. Ethanol, organophosphates (e.g. malathion, DDT)
Those which damage cell body of neuron
Organic mercury, vinca alkaloids
Those which damage NMJ specifically
tetrodoxin (from pufferfish), botulinum toxin (botox),
Those which cause lesions within CNS
e.g. Gold thioglucose
FOR NEUROTOXINS:
methods and
refl ex tests
DIAGNOSIS
Recall: reflex arc
Sensory -> interneuron -> motor




Tests help in localisation of nerve lesions
(some primitive reflexes are a sign of brain
injury in general)
REFLEX TESTS
Name What you have to do Positive sign What it means
Orbicularis
oris/snout/nasom
ental
tap finger/tongue
depressor on lateral
corner of mouth/lips
pursing of
lips




exaggerated with lesions
affecting supranuclear
corticopontine pathways-
e.g. multi-infarct dementia,
extrapyrimidal diseases
e.g. Parkinson)
Suck Gently stroke lips Sucking/swallowing movements

Biting

Mouth opening and head turning to
stimulus
Normal in babies, but in
adults indicates sv, diffuse
brain injury
Wartenberg/thumb
sign
Forcefully flex 2nd-5th
fingers
Flexion of thumb Pyramidal tract lesion
Palmomental
(exaggerated/asy
mmetrical)
Intensely stroke ball of
thumb/palm of hand
with fingernail
Contraction of ipsilateral chin
muscles

If unilateral, contralateral
brain lesion;
also in diffuse cerebral
injury
PATHOLOGICAL REFLEXES
Name of reflex What you have to do Positive sign What it means
Grasp stroke palm finger flexion, grasping Normal in infants
Otherwise, sign of
diffuse brain injury
Gegenhalten (paratonia) Attempted passive
stretching of muscle
active and intense
contraction of muscle in
question patient
involuntarily resist
movement
Frontal lobe damage,
neurodegenerative
conditions
Grasping/groping
(magnet phenomenon)
object brought near palm
of conscious patient
Hand follows presented
object like a magnet
Normal in infants
Otherwise, sign of
diffuse brain injury
Mass reflexes of lower
limbs
Forceful passive flexion
of toes/forefoot (Marie-
Foix handgrip)
Retraction of lower limb
by flexion at knee and
hip
reveals intactness of
spinal reflex arc =>
peripheral nervous sys
REFLEX TESTS
Name What you have to do Positive sign What it means
Babinski reflex Stroke lateral edge of
foot from heel to 5th toe
Tonic extension of big
toe, other toes
remain/splayed
Lesion of pyramidal
pathway on
corresponding side
Oppenheim reflex Forcefully stroking ant.
margin of tibia, proximal
-> distal (painful!)

Same as Babinski


Grasping/groping
(magnet phenomenon)
object brought near palm
of conscious patient
Hand follows presented
object like a magnet
Normal in babies, sign of
diffuse cerebral injury in
adults
Gordon reflex Forcefully
stroking/squeezing calf
muscles
Same as Babinski
REFLEX TESTS
Often used with EMG to differentiate nerve
disorder from muscle disorder
Speed of conduction depends on
degree of myelination
diameter of nerve
Normal: 50-60m/s
Slower could indicate problems with
myelination
False negative: lower body temperature => slower
conduction
NERVE CONDUCTION VELOCITY TEST
Procedure:
Two electrode patches placed on skin over the
nerve; electrodes attached
One electrode stimulates the nerve with electrical
current. The other records the nerves
Time taken for electrical
impulse to travel between
probes is measured.
NCV contd
Gold standard
for neuromuscular
disorders



Procedure:
Needles are inserted through skin into muscle
Electrical activity is measured during rest, slight
contraction and forceful contraction
ELECTROMYOGRAM (EMG)
To identify nerve defect more specifically
Typical sites: radial, sural nerves

NERVE BIOPSY
Common
peri pheral
nerve l esi ons
SIGNS AND SYMPTOMS
Nerve Probable cause Sensory loss Motor loss
Sciatic n. penetrating
wounds,
fractures of
the pelvis
hip
dislocations
badly-placed
intramuscular
injections
Below knee except
medial side of leg
and medial border of
foot

