Nerve Disorders Module: Overview of Peripheral Nerve Injuries
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This document provides an overview of nerve disorders and discusses various topics in detail, including peripheral nerve injuries, brachial plexus injuries, compression neuropathies, and carpal tunnel syndrome. It describes the anatomy and classifications of peripheral nerve injuries. Surgical treatment options for nerve injuries include neurolysis, nerve repair, nerve grafting, and nerve transfers. The timing of surgery and prognostic factors are also reviewed. Carpal tunnel syndrome is discussed as the most common compression neuropathy, along with its risk factors, prevalence, and gold standard for diagnosis.
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Nerve Disorders Module: Overview of Peripheral Nerve Injuries
- 1. Module: Nerve Disorders Chye Yew Ng MBChB(Hons) FRCS(Tr&Orth) British Diploma in Hand Surgery European Board of Hand Surgery Diploma Consultant Hand & Peripheral Nerve Surgeon Upper Limb Fellowship Director
- 2. Overview Peripheral nerve injuries Brachial plexus injuries Compression neuropathy CRPS
- 3. Hierarchical Approach to Revision Why? (Indications) What? (Treatment options) When? (Timing of surgery) How? (Technical details) HOT Higher Order Thinking
- 5. Cross Section of a Peripheral Nerve Axon Fascicle Nerve Endoneuriu m Epineurium Perineurium EpiPEn = Epi – Peri – Endo A&E Extrinsic & Intrinsic vascular supply Longitudinal – Segmental - Interconnected
- 6. Central Neuronal Death & Neuroprotection Neuronal death after peripheral nerve injury Acetyl-L-carnitine Arrests sensory neuronal death Speeds up regeneration N-acetyl-cysteine Provides sensory and motor neuronal protection Hart et al. Neurological Research 2008
- 7. Mechanoreceptors Slowly Adapting Rapidly Adapting Cutaneous Low frequency vibration Merkel discs Meissner corpuscles Subcutaneous High frequency vibration Ruffini terminals Pacinian corpuscles
- 8. Mechanisms of Nerve Injuries Crush / compression Stretch / traction Laceration / transection Metabolic disturbance Ischaemia Radiation Electrical injury Thermal injury
- 9. Classification of Nerve Injuries Seddon BMJ 1942 Neurapraxia (Transient Block) Axonotmesis (Lesion in Continuity) Neurotmesis (Division of a nerve) Brain 1943 • Localised degeneration of the myelin sheaths • Complete interruption of axons • Preservation of supporting structures (Schwann tubes, endoneurium, perineurium) • All essential parts destroyed • Interruption can occur without apparent loss of continuity
- 10. Classification of Nerve Injuries Neurapraxia Axonotmesis Neurotmesis Motor - - - Sensory +/- - - Autonomic +/- - - NCS Conduction block at the site Distal conduction preserved Loss of conduction both at and distal to the lesion Loss of conduction both at and distal to the lesion EMG No fibrillation Fibrillation ++ Fibrillation ++ Recovery Days to weeks provided the cause is removed Months provided the cause is removed No recovery unless repaired
- 11. Nerve Conduction Studies Recording electrode Neurapraxia Axonotmesi s Neurotmesis Wallerian degeneration Recording electrode Recording electrode HOT
- 12. In clinical practice, how do you distinguish? Axonotmesis versus Neurotmesis Nature of injury Serial observations Exploration Seddon BMJ 1942 (Imaging)
- 13. Nerve in Danger! Pain, Pain, Pain • Burning • Severe Autonomic dysfunction • Absence of sweating • Smoothness & dryness of skin Tinel sign • Distal to Proximal • Regenerating touch fibres
- 14. Classification of Nerve Injuries Sunderland 1951 I II III IV V Focal conduction block NO Wallerian degeneration Axonal Disruption Axon + Endoneurium Disruption Axon + Endoneurium + Perineurium Disruption Axon + Endoneurium + Perineurium + Epineurium Disruption Cross-innervation
- 15. Sunderland ‘VI’ Grabb & Smith’s Plastic Surgery 6th edition. Chapter 9 HOT
