PERIPHERAL NERVE INJURY:

SURGERY
CHAIR PERSON : DR. RANGANATH.H.D
PROFESSOR,
DEPARTMENT OF ORTHOPAEDICS

PRESENTED BY : DR. GIRISH.S

 GENERAL CONSIDERATIONS FOR SURGERY
INDICATIONS
In the presence of a traumatic peripheral nerve deficit,
exploration indicated as follows
When a sharp injury has obviously divided a nerve.
 early exploration is indicated for diagnostic, therapeutic, and
prognostic purposes.
When abrading, avulsing, or blasting wounds have rendered
the condition of the nerve unknown.
 exploration is required for identification of the nerve injury.
When a nerve deficit follows blunt or closed trauma, and no
clinical or electrical evidence of regeneration has occurred
after an appropriate time, exploration of the nerve is
indicated.(when a nerve deficit complicates a closed fracture.)
When a nerve deficit follows a penetrating wound,
such as that caused by a low-velocity gunshot, the part
is observed for evidence of nerve regeneration. If no
evidence of regeneration,exploration is indicated.
TIME OF SURGERY
The time-honored policy to advise primary suture when
possible.
Primary repair :A repair done soon after injury or up to a
week after (delayed primary) is defined as primary repair
Primary repair should shorten the time of denervation of
the end organs, and
 fascicular alignment should be improved because minimal
excision of the nerve ends is required.
done in the first 6 to 8 hours
delayed primary repair done in the first 7 to 18 days
Indications and
prerequisites
 1. Clean cut injury
 2. Absence of/or minimal
contamination
 3. No gross skeletal instability
 4. Good skin cover
 5. Good vascularity
 6. Appropriately trained staff
 7. Stable patient.
Contraindications are:
 1. Massive associated injuries
with a physiologically
unstable patient
 2. Doubtful limb viability
 3. Significant crushing and
contamination
 4. Segmental loss with poor
quality of the remainder
 5. Lack of proper instruments
and lack of personnel trained
in microsurgery.
Secondary repair :
A delayed nerve repair after the initial healing of skin
andsoft tissues is defined as secondary nerve repair
If primary nerve repair is contraindicated, it is often
preferable to do secondary repair
A fracture is not a contraindication for operation.
Operation before the fracture becomes united may be
advantageous for two reasons:
(1) if bone shortening is necessary, resection of an ununited
or partially united fracture is a much less formidable
procedure than resection of a fully united bone.
 (2) restriction of joint motion is minimal if the nerve is
repaired soon after the injury;
later, motion would be more limited, so severely as to
prevent flexing the joint enough to overcome a gap between
the nerve ends.
INSTRUMENTS AND EQUIPMENT
A nerve stimulator :
should be available for all peripheral nerve procedures
Intraoperative recording of somatosensory evoked potentials and
nerve action potentials is useful in surgical planning and
assessing nerve lesions.
These techniques require sensitive and sophisticated recording
and monitoring equipment and trained technicians
Useful in
investigating partially severed nerves and neuromas incontinuity
in locating and preserving nerve branches given off proximal to or
at the lesion that are still functioning but are encased in scar tissue.
magnifying loupes or the operating microscope
Instruments for handling and dissecting delicate
tissues always are essential.
Gelfoam and thrombin are useful for controlling the
bleeding from the cut ends of nerves.
Suture material : 8-0, 9-0, and 10-0 monofilament nylon.
The tensile strength, easy handling qualities, and minimal
tissue reaction of nylon make it the most desirable suture
material for neurorrhaphy.
epineurial repairs are best done with 8-0 or 9-0 nylon.
For perineurial or epiperineurial repair, 9-0 or 10-0
monofilament nylon is preferable
ANESTHESIA
general anesthesia for surgery in the upper extremities
and neck and
general or spinal anesthesia for surgery in the lower
extremities
TECHNIQUE OF NERVE REPAIR
INCISION :
Incision should extend well proximal and distal to the
lesion
when possible should follow the course of the nerve.
An incision should never cross the flexor creases of the
skin at a right angle.
Short incisions are probably the cause of more futile
nerve operations than any other
The injured nerve be exposed first proximal to and then distal to
the lesion before approaching the site of injury. Dissection and
exposure are made simpler.
If confronted with a neuroma in continuity, the nerve should be
stimulated proximal to and distal to the lesion and the response
should be recorded.
