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Title:

Peripheral Nerve Injury

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... post -injury 1 month ... Delayed intervention Early Intervention Enlarging hematoma/aneurysmal sac Predisposing to Volkmann s ischemic contracture ... mild burn ... – PowerPoint PPT presentation

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Title: Peripheral Nerve Injury


1
Peripheral Nerve Injury
  • Neurosurgeon
  • Yoon Seung-Hwan

2
Anatomy
  • Connective tissue
  • - major tissue componant
  • - epineurium, perineurium, endoneurium
  • Nerve tissue
  • - axon, schwann cell

3
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4
Peripheral Nerve Injury
  • Acute injury
  • Chronic injury
  • (entrapment neuropathy)

5
Classification
6
Neuropraxia
  • the mildest form, reversible conduction
  • block
  • loss of function, which persists for hours
  • or days
  • direct mechanical compression, ischemia,
  • mild burn trauma or stretch

7
Axontmetic
  • axon continuity is disrupted
  • fascicular integrity is maintained
  • Wallerian degeneration occurs

8
Neurotmesis
  • laceration from sharp or blunt forces
  • the only important consideration is
  • the timing of repair
  • acute repair or more bluntly lacerated
  • nerves are repaired 3-4 weeks

9
Factor s for Decision Making
  • Age
  • Segment between injury and end organ
  • Gap of injury
  • Mechanism of injury
  • Severity of injury
  • Presence of pain

10
Axonal Regeneration
  • Initial delay
  • to the distal stump 1-2 week delay
  • Growth rate
  • 1mm/day, 1 inch/month
  • Terminal delay
  • several weeks-several months
  • Recovery within 6 weeks? good prognosis

11
Acute Denervation
Fibrillation potentials and positive sharp waves
12
Regeneration
Long duration, small amplitude polyphasic motor
unit potentials
13
Clinical Signs
Diagnosis
  • Motor function
  • Tinels sign
  • positive-sensory function
  • negative(after 4-6weeks)-total interruption
  • Sweating-sympathetic fiber
  • Sensory function

14
Tinels sign
  • advancing along the anatomical distribution of
    the nerve, particularly if it is does so at the
    expected rate of nerve regeneration, then this
    provides evidence of ongoing regeneration.

15
Electrophysiological Tests
Diagnosis
  • EMG
  • SNAP
  • SSEP
  • Intraoperative NAP

16
EMG
SNAP
17
SSEP
18
Intraoperative NAP
19
Muscle Atrophy
  • 24 month rule
  • - 2? ?? ?? ? muscle scar tissue? ???? ?? ?
    (?????) ????
  • Muscle atrophy
  • start post-injury 1 month
  • peak 3rd - 4th month
  • Segment between injury and end organ

20
Time of Operation
Treatment
  • Open injury
  • Early intervention
  • Delayed intervention
  • Closed injury
  • Delayed intervention

21
Early Intervention
  • Enlarging hematoma/aneurysmal sac
  • Predisposing to Volkmanns ischemic contracture
  • Severe noncausalsic pain SD
  • Injury to N. in areas of potential entrapment
  • Simple, clean lacerating injury

22
Delayed Intervention
  • 2-3 months after injury
  • No clinical or substantial recovery
  • ??
  • 1. ????? ??? ? ? ??.
  • 2. ????? ??? ??? ???.
  • 3. Epineurium? ???? ??? ??.
  • 4. ????? ??? ??? ????.

23
Operations
  • Neurolysis internal/external
  • Nerve repair
  • end-to-end repair epineural/fascicular
  • autologous graft sural N.
  • Neurotization
  • intercostal N./accessory N./cervical plexus
  • within 1 year
  • Muscle and tendon transfer

24
Epineural Repair
25
Fascicular Repair
26
Nerve Graft
  • leading cause of failure of nerve graft
  • Inadequate resection
  • Distraction of repair site

27
Postoperative Care
  • Neurolysis ?????? ????
  • End-to-end repair 3? ?? ??
  • 6??? ??? ??
  • Graft ? ? ?? ?? ??
  • ??? ????? ???

28
Injured Peripheral Nerve
29
Evaluation of Closed Injury
30
Conclusions
  • 1. Immediate primary repair in sharp injuries
    with suspected transsection of nerve
  • Immediate repair is especially important for
    brachial plexus and sciatic nerve transsections
    because delay leads not only to retraction but
    also to severe scaring
  • Bluntly transsected nerve best repaired after a
    delay of several weeks.
  • A focally injured nerve should be explored if no
    functional return within 8-10 weeks
  • 3. Decision - making as to whether neurolysis or
    resection repair in a lesion in gross
    continuity based on intraoperative
    electrophysiological evaluation

31
Conclusions
4. Split repair with usually graft - lesion in
continuity? partial function or undergoing
partial regeneration 5. Careful patient selection
for operation - ?? plexus involved ? 6. Nerve
anastomosis ? failure ???? ? inadequate
resectin of scarred nerve ends ? nerve suture
distration 7. A good end result requiring
rehabilitation from onset of treatment.
Prevention of disuse, relief of pain, predicting
probable end results of operative procedures.
32
Chronic Injuries of Peripheral Nerves by
Entrapment
  • Pain
  • Paresthesia
  • Loss of function

33
Pathophysiology of Entrapment
  • Direct compression
  • segmental demyelination
  • wallerian degeneration(distal)
  • Ischemia
  • swelling of nerve
  • microcompartment SD

34
Conservative Tx
Treatment
  • Indications
  • not long history
  • mild-moderate, intermittent
  • reversible cause
  • pregnancy, oral contraceptive, endocrine

    abnormalities(DM), type
    writer
  • Method
  • nonsteroidal anti-inflammatory drugs
  • splint

35
Surgical Indications
Treatment
  • Failed conservative tx
  • Typical clinical finding
  • with electrodiagnostic data
  • Severe
  • sensory loss
  • muscle atrophy
  • motor weakness

36
Entrapment of Thoracic Outlet
  • ? ?
  • - Cervial rib or anomalous transverse process
    of C7
  • - Fibromuscular bands or scalene muscle
    abnomality
  • ? ?
  • - X-ray
  • - NCV EMG
  • - Angiography vascular anomaly
  • Tx Supraclavicular approach
  • - Best op. management

37
scalene anterior and medius M.
38
Carpal Tunnel Syndrome
39
thenal atrophy
40
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41
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42
Entrapment of Radial Nerve
43
Entrapment of Ulnar Nerve - Cubital tunnel -
Guyons canal
44
Motor Deficit of Ulnar Nerve
  • Bediction posture clawing of ring small
    finger
  • Froments sign weakness of adductor pollicis,
    there will be flexion of the interphalangeal
    joint of the thumb because of substitution of the
    median innervated flexior pollicus longus for a
    weak adductor pollicis

45
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46
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47
Meralgia Paresthesia
Lateral femoral cutaneous nerve injury (L1-2)
48
Tarsal Tunnel Syndrome
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