- 16. Physiological Conduction Block Type A Intraneural circulatory arrest Metabolic block with no nerve fibre pathology Immediately reversible Type B Intraneural oedema Increased endoneurial fluid pressure Reversible within days or weeks
- 17. Classification of Nerve Injuries Lundborg 1988 Physiological conduction block Myelin damage Axonal damage Axon + Endo damage Axon + Endo + Peri damage Axon + Endoneuriu m + Perineurium + Epineurium damage Type A Type B Sunder land 1951 I II III IV V Seddon 1942 Neurapraxia (Transient Block) Axonotmesis (Lesion in Continuity) Neurotmesis (Division of a nerve)
- 18. Classification of Nerve Injuries Lundborg 1988 Physiological conduction block Myelin damage Axonal disruption Axon + Endo Axon + Endo + Peri Axon + Endoneuriu m + Perineurium + Epineurium Type A Type B Sunder land 1951 I II III IV V Seddon 1942 Neurapraxia (Transient Block) Axonotmesis (Lesion in Continuity) Neurotmesis (Division of a nerve) Non- degenerative Degenerative
- 19. HOT
- 20. Nerve Surgery Neurolysis Nerve repair Nerve grafting Nerve transfer
- 21. Prerequisites for Nerve Repair Skeletal stability Healthy tissue bed Healthy nerve ends No undue tension Adequate soft tissue coverage
- 22. Epineurial versus Group Fascicular Repairs Epineurial Less exact Simple Group Fascicular Better alignment More dissection (scarring) The functional results of group fascicular repair has not been shown to be more superior than that of epineurial repair. Lee & Wolfe. Peripheral nerve injury & repair. JAAOS 2000
- 23. Prognostic Factors of Outcomes • Age • DM, alcohol Patient factors • Level of injury (distal vs proximal) • Type of nerve (pure vs mixed) • Condition of nerve ends Injury factors • Delay to repair • Length of gap Surgical factors
- 24. Which of the following is false regarding fibrin glue? a) Fibrin glue is nontoxic and does not block axon regeneration b) It may be used in combination with suture repair c) The outcome of fibrin glue repair is inferior to that of suture repair d) The common components of fibrin sealants include fibrinogen, thrombin and calcium chloride e) It has low tensile strength Tse & Ko. Nerve glue for upper extremity reconstruction. Hand Clinics 2012
- 25. Nerve Grafts/Conduits Autologous Source Nerve autograft Vein (+/- muscle) Off-the-shelf Type I collagen Caprolactone Polyglycolic acid (PGA) Submucosal ECM Processed nerve allograft Lin et al. Nerve Allografts & Conduits in Peripheral Nerve Repair. Hand Clinics 2013 Kaushik & Hammert. Options for Digital Nerve Gap. JHSAm 2015
- 26. A 35 year-old male presented with numbness along the radial border of his right index finger 9 months after he sustained a cut in his first web. After surgical exploration and debridement, there is a 3.5cm nerve defect in the radial digital nerve. What is the most appropriate surgical reconstructive option? a) Flexion of digit to achieve primary repair before gradual distraction b) Type I collagen nerve conduit c) Autologous vein graft d) Posterior interosseous nerve graft e) Polyglycolic acid (PGA) conduit
- 27. Principles of Motor Nerve Transfers Donor nerve near target motor end plates Expendable donor nerve Pure motor donor nerve Donor-recipient size match Donor function synergy with recipient function Motor re-education improves function Mackinnon SE, Novak CB. Hand Clin 1999
- 29. Brachial Plexus Injuries • Time• Breadth • Length• Depth Severity (Seddon, Sunderland) Level (Supra vs Infra clavicular) Acute vs Chronic Number of roots (C5-T1) HOT
- 30. Leffert Classification I Open II Closed IIA Supraclavicular Pre-ganglionic Post-ganglionic IIB Infraclavicular III Radiation induced IV Obstetric IVA Erb’s (upper root) IVB Klumpke’s (lower root) IVC Mixed
- 31. Objectives of Examination Where is the lesion? What functions are lost? What functions are present? How can you improve functions of the limb?
