Surgical repair of ulnar nerve lesions caused by gunshot and shrapnel: results in 407 lesions

Low-Velocity Ballistic Trauma-Related Upper Extremity Nerve Injury: A Systematic Review and Meta-Analysis

PURPOSE

Optimal management of upper extremity nerve palsy caused by low-velocity ballistic trauma (LBT) remains controversial. The aim of this systematic review was to summarize the available evidence on the management of nerve injuries caused by LBT to the upper extremity.

METHODS

A literature search was completed for the keywords "Upper extremity," "Nerve Injury," and "Ballistic." 2 independent reviewers conducted a systematic screening of all articles and collected data from relevant publications. The data were summarized and pooled using a random-effect model.

RESULTS

14 studies met inclusion criteria. Cohorts between 6 and 168 patients (n = 848) with upper extremity LBT were reported. Neurologic deficits were present in 45% (95% CI: 38 to 52%) of patients at the time of injury evaluation. Nerve exploration was done in 50% (95% CI: 27 to 73%) of these patients with neurologic deficits. Early nerve exploration was done in 19% (95% CI: 9 to 32%) of all patients. Surgical findings included nerve continuity (49%; 95% CI: 14 to 84%), nerve contusion (30%; 95% CI: 12 to 50%), and nerve transection (31%; 95% CI: 14 to 50%). Nerve transection rates found at the time of exploration ranged from 0 to 71% (mean 31%). Outcomes were good in 62% (95% CI: 41 to 81%); however, analyses were limited by subjective outcome reporting of the studies.

CONCLUSIONS

Contrary to historical teaching that LBT causes neurapraxia, this review identified that 31% of resulting nerve injuries were neurotmesis (transections). These results advocate for systematic clinical follow-up and appropriately timed nerve intervention (within 3 to 6 months of injury) when neurologic deficits persist after ballistic injury.

LEVEL OF EVIDENCE

Level III.

Supercharged end-to-side anterior interosseous nerve transfer to restore intrinsic function in high ulnar nerve injury: a prospective cohort study

BACKGROUND

High ulnar nerve injuries is known to have unfavorable motor outcomes compared to other peripheral nerve injuries in the upper extremity. Functional muscle recovery after peripheral nerve injury depends on the time to motor end plate reinnervation and the number of motor axons that successfully reach the target muscle. The purpose of this study is to assess the functional recovery, and complications following performing supercharge end-to-side (SETS) anastomosis for proximal ulnar nerve injuries. Our study focuses on the role of SETS in the recovery process of high ulnar nerve injury.

PATIENT AND METHODS

This study is a prospective, single-arm, open-label, case series. The original proximal nerve pathology was dealt with according to the cause of injury, then SETS was performed distally. The follow-up period was 18 months. We compared the neurological findings before and after the procedure. A new test was used to show the effect of SETS on recovery by performing a Lidocaine proximal ulnar nerve block test.

RESULTS

Recovery of the motor function of the ulnar nerve was evident in 33 (86.8%) patients. The mean time to intrinsic muscle recovery was 6.85 months ± 1.3, only 11.14% of patients restored protective sensation to the palm and finger and 86.8% showed sensory level at the wrist level at the end of the follow-up period. Lidocaine block test was performed on 35 recovered patients and showed no change in intrinsic hand function in 31 patients.

CONCLUSION

SETS exhibit a remarkable role in the treatment of high ulnar nerve damage. SETS transfer can act as a nerve transfer that can supply intrinsic muscles by its fibers and allows for proximal nerve regeneration. We believe that this technique improves recovery of hand motor function and allows recovery of sensory fibers when combined with treating the proximal lesion.

TRIAL REGISTRATION

Approved by Research Ethics Committee of Faculty of Medicine- Cairo University on 01/09/2021 with code number: MD-215-2021.

Gunshot-related nerve injuries of the upper extremities: clinical, electromyographic, and ultrasound features in 22 patients

Objectives

Gunshot wounds of the upper extremities may cause permanent neurovascular injuries, leading to significant morbidity, chronic pain, functional loss, and disability. While there are many reports on the incidence and intraoperative findings in gunshot-related nerve injuries (GSNI) sustained during wars, there is a paucity of details pertaining to GSNI of the upper extremities in civilians. The goal of this paper is to provide the clinical, electrodiagnostic (EDX), and ultrasound (US) findings in 22 patients with GSNI of the upper extremities.

Methods

This is a retrospective study of patients referred for EDX studies to evaluate the presence of nerve injury after sustaining GSWs to the upper extremities. All patients underwent EDX studies, and 16 patients had US evaluations. Numerous metrics were documented including presenting symptoms, neurological abnormalities, EDX findings, and US features.

Results

The forearm was the most frequent location of injury (8 [36%] patients). The ulnar nerve was the most common injured nerve (10 [45%] patients), followed by the brachial plexus (7 [32%] patients). All patients complained of muscle weakness; the most frequently affected muscles were the first dorsal interosseous (FDI) (14 [64%] patients) and abductor pollicis brevis (APB) (11 [50%] patients). Muscle atrophy was noted in 19 (86%) patients, 15 of whom had atrophy of the FDI. Axonotmesis was the type of nerve injury in all patients based on EDX studies. Of the 16 patients who underwent US studies, a neuroma in continuity was noted in 4 (25%) patients and neurotmesis in 1 (6.2%) patient. Eleven (69%) patients had enlarged and/or hypoechoic nerves.

