eMedicine Specialties > Orthopedic Surgery > Trauma
Peripheral Nerve Injuries: Treatment
Updated: Aug 29, 2008
Treatment
Medical Therapy
Initial therapy involves protection of the joints, including the surrounding ligaments and tendons, from further stress. Splints, slings, or both may be used in these cases. For example, a radial nerve injury results in a loss of wrist and finger extension, a wristdrop. A wrist-resting splint may be used to support the hand in a neutral wrist position and place the hand in a more functional position. In patients with brachial plexus nerve injuries, particularly when C5-6 is affected, continued downward stress at the glenohumeral joint may cause the glenohumeral joint to subluxate without the muscle support of the rotator cuff muscles. A sling is helpful to unload this joint, prevent complete shoulder dislocation, and decrease pain. The hormone erythropoietin has been used with some success to accelerate function use after an injury.9,10
Physical therapy is started in the early stages following nerve injury to maintain passive range of motion in the affected joints and to maintain muscle strength in the unaffected muscles.
No definitive studies have been done to support the use of electrical muscle stimulation to prevent muscle degeneration. In cases of muscle denervation, galvanic direct current stimulation is necessary to elicit a muscle contraction. The risks of galvanic stimulation include a thermal burn beneath the electrodes. Because no studies have shown that external stimulation will stop total degeneration of the muscle fibers and/or neuromuscular junction, the authors do not believe that direct current stimulation is worth the risk of a thermal burn.
If the nerve does not regenerate in time to reinnervate the muscle, there is no need to stimulate the muscle. With reinnervated muscle, it is theoretically possible to use alternating current stimulation. However, it is necessary to have a large number of reinnervated muscle fibers to stimulate the muscle with alternating current. The authors recommend exercise and biofeedback strategies to increase the strength of a reinnervated muscle.
Surgical Therapy
Lacerations
In patients with neurologic deficits following a laceration, an operative procedure to explore the nerve should be performed as soon after injury as possible. With clean, sharp injuries to the nerve, a direct repair is performed. With more crushing or avulsion injuries, the nerve ends are reapproximated so that motor and sensory topography can be aligned. The definitive reconstruction is done at 3 weeks or when the wound permits.11,12
Gunshot wounds
Typically, gunshot wounds associated with neurologic deficit have good potential for neurologic recovery. Thus, unless an associated vascular or bony problem is present, the patient with a neurologic deficit following a gunshot wound is managed conservatively and monitored with frequent clinical examinations. By 3 months following injury, if no evidence of clinical recovery or electrical recovery is noted on electrodiagnostic testing, surgical exploration is recommended.
Closed injuries
In patients with closed traction injuries, surgical intervention is recommended 3 months following nerve injury. These patients are reexamined both clinically and with electrodiagnostic studies. With no evidence of reinnervation clinically or electrically, surgical intervention is necessary.
Preoperative Details
With no clinical or electrodiagnostic evidence of recovery, surgical exploration is recommended. Preoperative sensory evaluation should include measurement of 2-point discrimination. In patients with no 2-point discrimination, light touch (Ten test) is used.13,14 In the Ten test, simultaneous light-touch stimuli are applied to the affected area of sensory compromise and to the contralateral region, and the patient compares the sensation on a scale of 0-10.
Motor assessment should include pinch and grip strength measurements and evaluation of individual muscle strength using the Medical Research Council (MRC) 0-5 grading scale when appropriate (M0 = no contraction; M1 = flicker contraction; M2 = muscle contraction with active motion with gravity eliminated; M3 = full range of motion against gravity; M4 = full range of motion against gravity with some resistance; M5 = full range of motion against gravity with maximum resistance for that muscle).
Intraoperative Details
Technique
- Loupe magnification, preferably 4.3, is used with use of the microscope for microneurosurgical repairs or grafts.
- Extremity surgery is performed using tourniquet control.
- Nerve coaptations are performed with 9-0 microsuture so that tension at the repair site is avoided.