Tingling suggests
nerve is not totally
severed
Weakness extending
hip joint and flexing
knee joint due to
impaired hamstring
ability
Cannot move foot
Cannot bend knee
Foot drop (below)
LOWER LIMBS
Nerve Probable cause Sensory loss Motor loss
Common
peroneal nerve
Commonly injured in
fractures of the neck of
the fibula.
LOS on skin of leg & foot
anteriorly & laterally except
the lateral border of the foot
(sural nerve) and medial
border of the foot
(saphenous).
Damaged to innervation of
anterior leg muscles =>
weakened extension of ankle
Innervation (superficial peroneal
nerve) to lateral leg muscles
damaged=>
weakened flexion of ankle joint;
inversion of foot
Unsupported/unopposed foot
exhibits foot drop and inversion
(equinovarus) (below)
LOWER LIMBS
LOWER LIMBS
Nerve Probable
cause
Sensory loss Motor loss
Femoral n. Rarely injured
unless
gunshot/stab
wounds
LOS over anterior and
medial sides of thigh, along
medial border of leg as far
as big toe
Unable to flex knee as all
quadriceps muscles are
paralyzed
Tibial n. Rarely injured;
protected by
muscles
LOS on sole of foot
Ulcers can develop
Posterior muscles of leg
paralysed => no plantar
flexion
Foot is dorsiflexed and
everted =>
calcaneovagus (left)


Where Probable cause
Nerves
affected
Motor loss
Sensory
loss
Observable effect
C
5
,

C
6

r
o
o
t
s

o
f

p
l
e
x
u
s

Blow to shoulder
Lat., post. cord,
suprascapular
nerve, nerve to
subclavius
Supraspinatus,
deltoid; biceps,
brachialis, teres
minor,
infraspinatus
Lat. side of
arm/forearm
Upper limb hang
limply by side
C
7
,

C
8
,

T
1

r
o
o
t
s

Excessive
abduction
Ulnar, mcedian
nerves
Small muscles of
hand (lumbricals,
interossei)
Along
medial side
of arm
Clawed hand
(hyperextension of
metacarpophalang
eal joints, flexion
of interphalangeal
joints) (below)
UPPER LIMBS NERVE LESIONS
(BRACHIAL PLEXUS)
Probable cause Motor loss Sensory loss Observable effect
Axillary n.
Badly adjusted crutch,
downward displacemt of
humerus in shoulder
dislocations, humerus
fracture
Paralysis of
deltoid/teres minor
Lower deltoid
Cannot abduct arm
past 15 deg
Radial n.
Axilla lesion:
triceps, anconeus,
extensor m. of
forearm
Post. forearm, lat.
dorsum of hand, lat.
3.5 fingers
Cannot extend
elbow + wrist joint,
fingers
Wrist drop (below)
UPPER LIMBS
NB: Radial n. lesions are also called Saturday night
palsy because people get drunk and fall asleep with
their arms hanging over the backs of chairs. Also
Honeymoon palsy when one of the newlyweds sleeps
on the arm of the other.

Motor loss Sensory loss Signs/symptoms
U
l
n
a
r

n
.

Elbow: flexor carpi ulnaris,
medial of flexor
digitorum profundus
Ant and post surfaces of
medial 1/3 of hand,
medial 1.5 fingers
Cannot flex terminal phalanges of medial 2
fingers
Hand m paralysed, cannot adduct/abduct
fingers
Metacarpophalangeal joints hyperextended
in 4
th
and 5
th
fingers, interphalangeal joints
flexed (claw hand)
Wrist: small muscles of
hand- i.e. paralysis of
adductor pollicis

Dorsum of hand
unaffected

LOS on medial 1/3 palm
and medial 1.5 fingers b/c
damage to superficial
branch of ulnar n and
palmar cutaneous branch
Claw hand more observable because
flexor digitorum profundus not paralysed
Froments sign- abn adduction of thumb
UPPER LIMBS
left image: positive
Froments sign
Motor loss Sensory loss Signs
M
e
d
i
a
n

n
.