Conclusions

Axonotmesis of the ulnar nerve was the most common finding among patients sustaining gunshot injuries to the upper extremities. EDX and US studies provide valuable insight into the underlying pathophysiology and guidance for management of patients with GSNI of the upper extremities.

Biomechanical Testing of a Novel Device for Sutureless Nerve Repair

Suboptimal nerve end alignment achieved with conventional nerve repair techniques may contribute to poor clinical outcomes. In this study, we introduce Nerve Tape®, a novel nerve repair device that integrates flexible columns of Nitinol microhooks within a biologic backing to entubulate, align, and secure approximated nerve ends. This study compares the repair strength of Nerve Tape with that of conventional microsuture repairs. Thirty small (2 mm) and 30 large (7 mm) diameter human cadaveric nerves were transected and repaired utilizing Nerve Tape or appropriate microsuture technique. Biomechanical testing was performed using a horizontal tensile tester. The repaired nerves were loaded until failure at a distraction rate of 40 mm/min, and the maximum failure load was determined. In the small nerve groups, the load-to-failure for Nerve Tape repairs (2.33 ± 0.66 N) was significantly higher than for suture repairs (1.22 ± 0.52 N; p < 0.05). In the large nerve groups, no significant difference in load-to-failure was found between Nerve Tape (7.45 ± 2.66 N) and suture repairs (5.82 ± 1.59 N: p = 0.12). Suture repairs tended to fail by rupture, whereas Nerve Tape failures resulted from microhook pullout. Nerve Tape is a novel nerve coaptation device that provides mechanical repair strength equal or greater to clinically relevant microsuture repairs.

Follistatin Protein Enhances Satellite Cell Counts in Reinnervated Muscle

Background Muscle recovery following peripheral nerve repair is sup-optimal. Follistatin (FST), a potent muscle stimulant, enhances muscle size and satellite cell counts following reinnervation when administered as recombinant FST DNA via viral vectors. Local administration of recombinant FST protein, if effective, would be more clinically translatable but has yet to be investigated following muscle reinnervation. Objective  The aim of this study is to assess the effect of direct delivery of recombinant FST protein on muscle recovery following muscle reinnervation. Materials and Methods  In total, 72 Sprague-Dawley rats underwent temporary (3 or 6 months) denervation or sham denervation. After reinnervation, rats received FST protein (isoform FS-288) or sham treatment via a subcutaneous osmotic pump delivery system. Outcome measures included muscle force, muscle histomorphology, and FST protein quantification. Results  Follistatin treatment resulted in smaller muscles after 3 months denervation ( p  = 0.019) and reduced force after 3 months sham denervation ( p  < 0.001). Conversely, after 6 months of denervation, FST treatment trended toward increased force output ( p  = 0.066). Follistatin increased satellite cell counts after denervation ( p  < 0.001) but reduced satellite cell counts after sham denervation ( p  = 0.037). Conclusion  Follistatin had mixed effects on muscle weight and force. Direct FST protein delivery enhanced satellite cell counts following reinnervation. The positive effect on the satellite cell population is intriguing and warrants further investigation.

Evidence-Based Approach to Timing of Nerve Surgery: A Review

ABSTRACT

Events causing acute stress to the health care system, such as the COVID-19 pandemic, place clinical decisions under increased scrutiny. The priority and timing of surgical procedures are critically evaluated under these conditions, yet the optimal timing of procedures is a key consideration in any clinical setting. There is currently no single article consolidating a large body of current evidence on timing of nerve surgery. MEDLINE and EMBASE databases were systematically reviewed for clinical data on nerve repair and reconstruction to define the current understanding of timing and other factors affecting outcomes. Special attention was given to sensory, mixed/motor, nerve compression syndromes, and nerve pain. The data presented in this review may assist surgeons in making sound, evidence-based clinical decisions regarding timing of nerve surgery.

Surgical management of pediatric patients with peripheral nerve and plexus lesions caused by stray bullets

PURPOSE

Children and adolescents are frequent victims of gunshot wounds (GSW), either by direct intent or accidentaly. Lesions caused by stray bullets represent a specific type of accidental GSW and are usually associated with urban violence or aerial firing. We thereby present a series of surgically treated pediatric patients with peripheral nerve and brachial plexus lesions caused by stray bullets, referring to their clinical presentation, surgical procedures, and outcomes.

METHODS

Retrospective study of a series of seven pediatric patients treated from 2012 to 2019 for nerve and/or plexus lesions caused by stray bullets at the Peripheral Nerve Unit of the Division of Neurosurgery of Gaffrée e Guinle University Hospital (HUGG). We used the Visual Analog Scale (VAS) to evaluate pain distress and the British Medical Research Council grading system (BMRC) to assess muscle strength.

