Peripheral nerves: injury

tumor
Moderator: Dr. Anteneh (plastic and reconstructive surgeon)
Presenter: Dr. Minale (GSR3)

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Outline
• Introduction
• Anatomy
• Pathophysiology
• Nerve injury type
• Evaluation
• Investigation
• Management

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Introduction
• The causes of nerve injuries are many; however, they
share common basic pathophysiological processes.

• Traction and laceration injuries are the commonest traumatic

mechanism with completely different approach to treatment.

• Entrapment neuropathy is the commonest non traumatic nerve injury

encountered in clinical practice

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Anatomy of the Peripheral
Nerves
• the axon is the basic unit of
nervous system, surrounded by myelin
• fascicles constitute the main
nerve trunk.
• Endoneurium surrounds the axons
• perineurium surrounds the fascicles
• epineurium surrounds the main nerve
trunk
• Epineurium is fibrovascular stroma
composed of type I&III collagen.

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Pathophysiology of surgical nerve disorder
• The PNS has the capacity to regenerate injured axon
• GAP–43, Tubulin, Actin upregulated and ChAT
AChE, neurofilament downregulated
• To augment this regenerative potential
• Microsurgical techniques
• Novel mechanisms for nerve reconstruction

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Cont’d

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Peripheral nerve injuries
• Peripheral nerve injuries affect 2.8% of all trauma patients
• Based on mechanism of injury;
• Direct
• Low (compressive neuropathies, compartment syndrome)

• Medium-high(nerve transection, traction, contusion, or avulsion )

• Indirect; thermal, electrical, or radiation injury and other complex nerve
injuries related to inflammatory processes.
• Surgical nerve disorders related to peripheral nerve tumors

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 Cont’d

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Traction injury
• common mechanism of injury affecting peripheral nerves;
• leads to stretch, rupture and avulsion injury to nerve
• 8% stretch; disturbs intraneural circulation and blood nerve repair
• stretch beyond 10% to 20%, leads to structural failure
• Leads to lesion in continuity, which presents in 70% of nerve lesion.

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Avulsion Injury
• Brachial plexus injury is commonly affected by this mechanism.
• Stretch or traction injuries to the plexus can occur # dislocation of humerus or
clavicle, or extreme mov’t at shoulder joint
• Injury occurs at preganglionic site poses challenge in mgt
• lower trunk spinal nerves(C8,T1) are prone to preganglionic injury
• Stretching mechanism results different grade of injury

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Cont’d

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nerve injury grading
• Nerve injuries are graded according to morphologic features that
also relate to recovery potential and hence reflect on the
management of these injuries
• Seddon
• Sunderland
• Mackonin sunderland modification

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 Medium to high energy to injury
Laceration Injury
soft tissue laceration with sharp object like knife, glass, auto metal, saw
surgical instrument, etc. cut nerves 30% of time
• Extent of functional loss could be mild, incomplete to severe or total
• Even partial transection seldom regenerates spontaneously, if restored
functional recovery poor—needs surgical correction
Sharp transection Blunt transection
• epineurium clean cut ragged epineurium
• Less hemorrhage or contusion more brusing/contution
• Less scar formation more scar formation
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 Low energy injury
Compression/Pressure Injury
• Blood flow and continuous nutrient delivery Is needed for nerve
• Abnormal compression of nerves as they run in their natural courses can lead to dysfunction by
• Ischemia
• mechanical distortion
• Chronic compression of the nerves produces
• alteration in paranodal myelination,
• axonal thinning, and
• segmental demyelination
• Carpal tunnel and cubital tunnel syndromes are the most common surgical
conditions affected by this mechanism

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 Cont’d
• brachial plexus and the ulnar, sciatic, and peroneal nerves are most
commonly affected by these more severe compressive etiologies
• The degree of recovery after compression or ischemic injury may be
accurately predicted in some clinical situations
• Saturday night palsy and unconsciousness due to anesthesia with out
proper positioning resulting compression has good recovery.