Elbow: ant. compt of
forearm
Palmar aspects of lat 3.5
fingers
Forearm in supine
position, wrist flexion
weak and accompanied
by adduction
When making a fist, lat 3
fingers cannot be flexed,
medial 2 flex weakly
Thumb laterally rotated,
adducted
Ape-like hand

CTS may be worse in
early morning b/c lying
position may redistribute
body liquids, consequent
increase in pressure
Wrist: (carpal tunnel
syndrome)
Weakness of thenar
muscles, may be
accompanied by wasting
Burning sensation along
lat 3.5 fingers b/c
compression of n. in
carpal tunnel

Tingling and numbness
over lat. 3.5 fingers and
nail beds
Phalens sign: flexion of
wrist 30-60s will
compress CT, replicate
symptoms;
Tinels sign: palpation of
n when it runs
superficially => tingling
in distal portions
supplied

UPPER LIMBS
Bodys response to
injury
Nerves can regrow under favourable
environment of the Schwann cells
In contrast, oligodendrites and astrocytes in
CNS are generally inhibitory to axonal
growth

CAN NERVES RECOVER?
Recovery depends on severity (naturally)
DEPENDS ON SEVERITY
Type of injury Spont? Rate of recovery Surgery
First degree Full Days- 3 months
after injury
None
Second degree Full Regenerates: 1
in/mth
Third degree Partial Neurolysis?
Fourth degree None After surgery, 1
in/mth
Nerve repair,
graft, transfer
Fifth degree None
1. Macrophage invasion
mitogenic input to Schwann cell
remove debris (e.g. axonal fragments)
2. Regenerating axon sprouts within hours
3. Axon contacts the Schwann cell basal laminae on
one side and the Schwann cell membrane on the
other
Schwann cell basal lamina provides promoters of axonal
outgrowth (e.g. laminin, fibronectin)
Schwann cell directs regenerating axon back to its target
using endoneurial tube
But can result in neuroma formation
4. BUT loss of cell body = irreversible
e.g. polio, motor neurone disease
No regeneration is possible
AFTER AN INJURY
Limited because:
neurons are postmitotic in the mature CNS
neurons are localised to certain sites
glial cells in CNS are inhibitory to axonal outgrowth
REGENERATION IN CNS
of nerve
l esi ons
TREATMENT
Surgical Nonsurgical
Indications:
Injury/continuity defect in nerve
which cannot regain normal function
without surgical intervention
Loss of normal neural function which
cannot be corrected non-surgically
Distressing subjective symptoms
Indications:
Evident improvement indicating
electrical regeneration
Mild, tolerable subjective symptoms
Effects last longer Short-term
CATEGORIES OF TREATMENT
of nerve
l esi ons
SURGICAL TREATMENT
= joining up of the ends of the nerves using
sutures
Best when nerve has been cut sharply
BUT nerve elasticity causes retraction of
segments
causes tension
can lead to scarring, ischemia
NERVE REPAIR
Requires a donor nerve
Average size 2-5cm
Cable grafts used if greater than 2-3cm->
Most common:
Sural n.
Great auricular n.
Decided by
Ease of harvesting
Minimising resulting loss of function
Because once you take out the donor nerve, the
dermatomes it innervates will have no sensation etc.
NERVE GRAFT
To consider:
Diameter of donor and host nerves
Should match!!
But can combine 2 strands => bigger diameter ( cable
graft)
Length of graft
Number of fascicles
Cross-sectional shape and area
Nerves can be round or flat
Patient preference!
Harvesting donor nerve => loss of sensation, patients
might prefer that the loss of sensation be somewhere
specific.
WHEN CHOOSING DONOR NERVES
Vascularity
Schwann cells survive when the graft is
revascularised quickly
Time since injury
Avoids problems like Wallerian degeneration, etc.
Extent of injury/length of graft required
(for peripheral nerves) Tension on prepared
nerve
The limb must be kept in a relaxed position
WHAT AFFECTS RECOVERY
Other tissues can be used to graft nerves
too!
Most common: veins
Generally good results in studies
Easy to find good size match for nerves
BUT:
poor resistance to kinking and collapse
Unsuitable for longer grafts
NERVE GRAFTING: ALTERNATIVES
of nerve
l esi ons
NONSURGICAL
TREATMENT
= removal of scar tissue
Works best when
nerve is entrapped, not cut
nerve is not transected, electrical impulses still can
flow
Requires skill and caution
Might damage surrounding, functional nerves
NEUROLYSIS
Medication
Lifestyle changes
e.g. for carpal tunnel syndrome, patients can be
taught to take frequent breaks during repetitive
tasks
NSAIDS
relieve pain
NONSURGICAL TREATMENT
Transcutaneous nerve stimulation (l ef t )
using gating mechanism