- 33. Draw the brachial plexus
- 38. C5 C6 C7 C8 T1
- 45. C5 C6 C7 C8 T1 MC MEDIAN ULNAR R AxLTN LPSSDS USs TD LSs MP MBC MABC Sc Roots Trunks Divisions Cords Terminal branches
- 46. C5 C6 C7 C8 T1 MC MEDIAN ULNAR R AxLTN LPSSDS USs TD LSs MP MBC MABC Sc Roots Trunks Divisions Cords Terminal branches Upper Lowe r Middle Lateral Medial Posterior Posterior Anterior Anterior
- 47. Dermatomes
- 48. Myotomes
- 49. Common Clinical Patterns Closed traction BPI Supraclavicular Upper roots Total palsy Infraclavicular Cord(s) Terminal branch(es) Motorcycle accident Shoulder trauma
- 50. Common Clinical Patterns 25yo RTA polytrauma No shoulder motion No elbow flexion GOOD HAND 25yo RTA polytrauma FLAIL UPPER LIMB 65yo anterior dislocation of shoulder NO DELTOID C5, C6 C5 – T1 Axillary nerve
- 51. Common Clinical Patterns 25yo RTA polytrauma No shoulder motion No elbow flexion GOOD HAND C5, C6 XR neck chest shoulder MRI cervical spine, BP NCS/EMG at 3 weeks 25yo RTA polytrauma FLAIL UPPER LIMB C5 – T1 XR MRI NCS/EMG at 3 weeks 65yo anterior dislocation of shoulder NO DELTOID Axillary nerve NCS/EMG at 6 weeks if no recovery
- 52. Pre- versus Post-ganglionic? Clinical Horner’s syndrome Rhomboid, serratus anterior, paraspinal muscles paralysis Absent Tinel sign Histamine test (historical) Radiology Phrenic nerve palsy (raised hemidiaphragm) Cervical transverse process /1st rib♯ Pseudomeningoceles Rootlets abnormalities Neurophysiology Preserved SNAP (but insensate) HOT
- 53. Intraoperative Assessment - Is there a graftable nerve stump? • Direct inspection • Palpation Surgery • Somatosensory Evoked Potentials(SSEP) • Motor Evoked Potentials(MEP) Neurophysiology • Frozen section (fascicles / scar) • Choline acetyltransferase (CAT) activity – identify motor fascicles Laboratory
- 54. Timing of Surgery Emergent - Open injury - Arterial injury - Deteriorating neurology Early (<3months) - Closed injury - Complete/partial palsy - Neurolysis/grafts/ transfers Late (>12months) - Muscle transfers - Bony procedures HOT
- 55. Surgical Priorities 1 – Restore elbow flexion 2 – Restore shoulder abduction & ER (stability) 3 – Restore hand function Other considerations: • Elbow extension • Scapular stability • Sensibility of hand
- 56. Common Nerve Transfers Palsy Donor Recipient C5, 6 Spinal accessory Radial (long head of triceps) Ulnar fascicle Median fascicle Suprascapular Axillary (anterior) Biceps branch Brachialis branch C5, C6, C7 Spinal accessory Intercostals Ulnar fascicle Median fascicle Suprascapular Axillary (anterior) Biceps branch Brachialis branch C8, T1 Brachioradialis or brachialis branch Supinator branch AIN PIN
- 57. Pan-plexus palsy remains an unsolved challenge! Limited available donor Any graftable root Spinal accessory Intercostals Phrenic nerve (NICE guideline) Contralateral C7 Hypoglossal Deep cervical plexus Which recipients (functions) do you target? Future donor for free functioning muscle transfers?
- 58. Common Clinical Patterns ?Prognosis 25yo RTA polytrauma No shoulder motion No elbow flexion GOOD HAND C5, C6 Regain good elbow flexion, moderate shoulder movement Return to work 25yo RTA polytrauma FLAIL UPPER LIMB C5 – T1 Poor-to-fair function Long-term disability 65yo anterior dislocation of shoulder NO DELTOID Axillary nerve Fair-to-good recovery
- 60. What do (I think) you need to learn? Carpal tunnel syndrome (detailed knowledge) Cubital tunnel syndrome Guyon canal syndrome Radial tunnel syndrome / PIN palsy Pronator syndrome / AIN palsy
- 61. Carpal Tunnel Syndrome A collection of symptoms and signs due to increased pressure within the carpal tunnel leading to compression of the median nerve • Pins & needles or Tingling • Numbness • Pain • Weakness or clumsiness • Wasting of thenar muscles
- 62. What is the Gold Standard? CTS Signs Symptoms Neurophysiology
- 63. Who is affected? Risk Factors Age: 45- 65 Females > males Family history Pregnancy Medical conditions: DM, RA, Hypothyroidism Obesity Vibration Anatomical abnormalities of the wrist
- 64. • Southern Sweden 3000 subjects (2466 responded) • Age 25 – 74 Criteria Prevalence Pain, numbness and/or tingling in median nerve distribution 14.4% Clinically certain CTS 3.8% NCS positive 4.9% Clinically & NCS confirmed CTS 2.7% Atroshi et al JAMA 1999
- 65. • Case-control study • UK GP Research Database • 3391 cases (72% women) • Mean age at diagnosis 46 (16-96) • 4 controls matched for age, sex, GP and duration of available data. • Smoking, HRT, COCP, Corticosteroids JHSE 2004; 29: 315-20
- 66. JHSE 2004; 29: 315-20 Risk Factor Odds Ratio Previous wrist fracture 2.29 Rheumatoid arthritis 2.23 Obesity 2.06 Osteoarthritis of wrist/carpus 1.89 Diabetes 1.51 Use of insulin 1.52 Sulphonylureas 1.45 Metformin 1.20 Thyroxine 1.36
- 67. Treatment Options Comments Nocturnal neutral wrist splint • Those with night symptoms Steroid injection • Consider in pregnancy-related CTS • 1 in 4-5 symptom-free at 1 year Carpal tunnel release • Complete division of transverse carpal ligament • Open and endoscopic CTR both equally effective. Endoscopic CTR may be associated with less postoperative pain and earlier return to work but this may not be justifiable by its increased risks of nerve injury and costs (in the NHS). For CTR, read papers by Gelberman & Atroshi!
