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Assessment of peripheral nerve surgery


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hand examination, hand injury, hand surgery

hand examination, hand injury, hand surgery

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  • 1. Assessment of peripheral nerve surgery Mr Vaikunthan Rajaratnam MBBS(Mal),AM(Mal),FRCS(Ed),FRCS(Glasg),FICS(USA),MBA(USA), Dip Hand Surgery(Eur), PG CertMedEd(Dundee),FHEA(UK),AFFST(Ed),FAcadMEd(UK). Senior Consultant Hand Surgeon Alexandra Health, SINGAPORE
  • 2. At the end of the lecture the participant will be able to: • 1. List the qualitative and quantitative methods for nerve function understanding their limitations • 2. Understand the role of electro diagnosis in nerve injury
  • 3. Issues & Challenges • cortical functional reorganization of hand representation result of axonal misdirection - cortical remapping • Modulation of central nervous processes rather than peripheral factors • Brain capacity for visuo-tactile and audio-tactile interaction • selective de-afferentation enhancing the effects of sensory relearning • no surgical technique which can ensure recovery of tactile discrimination in the hand of an adult after median nerve lesion • hand as a sense organ • MRC Scale subjective findings - psychometric drawbacks
  • 4. Regeneration after nerve repair regardless of the repair technique - axonal misdirection is unavoidable
  • 5. Assessment of hand function • sensibility • motor function • autonomic • pain and • discomfort
  • 6. Model Instrument for Outcome After Nerve Repair • Detection tests - Semmes-Weinstein monofilaments, • discrimination tests - two-point discrimination (2PD), • identification tests- shape/texture-identification (STI) test • activities of daily living (ADL) - The DASH was also the most commonly used condition-specific patient-reported outcome in the included clinical trials • (McPhail, Bagraith, Schippers, Wells, & Hatton, 2012)
  • 7. Factors influencing the outcome • Age • Cognitive brain capacities - Verbal learning capacity and visuo-spatial cognitive capacity • Timing of repair • Type of nerve • Level of injury • Type of injury • role of the brain in functional recovery - ‘new language spoken by the hand’.
  • 8. What happens in the brain after nerve injury and repair • silent ‘black hole • adjacent cortical areas expand and occupy the former • distorted discontinuous islands
  • 9. Sensory re-education and sensory relearning • mind does not understand the new ‘sensory code’ associated with specific textures and shapes • touch modalities, localise touch, shapes and textures • concepts of learning mechanisms, cortical remodelling and brain plasticity
  • 10. New strategies in sensory re-education and sensory relearning • Phase 1: maintaining the cortical hand map activate the cortical area representing the damaged nerve- visuo-tactile and audio-tactile interaction • Activation of motor neurones – ‘mirror neurones’ in premotor cortex by the mere observation of hand motor actions • activated by reading/listening to action or words • Phase 2: enhancing the effects of sensory re- education de-afferentation of the forearm would hypothetically result in expansion of the adjacent cortical hand representation • Cutaneous de-afferentation of the forearm (Rizzolatti et al. 2001, Rizzolatti & Craighero 2004)
  • 11. Outcomes • outcome shows ongoing improvements up to 5 years after the nerve repair • 59% of patients with median or ulnar nerve repairs returned to work within 1 year with an average time off work of 31 weeks (Jaquet 2004) • high education, high compliance to hand therapy and an isolated injury predict quicker return to work in patients with median and/or ulnar nerve injuries.
  • 12. Sollerman Hand Function Test • overall measure of hand and grip function when engaging in ADLs (Sollermen & Ejeskar 1985). • It was designed to measure grips that are needed for certain ADLs such as eating, driving, personal hygiene, and writing. • includes subtests that represent common handgrips (volar, transverse volar, spherical volar and pinch positions - pulp, lateral, tripod, and the five finger) and activities (using a key; picking up coins from a flat surface; writing with a pen; using a phone; and pouring water from a jug)
  • 13. Nerve Conduction Studies and Electromyography in the Evaluation of Peripheral Nerve Injuries
  • 14. NCS & EMG • essential in the evaluation of nerve disorders • localizing the site of injury • distinction of conduction block from axonal degeneration • prognostic information • dependent on the skills of the examiner • Augment physical examination
  • 15. NCS and Needle EMG • measurement of nerve response amplitude and conduction velocity along the course of each nerve • sensory nerve action potential (SNAP) 5–20 mV in amplitude orthodromically/antidromically • compound motor action potential (CMAP) • Needle EMG distinguish neurogenic / myopathic causes
  • 16. Post Injury - acute • Motor axons remain excitable for up to 7 days after injury. Sensory axons to 11 days • So perform 14 days post injury • Spontaneous activity in muscles - 2 – 6 weeks
  • 17. References • Lundborg G, Rosén B. Hand function after nerve repair. Acta Physiologica February 2007;189(2):207-217 • McPhail, S. M., Bagraith, K. S., Schippers, M., Wells, P. J., & Hatton, A. (2012). Use of Condition-Specific Patient-Reported Outcome Measures in Clinical Trials among Patients with Wrist Osteoarthritis: A Systematic Review. Advances in orthopedics, 2012, • Jaquet, J. 2004. Median and minor nerve injuries: Prognosis and predictors for clinical outcome. Thesis. Department of Plastic and Reconstructive Surgery, Erasmus Medical Center, Erasmus University, Rotterdam