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mesoneurium

perineurium
Fascicles of nerve fibers

epineurium
endoneurium











Focal contusion (gunshot wounds)
Stretch/traction injury
Drug injection injury
Compression
Crush inju...


Changes at proximal and distal site of injury
Seddon, Sunderland and lately by Mackinnon
 6 degrees

 1st

degree of injury(neuraparaxia)

› Segmental demylination
› Axons intact

› Recovery in 12 to 16 wks
 2nd

degree i...
3rd degree injury
› Axonal injury & fibrosis of endoneurium
› Incomplete recovery
 4th degree injury
› Axonal injury
› Da...
 5th degree

injury(neurotmesis)
› Complete nerve division
 6th degree injury
› Variable combination of previous five
de...
4th degree injury

2nd
degree
injury

1st degree injury

6th degree
injury

3rd degree injury

normal
•History
•Examination


Motor function
› Movements, muscle atrophy



sensory function
› Tinel sign, Ten test

› Two poi...
 Tinel

sign: › peripheral tingling or dysaesthesia'
provoked by percussion of the nerve
› Positive in axonal injuries




EMG
NCS
Intra operative nerve action potential


Microsurgical techniques
› Adequate magnification
› Microsurgical instruments & sutures



Different techniques:
› Pri...


Sharply transected nerves
› Immediate repair



Crushed, avulsed, blast injuries
› Nerve ends tacked together
› Repair...


Primary repair
› Tension free repair
› Mobilization of nerve ends

› Discourage
 Facilitation by postural position
 E...
 Primary nerve

repair
› Epineural repair
› Grouped fascicular repair
Standard repair
 Restore

the continuity of fascicles
 Internal topography
 Intra-operative nerve stimulation
 Neurolysis with the eye...
Tension at site of repair
 Need of postural positioning
 Alignment of sensory & motor components
 Maximize number of ax...
Sural nerve
› 30-40cm
› Lateral peroneal communicating br : 10-20cm
 Lateral antebrachial cutaneous nerve(LABC)
› 8cm
 M...
 Donor site

scarring
 Donor site sensory loss
› Patient education
Complete : resection and repair with graft
Incomplete neuroma
 Intra-operative nerve stimulation
 Black boxing around neuroma



Indications:
› Very proximal peripheral nerve injuries
› Root avulsions

› Excessive scarring
› Level of injury unclear...


Motor nerve transfer
› Pure motor axons
› Close proximity

› expendable
› Synergistic supply


Sensory nerve transfer
...
elbow flexion
 Shoulder abduction
 Ulnar-innervated intrinsic hand function
 Forearm pronation
 Radial nerve function
...
Transfer of radial nerve to axillary nerve
 Veins,

pseudo-sheaths, bioabsorbable tubes
 short nerve gaps ≤ 3cm
 Low antigenicity , biodegradability
 Trials to a...
Extensive injuries
 Limited donor material
 Immunosuppressive agents


› FK506( tacrolimus )
› Prednisone , azathioprin...
Nerve injury and repair
Nerve injury and repair
Nerve injury and repair
Nerve injury and repair
Nerve injury and repair
Nerve injury and repair
Nerve injury and repair
Nerve injury and repair
Nerve injury and repair
Nerve injury and repair
Nerve injury and repair
Nerve injury and repair
Nerve injury and repair
Nerve injury and repair
Nerve injury and repair
Nerve injury and repair
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Nerve injury and repair