RESULTS

Patients' ages ranged from 6 to 17 years old (median of 16), and two were female. All presented preoperatively with intense pain, with a median VAS of 9 (range 7 to 10), and six also had neurological deficits. External neurolysis was conducted in all cases, whereas reconstruction with grafts was needed in four patients. All experienced improvement of pain, and those with motor deficits also experienced some level of recovery.

CONCLUSION

Pediatric patients who endure lesions by stray bullets appear to present with debilitating pain, and often with motor deficits. Multidisciplinary management comprising of surgical treatment and physical and occupational therapy may ameliorate symptoms and improve quality of life, as young patients usually fare better after surgery.

Surgical Treatment of Upper Extremity Gunshot Injures: An Updated Review

INTRODUCTION

Firearm morbidity and mortality have been increasing in recent years, and with this, the demand for medical personnel firearm injury treatment knowledge. Extremities contribute to a majority of firearm injuries, with these injuries being particularly complex because of neurovascular proximity within a confined space. Knowledge of firearm mechanism of injury and treatment management options is important for any trauma hand surgeon. Many factors play vital roles in the treatment of complex upper extremity (UE) gunshot wounds (GSWs). The aim of our review and case illustrations is to provide hand surgeons with an up-to-date guide for initial emergent management, soft tissue, bony, and nerve repair and reconstruction.

PATIENT AND METHODS

A literature review was conducted in the current management of UE GSW injuries, and 2 specific patient case examples were included. High-energy versus low-energy GSWs were documented and compared, as well as containment injures. Management including soft tissue, bony, and nerve injuries was explored along with patient outcome. Based on these findings, guidelines for GSW management were purposed.

CONCLUSION

Gunshot wounds of the UE encompass a group of highly heterogeneous injuries. High-energy wounds are more extensive, and concomitant injuries to bone, vessel, nerve, muscle, and soft tissue are common. Early treatment with adequate debridement, skeletal fixation, and soft tissue coverage is indicated for complex injuries, and antibiotic treatment in the pre-, peri-, and postoperative period is indicated for operative injuries. Soft tissue coverage options include the entire reconstructive ladder, with pattern of injury and considerations of wound characteristics dictating reconstructive choice. There are arguments to using either external or internal bony fixation techniques for bone fracture management, with choice tailored to the patient. For management of nerve injuries, we advocate earlier nerve repair and a shorter duration of observation before secondary reconstruction in selective cases. If transected nerve endings cannot be brought together, nerve autografts of shorter length are recommended to bridge nerve ending gaps. A significant number of patients with GSW fail to make necessary follow-up appointments, which adds to challenges in treatment.

Electrical stimulation to enhance peripheral nerve regeneration: Update in molecular investigations and clinical translation

Peripheral nerve injuries are common and frequently result in incomplete functional recovery even with optimal surgical treatment. Permanent motor and sensory deficits are associated with significant patient morbidity and socioeconomic burden. Despite substantial research efforts to enhance peripheral nerve regeneration, few effective and clinically feasible treatment options have been found. One promising strategy is the use of low frequency electrical stimulation delivered perioperatively to an injured nerve at the time of surgical repair. Possibly through its effect of increasing intraneuronal cyclic AMP, perioperative electrical stimulation accelerates axon outgrowth, remyelination of regenerating axons, and reinnervation of end organs, even with delayed surgical intervention. Building on decades of experimental evidence in animal models, several recent, prospective, randomized clinical trials have affirmed electrical stimulation as a clinically translatable technique to enhance functional recovery in patients with peripheral nerve injuries requiring surgical treatment. This paper provides an updated review of the cellular physiology of electrical stimulation and its effects on axon regeneration, Level I evidence from recent prospective randomized clinical trials of electrical stimulation, and ongoing and future directions of research into electrical stimulation as a clinically feasible adjunct to surgical intervention in the treatment of patients with peripheral nerve injuries.

Ulnar Nerve Injuries (Sunderland Grade V): A Simplified Classification System and Treatment Algorithm

This study introduced a novel technical approach to the ulnar nerve injuries. The ulnar nerve was divided into 4 distinct surgical zones, each mandating a unique management strategy.

Methods

A prospective observational study was conducted to verify the hypothesized algorithm. The study included 110 patients diagnosed with ulnar nerve injury (Sunderland grade 5). We divided the patients into 4 groups depending on the site of injury. Each group of patients was managed in accordance with a particular strategy, exploiting nerve transfer techniques along with the updated knowledge of the internal topography of the ulnar nerve. The motor recovery of the small muscles of the hand was assessed after 2 years of follow-up, using the disabilities of the arm, shoulder, and hand score, and other parameters including key pinch strength, hand grip strength, and the motor power of the first dorsal interosseous muscle on the Medical Research Council scale.

Results

The mean values of the disabilities of the arm, shoulder, and hand score, key pinch strength, and hand grip strength showed a statistically significant improvement across all patient groups (P < 0.05). Of those with zone (I) injury, postoperatively, 79.9% patients attained a first dorsal interosseous muscle power grade >3 on the Medical Research Council scale, while 93.9% of patients with zone (II) damage achieved the same result. Surprisingly, 84% of patients included in both zones (III) and (IV) also recovered to the same extent.

