Method for obtaining a sural nerve graft

Multiple Mini Incision Technique for Sural Nerve Harvest: When to Add a Fibular Incision Based on a New Surgical Classification

Sural nerve is the most common nerve used as a source for nerve grafting. Open harvest with longitudinal incisions produces unsightly scars, and this have led to development of less invasive techniques using endoscopes, nerve stripper, and mini-incisions. Several anatomical classifications have also been proposed due to the variations in the anatomy of the sural nerve. A simple and practical surgicoanatomical classification of the sural nerve based on which we have refined our minimal access technique, the multiple mini-incision technique for sural nerve harvest is proposed. In this technique, the incisions required for harvest of the sural nerve are standardized and predictable. A fibular incision is required when the sural nerve has major contribution from the common peroneal nerve. We have found this a simpler and reliable technique of harvest of sural nerve in nerve reconstructive surgery.

Single-incision sural nerve harvest: Technical considerations for cross-facial nerve grafting

b.a. is the senior author and performed all of the procedures described, and conceptualized and edited the article. l.e.i. was responsible for data collection and analysis, editing the manuscript, and compiling the figures. d.b.y. performed the first single-incision nerve harvest with b.a. and is responsible for b.a. adopting the practice. b.l. is b.a.'s partner and assisted with the majority of surgeries and proofread the manuscript. g.g.m. was cosurgeon on many of the described cases and is partly responsible for conceptualizing the article. g.l.p. was responsible for data collection and writing of the original manuscript and compiling the illustrations. Laryngoscope, 129:2464-2466, 2019.

Endoscopically assisted sural nerve harvest in infants

A technique of endoscopic sural nerve harvest was devised to minimize the donor site scarring in infants requiring peripheral nerve grafting procedures. The harvests were performed under tourniquet control using three 2-cm incisions for access at the lateral malleolus, midcalf, and popliteal fossa. Endoscopic visualization and blunt dissection of the nerve was achieved with a 4-mm-diameter, 18-cm-long telescope with a 0-degree angle lens, stabilized in an Emory retractor and attached to a video camera. The medial sural nerve was divided in the popliteal fossa proximally under direct vision. The lateral sural nerve was identified and harvested when present. This technique has been in use since 1994 and has been undertaken in more than 200 patients. The most common indication for surgery was obstetrical brachial plexus palsy. No nerve graft injury was noted upon examination under the operating microscope. Postoperative pain, swelling, and ecchymosis were minimal. Most patients have a detectable area of sensory loss at long-term follow-up but are unaware of this finding. Donor site scarring has been aesthetically satisfactory.

Shaping the military wound: issues surrounding the reconstruction of injured servicemen at the Royal Centre for Defence Medicine

The conflict in Afghanistan has produced injuries similar to those produced from military conflicts for generations. What distinguishes the modern casualty of the conflict in Afghanistan from those of other conflicts is the effectiveness of modern field medical care that has led to individuals surviving with injuries, which would have been immediately fatal even a few years ago. These patients present several challenges to the reconstructive surgeon. These injured individuals present early challenges of massive soft-tissue trauma, unstable physiology, complex bony and soft-tissue defects, unusual infections, limited reconstructive donor sites, peripheral nerve injuries and traumatic amputations. Late challenges to rehabilitation include the development of heterotopic ossification in amputation stumps. This paper outlines the approach taken by the reconstructive team at the Royal Centre for Defence Medicine in managing these most difficult of reconstructive challenges.

The relative contributions of the medial sural and peroneal communicating nerves to the sural nerve

The medial sural cutaneous nerve (MSCN) and peroneal communicating nerve (PCN) conjoin in the calf area to form the sural nerve (SN). In previous anatomic studies, there was unresolved debate as to the main contributor to the sural nerve, and the relative contributions of MSCN and PCN had not been studied. The purpose of this study is to determine their relative neurophysiologic contributions to the SN by nerve conduction study (NCS). A total of 47 healthy subjects (25 males and 22 females, mean age 29.6 +/- 10.4 yrs, range 20-59 yrs) participated in the study. This study employed the orthodromic nerve conduction technique: stimulation at the ankle and recording at the mid calf (SN); specifically, we preformed stimulation at the mid calf (MSCN, PCN) and recording at 14 cm proximal to the middle of the popliteal fossa (MSCN) and fibular head (PCN). The onset and peak latencies (ms) were SN 2.3 +/- 0.2 and 3.0 +/- 0.2; MSCN 2.1 +/- 0.2 and 2.8 +/- 0.2; and PCN 2.1 +/- 0.2 and 2.8 +/- 0.2. The peak-to-peak amplitudes (microV) and areas (nVsec) of the SN, MSCN, and PCN were 9.7 +/- 3.9, 7.0 +/- 4.7, and 5.0 +/- 3.2; and 7.2 +/- 2.9, 5.7 +/- 3.4, and 4.0 +/- 2.4, respectively. The side-to-side difference was not statistically significant. The main contributor to the SN was found to be the MSCN. The relative contribution ratio of the MSCN to the PCN was 1.37:1 by amplitude and 1.42:1 by area. However, in 32.9% of the subjects, the contribution of the PCN was greater than that of the MSCN.

