1. Peripheral Nerve InjuryBy
Dr. Malik Irfan Ahmed
Senior Registrar Surgery
DHQ Hospital.

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

5. Peripheral Nerve Injury
Acute injury
Chronic injury
(entrapment neuropathy)

6. Classification

7. 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

8. Axontmetic axon continuity is disrupted
fascicular integrity is maintained
Wallerian degeneration occurs

9. 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

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

11. 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

12. Electrophysiological Tests
Diagnosis
Electrophysiological Tests
EMG
SNAP(sensory nerve action potential)
SSEP(Somatosensory evoked potentials)
Intraoperative NAP

13. Treatment Time of Operation Open injury Early intervention
Delayed intervention
Closed injury

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

15. Delayed Intervention 2-3 months after injury
No clinical or substantial recovery

16. 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

17. PRINCIPLES OF NERVE REPAIR
l. Quantitative assessment
2. Microsurgical technique
3. Tension-free repair
4. Primary repair is performed when feasible.
5.nerve graft

18. 6. Postural maneuvers cannot substitute for a
tension-free repairwith grafting
8. Repair is delayed for a minimum of 3 week
9. Postoperative early movement
10. Preoperativep hysicalt herapy

19. Epineural Repair

20. Fascicular Repair

21. Nerve Graft # leading cause of failure of nerve graft
Inadequate resection
Distraction of repair site

22. Postoperative Care
Neurolysis :
End-to-end repair :
Graft :

23. Injured Peripheral Nerve

24. Evaluation of Closed Injury

25. 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

26. Chronic Injuries of Peripheral Nerves by Entrapment
Pain
Paresthesia
Loss of function

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

28. Treatment Conservative Tx Indications not long history
mild-moderate, intermittent
reversible cause
pregnancy, oral contraceptive, endocrine abnormalities(DM…), type writer
Method
nonsteroidal anti-inflammatory drugs
splint

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

30. 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

31. scalene anterior
and medius M.

32. Carpal Tunnel Syndrome

33. thenal atrophy

36. Entrapment of Radial Nerve

37. Entrapment of Ulnar Nerve
- Cubital tunnel
- Guyon’s canal

38. Motor Deficit of Ulnar Nerve
Bediction posture : clawing of ring & small finger
Froment’s 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

41. Meralgia Paresthesia
Lateral femoral cutaneous nerve injury (L1-2)

42. Tarsal Tunnel Syndrome