Conclusions

This prospective observational study examined and successfully confirmed the validity of our proposed novel algorithm for the management of ulnar nerve injuries (Sunderland grade 5).

A single session of brief electrical stimulation enhances axon regeneration through nerve autografts

Nerve graft reconstruction of gap defects may result in poor clinical outcomes, particularly with long regeneration distances. Electrical stimulation (ES) of nerves may improve outcomes in such patients. A single session of ES at 20 Hz for 1 h significantly enhances axon regeneration in animals and human subjects after nerve crush or nerve transection and repair. The objectives of this study were to evaluate if ES enhances axon regeneration through nerve grafts and if there is added benefit of a second, delayed session of ES (serial ES) on axon regeneration as compared to a single session only of ES. In female rats, a gap defect was created in the hindlimb common peroneal (CP) nerve and immediately reconstructed with a 10 mm nerve autograft (Experiment 1) or a 20 mm nerve autograft (Experiment 2). In Experiment 1, rats were randomized to 1 h of CP nerve ES or sham stimulation. In Experiment 2, rats were randomized to control (sham ES + sham ES), single ES (ES + sham ES), or serial ES (ES + ES), which consisted of an initial 1 h session of either ES or sham stimulation of the CP nerve, followed by a second 1 h session of ES or sham stimulation of the CP nerve 4 weeks later. In both experiments, after a 6 week period of nerve regeneration, CP neurons that had regenerated axons distal to the autograft were retrograde labelled for enumeration, and the CP nerve distal to the autograft was harvested for histomorphometry. In Experiment 1, rats that received CP nerve ES had statistically significantly more motor (p < .05) and sensory (p < .05) neurons that regenerated axons distal to the 10 mm nerve autograft, with more myelinated axons on histomorphometry (p < .001). Similarly, in Experiment 2, significantly more motor (p < .01) and sensory (p < .05) neurons regenerated axons distal to the 20 mm nerve autograft after a single session or two sessions of CP nerve ES. There was no significant difference in the number of regenerated motor or sensory neurons between rats with 20 mm CP nerve autografts receiving either one or two sessions of CP nerve ES (p > .05). In conclusion, a single session of ES enhances axon regeneration following nerve autografting with no added effect of a second, delayed session of ES. These findings support previous studies in animals and humans of the robust effect of a single session of ES in promoting nerve regeneration following injury and repair.

Viral vector delivery of follistatin enhances recovery of reinnervated muscle

INTRODUCTION

Poor recovery following nerve repair is due to progressive temporal loss of muscle function. Follistatin (FS), a glycoprotein with anabolic properties, may enhance muscle recovery following reinnervation.

METHODS

Seventy-two male Sprague-Dawley rats underwent temporary (3 or 6 month) denervation or sham denervation. After reinnervation, rats were administered adeno-associated viral vectors expressing FS deoxyribonucleic acid (isoform FS-317) injected into the target muscle or sham treatment. Final assessment included muscle function testing, muscle histomorphology, nerve histomorphology, and FS protein quantification.

RESULTS

FS improved muscle mass and type IIB muscle fiber size, and increased G-ratios and mean axon diameter in the 6-month temporary denervation group (P < .05). Elevated FS protein levels were detected in treated muscle (P < .05). FS increased satellite cell counts following temporary denervation and repair (P < .05).

DISCUSSION

FS treatment had anabolic, neurotrophic, and satellite cell stimulatory effects when administered following prolonged (6-month) temporary denervation and repair.

Recovery of Motor Function after Mixed and Motor Nerve Repair with Processed Nerve Allograft

Supplemental Digital Content is available in the text.

Background:

Severe trauma often results in the transection of major peripheral nerves. The RANGER Registry is an ongoing observational study on the use and outcomes of processed nerve allografts (PNAs; Avance Nerve Graft, AxoGen, Inc., Alachua, Fla.). Here, we report on motor recovery outcomes for nerve injuries repaired acutely or in a delayed fashion with PNA and comparisons to historical controls in the literature.

Methods:

The RANGER database was queried for mixed and motor nerve injuries in the upper extremities, head, and neck area having completed greater than 1 year of follow-up. All subjects with sufficient assessments to evaluate functional outcomes were included. Meaningful recovery was defined as ≥M3 on the Medical Research Council scale. Demographics, outcomes, and covariate analysis were performed to further characterize this subgroup.

Results:

The subgroup included 20 subjects with 22 nerve repairs. The mean ± SD (minimum–maximum) age was 38 ± 19 (16–77) years. The median repair time was 9 (0–133) days. The mean graft length was 33 ± 17 (10–70) mm with a mean follow-up of 779 ± 480 (371–2,423) days. Meaningful motor recovery was observed in 73%. Subgroup analysis showed no differences between gap lengths or mechanism of injury. There were no related adverse events.

