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TPS 19.5 x 27 - 2 | 27.07.17 - 13:12

Manual of Peripheral Nerve Surgery

From the Basics to Complex Procedures

Mariano Socolovsky, MD
Head
Peripheral Nerve and Brachial Plexus Unit
Department of Neurosurgery
University of Buenos Aires School of Medicine
Buenos Aires, Argentina
Chairman, WFNS Peripheral Nerve Surgery Committee

Lukas Rasulic, MD, PhD


Professor and Head
Department of Peripheral Nerve Surgery, Functional Neurosurgery and Pain
Management Surgery, Clinic for Neurosurgery, Clinical Center of Serbia
School of Medicine University of Belgrade
Belgrade, Serbia
Vice Chairman, WFNS Peripheral Nerve Surgery Committee

Rajiv Midha, MD, MSc, FRCSC, FAANS, FCAHS


Professor and Head
Department of Clinical Neurosciences
University of Calgary
Calgary, Alberta, Canada
Peripheral Nerve Section Associate Editor, Neurosurgery and World Neurosurgery
Vice Chairman, WFNS Peripheral Nerve Surgery Committee

Debora Garozzo, MD
Head
Brachial Plexus and Peripheral Nerve Surgery Unit
Neurospinal Hospital
Dubai, UAE
Vice Chairman, WFNS Peripheral Nerve Surgery Committee

267 illustrations

Thieme
Stuttgart • New York • Delhi • Rio de Janeiro
Library of Congress Cataloging-in-Publication Data Important note: Medicine is an ever-changing science
undergoing continual development. Research and clinical
Names: Socolovsky, Mariano, editor. | Rasulic, Lukas, editor.
experience are continually expanding our knowledge, in
| Midha, Rajiv, editor. | Garozzo, Debora, editor.
particular our knowledge of proper treatment and drug
Title: Manual of peripheral nerve surgery : from the basics to
therapy. Insofar as this book mentions any dosage or appli-
complex procedures / [edited by] Mariano Socolovsky,
cation, readers may rest assured that the authors, editors,
Lukas Rasulic, Rajiv Midha, Debora Garozzo.
and publishers have made every effort to ensure that such
Description: Stuttgart ; New York : Thieme, 2017. | Includes
references are in accordance with the state of knowledge at
bibliographical references and index.
the time of production of the book.
Identifiers: LCCN 2017029566 (print) | LCCN 2017030596
Nevertheless, this does not involve, imply, or express any
(ebook) | ISBN 9783132410015 | ISBN 9783132409552
guarantee or responsibility on the part of the publishers in
(hardcover) | ISBN 9783132410015 (eISBN)
respect to any dosage instructions and forms of applications
Subjects: | MESH: Peripheral Nervous System Diseases–
stated in the book. Every user is requested to examine
surgery | Peripheral Nerves–surgery
carefully the manufacturers’ leaflets accompanying each
Classification: LCC RD124 (ebook) | LCC RD124 (print) |
drug and to check, if necessary in consultation with a phy-
NLM WL 520 | DDC 617.4/83–dc23
sician or specialist, whether the dosage schedules mentioned
LC record available at https://lccn.loc.gov/2017029566
therein or the contraindications stated by the manufacturers
Illustrators: differ from the statements made in the present book. Such
Luis Domitrovic, León, Castilla, Spain examination is particularly important with drugs that are
Martin Montalbetti, Buenos Aires, Argentina either rarely used or have been newly released on the market.
Every dosage schedule or every form of application used is
entirely at the user’s own risk and responsibility. The authors
and publishers request every user to report to the publishers
© 2018 by Georg Thieme Verlag KG any discrepancies or inaccuracies noticed. If errors in this
work are found after publication, errata will be posted at
Thieme Publishers Stuttgart www.thieme.com on the product description page.
Rüdigerstrasse 14, 70469 Stuttgart, Germany Some of the product names, patents, and registered
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Cover illustration: Martin Montalbetti,
Buenos Aires, Argentina
Typesetting by Thomson Digital, India This book, including all parts thereof, is legally protected by
copyright. Any use, exploitation, or commercialization out-
Printed in India by Replika Press Private Ltd. 54321 side the narrow limits set by copyright legislation without
the publisher’s consent is illegal and liable to prosecution.
ISBN 978-3-13-240955-2 This applies in particular to photostat reproduction, copying,
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Also available as an e-book: aration of microfilms, and electronic data processing and
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TPS 19.5 x 27 - 2 | 08.08.17 - 16:54

I dedicate this book to my beloved wife, Veronica, my partner in the fascinating journey of life;
to my children, Federico, Valentina, and Francisco, who give reason to my life; and to my parents,
Eddie and Mariela, who gave me life and continued to lovingly and generously
guide me through it for many years.
Mariano Socolovsky, MD

I dedicate this book to my driving force, my family: my wife Katarina, our daughter Milica, and our son Mihailo;
my parents: my father Grujica and my mother Dusanka;
my sister Katarina;
my mentor, Prof. Dr. Miroslav Samardzic, and my associates;
and last but not the least, my patients with peripheral nerve disorders.
Lukas Rasulic, MD, PhD

I dedicate this book to my brother, Samir, who, despite his shortened life, taught me how to live and love.
Rajiv Midha, MD, MSc, FRCSC, FAANS, FCAHS

I dedicate this book to Vita and the everlasting memory of Filippo, for the unconditional love and constant
support I received from them since I was brought into this world: I could have not found better parents and
I would like to thank them for the privileged life they bestowed upon me.
To my patients: I learned a lot from them, on science and surgery, but most of all, on life.
I would have never become the woman I am without them all.
Debora Garozzo, MD
TPS 19.5 x 27 - 2 | 27.07.17 - 13:12
Contents
Foreword ............................................................................... xiv
Miguel Arraez

Foreword ............................................................................... xv
Madjid Samii

Foreword ............................................................................... xvi


Franco Servadei

Foreword ............................................................................... xvii


Robert J. Spinner

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xviii

Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xix

Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xx

1 Nerve Anatomy of the Upper Limbs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1


Gilda Di Masi and Gonzalo Javier Hugo Bonilla

1.1 Supraclavicular Brachial Plexus . . . . . . . 1 1.3 Terminal Branches of the Brachial


Plexus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
1.1.1 Collateral Branches of the Supraclavicular
Brachial Plexus . . . . . . . . . . . . . . . . . . . . . . . 2 1.3.1 Radial Nerve . . . . . . . . . . . . . . . . . . . . . . . . . 4
1.3.2 Median Nerve . . . . . . . . . . . . . . . . . . . . . . . . 5
1.2 Infraclavicular Brachial Plexus . . . . . . . . 3 1.3.3 Ulnar Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . 6
1.3.4 Musculocutaneous Nerve . . . . . . . . . . . . . . 7
1.2.1 Collateral Branches of the Infraclavicular 1.3.5 Axillary Nerve . . . . . . . . . . . . . . . . . . . . . . . . 8
Brachial Plexus . . . . . . . . . . . . . . . . . . . . . . . 3
References . . . . . . . . . . . . . . . . . . . . . . . . . . 8

2 Surgical Anatomy and Approaches to the Nerves of the Lower Limb ............ 10
Fernando Martínez and Federico Salle

2.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . 10 2.3.1 Sciatic Nerve . . . . . . . . . . . . . . . . . . . . . . . . . 14


2.3.2 Terminal Branches of the Sciatic Nerve . . . 15
2.2 Lumbar Plexus . . . . . . . . . . . . . . . . . . . . . . . 10
References . . . . . . . . . . . . . . . . . . . . . . . . . . 16
2.2.1 Inguinal Group . . . . . . . . . . . . . . . . . . . . . . . 11
2.2.2 Femoral Group . . . . . . . . . . . . . . . . . . . . . . . 11

2.3 Sacral Plexus . . . . . . . . . . . . . . . . . . . . . . . . 14

3 Nerve Injuries: Anatomy, Pathophysiology, and Classification . . . . . . . . . . . . . . . . . . . . 18


Bassam M. J. Addas

3.1 Anatomy of the Peripheral Nerves . . . . 18 3.3 Laceration Injury . . . . . . . . . . . . . . . . . . . . . 20

3.2 Traction Injury . . . . . . . . . . . . . . . . . . . . . . . 19 3.4 Compression/Pressure Injury . . . . . . . . . 20

vii
Contents

3.5 Injection Injury . . . . . . . . . . . . . . . . . . . . . . 22 3.6.2 Thermal Injury . . . . . . . . . . . . . . . . . . . . . . . 22


3.6.3 Radiation Injury . . . . . . . . . . . . . . . . . . . . . . 23
3.6 Rare Forms of Peripheral Nerve Injuries 22
References . . . . . . . . . . . . . . . . . . . . . . . . . . 23
3.6.1 Electrical Injuries . . . . . . . . . . . . . . . . . . . . . 22

4 Clinical Aspects of Peripheral Nerve Lesions in the Upper Limb . . . . . . . . . . . . . . . . . . . 24


Javier Robla Costales, Luis Domitrovic, David Robla Costales, Javier Fernández Fernández, and
Javier Ibáñez Plágaro

4.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . 24 4.4.1 Motor Innervation . . . . . . . . . . . . . . . . . . . . 32


4.4.2 Sensory Innervation . . . . . . . . . . . . . . . . . . . 34
4.2 Musculocutaneous Nerve . . . . . . . . . . . . 24 4.4.3 Clinical Findings . . . . . . . . . . . . . . . . . . . . . . 35

4.3 Median Nerve . . . . . . . . . . . . . . . . . . . . . . . 26 4.5 Radial Nerve . . . . . . . . . . . . . . . . . . . . . . . . 36

4.3.1 Motor Innervation . . . . . . . . . . . . . . . . . . . . 26 4.5.1 Motor Innervation . . . . . . . . . . . . . . . . . . . . 36


4.3.2 Sensory Innervation . . . . . . . . . . . . . . . . . . . 30 4.5.2 Sensory Innervation . . . . . . . . . . . . . . . . . . . 39
4.3.3 Martin-Gruber and Riche-Cannieu 4.5.3 Clinical Findings . . . . . . . . . . . . . . . . . . . . . . 40
Anastomoses . . . . . . . . . . . . . . . . . . . . . . . . . 30
4.3.4 Clinical Findings . . . . . . . . . . . . . . . . . . . . . . 31 Further Readings . . . . . . . . . . . . . . . . . . . . 41

4.4 Ulnar Nerve . . . . . . . . . . . . . . . . . . . . . . . . . 31

5 Clinical Aspects of Traumatic Peripheral Nerve Lesions in the Lower Limb. . . . . . . 42


Yuval Shapira and Shimon Rochkind

5.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . 42 5.4.2 Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

5.2 Lumbosacral Plexus . . . . . . . . . . . . . . . . . . 42 5.5 Femoral Nerve . . . . . . . . . . . . . . . . . . . . . . 46

5.3 Sciatic, Tibial, and Peroneal Nerve . . . . . 42 5.5.1 Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46


5.5.2 Femoral Nerve Lesions . . . . . . . . . . . . . . . . . 46
5.3.1 Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 5.5.3 Saphenous Nerve Lesions. . . . . . . . . . . . . . . 46
5.3.2 Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 5.5.4 The Symptoms and Signs of Femoral
5.3.3 Common Sites and Types of Nerve Lesions 45 Nerve Involvement . . . . . . . . . . . . . . . . . . . . 46
5.3.4 Symptoms and Signs of Common Peroneal
Nerve Injury . . . . . . . . . . . . . . . . . . . . . . . . . . 45 5.6 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . 47
5.3.5 Symptoms and Signs of Tibial Nerve Injury 46
References . . . . . . . . . . . . . . . . . . . . . . . . . . 47
5.4 Obturator Nerve . . . . . . . . . . . . . . . . . . . . . 46

5.4.1 Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

6 Electrodiagnostic Pre-, Intra-, and Postoperative Evaluations . . . . . . . . . . . . . . . . . . . . . 48


Carlos Alberto Rodríguez Aceves, Miguel Domínguez Páez, and Victoria E. Fernández Sánchez

6.1 Basic Considerations . . . . . . . . . . . . . . . . . 48 6.2.2 Demyelination . . . . . . . . . . . . . . . . . . . . . . . . 48