- 68. 15 Hands in 12 patients At 6 weeks and 8 months 24% increase in canal volume Palmar displacement +3.5mm No change in carpal arch width Richman et al JHSAm 1989 Morphologic changes after release of the transverse carpal ligament
- 69. Anatomical variations of the recurrent motor branch of median nerve Lanz. JHSAm 1977. Lindley. JHSAm 2003.
- 70. 16 clinically successful cases At 1 month, sensory conduction velocity and distal motor latency improved CMAP worsened (?post-surgical oedema) At 6 month, all measures improved
- 71. Retrospective study 115 patients at mean 10 years post CTR 71 asymptomatic → 41 +ve NCS for CTS 44 symptomatic → 36 +ve NCS for CTS
- 73. Motor Latency
- 74. Classification of failed CTR Persistent symptoms Incomplete release Wrong diagnosis Recurrent symptoms Scar/cicatrix formation Tenosynovitis New symptoms Iatrogenic nerve injury Pillar pain
- 75. Cubital tunnel syndrome What is your preferred surgical treatment for primary cubital tunnel syndrome?
- 76. Cubital tunnel syndrome What is your preferred surgical treatment for primary cubital tunnel syndrome? I would perform in-situ decompression because meta- analyses have shown comparable clinical outcomes but lesser complications/morbidity when compared to anterior transposition.
- 77. Cubital tunnel syndrome What are the indications of anterior transposition?
- 78. Cubital tunnel syndrome What are the indications of anterior transposition? • Revision • Subluxation/Instability of ulnar nerve • Poor tissue bed for the nerve • (Elbow trauma surgery)
- 79. Sensory branch (after PB) Ulnar artery aneurysm or thrombosis Guyon’s canal What you need to know? Mixed LEFT HAND
- 80. Superficial branch (sensory only after Palmaris brevis) Ulnar artery aneurysm or thrombosis Deep motor branch Ganglion or hook of hamate fracture (zones 1 & 2) MixedLEFT HAND
- 81. Posterior Interosseous Nerve Radial tunnel syndrome Pain syndrome EMG normal PIN palsy Motor deficit EMG abnormal Common Sites of Compression: Fibrous band btw brachialis & BR Recurrent leash of Henry Extensor carpi radialis brevis edge Arcade of Fröhse Supinator muscle edge
- 82. Compression versus Neuritis Entrapment neuropathy Absent/minimal pain Spontaneous Progressive and complete Neuralgic amyotrophy Severe pain Precipitant event Severity changeable and reversible More widespread paralysis and possible sensory disturbance Hashizume et al JBJSBr 1996; 78: 771-6.
- 83. Proximal Median Nerve Pronator syndrome Pain (forearm) syndrome Paraesthesia EMG/NCS inconclusive AIN palsy Motor deficit only EMG/NCS abnormal Sites of Compression: Supracondylar process Ligament of Struthers Lacertus fibrosus Btw two heads of pronator teres FDS arch Sites of Compression: Tendinous edge of deep head of PT Lacertus fibrosus FDS arch Accessory head of FPL (Gantzer’s muscle) Accessory muscle from FDS to FDP Aberrant muscles (FCRB, palmaris profundus) Thrombosis of ulnar collateral vessels Aberrant radial artery Bicipital bursa
- 84. Complex Regional Pain Syndrome
- 85. Disproportionate Pain Sensory changes Abnormal skin color Temperature change Abnormal sudomotor activity Oedema Joint stiffness EXCLUSION OF OTHER CAUSES!
- 86. International Association for Study of Pain CRPS Type I Reflex sympathetic dystrophy (RSD) No definable nerve injury CRPS Type II Causalgia Definable nerve injury Symptoms NOT restricted to dermatome
- 87. CRPS – Budapest Criteria
- 88. Management of Suspect CPRS Prevention (Vitamin C – distal radius fractures) Treat any treatable cause Physiotherapy (Desensitisation, mirror therapy) Pain specialist Multimodal analgesics Regional blockade Bisphosphonate infusion Psychology
- 89. Summary / Testable Concepts • Most injuries are mixed • Pain, Autonomic dysfunction & Tinel sign Peripheral nerve injuries • 4 dimensions • Timing of surgery • Priorities of reconstruction Brachial plexus injuries • Carpal tunnel syndromes (learn everything you can!) Compression neuropathy • Budapest criteriaCRPS
- 90. Thank you and good luck! http://www.slideshare.net/ChyeYewNg @CY_Hand