Conclusions:

PNAs were safe and provided functional motor recovery in mixed and motor nerve repairs. Outcomes compare favorably to historical controls for nerve autograft and exceed those for hollow tube conduit. PNA may be considered as an option when reconstructing major peripheral nerve injuries.

Nerve transfers for peripheral nerve injury in the upper limb: a case-based review

Nerve transfer has become a common and often effective reconstructive strategy for proximal and complex peripheral nerve injuries of the upper limb. This case-based discussion explores the principles and potential benefits of nerve transfer surgery and offers in-depth discussion of several established and valuable techniques including: motor transfer for elbow flexion after musculocutaneous nerve injury, deltoid reanimation for axillary nerve palsy, intrinsic re-innervation following proximal ulnar nerve repair, and critical sensory recovery despite non-reconstructable median nerve lesions.

Epidemiological characteristics of surgically treated civilian traumatic brachial plexus injuries in Serbia

BACKGROUND

Traumatic brachial plexus injuries are generally severe, and in many cases associated with surrounding tissue injuries, which makes them hard to diagnose at the right time. This paper presents etiological and epidemiological characteristics of surgically treated civilian traumatic brachial plexus injuries.

METHODS

This retrospective study included 68 patients, operated due to the traumatic brachial plexus injuries at Clinic for Neurosurgery, Clinical Center of Serbia, during the 11-year period.

RESULTS

The vast majority of injured patients were men in full working maturity. In our study, there were seven different etiological factors. The road traffic accidents were the most common-41 (60.3%), while the motorcycle accidents were the most dominant subtype (53.7%) of all road traffic accidents, and also representing 32.4% of all causes of trauma. Supraclavicular elements of the brachial plexus were injured in more than 80% of patients. A total of 49 (72.1%) patients from our study had one or more associated injuries. The most common associated injuries were bone fractures, brain contusions, and vascular injuries.

CONCLUSION

Although rare, non-war-related severe brachial plexus injuries represent a group of patients carrying high risk of insufficient functional recovery regardless of treatment modality, or surgical technique. Epidemiological and etiological data are therefore very important to identify the groups in risk and to induce preventive actions aimed at these patients.

Optimal timing for repair of peripheral nerve injuries

BACKGROUND

Data regarding outcomes after peripheral nerve injuries is limited, and the optimal management strategy for an acute injury is unclear. The aim of this study was to examine timing of repair and specific factors that impact motor-sensory outcomes after peripheral nerve injury.

METHODS

This was a single-center, retrospective study. Patients with traumatic peripheral nerve injury from January 2010 to June 2015 were included. Patients who died, required amputation, suffered brachial plexus injury, or had missing motor-sensory examinations were excluded. Motor-sensory examinations were graded 0 to 5 by the Modified British Medical Research Council system. Operative repair of peripheral nerves was analyzed for patient characteristics, anatomic nerve injured, level of injury, associated injuries, days until repair, and repair method.

RESULTS

Three hundred eleven patients met inclusion criteria. Two hundred fifty-eight (83%) patients underwent operative management, and 53 (17%) underwent nonoperative management. Those who required operative intervention had significantly more penetrating injuries 85.7% versus 64.2% (p < 0.001), worse initial motor scores 1.19 versus 2.23 (p = 0.004), and worse initial sensory examination scores 1.75 versus 2.28 (p = 0.029). Predictors of improved operative motor outcomes on univariate analysis were Injury Severity Score less than 15 (p = 0.013) and male sex (p = 0.006). Upper arm level of injury was a predictor of poor outcome (p = 0.041). Multivariate analysis confirmed male sex as a predictor of good motor outcome (p = 0.014; Adjusted Odds Ratio, 3.88 [1.28-11.80]). Univariate analysis identified distal forearm level of injury (p = 0.026) and autograft repair (p = 0.048) as predictors of poor sensory outcome. Damage control surgery for unstable patients undergoing laparotomy (p = 0.257) and days to nerve repair (p = 0.834) did not influence motor-sensory outcome. Outcomes did not differ significantly in patients who underwent repair 24 hours or longer versus those who were repaired later.

CONCLUSION

Outcomes were primarily influenced by patient characteristics and injury level rather than operative characteristics. Peripheral nerve injuries can be repaired after damage control surgery without detriment to outcomes.

LEVEL OF EVIDENCE

Prognostic study, level III.

Nerve grafts bridging the thenar branch of the median nerve to the ulnar nerve to enhance nerve recovery: a report of three cases

We report a nerve graft procedure bridging the thenar branch of the median nerve to the ulnar nerve in three patients with ulnar nerve transection and defect at the mid-forearm. Ulnar nerve function was evaluated with electroneurography and quantitative sensory-motor testing before and after surgery, and at a 6-year follow-up. After surgery all patients showed electroneurographic evidence of median nerve innervation of the intrinsic muscles normally innervated by the ulnar nerve. The average strength was Grade 4 in the intrinsic muscles originally supplied by the ulnar nerve at the final follow-up. Our results indicate that the thenar branch of the median nerve may support ulnar nerve regeneration and so help prevent intrinsic muscles from irreversible atrophy, but our report is preliminary. This procedure should be validated by future clinical data, especially those with complete ulnar nerve transection at or above the elbow.

