Nerves Injury

Audi Hidayatullah
 Outline

Peripheral nerves: histology & physiology

Peripheral nerve injury & regeneration
NCV / EMG basics
Peripheral compression neuropathies
Vascular disorders
Peripheral Nerve Histology

Neuron:
1. Cell Body

2. Dendrite

3. Axon

4. Presynaptic
terminal
Peripheral Nerve Histology

Schwann Cells (PNS)

Surround cell body &
axons
Provide support and
nutrition, maintain
homeostasis, form
myelin, and assist in
signal transduction
Make myelin
Physiology
Electrical and chemical
signals
Resting Potential -
normal= -50 to -80mV,
maintained by
Na+/K+ pump
Action Potential -
depolarization beyond
threshold transmits
signal rapidly
 Peripheral Nerve
Cross Sectional Anatomy
Epineurium
Encompasses nerve and
runs between fascicles
Vascular
Perineurium
Layer that covers
individual fascicles
Tensile strength
Endoneurium
Inner most collagenous
matrix that surrounds
axons within fascicles
Nourish & protect axons
 Traumatic Nerve Injury
Classification
1943: Seddon
Neuropraxia

Axonotmesis

Neurotmesis

1951: Sunderland
Type I- V
 Traumatic Nerve Injury
Classification
1st Degree (Neuropraxia)
Interruption of
conduction at site
of injury
Axon preserved
No wallerian
degeneration
Motor fibers more
susceptible to injury
than sensory fibers
 Traumatic Nerve Injury
Classification
1st Degree (Neuropraxia)
Large myelinated fibers more susceptible
than fine or nonmyelinated fibers
Electrophysiologic Studies
NCV slowing or complete conduction block
Fibrillation potentials
Positive sharp waves
 Traumatic Nerve Injury
Classification
1st Degree (Neuropraxia)
Complete functional recovery after 1st
degree injuries because axonal continuity
preserved and changes responsible for the
conduction loss are fully reversible
Full restoration of function may take as long
as 3 to 4 months after the injury
 Traumatic Nerve Injury
Classification
2nd Degree (Axonotmesis)
Axon and myelin sheath disruption leads
to conduction block with Wallerian
degeneration
Endoneurium, perineurium and
epineurium intact
Axon regenerates along intact endoneurial
tube
 Traumatic Nerve Injury
Classification
2nd Degree (Axonotmesis)
Complete loss of motor and sensory
functions
Complete functional recovery expected
Time to recovery depends on severity and
level of injury, as axons must regenerate
distally
Usually months to recovery
 Traumatic Nerve Injury
Classification
3rd Degree (Axonotmesis)
Axons and endoneurial tube disrupted
Perineurium and epineurium intact
Complete loss of function
Onset of recovery delayed longer due to
more severe retrograde injury to cell bodies,
fibrosis
With longer delays in recovery, target
organs may undergo changes that prevent
full recovery
 Traumatic Nerve Injury
Classification
4th Degree (Axonotmesis)
Only epineurium left intact
Nerve in continuity, but extensive
intraneural scarring and disruption of
fascicular structure
Wallerian degeneration
Complete loss of sensory and motor
function
Minimal useful recovery
Usually requires excision of damaged
segment and repair or reconstruction
 Traumatic Nerve Injury
Classification
5th Degree (Neurotmesis)
Complete loss of continuity of nerve
Varying amounts of scar form between
severed ends, with neuroma formation at
proximal stump
Wallerian degeneration of distal stump
Spontaneous recovery negligible
Requires surgical repair
Causes of Nerve Injury

Compression
Stretch
Ischemic
Traumatic
Causes of Nerve Injury
Acute Compression
Immediate onset
Mechanical deformation
of nerve fibers
responsible for
pathologic changes

Chronic Compression
Delayed/ gradual onset
Ischemia significant
factor in genesis of
injury
Clinical example

Doctor, why is my
thigh numb??

Meralgia
Parasthetica???
Causes of Nerve Injury
Extent and Severity of Studies have shown that
Compression Injuries: excessive tourniquet
Magnitude and rate of
times and pressures can
lead to prolonged EMG
applied force changes
Duration
Recommended:
Manner which applied
(localized or over a UE no more than 50-
long segment) 100mmHg above
systolic
LE no more than 2x
systolic
Limit duration <2hrs
Causes of Nerve Injury
Stretch
1. Acute
Abrupt application of force of
considerable magnitude
Stinger = acute neuropraxia
2. Chronic
Slow stretching of nerve over
period of time
Usually tolerate significantly more