6.1.1 Anatomical Characteristics . . . . . . . . . . . . . 48 6.3 EDSs for Preoperative Evaluations . . . . . 49


6.1.2 Physiological Characteristics . . . . . . . . . . . . 48
6.3.1 Technical Considerations . . . . . . . . . . . . . . . 49
6.2 Pathophysiology . . . . . . . . . . . . . . . . . . . . . 48 6.3.2 Nerve Conduction Studies/
Electroneurography . . . . . . . . . . . . . . . . . . . 49
6.2.1 Axonal Damage . . . . . . . . . . . . . . . . . . . . . . . 48 6.3.3 Electromyography . . . . . . . . . . . . . . . . . . . . 51

viii
Contents

6.4 Electrophysiological Findings with 6.6.2 Intraoperative Monitoring Techniques . . . 54


Different Types of Nerve Injury . . . . . . . . 52 6.6.3 Surgical Procedures . . . . . . . . . . . . . . . . . . . 56

6.5 When Are EDSs Indicated? . . . . . . . . . . . . 53 6.7 EDSs for Postoperative Evaluations . . . . 56

6.6 EDSs for Intraoperative Evaluations . . . 53 6.8 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . 57

6.6.1 Lesions-in-continuity . . . . . . . . . . . . . . . . . . 53 References . . . . . . . . . . . . . . . . . . . . . . . . . . 57

7 Magnetic Resonance Neurography and Peripheral Nerve Surgery . . . . . . . . . . . . . . . . 59


Daniela Binaghi and Mariano Socolovsky

7.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . 59 7.4 Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

7.2 Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 7.5 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . 63

7.3 Entrapment Neuropathies . . . . . . . . . . . . 62 References . . . . . . . . . . . . . . . . . . . . . . . . . . 64

8 Ultrasound in Peripheral Nerve Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65


Maria Teresa Pedro and Ralph W. König

8.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . 65 8.4 Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68

8.2 How to Start (Basic Principles) . . . . . . . . 65 8.4.1 Preoperative HRU . . . . . . . . . . . . . . . . . . . . . 68


8.4.2 Intraoperative HRU . . . . . . . . . . . . . . . . . . . 68
8.3 Compression Neuropathies . . . . . . . . . . . 66
8.5 Tumor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
8.3.1 Compression Neuropathies of the Upper
Limb . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 References . . . . . . . . . . . . . . . . . . . . . . . . . . 73
8.3.2 Compression Neuropathies of the Lower
Limb . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
8.3.3 Recurrent Compression Neuropathies . . . . 66

9 Surgical Repair of Nerve Lesions: Neurolysis and Neurorrhaphy with Grafts


or Tubes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Sudheesh Ramachandran and Rajiv Midha

9.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . 74 9.6.2 Allografts . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78

9.2 Evaluation and Approach . . . . . . . . . . . . . 74 9.7 Nerve Tubes . . . . . . . . . . . . . . . . . . . . . . . . . 79

9.3 General Principles of Nerve Repair . . . . 75 9.7.1 Autologous Conduits . . . . . . . . . . . . . . . . . . 80


9.7.2 Artificial Conduits . . . . . . . . . . . . . . . . . . . . . 80
9.4 Neurolysis . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
9.8 Post-op Management . . . . . . . . . . . . . . . . 81
9.5 Direct Repair . . . . . . . . . . . . . . . . . . . . . . . . 75
9.9 Tissue Engineering and Future
9.5.1 End-to-End Repair . . . . . . . . . . . . . . . . . . . . 75 of Nerve Repairs . . . . . . . . . . . . . . . . . . . . . 81
9.5.2 End-to-Side Repair . . . . . . . . . . . . . . . . . . . . 76
References . . . . . . . . . . . . . . . . . . . . . . . . . . 82
9.6 Nerve Grafting . . . . . . . . . . . . . . . . . . . . . . 77

9.6.1 Autografts . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

ix
Contents

10 Timing in Traumatic Peripheral Nerve Lesions ...................................... 84


Leandro Pretto Flores

10.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . 84 10.5.1 Open Wounds: Laceration Mechanism . . . 86


10.5.2 Open Injuries: Gunshot Wounds . . . . . . . . 87
10.2 Basic Science as an Aid for Taking an 10.5.3 Closed Injuries: Traction or Compression . 87
Important Decision . . . . . . . . . . . . . . . . . . 84 10.5.4 Closed Injuries: Special Situations . . . . . . . 88

10.3 Initial Evaluation of a Peripheral 10.6 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . 89


Nerve Injury . . . . . . . . . . . . . . . . . . . . . . . . . 85
References . . . . . . . . . . . . . . . . . . . . . . . . . . 89
10.4 Causes of Traumatic Peripheral
Nerve Injury . . . . . . . . . . . . . . . . . . . . . . . . . 85

10.5 Specific Surgical Timing . . . . . . . . . . . . . . 86

11 Outcomes in the Repair of Nerve Injuries ........................................... 90


Lukas Rasulic and Miroslav Samardzic

11.1 Prognostic Factors . . . . . . . . . . . . . . . . . . . 90 11.2 General Grading Systems . . . . . . . . . . . . . 92

11.1.1 Patient Age . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 11.2.1 Upper Extremity Repair . . . . . . . . . . . . . . . . 94


11.1.2 Characteristics of the Nerve . . . . . . . . . . . . 90 11.2.2 Lower Extremity Repairs . . . . . . . . . . . . . . . 96
11.1.3 Characteristics of the Nerve Injury . . . . . . . 91
11.1.4 Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 References . . . . . . . . . . . . . . . . . . . . . . . . . . 97
11.1.5 Postoperative Rehabilitation . . . . . . . . . . . . 92

12 Gunshot and Other Missile Wounds to the Peripheral Nerves .................... 98


Miroslav Samardzic and Lukas Rasulic

12.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . 98 12.4 Indications for and Timing of Surgery . . . 100

12.2 Clinical Characteristics . . . . . . . . . . . . . . . 99 12.5 Results and Prognosis . . . . . . . . . . . . . . . . 101

12.2.1 Brachial Plexus . . . . . . . . . . . . . . . . . . . . . . . 99 12.5.1 Brachial Plexus . . . . . . . . . . . . . . . . . . . . . . . 101


12.2.2 Peripheral Nerves . . . . . . . . . . . . . . . . . . . . . 99 12.5.2 Peripheral Nerves . . . . . . . . . . . . . . . . . . . . . 102

12.3 Characteristics of Nerve Lesions . . . . . . 99 12.6 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . 103

12.3.1 Brachial Plexus . . . . . . . . . . . . . . . . . . . . . . . 99 References . . . . . . . . . . . . . . . . . . . . . . . . . . 103


12.3.2 Peripheral Nerves . . . . . . . . . . . . . . . . . . . . . 100

13 Compressive Lesions of the Upper Limb . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105


Gregor Antoniadis and Christine Brand

13.1 Median Nerve . . . . . . . . . . . . . . . . . . . . . . . 105 13.3 Radial Nerve . . . . . . . . . . . . . . . . . . . . . . . . 111

13.1.1 Carpal Tunnel Syndrome . . . . . . . . . . . . . . . 105 13.3.1 Radial Nerve Entrapment at the Elbow
13.1.2 Median Nerve Entrapment at the Elbow . . 107 (Posterior Interosseous Nerve
Syndrome) . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
13.2 Ulnar Nerve . . . . . . . . . . . . . . . . . . . . . . . . . 109 13.3.2 Radial Sensory Nerve Entrapment
(Wartenberg’s Syndrome, Cheiralgia
13.2.1 Ulnar Nerve Entrapment at the Elbow . . . . 109 Paresthetica) . . . . . . . . . . . . . . . . . . . . . . . . . 112
13.2.2 Ulnar Nerve Entrapment at the Wrist
(Guyon’s Syndrome) . . . . . . . . . . . . . . . . . . . 111 13.4 Suprascapular Nerve Entrapment . . . . . 112

x
Contents

13.4.1 Clinical Presentation . . . . . . . . . . . . . . . . . . 112 References . . . . . . . . . . . . . . . . . . . . . . . . . . 113


13.4.2 Timing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
13.4.3 Surgical Strategy . . . . . . . . . . . . . . . . . . . . . . 113

14 Compressive Lesions of the Lower Limb and Trunk ................................ 115


Christian Heinen and Thomas Kretschmer

14.1 Nerves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 14.1.5 Ilioinguinal Nerve/Iliohypogastric Nerve/


Genitofemoral Nerve . . . . . . . . . . . . . . . . . . 122
14.1.1 Sciatic Nerve . . . . . . . . . . . . . . . . . . . . . . . . . 115 14.1.6 Femoral Nerve . . . . . . . . . . . . . . . . . . . . . . . . 122
14.1.2 Peroneal Nerve . . . . . . . . . . . . . . . . . . . . . . . 117 14.1.7 Obturator Nerve . . . . . . . . . . . . . . . . . . . . . . 124
14.1.3 Tibial Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . 120 14.1.8 Pudendal Nerve/Pudendal Neuralgia . . . . . 124
14.1.4 Lateral Femoral Cutaneous Nerve
(Meralgia Paraesthetica). . . . . . . . . . . . . . . . 121 References . . . . . . . . . . . . . . . . . . . . . . . . . . 126

15 Thoracic Outlet Syndrome ............................................................ 128


Mariano Socolovsky, Daniela Binaghi, and Ricardo Reisin

15.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . 128 15.3 What Does the Literature Say about
TOS? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
15.2 Diagnosis and Management of TOS . . . 128
15.4 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . 133
15.2.1 Important Concepts Regarding TOS . . . . . . 128
15.2.2 Important Concepts in DNTOS . . . . . . . . . . 131 References . . . . . . . . . . . . . . . . . . . . . . . . . . 133

16 Traumatic Brachial Plexus Lesions: Clinical Aspects, Assessment, and Timing


of Surgical Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
Mario G. Siqueira and Roberto S. Martins

16.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . 135 16.5.2 Image Studies . . . . . . . . . . . . . . . . . . . . . . . . 137


16.5.3 Electrodiagnostic Studies . . . . . . . . . . . . . . 139
16.2 Types and Mechanisms of Injury . . . . . . 135
16.6 Indications for Surgery . . . . . . . . . . . . . . . 139
16.3 Location of the Injury . . . . . . . . . . . . . . . . 136
16.7 Timing of Surgery . . . . . . . . . . . . . . . . . . . 139
16.4 Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
16.8 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
16.5 Evaluation of Brachial Plexus Function
and Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 137 References . . . . . . . . . . . . . . . . . . . . . . . . . . 140

16.5.1 Physical Evaluation . . . . . . . . . . . . . . . . . . . 137

17 Traumatic Brachial Plexus Injuries: Surgical Techniques and Strategies . . . . . . . . . . 141


Debora Garozzo

17.1 Main Principles in Repair Strategy for 17.2.1 Repair Strategies Depending on the Injury
Brachial Plexus Injuries . . . . . . . . . . . . . . . 141 Pattern . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142

17.1.1 Reinnervation Priorities . . . . . . . . . . . . . . . . 141 17.3 Outcome of Surgical Reinnervation . . . 147


17.1.2 Surgical Approach . . . . . . . . . . . . . . . . . . . . . 141
References . . . . . . . . . . . . . . . . . . . . . . . . . . 147
17.2 Repair Strategies . . . . . . . . . . . . . . . . . . . . 141

xi
Contents

18 Neonatal Brachial Plexus Palsy: Clinical Presentation and Assessment .......... 149
Thomas J. Wilson and Lynda J-S Yang

18.1 Epidemiology and Risk Factors . . . . . . . . 149 18.4 Electrodiagnostics . . . . . . . . . . . . . . . . . . . 152

18.2 Clinical Assessment . . . . . . . . . . . . . . . . . . 150 18.5 Surgical Assessment . . . . . . . . . . . . . . . . . 152

18.3 Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151 References . . . . . . . . . . . . . . . . . . . . . . . . . . 153