Physical therapy
Radiofrequency techniques
cooking the nerve!
NONSURGICAL TREATMENT
Regional nerve-blocking procedures using
local anesthetics
Local anesthetic at nerve
At neuroma
= mass of nerve fibres and Schwann cells formed after
injury
Neurolysis at peripheral nerves
Usually for terminal patients
Phenol/ethanol injected directly to nerves supplying body
part in pain
Effect lasts 6-8 weeks
NONSURGICAL TREATMENT
SOURCES AND BIBLIO
ht t p: // www. i nst ant anat omy. net / arm/ nerves/ medi anwri st . html
ht t p: // www. ai c. cuhk. edu. hk/ web8/ peri pheral _nerve_l esi ons.htm
ht t p: // www. ncbi . nl m. ni h. gov/ pubmed/8832668
ht t p: // www. rsdsa. org/ gl i al _workshop/ gl i al pdf / James_Campbel l /Nerve
Lesi onsPai n.pdf
ht t p: // emedi ci ne. medscape.com/arti cl e/1172408-overvi ew
ht t p: // www. hopki nsmedi ci ne. org/ neurol ogy_neurosurgery/ speci al ty_
areas/ peri pheral _nerve_surgery/ condi ti ons/ nerve_i nj ury. html

NCV and EMG:
ht t p: // www. nl m. ni h. gov/ medl i nepl us/ency/ arti cl e/003927. ht m - NCV
ht t p: // www. urmc. rochest er. edu/encycl opedi a/ content.aspx?ContentT
ypeI D=92&Cont entID=P07657
ht t p: // www. hopki nsmedi ci ne. org/ heal thl i brary/ t est _procedures/ neuro
l ogi cal / el ectromyography_emg_92,P07656/ - about EMG
ht t p: // www. neneuro. com/ nn_12_use_of _emg.html - Use of EMG i n
nerve/ muscl e di sord
SOURCES
Cel l response t o i nj ury:
ht t p: // f acul ty. swosu. edu/ scott.l ong/ txcl /cnstox.htm - CNS t oxi ns
ht t p: // www. j neuroi nf l ammat i on. com/content/8/1/109
Surgi cal Management of Pai n edi t ed by Ki m Burchi el

Treat ment of nerve l esi ons:
ht t p: // www. medscape. com/ vi ewart i cl e/ 423216_6
ht t p: // www. ncbi . nl m. ni h. gov/ pmc/arti cl es/ PMC1201001/
ht t p: // surgerydept . wust l . edu/Surgery_M. aspx?i d=2936&menu_i d=28
4
ht t p: // cal .vet. upenn.edu/ proj ects/ saort ho/chapt er_65/ 65mast.htm
ht t p: // www. pai ncl i ni c. org/ t reat ment -peri pheral nervebl ocks.htm -
Nerve bl ocks
ht t p: // emedi ci ne. medscape.com/arti cl e/1298684-t reatment

Cl i ni cal :
ht t p: // www. dart mout h. edu/ ~dons/ i ndex.html
SOURCES
PICTURES:
http://i mages.rheumatol ogy.org/i mage_di r/al bum75674/m
d_99-12-0031.ti f.j pg
http://1.bp.bl ogspot.com/-
WhtUSzuIB54/ThhNNr7QF4I/AAAAAAAACu0/6bJ_wG8OL
fk/s1600/Radi al +nerve-wri st+drop.j pg
http://www.bai l ey-l aw.com/docs/acute-nerve-i nj uri es.htm
http://www.tari nga.net/posts/i magenes/15519439/Sabi a-
usted-que____-_Propi o_-_Curi osi dades_.html

INTERESTING READINGS:
http://ntp.neurosci ence.wi sc.edu/neuro670/ reqreadi ng/Re
generatingTheNervousSystem.pdf
PICTURE SOURCES