  1. 1. mesoneurium perineurium Fascicles of nerve fibers epineurium endoneurium
  2. 2.           Focal contusion (gunshot wounds) Stretch/traction injury Drug injection injury Compression Crush injuries Avulsion Laceration Electrical burns Idiopathic Others(Viral infections, metabolic and neural disorders)
  3. 3.  Changes at proximal and distal site of injury
  4. 4. Seddon, Sunderland and lately by Mackinnon  6 degrees 
  5. 5.  1st degree of injury(neuraparaxia) › Segmental demylination › Axons intact › Recovery in 12 to 16 wks  2nd degree injury(axonotmesis) › Axonal injury/ distal wallerian degeneration › Regeneration at rate of 1 inch per month › Complete slow recovery
  6. 6. 3rd degree injury › Axonal injury & fibrosis of endoneurium › Incomplete recovery  4th degree injury › Axonal injury › Damage to endo and perineurium with dense scarring › Needs surgical intervention 
  7. 7.  5th degree injury(neurotmesis) › Complete nerve division  6th degree injury › Variable combination of previous five degrees of nerve injury
  8. 8. 4th degree injury 2nd degree injury 1st degree injury 6th degree injury 3rd degree injury normal
  9. 9. •History •Examination  Motor function › Movements, muscle atrophy  sensory function › Tinel sign, Ten test › Two point discrimination › Touch, vibration
  10. 10.  Tinel sign: › peripheral tingling or dysaesthesia' provoked by percussion of the nerve › Positive in axonal injuries
  11. 11.    EMG NCS Intra operative nerve action potential
  12. 12.  Microsurgical techniques › Adequate magnification › Microsurgical instruments & sutures  Different techniques: › Primary nerve repair › Nerve grafting › Nerve transfer › Nerve conduits › Nerve allografts
  13. 13.  Sharply transected nerves › Immediate repair  Crushed, avulsed, blast injuries › Nerve ends tacked together › Repair delayed for 3 weeks or until wound bed permits  Re-exploration  Neuroma excision, nerve grafts  Acute nerve grafting in the 1st sitting  Bleeding control ,trimming of fascicles ,loose epineural suturing  Closed injuries treated expectantly for 12 weeks
  14. 14.  Primary repair › Tension free repair › Mobilization of nerve ends › Discourage  Facilitation by postural position  Extreme range of joint movements
  15. 15.  Primary nerve repair › Epineural repair › Grouped fascicular repair
  16. 16. Standard repair
  17. 17.  Restore the continuity of fascicles  Internal topography  Intra-operative nerve stimulation  Neurolysis with the eyes  Priority to the motor recovery(radial and peroneal nerve)
  18. 18. Tension at site of repair  Need of postural positioning  Alignment of sensory & motor components  Maximize number of axons  Reversal of graft  Exclusion of expendable nerve 
  19. 19. Sural nerve › 30-40cm › Lateral peroneal communicating br : 10-20cm  Lateral antebrachial cutaneous nerve(LABC) › 8cm  Medial antebrachial cutaneous nerve (MABC) › Anterior & posterior division › 20 cm  Expendable nerves(peroneal and radial)  Sensory branches of ulnar and median nerves  Distal anterior interosseous nerve and so on… 
  20. 20.  Donor site scarring  Donor site sensory loss › Patient education
  21. 21. Complete : resection and repair with graft
  22. 22. Incomplete neuroma  Intra-operative nerve stimulation  Black boxing around neuroma 
  23. 23.  Indications: › Very proximal peripheral nerve injuries › Root avulsions › Excessive scarring › Level of injury unclear  Idiopathic neuritides  Radiation induced nerve injury
  24. 24.  Motor nerve transfer › Pure motor axons › Close proximity › expendable › Synergistic supply  Sensory nerve transfer › pure sensory axons › Innervates non critical area › Expendable and lying in close proximity
  25. 25. elbow flexion  Shoulder abduction  Ulnar-innervated intrinsic hand function  Forearm pronation  Radial nerve function 
  26. 26. Transfer of radial nerve to axillary nerve
  27. 27.  Veins, pseudo-sheaths, bioabsorbable tubes  short nerve gaps ≤ 3cm  Low antigenicity , biodegradability  Trials to add a nerve graft inside the conduit › neurotrophic factors
  28. 28. Extensive injuries  Limited donor material  Immunosuppressive agents  › FK506( tacrolimus ) › Prednisone , azathioprine  Processed acellular cadaveric nerve allografts › AxoGen, Inc. ,Alachua, FL.
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