peripheral nerve injury Surgery for Peripheral Nerve

Surgery for Peripheral Nerve Injury Peripheral Nerve Injury Neurosurgeon Yoon Seung Hwan Anatomy Connective tissue major tissue componant epineurium, perineurium, endoneurium Nerve tissue axon, schwan.

Peripheral Nerve Injury

Neurosurgeon Yoon Seung-Hwan

Anatomy

- major tissue componant

- epineurium, perineurium, endoneurium

- axon, schwann cell

Peripheral Nerve Injury

(entrapment neuropathy)

Classification

• direct mechanical compression, ischemia,

mild burn trauma or stretch

• axon continuity is disrupted

• fascicular integrity is maintained

• Wallerian degeneration occurs

• 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

Factor s for Decision Making

several weeks-several months

Recovery within 6 weeks good prognosis

Fibrillation potentials and

positive sharp waves

Acute Denervation

Long duration, small amplitude polyphasic motor unit potentials

Regeneration

Tinel’s 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.

EMG SNAP

SSEP

Intraoperative NAP

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

Delayed Intervention

• 2-3 months after injury

• No clinical or substantial recovery

• Neurolysis : internal/external

• Nerve repair

end-to-end repair : epineural/fascicular

autologous graft : sural N.

Epineural Repair

Fascicular Repair

Injured Peripheral Nerve

Evaluation of Closed Injury

Bluntly transsected nerve best repaired after a delay of several weeks

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

4 Split repair with usually graft - lesion in continuity 장 partial function or undergoing partial regeneration

5 Careful patient selection for operation

7 A good end result requiring rehabilitation from onset of treatment Prevention of disuse, relief of pain, predicting probable end results of operative procedures

Conclusions

Chronic Injuries of Peripheral Nerves by Entrapment

Surgical Indications

• Failed conservative tx

• Typical clinical finding

with electrodiagnostic data

Entrapment of Thoracic Outlet

scalene anterior and medius M

Carpal Tunnel Syndrome

thenal atrophy

Entrapment of Radial Nerve

Entrapment of Ulnar Nerve

- Cubital tunnel

- Guyon’s canal

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

Meralgia Paresthesia

cutaneous nerve

injury (L1-2)

Tarsal Tunnel Syndrome