- Marcaine is used at the incision site, and in some cases, it also may be used in an infusion pump to control postoperative pain.
- A Jackson-Pratt drain also may be used in some cases to control postoperative drainage.
Nerve repair
Reconstruction of nerve continuity can be performed with direct repair.15,16 This is performed when the 2 ends of the nerve are directly coapted. This should be performed without tension. If the repair cannot be performed without tension, nerve grafting should be performed. If the adjacent joint must be flexed or extended to permit coaptation of the distal and proximal ends of the nerve, a nerve graft should be used. (With wrist flexion, the median nerve can be directly repaired; if it is under tension with a wrist neutral position, a nerve graft should be used.)
Nerve graft
In cases in which a gap is present between the proximal and distal end of the nerve, a nerve graft is recommended.17 The use of a donor nerve results in a sensory loss in the distribution of the donor nerve. This area of sensory loss becomes smaller over 1-3 years with collateral sprouting from the surrounding sensory nerves. In cases in which a large nerve gap is present, the sural nerve is used due to the large length of nerve graft material that can be obtained. The sural nerve can be harvested through one long incision or through multiple step incisions on the posterior calf.
For shorter nerve gaps, the anterior branch of the medial antebrachial cutaneous (MABC) nerve is a good nerve graft donor because the donor site scar is minimal and the resultant sensory loss is on the anterior aspect of the forearm. The MABC nerve is especially useful for surgical reconstructions in the upper extremity because all of the incisions are located in the same extremity. The lateral antebrachial cutaneous nerve provides about 6 cm of nerve graft material, but the scar on the forearm is more noticeable than that on the inner upper arm for the MABC.
Nerve transfer
The concept of a nerve-to-nerve transfer permits a normal neighboring noncritical nerve to be coapted to the distal end of the injured nerve. This is particularly useful in cases in which a large nerve gap is present and/or for proximal nerve injuries.18,19,20
Postoperative Details
The patient is immobilized in a bulky dressing for several days following surgery. The postoperative dressing (including the drain and pain pump) is removed 2-3 days following surgery. The area of nerve coaptation then is immobilized for a longer time postoperatively (nerve graft for 10-14 d, nerve repair for 3 wk), although the patient is instructed in range-of-motion exercises for the joints proximal and distal to the immobilized region. For example, a median nerve repair at the wrist would be immobilized with a wrist-resting splint, and the patient would continue with range of motion for the fingers, elbow, and shoulder.
Following surgery, the patient is sent to the hand therapist, initially for the splint and then for exercises. Initially, the goals of therapy are to regain passive range of motion of the joints and soft tissues that have been immobilized. The patient should be instructed in exercises to maintain strength in the unaffected muscles. In the later stages, sensory and motor reeducation is recommended to maximize the outcome.
Follow-up
Initially, the patient is monitored for postoperative wound healing. After immobilization and once the patient regains full passive range of motion, the patient is monitored every few months to evaluate for evidence of reinnervation. With nerve regeneration, a Tinel sign progresses distally along the nerve. With muscle reinnervation, a muscle contraction is visible; and with sensory reinnervation, the patient responds to light touch. Depending on the level of injury, the patient may continue to progress for varying periods; distal injuries respond more quickly than proximal brachial plexus injuries, which respond for 2-3 years following surgery.
Complications
Complications of nerve surgery are similar to those of other surgeries and include infection, hematoma, seroma, and injury to surrounding structures, including vascular structures. Unique to nerve surgery is the possibility of downgrading function by further injuring the nerve, particularly in mixed nerve injuries.
More on Peripheral Nerve Injuries |
| Overview: Peripheral Nerve Injuries |
| Workup: Peripheral Nerve Injuries |
 Treatment: Peripheral Nerve Injuries |
| Follow-up: Peripheral Nerve Injuries |
| References |
| Further Reading |
| « Previous Page | Next Page » |
References
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Omer GE, Spinner M, Van Beek AL. Management of Peripheral Nerve Problems. 1998.