19 The Neonatal Brachial Plexus Lesion: Surgical Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . 155


W. Pondaag and M.J.A. Malessy

19.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . 155 19.5.2 Group 2: C5, C6, C7, (C8) Lesions . . . . . . . . 162
19.5.3 Group 3: C5, C6, C7, C8, T1 Lesions
19.2 Selection for Surgery . . . . . . . . . . . . . . . . . 155 (Pan-plexopathy) . . . . . . . . . . . . . . . . . . . . . 163
19.5.4 Postoperative Care . . . . . . . . . . . . . . . . . . . . 163
19.3 Surgical Exposure . . . . . . . . . . . . . . . . . . . . 155
19.6 Results of Nerve Surgery . . . . . . . . . . . . . 163
19.3.1 Supraclavicular Exposure . . . . . . . . . . . . . . 155
19.3.2 Infraclavicular Exposure . . . . . . . . . . . . . . . 157 19.6.1 Factors That Affect Functional Recovery
19.3.3 Exposure and Technique for Nerve after Nerve Repair . . . . . . . . . . . . . . . . . . . . . 163
Transfers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158 19.6.2 Shoulder Function . . . . . . . . . . . . . . . . . . . . . 164
19.6.3 Hand Function . . . . . . . . . . . . . . . . . . . . . . . . 164
19.4 Assessment of the Severity of the 19.6.4 Elbow Flexion . . . . . . . . . . . . . . . . . . . . . . . . 165
Lesion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159 19.6.5 Evaluation of Outcome . . . . . . . . . . . . . . . . . 165

19.5 Principles Underlying Strategies for 19.7 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . 166


Surgical Reconstruction . . . . . . . . . . . . . . 159
References . . . . . . . . . . . . . . . . . . . . . . . . . . 166
19.5.1 Group 1: C5, C6/Upper Trunk Lesions . . . . 161

20 Lumbosacral Plexus Injuries .......................................................... 169


Debora Garozzo

20.1 Epidemiology and Causative 20.5 Indication for Surgery . . . . . . . . . . . . . . . . 172


Mechanisms . . . . . . . . . . . . . . . . . . . . . . . . . 169
20.6 Main Principles in Repair Strategy . . . . . 172
20.2 Clinical Pictures . . . . . . . . . . . . . . . . . . . . . 169
References . . . . . . . . . . . . . . . . . . . . . . . . . . 173
20.3 Management . . . . . . . . . . . . . . . . . . . . . . . . 170

20.4 Natural History . . . . . . . . . . . . . . . . . . . . . . 171

21 Facial Nerve Palsy: Indications and Techniques of Surgical Repair . . . . . . . . . . . . . . . . 174


Stefano Ferraresi
21.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . 174 21.2.5 Hypoglossal-Facial Intratemporal
Translocation (14 Patients) . . . . . . . . . . . . . 177
21.2 Surgical techniques and Results . . . . . . . 174 21.2.6 Timing of Repair . . . . . . . . . . . . . . . . . . . . . . 180
21.2.7 Facial Nerve Paralysis after Skull Base
21.2.1 Extracranial Nerve Repair (10 Cases) . . . . . 174 Fracture (82 Cases) . . . . . . . . . . . . . . . . . . . . 181
21.2.2 Intracranial Repair with Proximal Stump 21.2.8 Nuclear Peripheral Palsy (4 Cases) . . . . . . . 181
Available (3 Cases) . . . . . . . . . . . . . . . . . . . . 175
21.2.3 Nerve Transfers When the Proximal 21.3 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . 181
Stump is Unavailable (58 Cases) . . . . . . . . . 175
21.2.4 Hypoglossal-Facial Jump Graft (28 Patients) . 176 References . . . . . . . . . . . . . . . . . . . . . . . . . . 182

xii
Contents

22 Benign Peripheral Nerve Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184


José Fernando Guedes-Corrêa, Francisco José Lourenço Torrão, Jr., and Daniel Barbosa

22.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . 184 22.7.2 Symptomatic . . . . . . . . . . . . . . . . . . . . . . . . . 190

22.2 Types and Nomenclature . . . . . . . . . . . . . 184 22.8 Operative Techniques . . . . . . . . . . . . . . . . 190

22.2.1 Benign peripheral nerve sheath tumors . . 184 22.8.1 Brachial Plexus. . . . . . . . . . . . . . . . . . . . . . . . 191
22.2.2 Benign tumors of nonneural 22.8.2 Lumbosacral Plexus (or Pelvic Plexus) . . . . 191
sheath origin . . . . . . . . . . . . . . . . . . . . . . . . . 187
22.9 Surgical Outcome . . . . . . . . . . . . . . . . . . . . 192
22.3 Clinical Presentation . . . . . . . . . . . . . . . . . 188
22.9.1 Surgical Outcome of Benign Tumors of
22.4 Imaging (Magnetic Resonance Neural Sheath Origin . . . . . . . . . . . . . . . . . . 192
Imaging) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188 22.9.2 Outcomes of Operative Benign Tumors of
Nonneural Sheath Origin . . . . . . . . . . . . . . . 194
22.5 Electrodiagnostic Testing . . . . . . . . . . . . . 189
22.10 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . 194
22.6 Biopsy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189
References . . . . . . . . . . . . . . . . . . . . . . . . . . 194
22.7 Approach to Treatment . . . . . . . . . . . . . . 190

22.7.1 Asymptomatic . . . . . . . . . . . . . . . . . . . . . . . . 190

23 Malignant Peripheral Nerve Sheath Tumors ........................................ 196


Jennifer Hong, Jared Pisapia, Paul J. Niziolek, Viviane Khoury, Paul Zhang, Zarina Ali,
Gregory Heuer, and Eric L. Zager

23.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . 196 23.7 Workup and Evaluation . . . . . . . . . . . . . . 202

23.2 Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . 196 23.8 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . 202

23.2.1 Neurofibromatosis Type 1 . . . . . . . . . . . . . . 196 23.9 Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202


23.2.2 Previous Radiation . . . . . . . . . . . . . . . . . . . . 196
23.9.1 Chemotherapy . . . . . . . . . . . . . . . . . . . . . . . . 203
23.3 Clinical Presentation . . . . . . . . . . . . . . . . . 196 23.9.2 Radiation Therapy . . . . . . . . . . . . . . . . . . . . . 204
23.9.3 Neoadjuvant Therapy . . . . . . . . . . . . . . . . . . 204
23.4 Radiology . . . . . . . . . . . . . . . . . . . . . . . . . . . 197
23.10 Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . 204
23.4.1 Magnetic Resonance Imaging . . . . . . . . . . . 197
23.4.2 Positron Emission Tomography/Computed 23.10.1 Overall Survival . . . . . . . . . . . . . . . . . . . . . . . 204
Tomography . . . . . . . . . . . . . . . . . . . . . . . . . . 199 23.10.2 Disease Free Survival, Local and Distant
23.4.3 Computed Tomography . . . . . . . . . . . . . . . . 199 Recurrence . . . . . . . . . . . . . . . . . . . . . . . . . . . 204
23.4.4 Ultrasound . . . . . . . . . . . . . . . . . . . . . . . . . . . 200 23.10.3 Low-Grade MPNST . . . . . . . . . . . . . . . . . . . . 207
23.10.4 Pediatric MPNST . . . . . . . . . . . . . . . . . . . . . . 207
23.5 Pathology . . . . . . . . . . . . . . . . . . . . . . . . . . . 200 23.10.5 Postradiation MPNST . . . . . . . . . . . . . . . . . . 207

23.5.1 Gross Examination . . . . . . . . . . . . . . . . . . . . 201 23.11 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . 207


23.5.2 Microscopic Examination . . . . . . . . . . . . . . 201
23.5.3 Immunohistochemistry . . . . . . . . . . . . . . . . 201 References . . . . . . . . . . . . . . . . . . . . . . . . . . 207
23.5.4 Pathologic Subtypes of MPNST . . . . . . . . . . 202

23.6 Pathogenesis and Cancer Genetics . . . . 202

Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210

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Foreword
Once in a while, we have the opportunity to make a difficulty and complexity, and it is also true that
contribution to a great treatise in the field of neuro- medical industry customarily does not furnish any
surgery, and in this occasion through this foreword. financial support, as in this case, technology is substi-
A great neurosurgical treatise must be related to tuted by anatomical knowledge, fine microsurgical
difficult and complex topics and must be written by techniques, and passion. So, in the current world (in
expert neurosurgeons in the field with full dedication. the context of the importance of the financial aspect),
Peripheral nerve surgery comprises a long list of the devotion toward peripheral nerve must be con-
potentially difficult and complicated cases in the sur- sidered an enormous inspiration and an example to be
gery of the nervous system. Anatomy of the peripheral followed because of all the aforementioned reasons.
nerves, current diagnostic ancillary techniques (ultra- Last but not the least, it is important to mention how
sonography and MRI), the most advanced techniques this book and its very practical and didactic approach
for nerve reconstruction and repair, compressive syn- will contribute to the dissemination of knowledge of
dromes, adult and neonatal brachial plexus lesions, this field all around the globe, with special mention
facial nerve reconstruction, and benign and malignant and interest in developing countries—an aspect that
peripheral nerve tumors, are dealt with in this mon- the editors and many of the authors have promoted
umental book. The editors and contributors of this considerably.
book are leading experts in these difficult topics. My deepest and most sincere congratulations for
The activity of the WFNS Peripheral Nerve Surgery this magnificent contribution to the world’s neuro-
Committee has been outstandingly exemplary under surgical knowledge.
the guidance of Prof. Socolovsky, from 2013 to 2017.
We must consider this book as the colophon of the Miguel A. Arraez, MD, PhD
tireless activity of the committee with dozens of steps Chairman, Department of Neurosurgery
related to teaching courses, publications, countless Carlos Haya University Hospital
initiatives such as online courses, etc. These actions Associate Professor of Neurosurgery
of great value deserve further comments. The field of Malaga University
peripheral nerve surgery may be one of the less Malaga, Spain
developed areas in any average neurosurgical depart- WFNS, Coordinator of Committee Activities
ment all around the world. This is clearly due to its Chairman, WFNS Foundation

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Foreword
The Manual of Peripheral Nerve Surgery is a new this book. The same is true about the introduction of
book on all aspects of peripheral nerve systems. In ultrasound in peripheral nerve surgery which can also
this book, experienced scientists from the field of be used by compression neuropathy, trauma, and
peripheral nerve have contributed chapters to explain tumor.
the human peripheral nerve system in all existing A very interesting and important chapter is the
aspects, with the description of pathophysiology description of all existing compression syndromes of
of nerve degeneration and regeneration as well as peripheral nerve in the entire human body. Many
classification of Seddon and Sunderland. clinical examples of surgical repair of nerve lesions
With the study of the anatomy, the reader will get a give the reader a good understanding of the micro-
very precise orientation of the location and pathways surgical technique of neurolysis and neurorrhaphy
of individual peripheral nerves in upper and lower with grafts. The problem of diagnostic and treatment
extremities in which the brachial plexus and lumbo- of neonatal brachial plexus palsy has been described
sacral plexus are included. The collateral branches of very well for clinical evaluation and indication, as well
individual nerves have been specially considered, as results of surgery. I am very pleased that facial
which is very important in diagnostic and in surgical nerve palsy has become a very important chapter in
treatment. this book, particularly the indication, technique, and
A special chapter has been dedicated to surgical surgical repair. Peripheral nerve tumors are also an
anatomy and approaches to all peripheral nerve important part of peripheral nerve surgery as they
systems. create not only neurological deficit but also cause
The clinical and neurophysiological examination severe pain, and therefore this chapter is very helpful
and evaluation of individual peripheral nerve as well for all colleagues who are dealing with peripheral
as neuroradiological exposure have been very nicely nerve systems.
described. To demonstrate the fact that peripheral I would like to congratulate the editors of this book,
nerve can be injured not only by trauma, but also by Mariano Socolovsky, Lukas Rasulic, Rajiv Midha und
other circumstances, a special chapter has been ded- Debora Garozzo, as well as all chapter authors for
icated to the gunshot lesion as well as electrical, publishing such an excellent and very useful book to
thermal and radiation injuries. A special chapter is support all active surgeons from different specialities
dedicated to electrodiagnostic pre-, intra- and post- who are interested in the diagnostic and treatment of
operative evaluations which can give neurologists and human peripheral nerve systems.
neurosurgeons good information about the condition
of injuries of individual nerves. In the past 10 years,
magnetic resonance neurography has increasingly
been introduced to the diagnostic of peripheral nerve Prof. Dr. med. Dr. h. c. mult. M. Samii
systems and is giving very useful information some- President
times, not only about the peripheral nerve itself but INI Hannover GmbH
also about all the tissues around the nerves. That is Hannover, Germany
another reason that adds value to such a chapter in Honorary President, WFNS