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cont’d
Compartment Syndromes.
• Increased pressure in closed fascial compartment
• Severe compression and ischemic damage to peripheral nerves as well as
other soft tissues can result.
• Usually long segment of nerve affected
• Pain and paresthesia alerts compartment syndrome in swollen extremity
• Volkmann’s contracture is a serious example of ischemic compression due to
development of compartment syndrome

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cont’d

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 Cont’d
Injection
• Iatrogenic injury caused by a needle placed into or close to a nerve, and damage results
from neurotoxic chemicals in the agent injected.
• 10% of patients subsequently found to have an injection injury have a delay of hours or
even days before the onset of symptoms
• Presents by;
• Burning pain, paresthesia, and radiation of a deep discomfort down the limbs
in the distribution of the involved nerve

• electric-like shock down the extremity, followed by or concomitant with a severe burning
pain and paresthesia as the agent is injected
• Radial nerve and sciatic nerve usually affected

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 indirect Nerve Injury (Complex Nerve
Injuries)
Electrical
• Passage of a high current through a peripheral nerve usually results diffuse nerve and muscle
damage
• Nerves affected first by necrosis and then end up in perineural and endoneurial scar tissue
• Conservative management of the nerve injury itself and early orthopedic reconstruction of
the extremity seem to be best.
• Resection of a lengthy segment of damaged nerve and repair
by grafts is usually necessary

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 Cont’d
Thermal
• Thermal injury can result in neural damage ranging from a transient neurapraxia to
severe neurotmesis with extensive necrosis of nerve as well as adjacent tissues
• Patients with severe burns involving nerve present with complete motor and sensory
loss
• The clinical examination is often difficult because of associated soft tissue injuries,
extensive skin loss, and often a massively swollen extremity
• Prognosis is poor if there is severe associated soft tissue injury.
• Damage happen directly by burn or indirectly by constricting effect

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 Cont’d
Irradiation
• Irradiation is a relatively rare cause of iatrogenic nerve injuries compared with injection
injuries
• The irradiation usually affects the brachial plexus but can also occur at the level of the
lumbosacral plexus
• Extensive scar formation in surrounding soft tissues and severe intraneural changes, consisting
of myelin loss, axonal degeneration, and extensive endoneurial fibrosis, often result

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Clinical Evaluation of nerve injured patient
History
• Information about premorbid condition and mechanism of injury
• Open vs closed
• Stretch/crush vs laceration
• Nature of laceration (jagged vs sharp)
• Diabetes and preinjury neuropathy

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Physical Examination
Neuromuscular examination;
1. Motor
• sign of motor deficit
• Loss of function
• Weakness
• atrophy
• Should be assessed when mental status improved
• Be ware of certain anatomic anomaly.
• Martin Gruber & Rich cannieu

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Physical Examination
2. Sensory
Sign of sensory deficit
• loss of sensation, uncoordinated fine motor control
• Pinch and grip testing
• Two point discrimination
• Pain and temperature testing
• Touch and vibration testing
• Tinel testing

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Investigations
Electrodiagnosis studies(EDS)
• Sensory nerve conduction studies
• Motor nerve conduction studies
• Electromyography
• It should be noted that the optimal timing for performing EDSs is 2 to
3 weeks post injury (i.e., after the WD process is completed),

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Cont’d

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Cont’d
• Magnetic Resonance
Neurography (MRN)
• Different sequence
used
• High frequency/High
resolution U/S

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 Management
Conservative Surgical
• Grade IV-V
• Grade I-III
Options;
• Nerve repair
• Neurolysis
• Nerve grafting
• Nerve transfer
• Tendon transfer

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General approach to nerve injury

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Cont’d

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 General principle of nerve repair
Tools;
• Microsurgical techniques
• operating microscope or magnifying
loupes.
• 8-0 to 10-0 nylon stich
• technically perfect nerve repair
must consist of four parts
1) complete debridement to healthy
nerve tissue,
2) nerve approximation without
tension,
3) end-on alignment of fascicles, and
4) atraumatic and secure mechanical
coaptation of nerve ends.