Variable degree of injury

Causes: Fracture displacement, joint
dislocation, trauma, etc.
 Physiology of Nerve
Degeneration
Wallerian Degeneration
Breakdown of axon
distal to site injury
Begins within hours post
injury
Myelin and axons
deteriorates
Schwann cells proliferate
Macrophages
phagocytize myelin and
axonal debris
 Physiology of Nerve
Regeneration
Rate of regeneration varies
depending on the type &
location
In humans, an average
outgrowth of 1-2 mm/day
is generally quoted
Proximal budding occurs
after 1 month delay
Functional Recovery after
Nerve Injury
Clinical outcomes variable and related to:

1. AGE single most important factor

2. Level of injury - distance regenerating axons
must go to reach target organs, distal > prox
3. Length of injury zone
4. Type of injury sharp transection > crush
5. Timing of nerve repair
6. Status of end organ at time of re-innervation
7. Technical expertise of surgeon
 Nerve Repair

Primary Repair
Preferable: 0-3 weeks

Immediate repair technically easier

though emergent repair not necessary
Time limit of repair up to 18 months
 Nerve Repair
Epineurial Repair
Standard

Orientation critical

9-0 monofilament

Grouped Fascicular Repair

Not clinically better than epineurial

Indications
1. Median nerve in distal forearm
2. Ulnar nerve in distal forearm
3. Sciatic nerve in thigh
 Nerve Repair
Tension
Encourages gapping
and scar formation
Reduces blood flow:
8% elongation = 46%
decrease in perfusion
Grafting better than
repair in tension
(autografts)
 Rehabilitation of
Nerve Injuries
During re-innervation
continued motor and
sensory rehab critical
Sensory re-education
improves results
Assists brain in
reinterpreting
misdirected axon
impulses
EMG / NCV Studies
 EMG / NCV

EMG
Determines health of muscle and, indirectly, the
nerve supply
Fibrillations
Spontaneous activity at rest; indicates denervation
Insertional activity
Activity during needle insertion; high is bad
Motor unit potentials
Few, wide, and low amplitude = BAD
 EMG / NCV

NCV
Provides additional info on nerve function
Nerve conduction measured (saltatory
conduction)
>50 meters/second normal in extremities

EMG/NCV
When get to assess nerve damage?
* as early as 3 weeks; monthly as needed
Nerve Compression
Syndromes
Radial Tunnel Syndrome
Symptoms
Proximal / lateral arm pain
No motor or sensory
dysfunction .. PAIN only
No PIN dysfunction
Normal EMG/NCS
Provocative test: resisted long
finger extension
Tenderness over radial neck or
supinator
Recurrent or unresponsive
lateral epicondylitis
Coexists in 5%
 Radial Tunnel Syndrome
Causes of Compression: Treatment:
Recurrent radial vessels Longer periods of
(leash of Henry) conservative care 6-
ECRB leading edge 12mths (NSAIDS,
Arcade of Frohse
splinting, work
modifications)
Distal Supinator
Operative release often
disappointing
Careful patient
selection
 Posterior Interosseous
Nerve Syndrome
Pain at lateral elbow
Weakness and radial
deviation with wrist
extension (ECRL
innervated above PIN)
Motor neuropathy
EMG/NCS diagnostic
Sites of compression
same as radial tunnel
 Posterior Interosseous
Nerve Syndrome
Treatment
Initial conservative
(MRI r/o mass)
Decompression: if no
recovery by 3 months
or progression
If condition persists
>18 months
irreversible muscle
fibrosis occurs
 Pronator Syndrome
Compression neuropthy
of proximal median n.
Sites of Compression:
Supracondylar process
(1% of population)
Ligament of Struthers
Bicipital aponeurosis
Deep head of PT **
Accessory head of FPL
Origin of FDS
 Pronator Syndrome
Confused with CTS Provacative tests:
No Tinels sign at wrist A. Flexion past 120 deg.
No night symptoms - Supracondylar process
Sensory disturbance over or ligament of Struthers
region of palmar cutaneous B. Resisted supination with
branch and anterior elbow flexion
proximal forearm
- Bicipital aponeurosis
C. Resisted pronation with
elbow extended
- Pronator heads
D. Resisted MF PIP flexion
- FDS
EMG usually normal, though
may be positive in PQ &
FPL
 Pronator Syndrome
Treatment:
Nonoperative usually
successful
Decompression
considered if fails to
respond after 3-6
months
Requires global
decompression
(proximal to distal) of
all potential areas
 Anterior Interosseous
Nerve Syndrome
Sites of Compression:
Pronator teres
FDS Arcade
Lacertus Fibrosus
Enlarged bicipital bursa
Accessory FPL (Gantzers m.)
Diagnosis
Motor loss without sensory
involvement
Loss of FPL & FDP - Index
produce characteristic finding
EMG/NCS diagnostic
R/O Brachial Neuritis if B/L
Parsonage-Turner Syndrome
 Anterior Interosseous
Nerve Syndrome
Treatment:
Observe for 3-6
months
Surgical
decompression for
failures
Thank You