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Foreword
It is with immense pleasure that I am writing these tion of Neurosurgical Societies, and we truly appreci-
lines to introduce this book on peripheral nerve sur- ate and hold in high esteem the work done by the
gery, which represents the ultimate work of well- editors of this book: Drs Socolovsky, Midha, Rasulic,
known experts in the field. and Garozzo, who have coordinated a group of very
It has been estimated that the rate of posttraumatic distinguished specialists in the field in an effort to
peripheral nerve injuries has been continuously rising offer an updated and comprehensive approach to
in recent years due to widespread motorization in peripheral nerve surgery, providing a useful tool of
developing areas of the world, such as in Southeast knowledge to those who want to deal with the man-
Asia, and the ongoing warfare in the Arab world. This agement and treatment of such pathology in their
has consequently resulted in a major demand for professional practice. The book admirably presents
professionals presenting the cultural background, traumatic injuries, entrapment syndromes, and nerve
necessary to manage and treat these patients. tumors in every aspect, dealing, in an effective and
On the other hand, remarkable progress in imaging practical approach, with all the situations that neu-
and surgical technique has revolutionized this sub- rosurgeons are likely to face during daily practice.
specialty and today, peripheral nerve surgery has As the president of the World Federation of Neu-
become a much more complex and articulate art in rosurgical Societies, I am grateful to all the authors for
comparison with the past. their invaluable contribution to spread their expertise
Unfortunately, too many neurosurgeons around the and knowledge, and I do hope that this book will soon
world neglect and have abandoned this discipline be considered a fundamental source of information by
that, on the contrary, has become a major legacy of every neurosurgeon in the world.
surgeons from other specialties (such as plastic and
orthopaedic surgery). Yet we reckon that it should be Prof. Franco Servadei, MD
emphasized that peripheral nerve surgery should be Department of Neurosurgery
undeniably considered an integral and indispensable Humanitas University and Research Hospital
part of neurosurgery. We should reclaim this specialty Milano, Italy
as essential to knowledge and competence, especially President Elect, WFNS
of young neurosurgeons. Past President, Italian Society of Neurosurgery
We are therefore delighted to support the Periph- (SINCh)
eral Nerve Surgery Committee in the World Federa-

xvi
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Foreword
It is an honor to write the Foreword for this book on past, perspective on the present, and hope for the
peripheral nerve surgery, written and edited by dis- future.
tinguished colleagues and dear friends from around The future of peripheral nerve surgery is bright.
the globe. This book spans a spectrum of peripheral Growing interest and experience in the field and
nerve disorders including entrapments, injuries, technological advances are allowing us to reach newer
tumors, and neuropathic pain, and has broad applica- heights. This book will help raise the bar and will serve
tions (from head to toe in the neonate and the adult) a dual purpose: educating generalists and inspiring
and wide implications based on specific anatomy and experts with common purposes—to expand knowl-
pathology, physiology, and treatment. It offers pearls edge and to improve patient outcomes.
for the beginner and the subspecialist and, as in its
very title, an overview of the basics and the complex. Robert J. Spinner, MD
Peripheral nerve surgery is an exciting discipline Chairman, Department of Neurologic Surgery
with a rich heritage: it balances the failures and the Burton M. Onofrio, MD Professor of Neurosurgery
advances. This book reflects the excitement of our Professor of Orthopedics and Anatomy
times; it provides glimpses into what is known and Mayo Clinic
remains unknown, and what is fact and controversy. Rochester, Minnesota, USA
The voyage through history conjures respect for the

xvii
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Preface
This book is the product of the intense, concerted area of the skin. However, this theoretical advantage
efforts of numerous individuals who have dedicated is, at the same time, its Achilles tendon: the velocity of
their professional lives to the fascinating field of a regenerating axon's growth, at roughly 1 mm per
peripheral nerve surgery. The editors were fortunate day, requires intensive and constant follow-up by the
to receive contributions from several renowned physician, the patient's compliance with the rehabil-
experts from around the world. Spread over 23 chap- itation process, and both parties having the patience
ters, the book covers all of the essential topics. It starts to wait for positive results to become evident.
with the very basics, such as anatomy, physical exam- Historically, relatively few surgeons have been res-
ination, and diagnosis. It then progresses through the olute in their dedication to the surgical treatment of
surgical management of every nerve problem that is peripheral nerve disorders. However, this trend has
currently deemed amenable to surgical treatment, changed in recent years, probably due to the work of
including nerve trauma, nerve compressions, and the many pioneers who have revealed consistently
nerve tumors. To make the information easy to under- good results that can be obtained with nerve repairs,
stand and concise, but complete, descriptions of sur- nerve transfers, and nerve decompression. Moreover,
gical treatments are divided by pathology. The book the functional improvement that such patients expe-
has been designed to serve as a consultative reference rience is clinically and functionally so important that
for those surgeons or clinicians who have experience it is now becoming more and more recognized by the
with nerve problems; but it can also be used to gently entire medical community.
guide relative novices in the field who want to The World Federation of Neurosurgical Societies is a
immerse themselves more deeply in this engaging professional, nonprofit, scientific organization that is
and eminently rewarding subspecialty. composed of member societies from more than 130
This book has been written for neurosurgeons, different countries across 5 continents. As part of its
plastic surgeons, orthopaedic surgeons, hand sur- internal organization, the Peripheral Nerve Surgery
geons, vascular surgeons, neurologists, and physical Committee has been intensively working to promote
and occupational therapists, as well as any other this type of surgery and, thereby, encouraging even
health care provider who is interested in the surgical more surgeons to start practicing in this exciting field.
treatment of peripheral nerve disorders. This field is As mentioned initially, this book is a concerted effort
extremely rewarding because, contrary to brain and in this direction.
spinal surgery, peripheral nerve surgery has the
potential to induce the recovery of previously Mariano Socolovsky, MD
completely lost function. This is due to the innate Lukas Rasulic, MD, PhD
capacity that axons have to regenerate and grow, so Rajiv Midha, MD, MSc, FRCSC, FAANS, FCAHS
that, over time, they can reach an intended target, Debora Garozzo, MD
whether that be a denervated muscle or an insensate

xviii
Acknowledgments
We want to thank Dr. Kevin P. White, MD, PhD (www. betti-ilustracion.blogspot.com.ar) for illustrating the
scienceright.com), for the help in reviewing many of rest of the book and the cover.
the chapters; Luis Domitrovic, MD (https://ladvic.
myportfolio.com), for the illustrations in Chapters 2 Mariano Socolovsky, MD
and 4; and Martin Montalbetti (http://martinmontal- Lukas Rasulic, MD, PhD
Rajiv Midha, MD, MSc, FRCSC, FAANS, FCAHS
Debora Garozzo, MD

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Contributors
Carlos Alberto Rodríguez Aceves, MD Gonzalo Javier Hugo Bonilla, MD
Neurosurgeon and Peripheral Nerve Surgeon Staff Surgeon, Peripheral Nerve and
Neurosurgery Division Brachial Plexus Unit
Neurological Center, The American British Cowdray Department of Neurosurgery
Medical Center University of Buenos Aires School of Medicine
Mexico City, Mexico Buenos Aires, Argentina

Bassam M. J. Addas, FRCSC Christine Brand, MD


Associate Professor Peripheral Nerve Surgery Unit
Neurological Surgery Department of Neurosurgery
Department of Surgery University of Ulm
King Abdul-Aziz University Hospital Ulm, Germany
Jeddah, Saudi Arabia
David Robla Costales, MD
Zarina Ali, MD, MS Department of Plastic and Reconstructive Surgery
Assistant Professor Hospital Universitario Central de Asturias
Department of Neurosurgery Oviedo, Spain
Perelman School of Medicine
University of Pennsylvania Javier Robla Costales, MD
Philadelphia, Pennsylvania, USA Department of Neurosurgery
Complejo Asistencial Universitario de León
Gregor Antoniadis, MD, PhD León, Spain
Director
Peripheral Nerve Surgery Unit Luis Domitrovic, MD
Department of Neurosurgery Department of Radiology
University of Ulm Complejo Asistencial Universitario de León
Guenzburg, Germany León, Spain

Daniel Alves Neiva Barbosa Javier Fernández Fernández, MD


Research Internist Department of Neurosurgery
Division of Neurosurgery Complejo Asistencial Universitario de León
Hospital Universitário Gaffrée e Guinle (HUGG) León, Spain
Federal University of the State of Rio de Janeiro
(UNIRIO) Stefano Ferraresi, MD
Rio de Janeiro, Brazil Head
Department of Neurosurgery
Daniela Binaghi, MD Ospedale S.Maria della Misericordia
Chief of Peripheral Nerve Section Rovigo, Italy
Radiology Department
Favaloro University Leandro Pretto Flores, MD, PhD
Favaloro Foundation Chairman
Buenos Aires, Argentina Department of Neurosurgery
Hospital das Forças Armadas
Brasília–Distrito Federal, Brazil

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Contributors

Debora Garozzo, MD Thomas Kretschmer, MD, PhD, IFAANS


Head Professor of Neurosurgery and Director
Brachial Plexus and Peripheral Nerve Surgery Unit Department of Neurosurgery
Neurospinal Hospital Evangelisches Krankenhaus
Dubai, UAE Oldenburg University
Vice Chairman, WFNS Peripheral Nerve Oldenburg, Germany
Surgery Committee
Martijn J. A. Malessy, MD, PhD
José Fernando Guedes-Corrêa, MD, PhD Professor of Nerve Surgery
Full Professor of Neurosurgery Department of Neurosurgery
Head of the Division of Neurosurgery Leiden University Medical Center
Hospital Universitário Gaffrée e Guinle (HUGG) Leiden, The Netherlands
Federal University of the State of Rio de Janeiro
(UNIRIO) Fernando Martínez, MD
Rio de Janeiro, Brazil Associate Professor
Neurosurgical Department
Christian Heinen, MD Hospital de Clínicas
Senior Consultant Montevideo, Uruguay
Department of Neurosurgery Associate Professor
Evangelisches Krankenhaus Oldenburg Department of Anatomy
Carl-von-Ossietzky-University Oldenburg Facultad de Medicina CLAEH
Oldenburg, Germany Maldonado, Uruguay

Gregory Heuer, MD, PhD Roberto S. Martins, MD, PhD


Assistant Professor Co-Director
Department of Neurosurgery Peripheral Nerve Surgery Unit
Perelman School of Medicine Division of Functional Neurosurgery
The Children's Hospital of Philadelphia Institute of Psychiatry
Philadelphia, Pennsylvania, USA University of São Paulo Medical School
São Paulo, Brazil
Jennifer Hong, MD
Resident Gilda Di Masi, MD
Department of Neurosurgery Staff Surgeon, Peripheral Nerve and Brachial
Dartmouth-Hitchcock Medical Center Plexus Unit
One Medical Center Drive Department of Neurosurgery
Lebanon, New Hampshire, USA University of Buenos Aires School of Medicine
Buenos Aires, Argentina
Viviane Khoury, MD
Assistant Professor Rajiv Midha, MD, MSc, FRCSC, FAANS, FCAHS
Department of Radiology Professor and Head
Director of Musculoskeletal Ultrasound Department of Clinical Neurosciences
Perelman School of Medicine University of Calgary
University of Pennsylvania Calgary, Alberta, Canada
Philadelphia, Pennsylvania, USA Peripheral Nerve Section Associate Editor,
Neurosurgery and World Neurosurgery
Ralph W. König, MD, PhD Vice Chairman, WFNS Peripheral Nerve
Deputy Medical Director Surgery Committee
Department of Neurosurgery
University of Ulm
Guenzburg, Germany

