neurosurgery

1. Nerve injury
Hamad emad dhuhayr
Dr Saleh WaslAllah Alharby
www.ksu.edu.sa/DrSalehAlharby

2. OUTLINE
 DEFINITION.
 TYPES OF NERVE INJURIES.
 FATE (pathophysiology) AND
REHABILITATION.
 ETIOLOGY.
 PRESENTATION.
 DIAGNOSIS.
 CLINICAL EXAMPLES:
(ERB’S,CARPAL TUNNEL,RADIAL,ULNAR,SCIATIC AND
PERONEAL N.)
Dr Saleh WaslAllah Alharby
www.ksu.edu.sa/DrSalehAlharby

3. DEFINITION
Partial or complete interruption of normal
physiology of the nerve.
NERVE CONDUCTION IS AFFECTED.
Dr Saleh WaslAllah Alharby
www.ksu.edu.sa/DrSalehAlharby

4. Classification Of Nerve
Injuries
 Seddon, Sunderland and lately by Mackinnon
 6 degrees

5. Degrees Of Nerve Injury
 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. Degrees Of Nerve Injury
 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. Degrees Of Nerve Injury
 5th
degree injury(neurotmesis)
 Complete nerve division
 6th
degree injury
 Variable combination of previous
five degrees of nerve injury

9. FATE AND REHABILITATION
 WALLERIAN DEGENERATION
1 MM PER DAY
Dr Saleh WaslAllah Alharby
www.ksu.edu.sa/DrSalehAlharby

10. REHABILITATION
 PAIN CONTROL.
 SPLINT. (AVOID PRESSURE SORES)
 NERVE AND MUSCLE STIMULATION.
 NEARBY JOINTS RANGE OF MOTION.
 MONTHS ----- YEARS .
Dr Saleh WaslAllah Alharby
www.ksu.edu.sa/DrSalehAlharby

11. Nerve Injury
 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)

12. PERSENTATION
 PAIN
 LOSS OF SENSATION
 LOSS OF MOTION
 LOSS OF POWER
 LOSS OF REFLEXES
 WASTING
 TROPHIC CHANGES
(skin,sc,neurovascular,bones,muscles)
 CONTRACTURES
Dr Saleh WaslAllah Alharby
www.ksu.edu.sa/DrSalehAlharby

13. DiagnosisDiagnosis
 Motor functionMotor function
 Movements, muscle atrophyMovements, muscle atrophy
 sensory functionsensory function
 Tinel sign, Ten testTinel sign, Ten test
 Two point discriminationTwo point discrimination
 Touch, vibrationTouch, vibration
•HistoryHistory
•ExaminationExamination

14. Tinel Sign
 Tinel sign: -
 peripheral tingling or
dysaesthesia' provoked by
percussion of the nerve
 Positive in axonal injuries

15. Electrical Stimulation Tests:
 EMG
 NCS
 Intra operative nerve action potential

16. CLINICAL EXAMPLES
 ERB’ PALSY
 CARPAL TUNNEL SYNDROME(MEDIAN NV)
 RADIAL NERVE INJURY
 ULNAR NERVE INJURY
 SCIATIC NERVE INJURY
 LATERAL POPLITEAL NERVE INJURY
Dr Saleh WaslAllah Alharby
www.ksu.edu.sa/DrSalehAlharby

17. ERB’S PALSY
 BIRTH INJURY (DIFFICULT LABOUR)
 TRACTION ON NERVE ROOTS C5-6
 STRETCH-RUPTURE-AVULSION
 UPPER LIMB IN EXTENSION
 MOTHER NOTICE NO MOTION
 90% GOOD RECOVERY
 ROLE OF SURGERY AFTER 3 MONTHS
 REMEMBER PROPER REHABILITATION
Dr Saleh WaslAllah Alharby
www.ksu.edu.sa/DrSalehAlharby

18. CARPAL TUNNEL SYNDROME
 MEDIAN NERVE ENTRAPMENT BY FLEXOR RETINACULUM
PAIN,NUMBNESS,NIGHT
 MANUAL WORKERS
 DIAGNOSIS
 SURGERY
Dr Saleh WaslAllah Alharby
www.ksu.edu.sa/DrSalehAlharby

19. RADIAL NERVE INJURY
Dr Saleh WaslAllah Alharby
www.ksu.edu.sa/DrSalehAlharby

20. ULNAR NERVE INJURY
Dr Saleh WaslAllah Alharby
www.ksu.edu.sa/DrSalehAlharby

21. SCIATIC NERVE INJURY
Dr Saleh WaslAllah Alharby
www.ksu.edu.sa/DrSalehAlharby

22. PERONEAL NERVE INJURY
(LPN)
 FOOT DROP
 TIGHT POP
 SKELETAL TRACTION
 DIRECT INJURY (RARE)
 DYNAMIC SPLINT
Dr Saleh WaslAllah Alharby
www.ksu.edu.sa/DrSalehAlharby

23. Principals Of Nerve Repair
 Microsurgical techniques
 Adequate magnification
 Microsurgical instruments & sutures
 Different techniques:
 Primary nerve repair
 Nerve grafting
 Nerve transfer
 Nerve conduits
 Nerve allografts

24. Timing Of The Nerve Repair
 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

26. Primary Nerve Repair
 Primary nerve repair
 Epineural repair
 Grouped fascicular repair

27. Epineural Repair
Standard repair

28. Fascicular Repair
 Restore the continuity of fascicles
 Internal topography
 Intra-operative nerve stimulation
 Neurolysis with the eyes
 Priority to the motor recovery(radial
and peroneal nerve)

30. e.g. Ulnar Nerve Fascicular
Components

31. Nerve Grafts
 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

32. Options For Nerve Grafts
 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…

33. Disadvantages
 Donor site scarring
 Donor site sensory loss
 Patient education

34. Neuroma In Continuity
Complete : resection and repair with graft

36. Neuroma In Continuity
 Incomplete neuroma
 Intra-operative nerve stimulation
 Black boxing around neuroma

38. Nerve Transfer
 Indications:
 Very proximal peripheral nerve injuries
 Root avulsions
 Excessive scarring
 Level of injury unclear
 Idiopathic neuritides
 Radiation induced nerve injury

39. Nerve Transfer
 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

40. Most Common Uses Of Nerve
Transfer
 elbow flexion
 Shoulder abduction
 Ulnar-innervated intrinsic hand function
 Forearm pronation
 Radial nerve function

41. Transfer of radial nerve to axillary nerve

42. Nerve Conduits
 Veins, pseudo-sheaths,
bioabsorbable tubes
 short nerve gaps ≤ 3cm
 Low antigenicity , biodegradability
 Trials to add a nerve graft inside the
conduit
 neurotrophic factors

44. Nerve Allografts
 Extensive injuries
 Limited donor material
 Immunosuppressive agents
 FK506( tacrolimus )
 Prednisone , azathioprine
 Processed acellular cadaveric nerve allografts
 AxoGen, Inc. ,Alachua, FL.

46. Summary
 Axon degeneration occurs from mild
compression injury
 The prognosis for Neuropraxia is poor
 Axonotmesis is generally caused from
separation of the cell body from the neuron
 Wallerian Degeneration typically does not occur
in Neuropraxic injury
 Surgical reconstruction is necessary in
Neurotmesis
 Wallerian Degeneration does not occur in
Neurotmesis
 A ligamentous structure can cause Neuropraxia
Dr Saleh WaslAllah Alharby
www.ksu.edu.sa/DrSalehAlharby

47. Refferences
 Special surgery matary
Dr Saleh WaslAllah Alharby
www.ksu.edu.sa/DrSalehAlharby