nerve repair and grafting

1. NERVE REPAIR AND
GRAFTING
DR PRASANNA SOMVANSHI

2. ANATOMY

3. Types of Nerve injury
SEDDON SUNDERLAND INJURY RECOVERY
NEUROPRAXIA DEGREE I CONDUCTION NERVE BLOCK,
RESOLVES SPONTANEOUSLY
FAST/EXCELLENT
AXONOTMESIS • DEGREE II
• DEGREE III
• DEGREE IV
• AXONAL RUPTURE WITHOUT
INTERRUPTION OF THE BASAL
LAMINA
• RUPTURE OF BOTH AXONS AND
BASAL LAMINA TUBES
• COMPLETE SCAR BLOCK
• SLOW/EXCELLENT
• SLOW/INCOMPLETE
• NONE
NEUROTMESIS DEGREE V COMPLETE TRANSECTION NONE
DEGREE VI
(MACKINNON)
COMBINATION OF I-IV
WITH/WITHOUT NORMAL FASCICLES
MIXED

6. ALGORITHM
FOR
PENETRATING
NERVE
INJURY AND
LACERATION

7. ALGORITHM
FOR CLOSED
TRACTION,
STRETCH
AND
AVULSION
INJURIES

8. EVALUATION OF NERVE INJURY
CLINICAL EXAMINATION
 SEMMES-WEINSTEIN FILAMENTS
 TWO POINT STATIC AND MOVING
DISCRIMINATION
 TENS TEST
ELECTRODIAGNOSTIC
 EMG CHANGES PRECEED CLINICAL
RECOVERY (EG MOTOR UNIT
POTENTIALS)

9. GRADING OF SENSORY RECOVERY
 S0- NO RECOVERY
 S1 – DEEP CUTANEOUS SENSATION
 S2 – SUPERFICIAL CUTANEOUS SENSATION
 S2+ - HYPERRESPONSE OF S2
 S3 – PAIN AND TOUCH SENSATION WITH
LOSS OF HYPERRESPONSE, TWO POINT
DISCRIMINATION >15MM
 S3+ - GOOD LOCALIZATION, TWO POINT
DISCRIMINATION 7-15MM
 S4 – COMPLETE RECOVERY; TWO POINT
DISCRIMINATION 2-6MM
GRADING OF MOTOR RECOVERY
 M0 – NO CONTRACTION
 M1- PALPABLE CONTRACTION
 M2 – ACTIVE JOINT MOTION – BUT NOT AGAINST
GRAVITY
 M3 – ACTIVE JOINT MOVEMENT AGAINST
GRAVITY
 M4 – FULL RANGE OF ACTIVITY AGAINST
GRAVITY – SUBNORMAL STRENGTH
 M5 - FULL RANGE OF ACTIVE MOTION – NORMAL
STRENGTH

11. TIMING OF REPAIR
TIME
PRIMARY 0-2 DAYS
DELAYED PRIMARY 2-7 DAYS
SECONDARY AFTER 7 DAYS

12. EPINEURAL V/S
FASICULAR
 EPINEURAL REPAIR IS THE PREFERRED
METHOD
 FASICULAR REPAIR CAN BE TRIED FOR
MAJOR PERIPHERAL NERVE TO
IMPROVE ALIGNMENT
 CLINICAL STUDIES SUPPORT BOTH
TECHNIQUES AS LONG AS FASICLES
WERE NOT OVERLAPPED.
 DISADVANTAGE OF PERINEURAL
REPAIR WAS EXTENSIVE DISSECTION
AND PERMENANT INTRANEURAL
STITCH LED TO INCREASE FIBROSIS.

13. INTRA OPERATIVE NERVE
STIMULATION
 UNCOMPICATED NERVE INJURIES (TRANSECTION/NERUROMA IN
CONTINUITY INVOLVING THE ENTIRE CROSS SECTION) – NO USE
 MAINLY USED IN - CLOSED TRACTION INJURIES (BRACHIAL
PLEXUS/LARGER MIXED PERIPHERAL NERVES IN THE EXTREMITIES)
 ALSO, WHERE EMG RESULT IS EQUIVOCAL OR ADDITIONAL
REOCVERY MAY HAVE OCCURRED BETWEEN THE TIME OF PREVIOUS
STUDY AND OPERATION

14. FACTORS AFFECTING OUTCOME
 AGE OF PATIENT - CHILDREN V/S ADULTS
 DEGREE AND TYPE OF INJURY – CRUSH V/S SHARP CUT, PROXIMAL V/S DISTAL
 TIME OF REPAIR –
FUNCTIONAL RECOVERY = NUMBER OF MOTOR AXONS REACHING THE TARGET ENDPLATE
TIME OF DENERVATION

15. BRIDGING THE
NERVE GAP

16. NERVE TRANSFERS
INDICATIONS
1. BRACHIAL PLEXUS INJURY WITH ONLY VERY PROXIMAL OR NO NERVE AVAILABLE
FOR GRAFTING
2. HIGH PROXIMAL INJURY THAT REQUIRES A LONG DISTANCE FOR REGENERATION
3. SCARRED AREAS IN CRITICAL LOCATIONS WITH POTENTIAL FOR INJURY TO CRITICAL
STRUCTURES
4. MAJOR LIMB TRAUMA WITH SEGMENTAL LOSS OF NERVE TISSUE REQUIRING
SEVERAL GRAFTS
5. PROLONGED TIME FROM INJURY TO RECONSTRAUCTION AS AN ALTERNATIVE TO
NERVE GRAFTING
6. PARTIAL NERVE INJURY WITH A DEFINED FUCTIONAL LOSS
7. SPINAL CORD AVULSION INJURY
8. IDOPATHIC NEURITIDES,RADIATION TRAUMA, AND NERVE INJURIES WHERE THE
LEVEL OF INJURY IS UNCERTAIN.

17. NERVE TRANSFER V/S TENDON
TRANSFER
 NERVE TRANSFER CAN RESTORE SENSIBILITY IN ADDITION TO
MOTOR FUNCTION
 A NERVE THAT INNERVATES MULTIPLE MUSCLE GROUPS CAN BE
RESTORED WITH A SINGLE NERVE TRANSFER
 THE INSERTION AND ATTACHMENT OF MUSCLES ARE NOT
DISRUPTED

18. FUTURE IN NERVE REPAIR
 NEURAL TUBES POPULATED WITH SCHWANN CELLS AND
NEUROTROPHIC PROCESS.
 TROPHIC FACTORS – NERVE GROWTH FACTOR, BRAIN DERIVED
NEUROTROPHIC FACTOR,FIBROBLASTIC GROWTH FACTOR,CILIARY
NEUROTROPHIC FACTOR, IL-6
 NERVE GROWTH FACTOR AND FIBROBLAST GROWTH FACTOR –
ENHANCED NERVE REGENERATION
 LEUPEPTIN- CALPAIN INHIBITOR, BLOCKS THE CALPAIN PROTEASE
MEDIATED ABSORPTION OF MOTOR END-PLATES.