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Contributors

Paul J. Niziolek, MD Lukas Rasulic, MD, PhD


Resident Professor and Head
Department of Radiology Department of Peripheral Nerve Surgery, Functional
Perelman School of Medicine Neurosurgery and Pain Management Surgery
University of Pennsylvania Clinic for Neurosurgery, Clinical Center of Serbia
Philadelphia, Pennsylvania, USA School of Medicine University of Belgrade
Belgrade, Serbia
Miguel Domínguez Páez, MD Vice Chairman, WFNS Peripheral Nerve
Neurosurgeon and Peripheral Nerve Surgeon Surgery Committee
Neurosurgery Division
Malaga Regional University Hospital Ricardo Reisin, MD
Malaga, Spain Chairman of Neurology
Hospital Británico
Maria Teresa Pedro, MD Buenos Aires, Argentina
Peripheral Nerve Surgery Unit
Department of Neurosurgery Shimon Rochkind, MD, PhD
University of Ulm Professor and Director
Guenzburg, Germany Division of Peripheral Nerve Reconstruction
Department of Neurosurgery
Jared Pisapia, MD Head, Research Center for Nerve Reconstruction
Resident Tel Aviv Sourasky Medical Center
Department of Neurosurgery Tel Aviv University
Perelman School of Medicine Tel Aviv, Israel
University of Pennsylvania
Philadelphia, Pennsylvania, USA Federico Salle, MD
Neurosurgeon and Assistant Professor
Javier Ibáñez Plágaro, MD Neurosurgical Department
Department of Neurosurgery Hospital de Clínicas
Complejo Asistencial Universitario de León Montevideo, Uruguay
León, Spain
Prof. Dr. Miroslav Samardzic
W. Pondaag, MD, PhD Neurosurgeon and Professor
Neurosurgeon Department for Peripheral Nerve Surgery, Functional
Department of Neurosurgery Neurosurgery and Pain Management Surgery
Leiden University Medical Center Clinic for Neurosurgery, Clinical Center of Serbia
Leiden, The Netherlands School of Medicine University of Belgrade
Belgrade, Serbia
Sudheesh Ramachandran M.Ch Member, WFNS Peripheral Nerve Surgery Committee
Clinical Fellow
Peripheral Nerve Surgery Victoria E. Fernández Sánchez, MD
Department of Clinical Neurosciences Clinical Neurophysiologist
Hotchkiss Brain Institute Clinical Neurophysiology Department
University of Calgary Malaga Regional University Hospital
Calgary, Alberta, Canada Malaga, Spain

xxii
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Contributors

Yuval Shapira, MD Thomas J. Wilson, MD


Vice-Chairman of Neurosurgery Clinical Assistant Professor
Division of Peripheral Nerve Reconstruction Department of Neurosurgery
Department of Neurosurgery Stanford University
Tel Aviv Sourasky Medical Center Stanford, California, USA
Tel Aviv University
Tel Aviv, Israel Lynda J-S Yang, MD, PhD
Professor
Mario G. Siqueira, MD, PhD Department of Neurosurgery
Director University of Michigan
Peripheral Nerve Surgery Unit Ann Arbor, Michigan, USA
Division of Functional Neurosurgery
Institute of Psychiatry Eric L. Zager, MD, FACS, FAANS
University of São Paulo Medical School Professor
São Paulo, Brazil Department of Neurosurgery
Perelman School of Medicine
Mariano Socolovsky, MD University of Pennsylvania
Chief Philadelphia, Pennsylvania, USA
Peripheral Nerve and Brachial Plexus Unit
Department of Neurosurgery Paul Zhang, MD
University of Buenos Aires School of Medicine Professor
Buenos Aires, Argentina Department of Pathology and Laboratory Medicine
Chairman, WFNS Peripheral Nerve Perelman School of Medicine
Surgery Committee University of Pennsylvania
Philadelphia, Pennsylvania, USA
Francisco José Lourenço Torrão, Jr., MD
Neurosurgeon
Division of Neurosurgery
Gaffree e Guinle University Hospital
Federal University of Rio de Janeiro State

xxiii
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Nerve Anatomy of the Upper Limbs

1 Nerve Anatomy of the Upper Limbs


Gilda Di Masi and Gonzalo Javier Hugo Bonilla

Abstract terminal branches. Commonly when we refer to the bra-


A strong understanding of the anatomy of the brachial chial plexus, we say that it is formed by the union of the
plexus and its terminal branches (radial, axillar, median, C5–C8, and T1 roots.1 However, this is not entirely accu-
ulnar and musculocutaneous nerves) is critical for a cor- rate. In actuality, the brachial plexus is an anastomosis of
rect approach to the nerve injuries of the upper limb. the ventral rami of spinal nerves C5–C8 and T1, its poste-
In this chapter, we describe the anatomy and relation- rior rami being directed to the spinal muscles (▶ Fig. 1.2).
ships of these structures, focusing on those items that are There are two anatomic variants: the prefixed brachial
important when performing surgery on them. plexus receiving fibers from C4, with little to no contribu-
tion from T1; and the postfixed plexus receiving fibers
Keywords: upper limb, brachial plexus, median nerve, from T2, with little to no contribution from C5.2 Each spi-
ulnar nerve, radial nerve, axillary nerve, musculocutane- nal nerve consists of a ventral root, which has motor and
ous nerve autonomic functions, and a dorsal root, which is sensory.
The dorsal root enters the spinal ganglion. Distal to the
spinal ganglion, both roots coalesce to emerge through
the intervertebral foramen as the spinal nerve. Almost
1.1 Supraclavicular Brachial immediately, this nerve divides into two rami: ventral
Plexus and dorsal. The dorsal rami supply the paraspinal muscles
and the skin of the back, while the ventral rami form the
The brachial plexus is a complex structure located in the brachial plexus.3 The ventral and dorsal roots and the
lower half of the lateral neck, extending from the cervical intra-axial portion of the spinal nerve are only covered by
spine to the axilla (▶ Fig. 1.1). It provides motor, sensory, an arachnoid sheath. As it exits the intervertebral fora-
and autonomic innervation to the upper limb, except for men, this sheath continues as the epineurium. At this
the skin of the upper half of the medial and posterior part level, there are adhesions between the nerve sheath and
of the arm, which is supplied by the intercostobrachial the transverse process. These adhesions anchor the nerve
nerve. The brachial plexus can be divided into: (1) a structures, protecting the roots from traction injury. They
supraclavicular portion, constituted by roots C5 to T1, the are more important at the C5–C7 levels, and weaker at
upper, middle, and inferior trunks, and its divisions; and the C8 and T1 levels; for this reason, the C8 and T1 roots
(2) an infraclavicular portion, formed by the cords and its are more susceptible to root avulsion.3,4,5

Fig. 1.1 Schematic drawing of the brachial


plexus and its terminal branches. The roots,
trunks, divisions, cords, and terminal
branches can be seen. A, C4 root; B,
C5 root; C, C6 root; D, C7 root; E, C8 root;
F, T1 root; G, superior trunk; H, middle
trunk; I, inferior trunk; J, anterior division
of the upper trunk; K, posterior division of
the upper trunk; L, anterior division of the
middle trunk; M, posterior division of
the middle trunk; N, posterior division of
the lower trunk; O, anterior division of the
lower trunk; P, lateral cord; Q, posterior
cord; R, medial cord; S, musculocutaneous
nerve; T, axillary nerve; U, radial nerve;
V, median nerve; W, ulnar nerve.

1
Nerve Anatomy of the Upper Limbs

Fig. 1.2 Each spinal nerve consists of a


ventral root and a dorsal root that arise from
the spinal cord. The dorsal root enters the
spinal ganglion. Distal to the spinal gan-
glion, both roots coalesce to emerge
through the intervertebral foramen as the
spinal nerve. Almost immediately, this nerve
divides into two primary rami: ventral and
dorsal. The primary dorsal rami supply the
paraspinal muscles and the skin of the back,
while the primary ventral rami form the
brachial plexus.

clavicle, the three trunks are located between the anterior


and middle scalene muscles (▶ Fig. 1.3). The three trunks
emerge from the interscalene space and traverse the infe-
rior region of the posterior triangle of the neck.6

1.1.1 Collateral Branches of the


Supraclavicular Brachial Plexus
The most proximal collateral branches of the brachial
plexus arise from spinal nerves C5–C7 (the phrenic, long
thoracic, and dorsal scapular nerves) and upper trunk
(suprascapular nerve). They are intended to innervate
Fig. 1.3 Supraclavicular brachial plexus. ADUT, anterior division the muscles of the proximal upper limb. The function of
of the upper trunk; C, clavicle; LT, lower trunk; MT, medial this is to stabilize and mobilize the shoulder, with the
trunk; PDUT, posterior division of the upper trunk; exception of the phrenic nerve, which actually is not
SPN, suprascapular nerve; UT, upper trunk.
considered a collateral branch of the plexus, but has a
contribution from C5. More detailed descriptions of the
nerves and their consistency follow:
Before continuing with a description of how the bra- ● Phrenic nerve: The phrenic nerve receives contributions

chial plexus is formed, it is important to mention the rela- from C3–C5. It is purely motor and supplies the ipsilateral
tionship it has with the sympathetic nervous system. hemidiaphragm. It runs along the surface of the anterior
Immediately distal to its origin, the ventral rami of the scalene, its direction being from medial to lateral (making
spinal nerves that form the brachial plexus receive gray it the only nerve having this direction in the posterior
rami communications from the middle and inferior cervi- triangle). A proximal lesion of C5 (root avulsion) can cause
cal sympathetic ganglia and the first thoracic sympathetic ipsilateral diaphragmatic paralysis.7
ganglion. Sympathetic fibers destined for the face, via the ● Long thoracic nerve: This nerve receives contributions

trigeminal nerve, pass through spinal nerves T1 and T2. from C5–C7. It passes between the anterior and middle
It is for this reason that proximal lesions of T1 and/or T2 scalene, behind the brachial plexus. It innervates the
can cause Horner’s syndrome, which consists of anhidro- serratus anterior muscle, the function of which is to
sis, miosis, ptosis, and enophthalmos.3,4 stabilize the scapula and allow for scapular rotation and
The most proximal structures in the brachial plexus are anterior displacement. Injury to this nerve results in a
the trunks. The upper trunk is formed by the anastomosis winged scapula.
of C5 and C6, C7 continues as the middle trunk, and C8 ● Dorsal scapular nerve: The dorsal scapular nerve is a

and T1 form the lower trunk. Between the spine and the branch of C5, directed dorsally to pierce the middle

2
Nerve Anatomy of the Upper Limbs

scalene muscle, after which it continues to run below


the levator scapulae to ultimately reach and innervate
the rhomboid muscles and the levator scapulae. Its
function is to approximate the scapula to the midline.
Interscapular injuries cause atrophy, which may mani-
fest as a slightly winged scapula at rest. When this
nerve is affected in the context of a brachial plexus
injury, it indicates a proximal lesion affecting C5.
● Suprascapular nerve: This nerve is the only branch
that arises from the trunks of the brachial plexus, with
contributions from C5 and C6. It originates in the supe-
rior portion of the upper trunk, immediately proximal
to the clavicle (▶ Fig. 1.3). It then redirects back toward
the suprascapular notch. In the notch, it joins the supra-
scapular artery and vein, both of which are located
above the upper scapular ligament, while the nerve lies
below. It innervates the supraspinatus and infraspina-
tus muscles—the former stabilizes the humeral head
and contributes to the first 30 degrees of shoulder
abduction, while the latter is an external rotator.8

1.2 Infraclavicular Brachial


Plexus
Within the posterior triangle of the neck, each trunk is
divided into an anterior and a posterior division.9 Each
division passes under the midclavicle, thereby entering
the axilla. The combination of these divisions will form
the cords (i.e., the infraclavicular brachial plexus). The
cords are named according to their relationship with the
Fig. 1.4 Infraclavicular brachial plexus. AA, axillary artery;
axillary artery, so that we have the lateral, medial, and
BCN, antebrachial cutaneous nerve (medial cutaneous nerve of
posterior cords. The anterior divisions of the upper and the forearm); LT, lateral trunk; MC, musculocutaneous nerve;
middle trunks form the lateral cord, carrying fibers from MLB, median lateral branch; MMB, median medial branch;
C5–C7. The anterior division of the lower trunk continues MT, medial trunk; MN, median nerve; UN, ulnar nerve.
as the medial cord, carrying fibers from C8 and T1. The
posterior divisions of the three trunks are joined to form
the posterior cord, carrying fibers from C5–C8 and T1. In 1.2.1 Collateral Branches of the
the projection of the lateral border of the pectoralis
minor muscle, the three cords divide to give rise to the
Infraclavicular Brachial Plexus
five terminal branches of the brachial plexus. The lateral In addition to the above-mentioned terminal branches,
cord gives rise to the lateral contribution to the median the infraclavicular brachial plexus also gives out collateral
nerve (mainly sensitive) and the musculocutaneous nerve. branches.10 They are the following:
The medial cord gives rise to the medial contribution of ● Medial cutaneous nerve of the arm: This branch arises

the median nerve (mainly motor) and the ulnar nerve from the medial cord, and has its axonal origin in C8 and
(▶ Fig. 1.4). The axillary and radial nerves arise from the T1. After its origin, it descends on the medial side of
posterior cord. the axillary artery in an anterior direction. In the arm, it
One way to potentially simplify learning the anatomy initially is located medial and then anterior to the ulnar
of the brachial plexus is to relate each structure to a cer- nerve, descending in front of the basilic vein. It pierces the
tain function. Consequently, the posterior divisions form aponeurosis next to the basilic vein, and is distributed to
the posterior cord, which in turn gives birth to the radial the skin of the lower third of the medial surface of the arm.
and axillary nerves, both of which are responsible for ● Medial cutaneous nerve of the forearm: This nerve is

upper limb extension. Conversely, the anterior divisions also a branch of the medial cord that supplies the skin
form the lateral and medial cords that are responsible for of the anterior and posterior surfaces of the medial
upper limb flexion through their terminal branches: the aspect of the forearm. Within the axilla, it anastomoses
musculocutaneous, median, and ulnar nerves. with the intercostobrachial nerve, which provides

