Surgical Repair of Peripheral Nerve Lesions

When the decision is made to explore an injured nerve, it is important that the surgeon under stands the thought process involved. First, it is paramount that this surgical exploration be performed with the utilization of intraoperative electrophysiological monitoring to aid in the decision making. Usually, the decision to explore the nerve is based on the assumption that a neurotmetic injury exists or, unless this occurs in the case of an open wound, there is clear evidence of neural disruption.

Therefore, once the nerve is exposed both proximally and distally to the injured segment, direct electrical stimulation of the nerve should be performed. In situations where this results in a recordable response across a lesion, this suggests the presence of functioning nerve fibers (at least several thousand) and often, therefore, implies either a neurapraxic or an axonotmetic lesion [5]. Axonotmetic lesions should be managed medically and recovery usually occurs within weeks to months, as remyelination and/ or regeneration occur, and the wound should be closed. In neurotmetic lesions, no conduction will be recorded across the lesion and, in this case, surgery is indicated.

The surgical repair of neurotmetic peripheral nerve injuries has evolved in the past three decades, with significant advancements. First, microsurgical techniques have developed, including intraoperative magnification, microinstruments and fine suture material [6]. Secondly, the use of grafts has re-emerged, allowing surgeons to perform tension-free nerve repairs [7]. Thirdly, factors such as timing of surgery and fascicular anatomy are now better appreciated.

A principle tenet of peripheral nerve surgery is that a repair must be tension free. Tension can diminish the intraneural blood supply and compromise the clinical outcome of a peripheral nerve repair [7].

A primary nerve repair is desirable, but use of a nerve graft is indicated if an end-to-end repair cannot be made tension free. Positioning of an extremity should be neutral and not altered to accommodate a tension-free primary nerve repair, because the nerve must be able to remain tension free during flexion and extension of the extremity through a full range of movements.

No consensus exists as to a specific length of nerve gap (the distance between two nerve ends) that requires a nerve graft [6]. This is largely due to the variability between anatomic locations.

Peripheral Neuropathy Natural Treatment Options

Peripheral Neuropathy Natural Treatment Options

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