When a nerve is dissected from scar tissue, it should be
stimulated repeatedly to locate any branches that still might be
functioning.
Before the nerve is mobilized completely, sutures are placed in
the epineurium proximal to and distal to the lesion for
orientation
alignment of the longitudinal epineurial vessels, aid in
appropriate rotation of the nerve ends
Handling of the nerve during mobilization is made by the use of
moist umbilical tape or pieces of rubber tissue drains.
ENDONEUROLYSIS (INTERNAL NEUROLYSIS)
When both motor and sensory responses to stimulation are
not good, endoneurial exploration is advisable.
When an endoneurial exploration is undertaken, partial or
complete neurorrhaphy may be necessary
The epineurium is incised longitudinally proximal to the
lesion, beginning not more than 0.5 cm from the level of
gross changes in the nerve as determined by palpation.
If neurorrhaphy becomes necessary, more of the nerve may
have to be sacrificed. So,distal end of the incision is limited.
 The flaps of epineurium on each side may be retracted
laterally by nylon sutures and are undermined widely.
The funiculi are separated if possible with a pointed or
diamond-bladed knife, using sharp or blunt
dissection. then
 1.most of the fasciculi are intact and can be separated
and traced through the neuroma, nothing further
should be done. OR
2.stimulation fails to elicit a response, and few intact
fasciculi can be found, resection of the neuroma and
neurorrhaphy are probably indicated
 PARTIAL NEURORRHAPHY
Indicated in Partial severance of the
larger nerves, such as the sciatic nerve
and the cords and trunks of the
brachial plexus
The intact funiculi are dissected out
The ends of the injured part of the
nerve are resected to normal tissue.
At the cut ends, an end-to-end
neurorrhaphy is performed.
If the epineurium is inadequate for
placement of epineurial sutures,
epiperineurial or perineurial
(fascicular) sutures applied.
NEURORRHAPHY AND NERVE GRAFTING
When a nerve has been completely severed neurorrhaphy after
sufficient resection of the proximal and distal ends of the nerve is
indicated.
considerable gap or defect (actual loss of nerve tissue) remains after
excision.
selecting a method for overcoming the gap is difficult.
Extension of the incision proximally and distally can be helpful in
permitting adequate dissection for closure of the gap..
Regardless of the technique used, there is general agreement that
nerve repair under excessive tension is detrimental to satisfactory
regeneration.
It generally is recommended that if a single 8-0 nylon epineurial
suture can maintain approximation of the nerve ends, excessive
tension is not present.
METHODS OF CLOSING GAPS
BETWEEN NERVE ENDS
mobilization of the nerve ends
Positioning of the extremity.
nerve transposition
bone resection
bulb suture
nerve grafting
nerve crossing (pedicle grafting).
MOBILIZATION
The exact amount of mobilization
a peripheral nerve can tolerate
before its regenerating potential is
compromised is unknown
The nerve gap is determined at
the time of surgery with the
extremity in the anatomical
position and after distal and
proximal neuroma excision.
There is guidelines for maximal
nerve gap over which mobilization
may become a futile
extensive dissection of a nerve from its surrounding
tissues does disrupt the segmental blood supply,
causing subsequent ischemia and increased
intraneural scarring.
Mobilization has been shown to be more detrimental
to the distal nerve segment.
 POSITIONING OF EXTREMITY
Relaxing nerves by flexing various joints and occasionally by abducting,
adducting, rotating, and elevating the extremity.
Flexing joints is most important in repairing gaps in the long nerves of the
extremities.
External rotation and abduction are helpful when repairing radial and axillary
nerves.
elevation of the shoulder girdle in brachial plexus injuries.
extension of the hip in sciatic injuries.
Using both mobilisation and positioning methods, gaps can be closed in
nearly all of the peripheral nerves
When joints that are excessively flexed or awkwardly positioned are mobilized,
tension on the neurorrhaphy cause intraneural fibrosis that compromises
axonal regeneration.
It is a reasonable to flex the knee and elbow no more than 90 degrees. Also,
flexion of the wrist no more than 40 degrees
After the wound has healed sufficiently, the joint can be extended about 10
degrees per week until motion is regained.
TRANSPOSITION
The anatomical course of some nerves can be changed
to shorten the distance between severed ends.
ulnar nerve at the elbow.