LEVEL OF EVIDENCE

IV.

Technical Assessment of Connector-Assisted Nerve Repair

PURPOSE

Clinical outcomes of nerve repair have not substantially improved over the last several decades. Although clearly a multifactorial problem, basic principles including proper fascicular alignment are not always realized. The use of short conduits as connectors may enhance nerve alignment by entubulating and directing the approximation of nerve ends.

METHODS

Ten hand surgeons (5 experienced and 5 inexperienced) performed a series of in vitro human cadaver nerve repairs. Three small-diameter (2 mm), 3 medium-diameter (3-4 mm), and 3 large-diameter (5-6 mm) nerves were repaired (under 10× magnification) utilizing each of 3 techniques: suture-only, connector-only (sutures placed through the ends of the connector), and connector-assisted (alignment sutures at the nerve interface plus connector). Three judges (blinded to who performed the repairs) assessed each repair for fascicular alignment based on predetermined qualitative scales.

RESULTS

Across all surgeons, 23 of 30 connector-assisted repairs were judged good or excellent versus 18 of 30 of the suture-only and 13 of 30 of the connector-only repairs. Experienced surgeons in general did better repairs and in particular were more likely to obtain superior alignment for conduit-only repairs (73.3% vs 13.3% good or excellent) and suture-only repairs (73.3% vs 46.7% good or excellent) and were not statistically different for connector-assisted repairs (86.7% vs 66.7% good or excellent) compared with inexperienced surgeons.

CONCLUSIONS

In a cadaver nerve model, there was no significant difference in the technical alignment of conduit-assisted repairs between experienced and inexperienced surgeons whereas inexperienced surgeons were more likely to achieve inadequate alignment with suture-only or conduit-only repairs.

CLINICAL RELEVANCE

Connector-assisted repairs combining suture-approximation and entubulation may improve the technical alignment of nerve repairs performed, especially by less-experienced surgeons.

Nerve injuries of the upper extremity associated with vascular trauma-surgical treatment and outcome

Peripheral nerve injuries are often associated with injuries of adjacent tissue. As a result of anatomic proximity between nerves and vascular structures, there is a high chance of combined injuries of these structures (23 %). The aim of our study is to describe and analyze associated nerve and vascular injuries of the upper extremity in patients treated at the Clinic of Neurosurgery in Belgrade over a 10-year period. This study included 83 patients that received surgical treatment at the Clinic of Neurosurgery in Belgrade after having been diagnosed with upper extremity nerve injury. The study included all patients that satisfied these criteria over a period of 10 years. The patients with associated vascular injuries, 36 of them, were considered our study group, while 47 patients without associated vascular injuries were considered our control group. Finally, we compared treatment outcome between these groups. The final outcome evaluation was performed 2 years after surgical treatment. In our study group, 84.8 % surgical nerve repair was successful (fair, good, and excellent outcome), while in the control group (patients without vascular injury), surgical nerve repair was successful in 87.9 %. The overall satisfactory neurological outcome (M3-M5) was present in 86.6 % of nerve repairs. Our study shows that there is no significant difference between the treatment outcome in patients with associated nerve and vascular injuries and patients with isolated nerve injuries if they are diagnosed in time and treated appropriately. Successful treatment can only be accomplished through a multidisciplinary approach undertaken by a highly qualified medical team.

Factors predicting sensory and motor recovery after the repair of upper limb peripheral nerve injuries

OBJECTIVE:

To investigate the factors associated with sensory and motor recovery after the repair of upper limb peripheral nerve injuries.

DATA SOURCES:

The online PubMed database was searched for English articles describing outcomes after the repair of median, ulnar, radial, and digital nerve injuries in humans with a publication date between 1 January 1990 and 16 February 2011.

STUDY SELECTION:

The following types of article were selected: (1) clinical trials describing the repair of median, ulnar, radial, and digital nerve injuries published in English; and (2) studies that reported sufficient patient information, including age, mechanism of injury, nerve injured, injury location, defect length, repair time, repair method, and repair materials. SPSS 13.0 software was used to perform univariate and multivariate logistic regression analyses and to investigate the patient and intervention factors associated with outcomes.

MAIN OUTCOME MEASURES:

Sensory function was assessed using the Mackinnon-Dellon scale and motor function was assessed using the manual muscle test. Satisfactory motor recovery was defined as grade M4 or M5, and satisfactory sensory recovery was defined as grade S3⁺ or S4.

RESULTS:

Seventy-one articles were included in this study. Univariate and multivariate logistic regression analyses showed that repair time, repair materials, and nerve injured were independent predictors of outcome after the repair of nerve injuries (P < 0.05), and that the nerve injured was the main factor affecting the rate of good to excellent recovery.

CONCLUSION:

Predictors of outcome after the repair of peripheral nerve injuries include age, gender, repair time, repair materials, nerve injured, defect length, and duration of follow-up.