3
Nerve Anatomy of the Upper Limbs

sensory innervation to the distal axillary region and to the third portion of the axillary artery and anterior to
proximal inner arm. the subscapularis, teres major, and latissimus dorsi
● Medial pectoral nerve: This is a collateral branch of the muscles. In the arm, it is directed obliquely downward,
medial cord. It passes through the pectoralis minor and laterally and posteriorly, and passes through the
pectoralis major, supplying both muscle groups. humeral-tricipital slit located below the teres major and
● Upper and lower subscapular nerve: These are the latissimus dorsi.4 This is a musculoskeletal conduit
branches of the posterior cord. The former innervates between the radial sulcus of the humerus dorsally and
the subscapularis muscle, while the latter supplies the the long and lateral heads of the triceps ventrally, accom-
teres major and the distal portion of the subscapularis. panied by the deep humeral artery. Near its origin, the
● Thoracodorsal nerve: Also a branch of the posterior nerve emits a variable number of branches to the triceps
cord, this nerve innervates the latissimus dorsi muscle.11 directed to innervate its long, medial, and lateral portions
● Lateral pectoral nerve: A collateral branch of the separately, as well as a sensory branch, the posterior
lateral cord, the lateral pectoral nerve pierces the cutaneous nerve of the arm, which, as its name suggests,
clavipectoral fascia and innervates the pectoralis provides sensation to the proximal posterior region of
major muscle. the arm. It then continues its course as a satellite of the
deep artery of the arm, located between the long and
medial heads of the triceps (▶ Fig. 1.5). From there, it
1.3 Terminal Branches of the comes into contact with the humerus within the radial
Brachial Plexus sulcus or spiral groove, where it gives off additional mus-
cular branches for the lateral and medial heads of the
1.3.1 Radial Nerve triceps, as well as for the anconeus muscle. It is important
to note the anatomy of the collateral sensory branches:
The radial nerve has its axonal origin in the roots C5–C8,
the inferior lateral cutaneous nerve of the arm and the
and its macroscopic origin in the posterior cord, posterior
posterior cutaneous nerve of the forearm. They provide
sensory innervation to the posterior and medial region of
the distal arm, elbow, and proximal forearm. At the level
of the elbow, the radial nerve can be found between the
biceps medially and the brachioradialis laterally, along
with the radial recurrent artery; and 2 to 3 cm from this
point, it provides a motor branch for the brachioradialis.
Once it is beyond the elbow crease, it divides into its two
terminals branches, anterior or superficial (sensory) and
posterior or deep (motor) (▶ Fig. 1.6).
The deep branch or posterior interosseous nerve pro-
ceeds posteriorly through the two layers (superficial and
deep) of the supinator muscle.12 These layers form the
arcade of Frohse, through which the nerve passes to

Fig. 1.6 Terminal branches of radial nerve. AB, anterior branch;


Fig. 1.5 Radial nerve. AA, axillar artery; MC, musculocutaneous BRM, brachioradialis muscle; PB, posterior branch; RN, radial
nerve; MLB, median lateral branch; RN, radial nerve. nerve; SM, supinator muscle.

4
Nerve Anatomy of the Upper Limbs

reach the posterior aspect of the forearm. It supplies the nator teres muscle, flexor digitorum superficialis, flexor
muscles in the posterior compartment.13 carpi radialis, and palmaris longus. Once past the elbow
The superficial or anterior branch continues parallel crease, it is located between the humeral (surface) and
but dorsal to the brachioradialis muscle (▶ Fig. 1.7), ulnar (deep) heads of the pronator teres muscle, crossing
accompanied by the radial artery so that, once through the ulnar artery from medial to lateral. Almost immedi-
the posterior fascia of the hand, it gives sensation to the ately after passing through the heads of the pronator
posterior surface of the hand. teres, it gives off one of its longer branches, the anterior
interosseous nerve, located posterior (deep) to the main
trunk of the median nerve (▶ Fig. 1.10), along with the
1.3.2 Median Nerve anterior interosseous artery, above the pronator quadratus
The median nerve originates in the roots C5–C8 and T1. muscle and the interosseous membrane. Approximately
Macroscopically, it stems from the union of the internal 4 cm distal to the origin of the anterior interosseous
fibers of the medial cord and the external fibers of the nerve, the median nerve gives off its first branch to the
lateral cord, forming an “M” above the axillary artery.14 It flexor pollicis longus, followed by branches to the first
should be noted that there is considerable anatomical and second flexor digitorum profundus.
variety in how the cords divide and in the conformation There are some anastomosis between the median and
of the median nerve (▶ Fig. 1.8). From its origin, the nerve ulnar nerves, that is, the so-called Martin-Gruber anasto-
always runs adjacent to the brachial artery (▶ Fig. 1.9). mosis, existing in roughly 10 to 25% of the population.
There are no collateral branches in the arm. Distally in Another anastomosis between both nerves are the so-
the arm, it is located in the cubital fossa, along with the called Riche-Cannieu anastomosis, between the thenar
humeral artery and articular branches, where muscular branch of the median nerve and the deep branch of the
branches arise from the medial side and travel to the pro- ulnar nerve in the palm.

Fig. 1.8 Median nerve conformation (“M”). AA, axillary artery;


LT, lateral trunk; MC, musculocutaneous nerve; MLB, median
lateral branch; MMB, median medial branch; MN, median nerve;
Fig. 1.7 Radial nerve (superficial branch). BRM, brachioradialis MT, medial trunk.
muscle; RA, radial artery; RN, radial nerve; FDS, flexor digitorum
superficialis muscle.

Fig. 1.9 Median nerve conformation. AA, axillary artery;


Fig. 1.10 Anterior interosseous nerve. AIA, anterior inteross-
LT, lateral trunk; MC, musculocutaneous nerve; MLB, median
eous artery; AIN, anterior interosseous nerve; PQ, pronator
lateral branch; MMB, median medial branch; MT, medial trunk.
quadratus.

5
Nerve Anatomy of the Upper Limbs

Fig. 1.12 Median and ulnar nerve in the wrist. MN, median
Fig. 1.11 Thenar branches of median nerve. MN, median nerve; nerve; RA, radial artery; UA, ulnar artery; UN, ulnar nerve.
PB, palmaris brevis muscle; RMB, recurrent motor branch.

The median nerve continues its course through the


antebrachial region to about 5 cm proximal to the wrist,
where it is located superficial and lateral to the flexor dig-
itorum superficialis muscle. One of the sensory branches
in this region is the palmar cutaneous branch, which
gives sensation to the proximal palm. Already in the distal
forearm region, the nerve is located between the tendons
of the palmaris longus muscle medially and the flexor
carpi radialis laterally, before entering the carpal tunnel.
The carpal tunnel is an osteofibrous structure through
which several structures pass, including the median nerve,
the tendons of the flexor digitorum superficialis and pro-
fundus, and flexor pollicis longus and, in 10% of the popu-
lation, an arterial branch called the median persistent
artery.15 Distal to the carpal tunnel, the nerve divides into
its terminal branches: the recurrent branch (▶ Fig. 1.11 and
▶ Fig. 1.12) (to the opponens pollicis, abductor pollicis bre-
vis, and superficial part of flexor pollicis brevis); branches
for the first and second lumbricals; and digital cutaneous
branches to the first, second, and third fingers, as well as
the inner (lateral) surface of the fourth finger.

1.3.3 Ulnar Nerve


The ulnar nerve has its axonal origin in roots C8 to T1,
and its macroscopic origin in the medial cord (▶ Fig. 1.13),
along with the internal brachial cutaneous and brachial
cutaneous accessory nerve, located medially to the hum-
eral artery.4 About 8 cm proximal to the epicondyle, the
ulnar nerve pierces the medial intermuscular septum to
Fig. 1.13 Ulnar nerve. AA, axillary artery; CBM, coracobrachialis
end up located in the posterior compartment of the arm.
muscle; MC, musculocutaneous nerve; MN, median nerve;
This region, formed by the arch of the brachial fascia and RN, radial nerve; UN, ulnar nerve.
muscle fibers of the medial head of the triceps, is called

6
Nerve Anatomy of the Upper Limbs

Fig. 1.15 Ulnar nerve in the proximal forearm. FCU, flexor carpi
ulnaris muscle; UN, ulnar nerve.

Fig. 1.14 Arcade of Struthers. SA, arcade of Struthers; UN, ulnar


nerve between the medial epicondyle and the olecranon.

Fig. 1.16 Ulnar nerve in the distal forearm. FCU, flexor carpi
ulnaris muscle; FDS, flexor digitorum superficialis muscle;
Fig. 1.17 Guyon’s canal. DB, deep branch; GC, Guyon’s canal;
PB, palmaris brevis muscle; UN, ulnar nerve.
SB, superficial branch; UN, ulnar nerve.

the arcade of Struthers (▶ Fig. 1.14); it is a potential nerve The superficial branch descends in front of the
compression site. Once at the elbow, the nerve passes hypothenar eminence to end as digital branches for the
between the medial epicondyle and the olecranon, cov- fourth and fifth fingers and the ulnar aspect of third
ered by the ulnar ligament. Continuing its route, it enters finger, while the deep branch passes below the hypoth-
under a tendinous arch formed by the humeral and ulnar enar muscles and gives off muscular branches to them.
heads of the flexor carpi ulnaris muscle, called the cubital Finally, it innervates the palmar interossei, the third
tunnel. The ulnar nerve emerges 4 to 6 cm from the and fourth lumbrical muscles, and the adductor pollicis
medial epicondyle through the flexor pronator muscle fas- (▶ Fig. 1.12).
cia, where it gives off two motor branches to the flexor
carpi ulnaris muscle, and more distally to the fourth
and fifth flexor digitorum profundus. Then it continues
1.3.4 Musculocutaneous Nerve
distally in the medial forearm above the flexor digitorum The musculocutaneous nerve has its axonal origin in
profundus and under the flexor carpi ulnaris (▶ Fig. 1.15). roots C5 and C6, with a small contribution from C7.4 Its
Distally, it is located lateral to the flexor carpi ulnaris, macroscopic origin is in the lateral cord, together with
always in relation to the ulnar artery, the artery satellite the lateral root of the median nerve near the inferior edge
of the ulnar nerve (▶ Fig. 1.16). It gives off a sensory of the pectoralis minor muscle.
branch, the palmar branch of the ulnar nerve, and then It runs laterally to the axillary artery, emitting branches
enters Guyon’s canal.16 This canal is formed by the palmar to the coracobrachialis muscle. It pierces the coracobra-
carpal ligament anteriorly, the pisiform medially, and chialis muscle and passes obliquely between the biceps
extensions of the flexor carpi ulnaris and the deeper and the brachialis, giving off a variable number of motor
flexor retinaculum posteriorly.17 Immediately distal to this branches to these two muscles (▶ Fig. 1.18, ▶ Fig. 1.19).
tunnel, or in some cases within the tunnel, the ulnar Then the musculocutaneous nerve continues its course
nerve divides into its two terminal branches: the superfi- as the lateral cutaneous nerve, running in an oblique and
cial branch and the deep branch (▶ Fig. 1.17). superficial direction and having an exclusively sensory

7
Nerve Anatomy of the Upper Limbs

Fig. 1.19 Musculocutaneous nerve. BB, biceps brachialis


muscle; MB, motor branches; MC, musculocutaneous nerve;
MN, median nerve.

Fig. 1.18 Musculocutaneous nerve. AA, axillary artery;


CBM, coracobrachialis muscle; MC, musculocutaneous nerve;
MLB, median lateral branch.