The median nerve can be transposed anterior to the
pronator teres if the lesion is distal to its branches to
the long flexor muscles of the Forearm
the tibial nerve can be placed superficial to the soleus
or gastrocnemius in the leg if the lesion is distal to its
branches to the calf muscles.
BONE RESECTION
Bone resection is of particular value in the upper arm
for closing large gaps in the ulnar, radial, or median
nerves when the humerus already has been fractured.
war wounds, because the joints of the extremity had
become so stiff from immobilization caused by
fracture or injudicious use of casts that limited flexion.
Both bones of the forearm or leg in the absence of a
fracture should never be shortened
NERVE STRETCHING AND BULB SUTURE
Stretching of nerves by bulb suture with the joints
acutely flexed followed by progressive extension of the
joints and later by end-to-end neurorrhaphy during a
second operation has been proposed.
This method of overcoming gaps should be avoided
because
Excessive fibrosis
later neurorrhaphy difficult or impossible
successful axon regeneration poor.
Two operations are required
NERVE GRAFTING
Interfascicular nerve grafting as described by Seddon and
later by Millesi
It is indicated when primary nerve repair cannot be done
without excessive tension.
 In general, a nerve gap that is caused simply by elastic
retraction usually can be overcome with local nerve
mobilization, limited joint positioning, and primary repair.
 If the defect is caused in part by loss of nerve tissue,
however, nerve grafting is our procedure of choice.
Autogenous sural nerve is the preferred source of graft.
nerve injuries.
SOURCE OF NERVE FOR INTERFASCICULAR
NERVE GRAFTING
The sural nerve is the most commonly used
From each leg,40 cm of graft material can be obtained.
The lateral antebrachial cutaneous nerve
 for digital nerve grafts
found just lateral to the biceps tendon alongside the cephalic vein.
20 cm of graft material can be obtained.
The medial antebrachial cutaneous nerve,
the terminal articular branch of the posterior interosseous nerve
found adjacent to the basilic vein.
The dorsal sensory branch of the ulnar nerve also have been
used for digital nerve grafting.
 NERVE ALLOGRAFTS
The use of fresh nerve allograft can potentially allow functional
recovery equivalent to autograft.
it requires systemic immunosuppression.
Grafts are selected from ABO blood type–compatible individuals
(cadaveric or living related donors) and stored at 4°C in University of
Wisconsin solution for 7 days before implantation.
Rejection and increased vulnerability to opportunistic infection are
potential complications.
Acellularized nerve allografts are now available with the advantage of
decreased host rejection.
Available in diameters of 1 to 5 mm and in lengths up to 5 cm
 Sensory recovery was more likely than motor recovery
Although autograft is superior, acellularized nerve allograft play a role
when sufficient autograft is not available.
NERVE CROSSING (PEDICLE GRAFTING)
Nerve-crossing operations in the extremities rarely possible.
When a combined median and ulnar lesion is so great that the gap
cannot be closed in either nerve in any other way.
the ulnar nerve can be sectioned again in the upper arm, creating a
segment long enough to bridge the gap between the two ends of the
median nerve.
The distal end of the median nerve is sutured to the distal end of the
free segment of the ulnar nerve to form a U-shaped neurorrhaphy.
The vasa nervorum should be left intact.
At a second operation 6 weeks later, the ulnar nerve is completely
transected and sutured into the distal segment of the median nerve.
This procedure has been advised in situations such as nerve injury
caused by massive ischemic necrosis of the forearm,
SYNTHETIC NERVE CONDUITS
Synthetic conduits can be used to bridge neural gaps.
Various conduit materials have been investigated
including
Silicone,
type I collagen,
polyglactin,
poly-l-lactic acid (PLLA),
Polyglycolic acid (PGA), and
polyvinyl alcohol (PVA) hydrogel.
TECHNIQUES OF NEURORRHAPHY
All methods of nerve repair approximate the neural
connective tissue and ‘healing’ implies collagenous union
mediated by wound fibroblasts.
 The task of the correct axon to find the correct end organ is
still left largely to nature apart from matching the
geometrical shapes and sizes.