Clinical aspects of ballistic peripheral nerve injury: shrapnel versus gunshot

OBJECTIVES

Ballistic injuries to peripheral nerves pose special challenges in terms of indications, timing and type of surgical intervention. The aim of the present work was to analyze our experience in the surgical treatment of peripheral nerve ballistic injuries with respect to the mechanism of injury (gunshot versus shrapnel), and identify common and dissimilar prognostic factors in both types of injury.

METHODS

This study was conducted on 42 patients totaling 58 nerves. Twenty-two patients (32 nerves) were injured by gunshot and 20 patients (26 nerves) by shrapnel. Median postoperative follow-up was 33 months (range 12 months to 14 years).

RESULTS

Overall postoperative outcome appears to be more favorable for gunshot-wound (GSW) patients than shrapnel-injured patients, especially in terms of neuropathic pain relief (75 % vs. 58 % respectively, p < 0.05). Presence of foreign particles in shrapnel injured patients has a negative impact on the surgical outcome in terms of rate of pain improvement (28 % compared to 67 % in patients with and without foreign particles, respectively). Nerve graft reconstruction, rather than neurolysis, seems to be the more beneficial treatment for shrapnel-induced neuropathic pain (100 % vs. 47 % in improvement rate, respectively). Early surgical intervention (median 2 months after injury) significantly relieved neuropathic pain in 83 % of shrapnel-injured patients compared to 58 % in patients operated later.

CONCLUSIONS

This study suggests that shrapnel injury is more destructive for nerve tissue than gunshot injury. Our impression is that early surgical intervention in shrapnel injuries and split nerve grafting (especially when small fragments are recognized in the nerve) significantly improve the patient's functional activity and quality of life.

Major peripheral nerve injuries

Major peripheral nerve injuries in the upper extremities can result in significant morbidity. Understanding the pathophysiology of these injuries aids in the assessment and planning of appropriate treatment. With limited nerve mobilization, tension-free repairs can often be performed using sutures, fibrin glue, or nerve connectors. Acellular allograft and autograft reconstruction are better for bridging any gaps greater than a few millimeters. Adherence to proper principles of nerve repair improves the chances of achieving a favorable result, although in general these injuries portend a guarded prognosis.

Distal anterior interosseous nerve transfer to the deep ulnar nerve and end-to-side suture of the superficial ulnar nerve to the third common palmar digital nerve for treatment of high ulnar nerve injuries: experience in five cases

OBJECTIVE: To demonstrate the results of a double nerve transfer at the level of the hand for recovery of the motor and sensory function of the hand in cases of high ulnar nerve injuries. METHOD: Five patients underwent a transfer of the distal branch of the anterior interosseous nerve to the deep ulnar nerve, and an end-to-side suture of the superficial ulnar nerve to the third common palmar digital nerve. RESULTS: Two patients recovered strength M3 and three cases were graded as M4; recovery of protective sensation (S3+ in three patients and S4 in two) was observed in the fourth and fifth fingers, and at the hypothenar region. The monofilament test showed values of 3.61 or less in all cases and the two-point discrimination test demonstrated values of 7 mm in three cases and 5 mm in two. CONCLUSION: This technique of double nerve transfer is effective for motor and sensory recovery of the distal ulnar-innervated side of the hand.

Trends in median, ulnar, radial, and brachioplexus nerve injuries in the United States

significant constraints on an individual's quality of life.

OBJECTIVE

To promote efforts to reduce exposure to injury risk factors and to utilize effective therapies when damage does occur, it is important to understand historical trends in both the demographics of peripheral nerve injury (PNI) patients and their treatment. We sought to examine some of these trends.

METHODS

We searched the Nationwide Inpatient Sample for discharges classified with International Classification of Diseases, Ninth Revision diagnosis codes of median, ulnar, radial, or brachioplexus nerve injury between 1993 and 2006. We analyzed these data to obtain trend information for the number of discharges, hospital charges, treatment course, patient demographics, and other measures.

RESULTS

Although aggregate discharges involving these injuries decreased slightly between 1993 and 2006, mean nominal hospital charges for their treatment increased significantly, in particular, for brachial plexus injuries. In 2006 30 to 40% of median, ulnar, and radial nerve injuries required acute repair by direct nerve suture. PNI patients in 2006 were more likely to be male, between the ages of 18 and 44 years, and from regions where the median income level is greater than $36 000. Approximately 75% of PNIs were treated in academic hospitals and 95% in metropolitan areas.

CONCLUSION

PNIs are complex injuries that primarily affect males in key years of adulthood, frequently requiring high-cost acute surgical repair. Although there has been a slight decline in their incidence in the past decade, treatment cost has increased.