Fig. 1.20 Axillary nerve. AA, axillary artery; AN, axillary nerve;
MLB, median lateral branch; MMB, median medial branch; RN,
radial nerve; TMA, teres major muscle; TMI, teres minor muscle.
function. It ends in the skin of the elbow crease and lat-
eral surface of the forearm.18

1.3.5 Axillary Nerve


The axillary nerve has its axonal origin in roots C5 and neck of the humerus, giving off branches to the anterior
C6, and its macroscopic origin in the posterior cord of the and medial portions of the deltoid muscle. Likewise, it
brachial plexus along the radial nerve.4 It is located lateral gives sensory cutaneous branches to the shoulder girdle.
to the radial nerve and posterior to the axillary artery. The posterior branch supplies the teres minor and
It passes over the subscapularis until it reaches its inferior posterior deltoid muscles.20
edge, where it encounters the posterior humeral circum-
flex artery, a collateral branch of the axillary artery.
There it is located in the quadrangular space,19 where it is References
bounded by the subscapularis (anterior), the teres minor [1] Sunderland S, ed. Nervios Perifericos y sus Lesiones. Barcelona:
muscle (posterior), the surgical neck of the humerus and Salvat; 1985
long head of the triceps (lateral), and the teres major [2] Thompson GE, Rorie DK. Functional anatomy of the brachial plexus
sheaths. Anesthesiology. 1983; 59(2):117–122
muscle (inferior) (▶ Fig. 1.20).
[3] Russel SM, ed. Examination of Peripheral Nerve Injury: An Anatomi-
Approximately 3 cm distal to this space, it divides into cal Approach. 2nd ed. New York, NY: Thieme; 2008
two branches. The anterior branch is accompanied by the [4] Siqueira MG, Martins RS, eds. Anatomia Cirúrgica das Vias de Acceso
posterior circumflex vessels surrounding the surgical aos Nervos Periféricos. 1st ed. Rio de Janeiro: DiLivros; 2006

8
Manual of Peripheral Nerve Surgery | 25.07.17 - 10:00

Nerve Anatomy of the Upper Limbs

[5] Museti Lara A, Dolz C, Rodriguez Baeza A. Anatomy of the brachial [13] Testut L, Jacob O, eds. Tratado de Anatomia Topográfica con
plexus. In: Gilbert A, ed. Brachial plexus injuries. London: Martin Aplicaciones Medicoquirúrgicas Tomo 2. Barcelona: Salvat; 1982
Dunitz; 2001 [14] Blunt MJ. The vascular anatomy of the median nerve in the forearm
[6] Pro A, ed. Anatomía Humana de Latarjet-Ruiz Liard. Buenos Aires: and hand. J Anat. 1959; 93(1):15–22
Editorial Médica Panamericana; 2004 [15] Williams P, Warwick R, eds. Anatomía de Gray, Tomo 11. 36th ed.
[7] Alnot JY, Narakas A, eds. Les Paralysies du Plexus Brachial. Monogra- Barcelona, Salvat; 1985
phies du Groupe d'étude de la main. Paris: Expansion scientifique [16] Netter FH, ed. Sistema Nervioso. Anatomía y Fisiología. Tomo 1. 1.
francaise; 1989 Colección Ciba de ilustraciones médicas. Barcelona: Salvat; 1990
[8] Franco CD, Rahman A, Voronov G, Kerns JM, Beck RJ, Buckenmaier CC, [17] Reyes JT, Nuñez CT. Nomenclatura Anatómica Internacional. Mexico:
III. Gross anatomy of the brachial plexus sheath in human cadavers. Editorial Médica Panamericana; 1998
Reg Anesth Pain Med. 2008; 33(1):64–69 [18] Rouvière H, Delmas A, eds. Anatomía Humana. Descriptiva, Topográf-
[9] Bollini CA. Revision anatómica del plexo braquial. Revista Argentina ica y Funcional. 10th ed. Barcelona: Masson; 1999
de Anestesiología. 2004; 62:386–398 [19] Bouchet A, Cuilleret J, eds. Anatomía descriptiva, topográfica y
[10] Moore K, Dalley AF, eds. Anatomía con Orientación Clínica. 5th ed. funcional. Buenos Aires: Editorial Médica Panamericana; 1987
Madrid: Editorial Médica Panamericana; 2007 [20] Kahle W, ed. Atlas de Anatomía, tomo 3: Sistema Nervioso y Organos
[11] Netter FH, ed. Atlas de Anatomía Humana. 2nd ed. Barcelona: de los Sentidos. Barcelona: Omega; 1995
Masson; 1999
[12] Testut L, Jacob O, eds. Anatomía Humana Tomo 1. 8th ed. Barcelona:
Salvat; 1981

9
Surgical Anatomy and Approaches to the Nerves of the Lower Limb

2 Surgical Anatomy and Approaches to the Nerves


of the Lower Limb
Fernando Martínez and Federico Salle

Abstract
The innervation of the lower limb is given by the lumbar
plexus (L1–L4) and sacral plexus (L5–S3). The lumbar
plexus innervates through its branches: the abdominal
wall, the inguinocrural region, and the anterior, lateral,
and inner thigh regions. From the motor point of view,
it is responsible for the flexion of the thigh over the pelvis
and the extension of the knee. The sacral plexus inner-
vates from the motor point of view: the posterior region
of the thigh, posterior and anterior region of the leg, and
dorsal and ventral aspects of the foot. This chapter details
the collateral and terminal branches of the lumbar and
sacral plexuses, their motor and sensory distribution, as
well as the surgical approaches to these nerve structures.

Keywords: lumbar plexus, sacral plexus, lateral femoral


cutaneous nerve, femoral nerve, sciatic nerve

2.1 Introduction
Innervation of the lower limbs follows a basic pattern:
two nerve plexuses (lumbar and sacral) give rise to a
number of nerves that enter the extremity through three
anatomical regions—the inguinal, gluteal, and obturator—
to distribute themselves throughout the muscular, cuta-
neous, bony, and vascular structures of the limb.1,2,3,4,5,6,7,8
In this chapter, we review the anatomy of the nerves
of the lower limb, especially focusing on: (1) how this
anatomy can cause clinical disorders, and (2) how it
influences surgical approaches to treatment.
Fig. 2.1 Schematic drawing of the lumbar and sacral plexus.
A, ilioinguinal nerve; B, iliohypogastric nerve; C, femorocu-
2.2 Lumbar Plexus taneous nerve; D, femoral nerve; E, genitofemoral nerve;
F, obturator nerve; G, sciatic nerve; H, pudendal nerve.
The lumbar plexus is formed by the union of the anterior
branches of spinal roots L1–L4, with additional nerve
fiber contributions from T12 (▶ Fig. 2.1). The anterior
branches of the aforementioned roots emerge from their nerves; L2 and L3 contribute to the lateral femoral cutane-
corresponding neural foramina and, thereafter, remain ous nerve of the thigh; and L2–L4 give rise to the obturator
inside the psoas major muscle which has two fascicles of and femoral nerves. Conceptually, Russell has divided the
insertion. The anterior insertions correspond to the lum- terminal branches of the lumbar plexus into two groups of
bar vertebral bodies, while the posterior ones can be three nerves each: (1) the inguinal group, composed of the
found at the level of the transverse processes of the same ilioinguinal, iliohypogastric, and genitofemoral nerves; and
vertebrae. This is how a V-shaped interstice is created (2) the femoral group, composed of the lateral femoral
between the two fascicles.3 cutaneous, femoral, and obturator nerves. From an ana-
Within the substance of the muscle, L1–L4 exchange tomical point of view, the first four nerves are considered
fibers and form the lumbar plexus as follows: L1 mostly collateral branches of the lumbar plexus, while the last
supplies the ilioinguinal, iliohypogastric, and genitofemoral two are considered terminal branches.

10
Surgical Anatomy and Approaches to the Nerves of the Lower Limb

2.2.1 Inguinal Group


The three nerves within the inguinal group originate
within the psoas major muscle and run across the ante-
rior abdominal wall to reach the inguinal region. These
nerves can suffer direct trauma, can be damaged by trac-
tion or kinking, and can even be injured by sutures placed
during operative procedures involving the lower anterior
abdominal wall (such as, appendectomies, C-sections,
etc.) or lateral wall (lumbotomy), giving rise to sensory
disturbances or pain syndromes across their territory of
distribution (i.e., the inguinal area and genitalia).9,10,11,12

Iliohypogastric Nerve
The iliohypogastric nerve has its origins in L1, although it
also receives a T12 anastomosis. After emerging from
under the psoas muscle, it runs outward across the quad-
ratus lumborum muscle to finally rest between the trans-
versus abdominis and internal oblique muscles. In the
region of the anterior superior iliac spine, it divides into
two branches. The outer branch becomes superficial and
innervates the lateral gluteal region. The internal branch
continues its descending path, passing through the ingui-
nal canal to innervate the inguinal region. The sensory
distributions of all the nerves of the inferior limb are
shown in ▶ Fig. 2.2.

Ilioinguinal Nerve
The ilioinguinal nerve stems from a branch of the L1 root
and has a trajectory which is similar to that of the iliohy-
pogastric nerve, albeit somewhat more caudal. It runs at
the level of the oblique muscles of the abdomen and
innervates structures, such as, the spermatic cord and
cremaster muscle. Along with the iliohypogastric nerve,
it provides sensory innervation to the inguinal and
genital regions.

Fig. 2.2 Sensory distribution of the nerves of the inferior limb.


Genitofemoral Nerve At left, an anterior view of the lower limb; at right, a posterior
The genitofemoral nerve receives nerve fibers from both view. 1-A, ilioinguinal nerve; 2.1, iliohypogastric nerve;
2.2, genitofemoral nerve; 3-F, lateral femoral cutaneous nerve;
L1 and L2. It has a deeper trajectory than the aforemen-
4.1, femoral nerve (musculocutaneous branches); 4.2-J, femoral
tioned two nerves within the lumbar region. Before nerve (internal saphenous nerve); 5-H, obturator nerve;
reaching the inguinal ligament, it divides into two 6, peroneal nerve; 7, musculocutaneous nerve; 8, anterior tibial
branches: genital and femoral.9 The femoral branch runs nerve; 9-K, external saphenous nerve; 10, calcaneal nerve;
beneath the inguinal ligament, lateral to the common E, gluteal and sacral nerves; G, lesser sciatic nerve; I, cutaneous
femoral artery, and innervates the region of the femoral peroneal nerve; L1-L2, internal and external plantar nerves.
triangle. The genital branch enters the inguinal canal and
terminates in the skin of the external genitalia and
cremaster muscle (in males). reveal the source of pain, guiding the location and extent
of the surgical incision.

Surgical Approach
These three nerves are not generally approached per se,
2.2.2 Femoral Group
except when they are affected by postoperative fibrosis or The femoral group of nerves is composed of two mixed
iatrogenic lesions secondary to different kinds of surgery (both motor and sensory) nerves and one that is purely
in the region. Ideally, a thorough clinical examination will sensory.

11
Surgical Anatomy and Approaches to the Nerves of the Lower Limb

Lateral Femoral Cutaneous Nerve Surgical Approach


The lateral femoral cutaneous nerve (LFCN) is an exclu- Consistent with the anatomical features just reviewed,
sively sensory nerve that has its origins in branches from the LFCN is approached by creating an incision parallel
L2 and L3. From its origin, it runs lateral and downward, to the inguinal ligament, 2 cm below and 2 cm medial
relative to the iliac muscle. When it reaches the inguinal to the anterior superior iliac spine (▶ Fig. 2.3, ▶ Fig. 2.4,
ligament, anatomical variations may be evident.5,13,14 It ▶ Fig. 2.5).
usually passes below the outermost sector of the liga-
ment, and traverses the superficial fascia 2.5 cm below
and medial to the anterior superior iliac spine.14 After Obturator Nerve
entering the anterior region of the thigh, it then divides The obturator nerve has its origin in L2–L4. From its ori-
into two branches that innervate the anterolateral thigh, gin, it runs medially along the internal border of the
from the gluteal region to the knee.2 psoas muscle into the retroperitoneum, to finally enter
Among the anatomical variations that have particular the lower pelvis.17,18 In the pelvis, it follows the lateral
clinical relevance, we note the following: passage of the wall until the subpubic canal, through which the nerve
nerve between the fibers of the inguinal ligament; enters the obturator region (▶ Fig. 2.6). Just before exiting
entrance into the thigh lateral to the anterior superior iliac the pelvis, it divides into an anterior and posterior
spine; absence of the main nerve trunk in the thigh with branch.
two or more branches already divided; and a nerve that The anterior branch runs deep to the adductor longus
pierces the sartorius muscle to become superficial.14,15 and superficial to the adductor brevis muscle. From this,
In its passage from the inguinal region to the thigh, the a sensory branch sprouts extending to the subcutaneous
LFCN can be trapped by aponeurotic fibers or can suffer layer to innervate the medial surface of the knee.
direct trauma. Iatrogenic trauma can arise from specific The anterior branch of the obturator nerve innervates the
surgical positions (ventral decubitus) and interventions, adductor magnus, gracilis, and adductor brevis muscles.
such as, obtaining bony grafts from the anterior superior The posterior branch runs downward between the
iliac spine.16 Compressive neuropathy affecting the LFCN adductor brevis and adductor magnus, innervating both
typically is associated with pain in the anterolateral part muscles.10,17 In total, the obturator nerve innervates the
of the thigh. adductor muscles (longus and magnus, shared with the
femoral and sciatic nerves, respectively), the gracilis, pec-
tineus, and obturator externus.18
Clinical Exploration Between 13 and 40% of individuals have an accessory
Since these nerves are largely sensory, their examination obturator nerve that stems from L3 and L4 and follows a
requires an assessment of sensory function throughout similar course to that of the anterior branch, innervating
their territory of cutaneous distribution. the pectineus muscle and hip joint.10,19

Fig. 2.3 Superficial anatomy and topography of the groin Fig. 2.4 Surgical approach for the lateral cutaneous nerve. Note
region, left side. ASIS, anterosuperior iliac spine; LCFN, lateral the nerve retracted with a red silicone band and its two terminal
cutaneous femoral nerve; VAN, femoral vein, artery, and nerve. branches.