The anatomical methods of nerve repair are based on the
structure of the nerve
1.EPINEURIAL NEURORRHAPHY
2.PERINEURIAL (FASCICULAR)NEURORRHAPHY
3.INTERFASCICULAR NERVE GRAFTING
EPINEURIAL NEURORRHAPHY
traditional method of nerve repair
After exposing and dissecting the ends of the nerves, determine that
any remaining gap,closed by endto-end repair without excessive
tension.
appropriate rotational alignment by observing the orientation of
surface vessels and the appearance and location of fasciculi
Place the first suture in the deep surface of the nerve in the
epineurium, next three sutures in the remaining three quadrants of
the nerve
place sufficient interrupted sutures to produce a satisfactory
neurorrhaphy
limited range of motion to assess positional tension at the repair
site.
PERINEURIAL (FASCICULAR) NEURORRHAPHY
This method sutures matching fascicles using perineurial sutures.
Place the nerve ends in proper rotation.
Using magnification, attempt to identify corresponding groups of
fasciculi in the proximal and distal nerve stumps
Incise the epineurium longitudinally proximally and distally to
expose the fascicul
 approximate them individually with interrupted 9-0 or 10-0 nylon
sutures
close the epineurium with interrupted nylon sutures,
OR if the neurorrhaphy is secure, and there is no tension on the
repair, omit the epineurial closure to decrease the amount of
fibrosis
Sunderland pointed out that funicular (fascicular) repair cannot
be done accurately because
(1)funicular patterns at nerve ends match exactly only after clean
transection,
(2) the numbers of funiculi at nerve ends may not correspond, and
(3) any discrepancies in funiculi within the nerve would require
excessive intraneural suture material.

He suggested that funicular repair might be practical when

(1) funicular groups are large enough to take sutures that maintain
funicular apposition,
(2) nerve ends show a funicular pattern that would predispose to
wasteful regeneration of axons if epineurial repair were done, and
(3) each funicular group is composed of nerve fibers to a particular
branch occupying a constant position at the nerve ends.
INTERFASCICULAR NERVE GRAFTING
(MILLESI, MODIFIED)
Excise a circumferential cuff of epineurium from each stump.
transect each fasciculus or group of fasciculi individually at
the level where the fibrosis begins.
When this dissection has been completed to six fasciculi or
fascicular groups, all of different lengths,present in each end
of the stump.
clinical judgment in matching the fasciculi and the fascicular
groups in the ends of the stumps.
Each major fasciculus or group requires a segment of graft
the graft should be 10% to 15% longer than the combined
gaps to be filled
Select the appropriate donor nerve and expose it with
wider incision
Transect the nerve so that its proximal end retracts
beneath the fascia in the proximal calf
Using the operating microscope, place each graft
between the corresponding fasciculi
secure the epineurium of each end to the perineurium
of the fasciculus or fascicular group with a single
suture of 10-0 monofilament nylon
The same technique can be used for a nerve lesion in
continuity or for repair of an unsuccessful primary
neurorrhaphy.
POSTOPERATIVE CARE
After neurorrhaphy or nerve grafting, the extremity is immobilized
in a plaster splint or cast.
The wound should not be dressed until the 7th to 10th day.
The sutures are then removed.
In removing the splint or cast, extreme care is necessary to avoid
tension on the line of suture.
In the upper extremity is to retain the plaster splint for 4 weeks and
then to replace it with a plastic splint that can be extended gradually
over 2 to 3 weeks.
In the lower extremity, spica cast for at least 6 weeks, then longleg
brace that controls extension of the knee and allow 4 weeks or more,
depending on the tension on the line of suture, for complete
extension of the knee.
Physical therapy is essential to recovery of function of the extremity.
After interfascicular grafting, the joints should be
immobilized no longer than 10 days.
 Millesi recommended immobilization of the extremity in
the exact position it was in at surgery, maintains the graft
in its elongated position and minimizes later disruption.
The plaster cast or splint is removed, and active exercises
of all joints are begun.
The progress of regeneration is determined by the
advance of the Tinel sign.
As this sign progresses along the graft, it may stop at the
distal repair temporarily, resumes progress eventually.
If the Tinel sign does not progress after 3 to 4 months,
blockage at the distal line of suture is assumed and
resection of this area followed by repair is indicated.
Thank you
References
Campbell’s operative orthopaedics
Textbook ob basic and clinical orthopaedis by M N
Kumar
Tachdijian’s paediatric orthopaedics volume 1 by john
anthony herring
Textbook of orthopaedics and trauma by G S Kulkarni