peripheral)nerve)injuries) · nerve)injury)response) • distally) – wallerian)degeneraon) –...
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Peripheral nerve Injuries
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Nerve Structure
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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
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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
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Conclusion
• Early referral • MeAculous assessment • Many reconstrucAve opAons available
• ?