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Surgical options
Neurolysis
• Dissection outside of epineurium to
release it from point of compression
or tethering due to scaring
• Dissection performed from normal to
injury site
Direct repair
• Ends repaired without tension
• Whenever there is excess tension at
repair site, nerve grafting is preferred.

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 Type of direct repair
Epineural Repair
• Those with good fascicle alignment.
• Aligning the longitudinal blood vessels in
the epineurium
• 8–0 or 9–0 nylon sutures used under
magnification
• Minimal number of sutures (usually four)
for accurate coaptation are preferred to
reduce the scarring process
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Grouped fascicular repair
• external epineurium is reflected back to
organize the fascicles.
• Fascicular coaptation with, nylon 8-0 to 10-0
• mixed motor and sensory nerves
• Eg. ulnar nerve at wrist, radial nerve
above elbow before giving rise to posterior
interosseous nerve, and superficial sensory
radial nerve
37
 Cont’d
Fascicular repair
• Used in motor and sensory
fascicles that can be identified, neighboring nerve(the donor nerve)
• partially damaged nerve
• use two to three 10–0 or 11–0
nylon sutures 120 to 180
degrees apart, in the
perineurium
• End-to-Side Repair
• distal stump of a transected nerve(recipient)
to the side of an intact adjacent or
• Adequate mobilization of the recipient
nerve
• a small epineural window on donor nerve.
• Coapitation with two to three microsutures
placed 180 degrees apart through the
epineurium.

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 NERVE Grafting
Donor nerves:
1.Autografts • Sural nerve
• Gold standard against all, when • Medial antebrachial cutaneous nerve above and
graft needed below elbow
• Lateral antebrachial cutaneous nerve below elbow
• Give neurotrophic factor and
• Superficial sensory radial nerve
viable shewann cells
• Dorsal cutaneous branch of ulnar nerve, and
• Vascularized graft is preferred in • Lateral femoral cutaneous nerve of
long gap thigh

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 Cont’d
Allograft
Allografts from cadaveric donors have
been used rarely when the bridging
gap is exceedingly high so that
available autografts would not suffice.
Not immunogenic as other tissue
Nerve conduits
• Used for smaller gaps<3cm
• Non critical sensory nerve
• It could be biologic or artificial
• Can used as temporary gap holding
before nerve grafting.

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Nerve transfer
• Converting proximal nerve injury to distal injury
• Indication:
• Proximal nerve injury
• Brachial plexus injury
• Delayed presentation
• Segmental loss
• Scarred wound bed

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Post-op Management

• The strength of a nerve repair usually plateaus by the third week.

• Hence, all limb movements should be exercised with caution
during this time period
• Most nerve repairs are performed in extension to avoid suture
distraction postoperatively.

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Common peripheral nerve injuries
• Brachial plexus injury
• Radial nerve injury
• Median nerve injury
• Ulnar nerve injury
• Sciatic nerve injury
• Peroneal nerve injury
• Tibial nerve injury

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Brachial plexus injury
• Formed by C6-T1 spinal nerves
• Typically occurs in young
individual involved in motor
cycle accident and birth related
traction injury in new born.
• Closed injury 73%
• Motor cycle(79%)
• Open injury(23%)
• Gunshot wound
• Laceration(sharp/blunt)
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 Brachial plexus injury • Sensory examination helps in locating the
• Location of injury lesion
• Preganglionic
• Post ganglionic • deep pressure sensation may be the only
clue to continuity in a nerve with no
• Preganglionic motor function or other sensation
• Absence of Tinel’s signs(supraclavicular)
• Horner’s syndrome (sympathetic/T1 level) • The thumb is related to C6 root, the
• Proximal nerve injury(dorsal scapular, long thoracic, phrenic nerve) middle finger to C7,and the little finger to
• cervical paraspinal muscle weakness and C8.
denervation
• pseudomeningocele in image studies
• intact sensory nerve action potentials in the
area of sensory deficit
• Severe pain in an anesthetic extremity

