7. Nerve injury and regeneration
• Distal to injury or transection
• Loss of axon
• Wallerian degeneration
• Proximal axon budding after 1
month
• 8% elongation damages circulation
• 15% elongation disrupt neuron
• Regeneration occurs 1mm a day
• Pain is the first modality to return
12. Repair of nerve injury
• Resection of glioma
• Epineural repair
• Direct muscular neurotization
• Grouped fascicular repair
13. Factors affecting nerve repair
• Non technical factors
• Age
• Type of nerve
• Level of injury
• Type of injury
• Delay to repair
• 1% loss of neural function every
week beyond third week
• Cut off time- 18 months
• Technical factors
• Tension
• Accurate alignment
• Repair technique
• Post op rehabilitation
14. Nerve repair
• Axon
• Axonal sprouting and growth
cones
• Branching
• Guidance and misdirection
• Reconstitution of nerve fibres
• Intrinsic
• Schawnn cells from epineurium,
endothelial cells- fascicles
• Extrinsic
• Fibroblast and inflammation- scar
15. Surgical technique
• Mobilisation
• 1.5 to 7 cm
• Rerouting, positioning,
transposition or graft
• Resection of neuroma
• Tension of repair leads to poor
vascularisation and scarring
• Alignment of vessels and
fascicles (microscope or loupes)
16. Post operative regime and assessment
• Splinting
• Nerve gliding exercise to prevent
adhesion
• Regeneration starts after lag of
3-4 weeks at the rate of 1mm
per day or 1 inch per month
17. Assessment of nerve recovery
• Tinel sign
• Sequential recovery of muscle
• Recovery of sweating and
sensation
• MRC grade
• 1-5
• EMG and NCS
22. Carpal tunnel syndrome
• Compression of median nerve
• Presentation
• Numbness in lateral 3.5 fingers
• Pins and needles
• Pain
• Night symptoms
• Positive Phalen test
• Late presentation
• Loss of sensation (dropping things
and can’t undo buttons)
• Wasting of thenar eminence
23. Presentation
• Can be confused as ulnar nerve
compression
• Look out for cervical pathology
and other neurological
symptoms
24. Tests for Carpal tunnel
• Phalen test
• Durkan test
• Combined test
25. Role of nerve conduction study
• Not sure of diagnosis- vague symptoms
• Young male patients (not a typical patient)
• No signs to elicit
• Classic patients are - Middle to elderly ladies with night +/- day
symptoms
• Recovery is guarded following delay in treatment or associated
muscle wasting.
26. Management
• Role of conservative treatment
• Early cases
• Pregnancy
• Very late cases
• ? Only night symptoms
• Methods of treatment
• Night splint
• ? Steroid injection
• Early cases
• Temporary benefit
• Surgery and tendon transfer
30. Presentation
• Weakness of hand
• Numbness in the little finger
• Deformity
• Benedict’s hand
• Clinical signs
• Sensory
• Paper test
• Froment’s sign
36. Muscles and tendon transfer
• Radial nerve- Jones transfer
• Restore thumb, finger and wrist extension
• Median nerve
• Low – restore thumb opposition
• High- restore finger and thumb flexion
• Ulnar nerve
• High
• Low
