nerve surgeries

8/2/2019 Nerve Surgeries

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- Presented byAnkita tiwari



Nerve Repairs (timing)

Primary nerve repair:◦ Indicated for clean, sharply cut nerves. Performed

immediately after an injury or within 1 to 2 weeks

Secondary nerve repair:◦ Usually indicated in the presence of a severely

crushed , avulsed nerve or multilevel lesions.◦ Early secondary repairs r performed within 6

weeks nd late secondary repairs after 3 months.



Injured Peripheral Nerve



Neurolysis : internal/externalNerve repair

end-to-end repair : epineural/fascicularautologous graft : sural N.

Neurotizationintercostal N./accessory N./cervical plexus

within 1 yearMuscle and tendon transfer



1 NEUROLYSIS : It is the process of:

◦

1. release of a nerve sheath by cutting itlongitudinally.(internal neurolysis)◦ 2. operative breaking up of perineural

adhesions.(external neurolysis)◦ 3. relief of tension upon a nerve obtained by

stretching.◦ 4. destruction or dissolution of nerve tissue.



Epineural Repair



Completely transected nerve.

Cut nerve end debrided and serially sectioneduntil the axoplasmic outflow mushrooms underpositive intrafascicular pressure nd fasicularpattern is identified and relatively free of scar.

Magnification increased to 25 power and 10-0nylon sutures used.

8-10 sutures for large nerve nd 2 for small one.

Leading cause of failure is gapping,overriding,buckling,straddling of fascicle ends.



Fascicular Repair



Perineurial repair.Nerve ends prepared nd epineurium is

dissectd away.Fascicles r seperated nd coaptation isperfrmd btwn matching fascicles wid suturesplacd into d inner epineurium.nd not to enterin endoneurium.Advantage is accurate coaptation of similarsize fascicles.Disadvantage is stimulation of grtr amnts of intraneural scar by increased dissection ndforeign material.



Nerve Graft

• Inadequate resection• Distraction of repair site



Nerve-lengthening techniques(tissueexpansion or nerve distraction)

Or bridged by tubes of biological or

nonbiologic material

Eg. Polyglycolic acid,autogenous vein andamnion.



Tendon transfers-◦ Application of motor power of one muscle to

another weaker or paralysed muscle by transfer of its tendinous junction.

◦ Donor mst b strengthened postoperatively.



Detailed history.◦ Nature of injury◦ Level of injury◦ Date of injury/repair◦ Patient’s problems. Evaluation of sympathetic function.MMT◦ Aware of d limitation in PROM due to muscle

shortening or contractures.◦ Trick motions –rebound,supplementary

action,antagonist,common tendons.



ROMSensibility examination.◦

An initial latent period of 3-4 weeks ,axonalregeneration progresses at a rate of approx.1mm/day.

◦ Sensibility recovery occur in following sequenceDeep pressure and pinprick,moving touch,static lighttouchAt first, a stimulus will be poorly localized and mayradiate proximally or distally.Accurate localization is among d last sensibilityfunctions to recover.Typical tests –tinel’s sign -sharp/dull discrimination,

Semmes –weinstein light touch deep-pressure testing



Pain asssmnt.◦ Burning pain in distribution of injured nerve

(causalgia)◦ Extreme pain when touched(neuroma)Analysis of d impact of injury on d patient’sfunctional status



maintain range motion.

maintain nerve integrity.

increase muscle strength.

increase sensation.

manage neuropathic pain.



To prevent stretch of the sutured nerve end, aplaster slab is applied after the operation andworn for 2-3weeks,with adjacent jointpositioned to reduce tension.No passive stretch of nerve is allowed for8weeks.The limb is supported initially in elevation to

prevent oedema, and exercise are given tomaintain the range of any free joint duringthis period of immobilization.



Dynamic splint for ulnar nerveinjury

Lumbrical bar splint

Ulnar Nerve



Short opponens for Median Nerve

C-bar for correction of a thumb adductioncontracture



Long arm splint for more

proximal Radial nerveinjury



Splinting for Radial Nerve

Dynamic Splint, Active wrist extension

Volar wrist splintBegin with wrist extension at 60 and

Serial splint towards neutral

Dynamic splint, no active wrist extension



The limb must be supported comfortably inelevation.Active movements of the unaffected joint of the limb are encouraged.Pulsed electromagnetic energy (PEME) shouldbe given daily through the dressing to theaffected part



Free active movement are encouraged inorder to retain range.Passive physiological movement must begiven in the absence of normal voluntarymovement.Electrical stimulation for proprioceptivefeedback of recovering muscle.

Position-hold exercises.Avoid putting tension on the nerve ends atthis stage.



Deeper massage is given to help freeadhesion scar and soften indurated areasIt safe in this stage to introduce graduatedresistance to all movement which will help tofree adherence and mobilise any residualstiffness of joints.Pain is usually decreased by the use of TENS.

Splint can be used in night only.



More vigorous resisted exercises are nowintroduced.(pre)Passive stretching is required if full mobilityof the soft tissues has no being gained. Serialstretch plaster are necessary in stubborncases.Special care must be taken to assess the

patient suitability to wear splint.Desensitization.



Localization of stimulus.Identification of sand paper on dowels.Identification of textures.Identification of velcro letters on wood.ADL with vision occluded

nerve surgeries

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