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nerve injury

neurosurgery

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nerve injury

  1. 1. Nerve injury Hamad emad dhuhayr Dr Saleh WaslAllah Alharby www.ksu.edu.sa/DrSalehAlharby
  2. 2. OUTLINE  DEFINITION.  TYPES OF NERVE INJURIES.  FATE (pathophysiology) AND REHABILITATION.  ETIOLOGY.  PRESENTATION.  DIAGNOSIS.  CLINICAL EXAMPLES: (ERB’S,CARPAL TUNNEL,RADIAL,ULNAR,SCIATIC AND PERONEAL N.) Dr Saleh WaslAllah Alharby www.ksu.edu.sa/DrSalehAlharby
  3. 3. DEFINITION Partial or complete interruption of normal physiology of the nerve. NERVE CONDUCTION IS AFFECTED. Dr Saleh WaslAllah Alharby www.ksu.edu.sa/DrSalehAlharby
  4. 4. Classification Of Nerve Injuries  Seddon, Sunderland and lately by Mackinnon  6 degrees
  5. 5. Degrees Of Nerve Injury  1st degree of injury(neuraparaxia)  Segmental demylination  Axons intact  Recovery in 12 to 16 wks  2nd degree injury(axonotmesis)  Axonal injury/ distal wallerian degeneration  Regeneration at rate of 1 inch per month  Complete slow recovery
  6. 6. Degrees Of Nerve Injury  3rd degree injury  Axonal injury & fibrosis of endoneurium  Incomplete recovery  4th degree injury  Axonal injury  Damage to endo and perineurium with dense scarring  Needs surgical intervention
  7. 7. Degrees Of Nerve Injury  5th degree injury(neurotmesis)  Complete nerve division  6th degree injury  Variable combination of previous five degrees of nerve injury
  8. 8. FATE AND REHABILITATION  WALLERIAN DEGENERATION 1 MM PER DAY Dr Saleh WaslAllah Alharby www.ksu.edu.sa/DrSalehAlharby
  9. 9. REHABILITATION  PAIN CONTROL.  SPLINT. (AVOID PRESSURE SORES)  NERVE AND MUSCLE STIMULATION.  NEARBY JOINTS RANGE OF MOTION.  MONTHS ----- YEARS . Dr Saleh WaslAllah Alharby www.ksu.edu.sa/DrSalehAlharby
  10. 10. Nerve Injury  Focal contusion (gunshot wounds)  Stretch/traction injury  Drug injection injury  Compression  Crush injuries  Avulsion  Laceration  Electrical burns  Idiopathic  Others(Viral infections, metabolic and neural disorders)
  11. 11. PERSENTATION  PAIN  LOSS OF SENSATION  LOSS OF MOTION  LOSS OF POWER  LOSS OF REFLEXES  WASTING  TROPHIC CHANGES (skin,sc,neurovascular,bones,muscles)  CONTRACTURES Dr Saleh WaslAllah Alharby www.ksu.edu.sa/DrSalehAlharby
  12. 12. DiagnosisDiagnosis  Motor functionMotor function  Movements, muscle atrophyMovements, muscle atrophy  sensory functionsensory function  Tinel sign, Ten testTinel sign, Ten test  Two point discriminationTwo point discrimination  Touch, vibrationTouch, vibration •HistoryHistory •ExaminationExamination
  13. 13. Tinel Sign  Tinel sign: -  peripheral tingling or dysaesthesia' provoked by percussion of the nerve  Positive in axonal injuries
  14. 14. Electrical Stimulation Tests:  EMG  NCS  Intra operative nerve action potential
  15. 15. CLINICAL EXAMPLES  ERB’ PALSY  CARPAL TUNNEL SYNDROME(MEDIAN NV)  RADIAL NERVE INJURY  ULNAR NERVE INJURY  SCIATIC NERVE INJURY  LATERAL POPLITEAL NERVE INJURY Dr Saleh WaslAllah Alharby www.ksu.edu.sa/DrSalehAlharby
  16. 16. ERB’S PALSY  BIRTH INJURY (DIFFICULT LABOUR)  TRACTION ON NERVE ROOTS C5-6  STRETCH-RUPTURE-AVULSION  UPPER LIMB IN EXTENSION  MOTHER NOTICE NO MOTION  90% GOOD RECOVERY  ROLE OF SURGERY AFTER 3 MONTHS  REMEMBER PROPER REHABILITATION Dr Saleh WaslAllah Alharby www.ksu.edu.sa/DrSalehAlharby
  17. 17. CARPAL TUNNEL SYNDROME  MEDIAN NERVE ENTRAPMENT BY FLEXOR RETINACULUM PAIN,NUMBNESS,NIGHT  MANUAL WORKERS  DIAGNOSIS  SURGERY Dr Saleh WaslAllah Alharby www.ksu.edu.sa/DrSalehAlharby
  18. 18. RADIAL NERVE INJURY Dr Saleh WaslAllah Alharby www.ksu.edu.sa/DrSalehAlharby
  19. 19. ULNAR NERVE INJURY Dr Saleh WaslAllah Alharby www.ksu.edu.sa/DrSalehAlharby
  20. 20. SCIATIC NERVE INJURY Dr Saleh WaslAllah Alharby www.ksu.edu.sa/DrSalehAlharby