The evolution of military neurosurgery in the Turkish army

The history of neurosurgery in the Turkish army is not long and complex. Neurosurgery was first practiced in the Ottoman army by Cemil Pasha, who was a general surgeon. After the fall of the Ottoman Empire, the Republic of Turkey was established and modern neurosurgical procedures were applied at the Gulhane Military Medical Academy (GMMA). Maj. Zinnur Rollas, M.D., was the founder of the Department of Neurosurgery at GMMA in 1957. A modern neurosurgical program and school was established in 1965 by Col. Hamit Ziya Gokalp, M.D., who completed his residency training in the US. Today, 26 military neurosurgeons are on active duty in 11 military hospitals in Turkey. All of these neurosurgeons work in modern clinics and operating theaters. In this paper, military neurosurgery in the Turkish army is reported in 3 parts: 1) the history of neurosurgery in the Turkish military, 2) the Department of Neurosurgery at the GMMA, and 3) the duties of a military neurosurgeon in the Turkish army.

Treatment of acute peripheral nerve injuries: current concepts

Although clinical outcomes of peripheral nerve injuries are often suboptimal, an adherence to well-established basic principles of evaluation and repair can optimize results of even the most complex injuries. Proper assessment of injury patterns both preoperatively and intraoperatively can guide treatment, and multiple repair techniques including strategies for overcoming both small and large gaps offer different advantages and disadvantages. New technologies and ideas address some unsolved problems, but more experience and research is necessary to elucidate fully their roles in the treatment algorithm.

UPPER-EXTREMITY PERIPHERAL NERVE INJURIES

OBJECTIVE

Data from three Louisiana State University Health Sciences Center (LSUHSC) publications were summarized for median, radial, and ulnar nerve injuries.

METHODS

Lesion types, repair techniques, and outcomes were compared for 1837 upper-extremity nerve lesions.

RESULTS

Sharp laceration injury repair outcomes at various levels for median and radial nerves were equally good (91% each) and better than those for the ulnar nerve (73%). Secondary suture and graft repair outcomes were better for the median nerve (78% and 68%, respectively) than for the radial nerve (69% and 67%, respectively) and ulnar nerve (69% and 56%, respectively). In-continuity lesions with positive nerve action potentials during intraoperative testing underwent neurolysis with good results for the median (97%), radial (98%), and ulnar nerves (94%). For radial, median, and ulnar nerve in-continuity lesions with negative intraoperative nerve action potentials, good results occurred after suture repair in 88%, 86%, and 75% and after graft repair in 86%, 75% and 56%, respectively.

CONCLUSION

Good outcomes after median and radial nerve repairs are attributable to the following factors: the median nerve's innervation of proximal, large finger, and thumb flexors; and the radial nerve's similar innervation of proximal muscles that do not perform delicate movements. This is contrary to the ulnar nerve's major nerve supply to the distal fine intrinsic hand muscles, which require more extensive innervation. The radial nerve also has a motor fiber predominance, reducing cross-motor/sensory reinnervation, and radial nerve-innervated muscles perform similar functions, decreasing the chance of innervation of muscles with opposite functions.

Surgical outcomes of the brachial plexus lesions caused by gunshot wounds in adults

BACKGROUND

The management of brachial plexus injuries due to gunshot wounds is a surgical challenge. Better surgical strategies based on clinical and electrophysiological patterns are needed. The aim of this study is to clarify the factors which may influence the surgical technique and outcome of the brachial plexus lesions caused by gunshot injuries.

METHODS

Two hundred and sixty five patients who had brachial plexus lesions caused by gunshot injuries were included in this study. All of them were male with a mean age of 22 years. Twenty-three patients were improved with conservative treatment while the others underwent surgical treatment. The patients were classified and managed according to the locations, clinical and electrophysiological findings, and coexisting lesions.

RESULTS

The wounding agent was shrapnel in 106 patients and bullet in 159 patients. Surgical procedures were performed from 6 weeks to 10 months after the injury. The majority of the lesions were repaired within 4 months were improved successfully. Good results were obtained in upper trunk and lateral cord lesions. The outcome was satisfactory if the nerve was intact and only compressed by fibrosis or the nerve was in-contunuity with neuroma or fibrosis.

CONCLUSION

Appropriate surgical techniques help the recovery from the lesions, especially in patients with complete functional loss. Intraoperative nerve status and the type of surgery significantly affect the final clinical outcome of the patients.

Evaluation and management of peripheral nerve injury

Common etiologies of acute traumatic peripheral nerve injury (TPNI) include penetrating injury, crush, stretch, and ischemia. Management of TPNI requires familiarity with the relevant anatomy, pathology, pathophysiology, and the surgical principles, approaches and concerns. Surgical repair of TPNI is done at varying time intervals after the injury, and there are a number of considerations in deciding whether and when to operate. In neurapraxia, the compound muscle and nerve action potentials on stimulating distal to the lesion are maintained indefinitely; stimulation above the lesion reveals partial or complete conduction block. The picture in axonotmesis and neurotmesis depends on the time since injury. The optimal timing for an electrodiagnostic study depends upon the clinical question being asked. Although conventional teaching usually holds that an electrodiagnostic study should not be done until about 3 weeks after the injury, in fact a great deal of important information can be obtained by studies done in the first week. Proximal nerve injuries are problematic because the long distance makes it difficult to reinnervate distal muscles before irreversible changes occur. Decision making regarding exploration must occur more quickly, and exploration using intraoperative nerve action potential recording to guide the choice of surgical procedure is often useful.