Sunderland S. Nerve and Nerve Injuries. 1978.
Sanders VM, Jones KJ. Role of immunity in recovery from a peripheral nerve injury. J Neuroimmune Pharmacol. Mar 2006;1(1):11-9. [Medline].
Seddon HJ. Three types of nerve injuries. Brain. 1943;66:237.
Sunderland S. A classification of peripheral nerve injuries producing loss of function. Brain. 1951;74:491-516.
Boivin A, Pineau I, Barrette B, Filali M, Vallières N, Rivest S, et al. Toll-like receptor signaling is critical for Wallerian degeneration and functional recovery after peripheral nerve injury. J Neurosci. Nov 14 2007;27(46):12565-76. [Medline].
Mackinnon SE, Dellon AL. Surgery of the Peripheral Nerve. 1988.
Elfar JC, Jacobson JA, Puzas JE, Rosier RN, Zuscik MJ. Erythropoietin accelerates functional recovery after peripheral nerve injury. J Bone Joint Surg Am. Aug 2008;90(8):1644-53. [Medline].
Lykissas MG, Korompilias AV, Vekris MD, Mitsionis GI, Sakellariou E, Beris AE. The role of erythropoietin in central and peripheral nerve injury. Clin Neurol Neurosurg. Oct 2007;109(8):639-44. [Medline].
Ducic I, Mafi AA, Attinger CE, Couch K, Al-Attar A. The role of peripheral nerve surgery in the management of painful chronic wounds: indications and outcomes. Plast Reconstr Surg. Jul 2008;122(1):193-7. [Medline].
Taras JS, Jacoby SM. Repair of lacerated peripheral nerves with nerve conduits. Tech Hand Up Extrem Surg. Jun 2008;12(2):100-6. [Medline].
Novak CB, Mackinnon SE, Williams JI. Establishment of reliability in the evaluation of hand sensibility. Plast Reconstr Surg. Aug 1993;92(2):311-22. [Medline].
Strauch B, Lang A, Ferder M. The ten test. Plast Reconstr Surg. Apr 1997;99(4):1074-8. [Medline].
Gelberman RH. Operative Nerve Repair and Reconstruction. 1991.
Kline DG, Hudson AR. Nerve Injuries - Operative Results for Major Nerve Injuries, Entrapment and Tumor. 1995.
Seddon HJ. Nerve grafting. Journal of Bone & Joint Surgery. 1963;43B:447-461.
Mackinnon SE, Novak CB. Nerve transfers. New options for reconstruction following nerve injury. Hand Clin. Nov 1999;15(4):643-66, ix. [Medline].
Oberlin C, Beal D, Leechavengvongs S. Nerve transfer to biceps muscle using a part of ulnar nerve for C5-C6 avulsion of the brachial plexus: anatomical study and report of four cases. J Hand Surg [Am]. Mar 1994;19(2):232-7. [Medline].
Xu WD, Lu JZ, Qiu YQ, Jiang S, Xu L, Xu JG, et al. Hand prehension recovery after brachial plexus avulsion injury by performing a full-length phrenic nerve transfer via endoscopic thoracic surgery. J Neurosurg. Jun 2008;108(6):1215-9. [Medline].
Further Reading
EFNS guidelines on the use of skin biopsy in the diagnosis of peripheral neuropathy.
European Federation of Neurological Societies - Medical Specialty Society. 2005 Oct. 12 pages. NGC:005166
Management of paraneoplastic neurological syndromes: report of an EFNS Task Force.
European Federation of Neurological Societies - Medical Specialty Society. 2006 Jul. 9 pages. NGC:005486
Keywords
peripheral nerve injuries, peripheral nervous system, epineurium, perineurium, endoneurium, spinal nerves, ganglia, mononeuropathy, polyneuropathy, nerve repair, traumatic nerve injuries, nerve compression, traumatic peripheral nerve lesions, nerve injury, nerve injuries, brachial plexus injury, radial nerve injury