  21. 21. PERONEAL NERVE INJURY (LPN)  FOOT DROP  TIGHT POP  SKELETAL TRACTION  DIRECT INJURY (RARE)  DYNAMIC SPLINT Dr Saleh WaslAllah Alharby www.ksu.edu.sa/DrSalehAlharby
  22. 22. Principals Of Nerve Repair  Microsurgical techniques  Adequate magnification  Microsurgical instruments & sutures  Different techniques:  Primary nerve repair  Nerve grafting  Nerve transfer  Nerve conduits  Nerve allografts
  23. 23. Timing Of The Nerve Repair  Sharply transected nerves  Immediate repair  Crushed, avulsed, blast injuries  Nerve ends tacked together  Repair delayed for 3 weeks or until wound bed permits  Re-exploration  Neuroma excision, nerve grafts  Acute nerve grafting in the 1st sitting  Bleeding control ,trimming of fascicles ,loose epineural suturing  Closed injuries treated expectantly for 12 weeks
  24. 24. Primary Nerve Repair  Primary nerve repair  Epineural repair  Grouped fascicular repair
  25. 25. Epineural Repair Standard repair
  26. 26. Fascicular Repair  Restore the continuity of fascicles  Internal topography  Intra-operative nerve stimulation  Neurolysis with the eyes  Priority to the motor recovery(radial and peroneal nerve)
  27. 27. e.g. Ulnar Nerve Fascicular Components
  28. 28. Nerve Grafts  Tension at site of repair  Need of postural positioning  Alignment of sensory & motor components  Maximize number of axons  Reversal of graft  Exclusion of expendable nerve
  29. 29. Options For Nerve Grafts  Sural nerve  30-40cm  Lateral peroneal communicating br : 10-20cm  Lateral antebrachial cutaneous nerve(LABC)  8cm  Medial antebrachial cutaneous nerve (MABC)  Anterior & posterior division  20 cm  Expendable nerves(peroneal and radial)  Sensory branches of ulnar and median nerves  Distal anterior interosseous nerve and so on…
  30. 30. Disadvantages  Donor site scarring  Donor site sensory loss  Patient education
  31. 31. Neuroma In Continuity Complete : resection and repair with graft
  32. 32. Neuroma In Continuity  Incomplete neuroma  Intra-operative nerve stimulation  Black boxing around neuroma
  33. 33. Nerve Transfer  Indications:  Very proximal peripheral nerve injuries  Root avulsions  Excessive scarring  Level of injury unclear  Idiopathic neuritides  Radiation induced nerve injury
  34. 34. Nerve Transfer  Motor nerve transfer  Pure motor axons  Close proximity  expendable  Synergistic supply  Sensory nerve transfer  pure sensory axons  Innervates non critical area  Expendable and lying in close proximity
  35. 35. Most Common Uses Of Nerve Transfer  elbow flexion  Shoulder abduction  Ulnar-innervated intrinsic hand function  Forearm pronation  Radial nerve function
  36. 36. Transfer of radial nerve to axillary nerve
  37. 37. Nerve Conduits  Veins, pseudo-sheaths, bioabsorbable tubes  short nerve gaps ≤ 3cm  Low antigenicity , biodegradability  Trials to add a nerve graft inside the conduit  neurotrophic factors
  38. 38. Nerve Allografts  Extensive injuries  Limited donor material  Immunosuppressive agents  FK506( tacrolimus )  Prednisone , azathioprine  Processed acellular cadaveric nerve allografts  AxoGen, Inc. ,Alachua, FL.
  39. 39. Summary  Axon degeneration occurs from mild compression injury  The prognosis for Neuropraxia is poor  Axonotmesis is generally caused from separation of the cell body from the neuron  Wallerian Degeneration typically does not occur in Neuropraxic injury  Surgical reconstruction is necessary in Neurotmesis  Wallerian Degeneration does not occur in Neurotmesis  A ligamentous structure can cause Neuropraxia Dr Saleh WaslAllah Alharby www.ksu.edu.sa/DrSalehAlharby
  40. 40. Refferences  Special surgery matary Dr Saleh WaslAllah Alharby www.ksu.edu.sa/DrSalehAlharby

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