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Nerve repair and grafting
This document discusses nerve repair techniques including nerve grafting and transfers. It describes different types and degrees of nerve injuries and factors that influence recovery outcomes. Surgical timing, epineural versus fasicular repair techniques, and the use of intraoperative nerve stimulation are reviewed. Bridging nerve gaps using grafts or transfers is described. Future areas of research on enhancing regeneration through the use of neural tubes and trophic factors are also mentioned.
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Introduction to nerve repair and grafting presented by Dr. Prasanna Somvanshi.
Basic anatomical understanding necessary for nerve repair and related procedures.
Classification of nerve injuries as per Seddon and Sunderland with recovery prognosis.
Algorithms outlining management for penetrating and closed traction nerve injuries.
Methods for evaluating nerve injury including clinical examination and electrodiagnostic tests.
Detailed grading scale for sensory and motor recovery post nerve injury.
The importance of timing in nerve repair with classifications for primary, delayed, and secondary repairs.
Comparison of epineural and fascicular repair techniques, their advantages, and disadvantages.
Application of intraoperative nerve stimulation in identifying nerve injuries during surgery.
Critical factors affecting outcomes after nerve repair including age, injury type, and repair timing.
Methods for bridging gaps in nerve continuity to promote regeneration.
Various indications and scenarios where nerve transfers are preferable to nerve grafting.
Advantages of nerve transfer over tendon transfer for restoring motor function and sensibility.
Innovative approaches in nerve repair involving neural tubes and growth factors to enhance recovery.
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Nerve repair and grafting
- 1. NERVE REPAIR AND GRAFTING DRPRASANNA SOMVANSHI
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- 3. Types of Nerveinjury 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
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- 8. EVALUATION OF NERVEINJURY 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 SENSORYRECOVERY 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 PRIMARY0-2 DAYS DELAYED PRIMARY 2-7 DAYS SECONDARY AFTER 7 DAYS
- 12. EPINEURAL V/S FASICULAR EPINEURALREPAIR 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
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- 16. NERVE TRANSFERS INDICATIONS 1. BRACHIALPLEXUS 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/STENDON 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 NERVEREPAIR 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.