Subjective Outcomes Following Sural Nerve Harvest

PURPOSE

The goal of this study was to assess subjective patient recovery of donor site sensory deficit following sural nerve harvest for trigeminal nerve repair surgery.

PATIENTS AND METHODS

A review of 42 consecutive sural nerve graft patient records yielded 26 patients, at least 20 months following sural nerve grafting for trigeminal nerve repair, who participated in a telephone questionnaire survey to assess subjective outcomes. The association between donor site outcome and other factors, including nerve graft recovery, age, gender, pain, cold sensitivity, scar cosmesis and tactile sensitivity, and legal involvement were analyzed, and presurgical and present levels of donor and nerve graft site sensibility were compared.

RESULTS

The perceived area of donor site sensory deficit decreased significantly over time. Postoperative donor site pain and cold sensitivity at low levels were reported by few patients, and the majority have completely resolved. Most patients reported no problems with scar cosmesis or pain. There was a moderate agreement between donor site recovery and nerve graft recovery (kappa = 0.32). Few patients reported satisfaction with one site and not the other or complete dissatisfaction with both sites. Other factors such as age, gender, or legal involvement were not found to correlate with satisfaction level.

CONCLUSIONS

The use of a questionnaire for subjective assessment of neurosensory recovery following nerve graft repair yields outcomes information that is generally not considered in the traditional clinical patient assessment. The majority of patients tolerate sural nerve harvest without significant donor site morbidity.

The anatomic features of the sural nerve with an emphasis on its clinical importance

BACKGROUND

The sural nerve is formed by the union of the medial and lateral cutaneous nerves of the leg that originate from the tibial and common peroneal nerves. Operative procedures and traumatic injuries to the popliteal fossa, leg, ankle and foot place the sural nerve and its branches at risk. The aim of this study was to describe the course, variations and some clinically significant relations of the sural nerve.

METHODS

The sural nerve was dissected in 30 lower limbs (leg-ankle-foot) of 15 cadavers. The specimens were measured, drawn and photographed.

RESULTS

In 18 specimens (60%) the sural nerve originated from the union of the medial and lateral cutaneous nerves of the leg in the upper two-thirds of the leg (classic type). The union of the medial and lateral cutaneous branches was in the distal third of the leg in three specimens (10%). The lateral cutaneous nerve was absent in five (16.7%), and the medial cutaneous nerve was absent in 2 (6.7%) specimens. In two specimens (6.7%) the nerves had separate courses. The mean distance between the most prominent part of the lateral malleolus and the sural nerve was 12.76 +/- 8.79 mm. The mean distance between the tip of the lateral malleolus and sural nerve was 13.15 +/- 6.88 mm. The most common distribution of the sural nerve in the foot was to the lateral side of the fifth toe (60%), followed by the lateral two and a half toes (26.7%).

CONCLUSIONS

These described variations and measurements should be helpful for planning operative approaches that minimize the risk of sural nerve injury.

Peculiarities of the sural nerve complex morphologic types in human fetuses

The sural nerve is the most frequently used sensory nerve in nerve transplantation. It can be transplanted alone or together with the other elements of the neurovascular stalk within the superficial sural flap. The aim of this study was to define the morphologic types of the sural nerve complex, as well as to describe their specific characteristics. Microdissection was performed on 100 human fetuses (200 calves) after 10% formalin fixation. Five morphologic types of sural nerve complex with different incidence were defined. Two morphologic types dominated: type I (58.5%) in which the sural nerve was formed by merging of a fibular communicating branch and the medial sural cutaneous nerve, and type III (26%) in which the medial sural cutaneous nerve took over the function of the sural nerve. Other morphologic variations were less common.

Minimally invasive technique for sural nerve harvesting: technical description and follow-up

OBJECTIVES

To provide instruction and the results of a minimally invasive technique for sural nerve harvesting in preparation for interposition nerve grafting during radical retropubic prostatectomy.

METHODS

Twelve men underwent nerve harvesting performed using a tendon stripper. The short-form McGill Pain Questionnaire was completed preoperatively and at 6 months postoperatively.

RESULTS

No significant morbidity from the leg resulted as a result of the sural nerve harvest. The results of the short-form McGill Pain Questionnaire demonstrated no significant sensory or affective changes in the leg. The average operative time for the entire harvesting procedure, including skin closure, was 15 minutes. The estimated blood loss was less than 5 mL (range 2 to 10). No wound infection or skin erythema was observed. The discharge to home was not delayed compared with the usual length of stay after radical retropubic prostatectomy.

CONCLUSIONS

This minimally invasive sural nerve harvesting technique is easy to perform and has minimal morbidity.

