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Page 1: Peripheral)nerve)Injuries) · Nerve)Injury)Response) • DISTALLY) – Wallerian)degeneraon) – Myelin)sheath)breakdown) – End/targetorgan)effects) • PROXIMAL)

Peripheral  nerve  Injuries  

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Nerve  Structure  

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3  

Peripheral  Nervous  system  Dorsal  roots  –  sensory  fibers  arising  from  cell  bodies  in  dorsal  root  ganglia  Ventral  roots  –  motor  fibers  arising  from  anterior  gray  column  of  spinal  cord    

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Rob  Taylor  Drinks  Cold  Beer  

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Nerve  Injury  Mechanism  •  LaceraAon  •  Stretch/TracAon  •  Compression  –  acute  &  chronic  •  CombinaAon  (blast)  •  Ischaemia-­‐  acute  &  chronic  (incl  infecAon)  •  Temperature  •  Electrical  shock  •  VibraAon  •  RadiaAon  •  InjecAon  (lac  &  compartment)  

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Nerve  Injury  Response  

•  DISTALLY  – Wallerian  degeneraAon  – Myelin  sheath  breakdown  – End/target  organ  effects  

•  PROXIMAL  – Axonal  calibre  reducAon  – Decreased  conducAon  velocity  

– Cell  body  atrophy  &  loss  

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ClassificaAon  SEDDON  (1943)   SUNDERLAND  (1978)   BIRCH  

Neurapraxia   1  (myelin  only)   Non-­‐degeneraAve  

Axonotmesis   2  (myelin  &  axon)   DegeneraAve  

Neurotmesis   3  (myelin,  axon,  endoneurium)   DegeneraAve  

4  (myelin,  axon,  endoneurium,  perineurium)   DegeneraAve  

5  (myelin,  axon,  endoneurium,  perineurium,  epineurium)    

DegeneraAve  

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Nerve  Healing  

•  Cell  body  response  •  Schwann  cell  proliferaAon  •  Axonal  sprouAng  (~  neuroma)  •  Growth  cone  •  Neurotrophic  &  neurotropic  factors  •  Axonal  growth  rates  

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Nerve  Repair  

•  Neurolysis  •  Direct  suture  – Epineural  repair  – Fascicular  repair  

•  InterposiAon  graZ  •  Glue  •  Conduits  

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Direct  suture  

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Nerve  graZ  

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Nerve  Cable  GraZing  

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Nerve  Conduits  

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ReconstrucAve  Surgical  OpAons  •  Orthopaedic  surgery  –  Tendon  transfer  –  Arthrodesis  

•  Neurosurgery  –  Nerve  transfer  

•  Free  Assue  surgery  – Muscle  transfer  –  Vascularized  nerve  

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Tendon  Transfers    

•  Mr  Broome  

•  Examples  – Radial  nerve  – Median  nerve  – Upper  limb  rehabilitaAon  in  Tetraplegia  

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Arthrodesis  

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Arthrodesis  

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Nerve  Transfer  

•  Accesory  to  Suprascapular  •  Phrenic  to  Musculocutaneous/Axillary  •  Intercostals  to  Musculocutaneous  •  Ulna  (2  fascicles)  to  Musculocutaneous  •  Radial  (long  hd)  to  axillary  •  etc  

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Intercostal  nn.  to  MC  n.  

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Intercostal  nn.  to  MC  n.  

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Intercostal  nn.  to  MC  n.  

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Free  Muscle  Transfer  

•  Gracilis  •  Rectus  femoris  

Page 30: Peripheral)nerve)Injuries) · Nerve)Injury)Response) • DISTALLY) – Wallerian)degeneraon) – Myelin)sheath)breakdown) – End/targetorgan)effects) • PROXIMAL)

Rectus  Femoris  Transfer  

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Rectus  Femoris  Transfer  

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Rectus  Femoris  Transfer  

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AmputaAon  

•  IndicaAons  –  Irreparable  vascular  or  limb  injury  –  Sepsis  –  Non-­‐union  with  no  chance  

•  Level  •  Prosthesis    •  UNCOMMON  

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Therapy  

•  Early  &  pre-­‐operaAve  stage  –  Maintain  range  of  movement  &  prevent  contractures  

•  MobilizaAon  &  appropriate  splintage  –  Oedema  management  

•  Massage  (paAent  &  relaAves  involved)    •  Pressure  garments  •  Flowtron  device  •  MobilizaAon    •  ElevaAon.  

–  SAmulaAon  •  Sensory  •  Electrical  sAmulaAon  of  denervated  muscles  

–  Above  all  educaAon  &  empowerment  of  paAent  

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Therapy  

•  Post-­‐operaAve  stage  –  IniAally  restricted  mobilizaAon  

»  eg:  Intercostal  nerve  to  musculocutaneous  transfer  

–  AZer  4  weeks  •  Mobilize  within  specified  range  •  Re-­‐educaAon      

»  cf  tendontransfers  •  Biofeedback  -­‐  visual  and  tacAle  •  Electrical  sAmulaAon  

–  May  take  months  (12  -­‐  24  months)  

– When  voluntary  movement  noted  •  Strengthening  against  resistance  

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Prognosis  

•  Mechanism  of  injury  •  Age  •  Level  of  lesion  •  Co-­‐morbidiAes  •  Delay  to  repair/reconstruct  •  Quality  of  repair  

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     Motor  Recovery  M0  No  contracAon    M1  Return  of  percepAble  contracAon  in  the  proximal  muscles    M2  Return  of  percepAble  contracAon  in  both  the  proximal  and  distal  muscles    M3  Return  of  percepAble  contracAon  in  both  the  proximal  and  distal  muscles  of  such  a  degree  that  all  important  muscles  are  sufficiently  powerful  to  act  against  resistance    M4  Return  of  funcAon  as  in  stage  3  with  the  addiAon  that  all  synergic  and  independent  movements  are  possible    M5  Complete  recovery      

 Sensory  Recovery      S0  Absence  of  sensibility  in  the  autonomous  area    S1  Recovery  of  deep  cutaneous  pain  sensibility  within  the  autonomous  area  of  the  nerve    S2  Return  of  some  degree  of  cutaneous  pain  and  tacAle  sensibility  within  the  autonomous  area    S3  Return  of  some  degree  of  superficial  cutaneous  pain  and  tacAle  sensibility  within  the  autonomous  area  with  disappearance  of  any  previous  overreacAon    S3+  Return  of  sensibility  as  in  stage  3  with  the  addiAon  that  there  is  some  recovery  of  two-­‐point  discriminaAon  within  the  autonomous  area    S4  Complete  recovery    

Grading  of  Recovery  

Page 38: Peripheral)nerve)Injuries) · Nerve)Injury)Response) • DISTALLY) – Wallerian)degeneraon) – Myelin)sheath)breakdown) – End/targetorgan)effects) • PROXIMAL)

Conclusion  

•  Early  referral    •  MeAculous  assessment  •  Many  reconstrucAve  opAons  available  

• ?  


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