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Evaluation
• Hx • Investigation
• PX • Plain x ray(neck &shoulder)
• Location of trauma marks • CXR
• Motor and sensory exams • CT myelography
• Reflexes • MR myelography
• tinel’s sign • EDS

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Cont’d
Indication for surgery
• 2/3 recover spontaneously after
1 mon.
• If there is no spontaneous
recovery or electrical evidence
of recovery, surgery is needed.
Timing
• Early/immediate-within 3-4 wks.
• Open/sharp injury
• Increasing neurological deficit
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Cont’d
• Closed injury(
contusion/stretch)-4-6 mon.
• Flail arm lesion(c5-T1) ,3 mon.
• Low velocity gunshot injury-3-4
mon.
• high-velocity gunshot wounds-
demand an earlier surgical
exploration
Reinnervation principle
• elbow flexion and
shoulder function (stabilization,
abduction, and extrarotation)
are the primary goals of surgical
reinnervation.
Options
• Graft(nerve root maintained)
• Neurotization (avulsive)

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Neonatal brachial plexus injury
• occurs before, during, or after labor and parturition
• incidence 0.5 and 5 per 1,000 live births
• the upper trunk commonly involved
• Persistent deficit in 20 to 30% of patients.

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Radial nerve injury
• Posterior cord, with C5-T1 contributions. • Hx
• The radial nerve is injured through • PE
orthopedic injury more than any other
major nerve • PIN- unable to extend MP joint
• 12% of humeral shaft fractures being • Radial palsy-extensor muscle paralysis,
complicated by radial nerve paralysis
sensory loss
• 1.9 and 3.3% iatrogenic injury during
fixation • Tenodesis effect
• A common site for iatrogenic radial nerve
injury lateral intermuscular septum

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Cont ‘d

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Management options
• Open –explore
• Closed-observe 3 mon.
Surgical options
• Primary repair
• Neurolysis
• Tendon transfer
• Nerve transfer

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Ulnar nerve inury
• From medial cord formed by C8-
T1
• Cubital tunnel is the second
most common compression
neuropathy in the upper
extremity
• ulnar nerve is susceptible to
injury from direct trauma

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Median Nerve Injury

• From medial (C6,C7) and lateral

cord(C8,T1)
• Martin-Gruber and Riche-
Cannieu anastomoses.
• Most affected by compression

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Sciatic nerve injury
• Longest and thickest nerve in the
body.
• Ends in tibial nerve, common
peroneal nerve and sensory
branches.

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Tibial nerve injury
tibial nerve
• Plantar flexion
• Inversion of the foot
• claw deformity (intrinsic muscle
paralysis)
• Abnormal sensation in the tibial
aspect of the leg and
inner aspect of the foot

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Peroneal nerve injury
Peroneal nerve
• Paresthesia and pain down the
outer aspect of the leg and
dorsum of the foot
• Tenderness to deep pressure
over the neck of the fibula.
• foot drop.

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 Reference
• Manual of Peripheral Nerve Surgery; Mariano Socolovsky, MD. 2018 Georg Thieme Verlag KG
• Nerve Surgery ; Susan E. Mackinnon, MD, FACS, FRCS(C) , © 2015 Thieme Medical Publishers,
Inc.Thieme Publishers New York
• Atlas of Peripheral Nerve Surgery; Second Edition;Daniel H. Kim, MD, FAANS, FACS /© 2013, 2001 by
Saunders, an imprint of Elsevier Inc.
• Youmans & Winn Neurological Surgery , SEVENTH EDITION; H. RICHARD WINN, MD © 2017 by
Elsevier, Inc.
• Michigan manual of plastic surgery / [edited by] David L. Brown, Gregory H. Borschel, Benjamin Levi.
— Second edition2014 by LIPPINCOTT WILLIAMS & WILKINS

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 Thank you!

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