Harvesting of the sural nerve with a tendon stripper

The nerve most commonly used for peripheral nerve reconstruction is the sural nerve. The nerve can be dissected free through one long calf incision, by utilizing multiple small incisions, or by using a tendon stripper. We studied 12 above-knee amputation specimens harvesting the nerve in the ways described. We found that the length of nerve harvested averaged 32, 36, and 25 cm for the open, limited open, and stripper techniques, respectively. Epineurial damage occurred with the stripper, but no perineurial damage was documented histologically. We concluded that the closed method (stripper) of harvesting sural nerve would provide quality graft material, but of unpredictable length. When reliably long segments of nerve are required, at least a limited open or an open approach for harvest is recommended.

Endoscopic sural nerve harvest in the pediatric patient

A technique of endoscopic sural nerve harvest was devised to minimize the donor-site scarring in pediatric patients requiring peripheral nerve-grafting procedures. The harvests were performed under tourniquet control using two 2-cm incisions for access at the lateral malleolus and the midcalf. Endoscopic visualization and blunt dissection of the nerve were achieved with a 4-mm Hopkins telescope with 30-degree angled lens (Karl Storz GmbH, Tuttlingen, Germany) stabilized in an Emory retractor and attached to a video camera. The medial sural nerve was divided in the popliteal fossa proximally under endoscopic visualization. The lateral sural nerve was identified and harvested when present. Between June of 1994 and March of 1995, 18 patients underwent 27 sural nerve harvests using the endoscopic technique. Mean patient age was 3.3 years (range 4 to 197 months). Indications for surgery included obstetrical brachial plexus palsy (12), facial palsy (5), and ulnar nerve neuroma (1). Nerve-graft length harvested ranged from 13 to 41 cm. Mean tourniquet time per limb was 92 minutes. No nerve graft injury was noted on examination under the operating microscope. Postoperative pain, swelling, and ecchymosis were minimal. Donorsite scarring has been aesthetically satisfactory to date.

The anatomy of the lateral cutaneous nerve of the thigh--a possible donor nerve for facial nerve repair

One hundred anterior branches of the lateral cutaneous nerve of the thigh were dissected and measured in 50 adult cadavers. The results show that this nerve was present in all sides, and the average length from the point of the nerve piercing the fascia lata to the point of its first branch was about 79 mm, the average width was 2.25 mm, and the average thickness was 0.79 mm. It was found that the nerve was approximately along the line between the anterior superior iliac spine and the midpoint of the upper margin of the patella. This study presents a simple method of locating this nerve for clinical reference. The results also reveal that this nerve is a possible donor for facial nerve repair.

Donor site morbidity of greater auricular nerve graft harvesting

To better understand the risks of obtaining greater auricular nerve (GAN) grafts, a retrospective analysis of 29 patients who underwent GAN graft procurement between 1985 and 1990 was conducted. No short-term morbidity was noted. Thirteen patients developed symptomatic nerve injuries, of which 6 reported spontaneous resolution in an average of 4.6 months. Three patients developed neuromas and 1 formed a hypertrophic scar. Persistent nerve injury symptoms were well tolerated in all but one patient, who developed sympathetic-mediated pain.

Anatomic-histologic survey of the sural nerve: implications for inferior alveolar nerve grafting

An anatomic and histologic study of the sural nerve was made as part of an effort to formulate a rationale governing selection of appropriate segments of the nerve as a donor graft for repair of the inferior alveolar nerve. Ten sural nerves were obtained by dissection at autopsy and their topography assessed. Hematoxylin and eosin stained transverse sections were prepared from samples taken at 32 locations along each nerve. Nerve diameter and shape, fascicle number, and fascicular arrangement were assessed at low power using light microscopy. It was concluded that technical objectives of graft repair can be better attained by selective sural nerve harvest.

Anatomy of the sural nerve complex

The anatomy of the sural nerve complex in 20 cadaveric limbs was determined by dissection. The nerve usually consists of four named components: the medial sural cutaneous nerve, the lateral sural cutaneous nerve, the peroneal communicating branch, and the sural nerve. In most instances (80%), the sural nerve is formed in the distal portion of the leg by the union of the medial sural cutaneous nerve and the peroneal communicating branch. In 20% of cases, the peroneal communicating branch is absent. In such cases, the sural nerve is derived from the medial sural cutaneous nerve alone. The lateral sural cutaneous nerve is laterally situated and usually divides into medial and lateral branches. In a few cases, its medial division may contribute to the sural nerve through the peroneal communicating branch. The peroneal communicating branch can be of substantial caliber and may be useful as a source of nerve graft without complete sacrifice of the sural nerve. We describe a technique of isolation of the peroneal communicating branch for use as a nerve graft.

Autogenous sural nerve grafts: a harvesting technique

Sural nerve grafts have applicability in many facets of reconstructive surgery. A harvesting technique is described which utilizes a tendon stripper introduced through a single distal incision. This method provides adequate length of autogenous graft material without significant difficulty or morbidity.