12
Surgical Anatomy and Approaches to the Nerves of the Lower Limb

Fig. 2.5 Groin region, left side (formalin specimen). Located Fig. 2.6 Intrapelvic topography of the obturator nerve and
lateral to the femoral vessels are the branches of the femoral vessels. In this cadaveric specimen, note the obturator vessels
nerve. ASIS, anterosuperior iliac spine; LCFN, lateral cutaneous and nerve and their relationship with the obturator foramen
femoral nerve. and internal obturator muscle.

Clinical Exploration saphenous nerve and the nerve of the quadriceps in the
deep plane, and the lateral and medial musculocutaneous
As their name suggests, hip adductor muscles adduct the
nerves in the superficial plane. Even though this is the
thigh and, during normal walking, are crucial flexors of
classical description, the femoral nerve can also reach the
the hip, whereby they initiate each step, causing the trail-
thigh already divided into two branches (superficial and
ing leg to swing forward to become the lead leg. The gra-
deep) or already as its four terminal branches. These four
cilis muscle contributes to flexing the knee and can be
terminal branches are:
used as a donor for free muscle transplants. The obturator ● Nerve to the quadriceps: This can be a single nerve or
externus participates in external rotation of the hip.3 The
several branches that supply the four different parts of
obturator nerve’s sensory function covers the territory
the muscle: the vastus medialis, vastus lateralis, vastus
depicted in ▶ Fig. 2.2.
intermedius, and rectus femoris.
● Saphenous nerve: This is a sensory nerve that traverses
Surgical Approach the entire lower limb, from the inguinal region to the
The obturator nerve is not prone to any specific entrap- medial aspect of the foot, although it does not give off
ment syndrome, so there is infrequently any need to any branches in the thigh. The nerve follows the
access it. When access is required, the surgical approach femoral artery in the thigh until the knee, where it
ultimately selected should be planned taking into consid- perforates the superficial fascia and descends toward
eration the section of nerve involved, as well as the the medial side of the leg until it reaches the medial
nerve’s anatomical course. border of the foot.
● Medial musculocutaneous nerve: This is a mixed

Femoral Nerve motor–sensory nerve that supplies the pectineus


and adductor longus muscles. It gives off cutaneous
The femoral nerve is a mixed motor and sensory nerve branches for the skin that lies between the territories
that stems from L2–L4.3,18 It descends within the interior of the genitofemoral and obturator nerves.
of the psoas (innervating it) and then travels through the ● Lateral musculocutaneous nerve: Also a mixed nerve,
region of the internal iliac fossa in relation to the caecum it supplies the sartorius muscle before giving off three
and sigmoid (to the right and left, respectively). It can be perforating branches that innervate the skin of the
located here at the angle that forms the iliac and psoas anterolateral region of the thigh.
muscles, before traversing behind the inguinal ligament
into the thigh. At the level of the inguinal ligament, the
nerve and femoral vessels lie as follows: vein, artery, and
Clinical Exploration
nerve, from medial to lateral. In the thigh, the nerve is The motor function of the femoral nerve can be summar-
located within the femoral triangle, medial to the sartor- ized by saying that this nerve allows for flexion of the
ius and lateral and in front of the pectineus. In this region, thigh (via the psoas, iliac, pectineus, and rectus femoris)
the femoral nerve divides rapidly into its four terminal and extension of the knee (via the quadriceps).20 The
branches, which are organized in two planes: the territory for sensory function is shown in ▶ Fig. 2.2.

13
Surgical Anatomy and Approaches to the Nerves of the Lower Limb

Surgical Approach obturator internus, gluteus maximus, piriformis, gastro-


cnemius, quadratus femoris, and gluteus minimus. It also
The femoral nerve can be approached by making a linear,
supplies a collateral branch that travels through the
vertical incision, which is located lateral to the pulse of
gluteal region and posterior thigh, producing sensory
the femoral artery.
branches for these zones.

2.3 Sacral Plexus 2.3.1 Sciatic Nerve


The sacral plexus is formed by the anterior branches of The sciatic nerve is the thickest and longest nerve in our
nerve roots S1–S3 and the lumbosacral trunk (▶ Fig. 2.1). body. Even though it has traditionally been considered a
The latter is composed of the union of the anterior branch single nerve, there are actually two nerves with a com-
of L5 and an anastomotic branch of L4. These elements mon epineural sheath. This can be explained by histologic
travel in front of the anterior sacral foramen and join cuts that show that the components of the sciatic nerve
inside the pelvis to form a single terminal trunk: the sci- (peroneus and tibial) are already separated from its origin
atic nerve. Both the plexus and the sciatic nerve are origi- with segregation of the motor flexor and extensor func-
nally situated deep in the pelvis, in front of the sacrum tions of the foot.4,21
and the sacroiliac joint and behind the rectum. For this Once the nerve is formed in the pelvis, it runs back-
reason, traumatic injuries to the sacral plexus and initial ward and passes through the greater sciatic notch, deep
part of the sciatic nerve are infrequent and almost always to the piriformis muscle, into the gluteal region. Although
associated with fractures of the sacrum itself. this is a matter of debate, at this point the nerve can be
The sacral plexus gives off various collateral branches compressed by aponeurotic bands or variants of the piri-
that mostly supply muscles in the proximal part of formis muscle, giving rise to what is known as “piriformis
the lower limb. It provides muscular branches for the syndrome” (▶ Fig. 2.7 and ▶ Fig. 2.8).

Fig. 2.7 Anatomic specimen, view of the gluteal region. The


greater gluteal muscle is retracted, revealing the piriformis
Fig. 2.8 The same specimen as in ▶ Fig. 2.7, after resection of
muscle (arrow) and the superior gluteal nerve and vessels (1).
the piriformis muscle. 1, Sciatic nerve; 2, pudendal nerve;
Located below the piriformis muscle are the pudendal nerve (2)
3, superior gluteal vessels and nerve.
and the sciatic nerve (3) in close proximity to the inferior gluteal
vessels and nerve.

14
Surgical Anatomy and Approaches to the Nerves of the Lower Limb

In the gluteal region, the nerve has a descending course the patient to flex the knee. If the sciatic nerve is injured
within the ischiotrochanteric canal, where it passes in in the gluteal region, there will be paralysis of the
close proximity to the neck of the femur. As such, it can muscles innervated by its collateral and terminal
be injured in hip fractures in which any bony fragment is branches. However, if the lesion is located at the level of
directed posteriorly, as well as during hip replacement the thigh, some collateral branches may be preserved.
surgeries.
In the thigh, the nerve descends between the biceps
femoris (lateral), semimembranosus, and semitendinosus Surgical Approach
(medial) muscles and innervates all three. The collateral The proximal portion of the sciatic nerve can be
branches along this section of the nerve mostly originate approached in a classic way through a long incision that
from the medial border of the nerve (nerves for the semi- starts in the gluteal region and is directed laterally,
tendinosus, semimembranosus, and adductor magnus) descending to the gluteal fold. The current authors prefer
(▶ Fig. 2.9). The lateral border only gives off nerves to the the transgluteal or subgluteal approaches, either alone or
biceps.7 combined, due to their better functional and aesthetic
Near the vertex of the popliteal fossa, it divides into its results.22
two terminal branches: the common fibular nerve and The middle third of the nerve can be approached sim-
tibial nerve. This division, however, can sometimes be ply through a linear incision in the midline of the thigh
found at a higher level in the thigh or even within the posteriorly. Once the fascia is opened, the nerve can be
gluteal region. located easily between the posterior thigh muscles.
The inferior third requires a similar incision, but
Clinical Exploration extended to the flexion fold of the knee should the nerve
and its terminal branches need to be exposed.23
The sciatic nerve gives off collaterals that innervate the
muscles of the posterior region of the thigh, which is
why, when examining its motor function, one should ask 2.3.2 Terminal Branches of the
Sciatic Nerve
Tibial Nerve
The tibial nerve originates within the superior part of the
popliteal fossa and is located medial to the fibular nerve
and posterior to the popliteal vessels. It travels along the
main axis of the popliteal fossa and enters the posterior
compartment of the leg, where it passes deep to the
medial and lateral heads of gastrocnemius muscle and to
the ring of the soleus (i.e., the upper fibrous border of the
muscle). At this level, it gives off motor branches to these
muscles. It then takes a somewhat oblique course to end
up behind the medial malleolus. In the leg, it gives off the
inferior branches for the soleus and its terminal branch:
the posterior tibial nerve. This nerve enters an osteofi-
brotic tunnel located behind the medial malleolus: the
tarsal tunnel. In this tunnel, the nerve can be located,
along with the posterior tibial vessels and the tendons of
the posterior tibial, flexor digitorum, and flexor hallucis
longus muscles. In the most distal part of the tunnel,
there are fibrotic partitions that “guide” the vessels and
nerves to the plantar region. The posterior tibial nerve
terminates by dividing into the medial and lateral plantar
nerves. It also gives off a calcaneal branch. The medial
plantar nerve is large and innervates the muscles of the
hallux.8 It also has a branch that runs laterally to inner-
Fig. 2.9 Popliteal region. 1, Sciatic nerve; 2, common peroneal
vate the muscles of the middle plantar compartment. The
nerve; 3, tibial nerve; 4, gastrocnemius muscle. lateral plantar nerve mostly innervates the muscles of the
lateral plantar compartment.

15
Surgical Anatomy and Approaches to the Nerves of the Lower Limb

Clinical Exploration first interosseous space in close proximity to the pedal


artery and muscle.
Through the muscles that it innervates, the posterior
tibial nerve produces plantar flexion of the foot and the
Clinical Exploration
toes as a whole. It also innervates foot inversion.
The fibular nerve innervates extension and eversion of
the foot. Lesions affecting the nerve produce a typical
Surgical Approach
gait, associated with a dropped foot, which is often called
The tibial nerve does not have a specific entrapment neu- a “steppage gait.”
ropathy, so it is approached when it suffers traumatic
lesions, the incision made dependent on the location of Surgical Approach
the lesion itself.
The fibular nerve can become entrapped within the pero-
neal tunnel. In such patients, it can be approached
Common Fibular Nerve through an S-shaped incision created just distal to the
As the common fibular nerve descends, it follows the fibular head.23,24
medial border of the biceps femoris muscle, lateral to the
popliteal vessels and the tibial nerve. More distally, it References
crosses the superior border of the lateral gastrocnemius
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neck. At this point, it is relatively superficial, covered only
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tunnel (peroneal tunnel) where the nerve can be Èditeurs; 1955
[4] Lucien M. Le carrefour sciatique du plexus crural. Compt Rend Assoc
compressed.16,24,25 At this level, the nerve divides into its
Anat. 1956:967–971
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nerves. It also gives off the articular branch to the proxi- periférico. Parte II: Inervación del miembro inferior. In: Socolovsky
mal tibiofibular joint that generates the synovial cysts M, Siqueira M, Malessy M, eds. Introducción a la cirugía de los nervios
that can affect this portion of the nerve.25 periféricos. Buenos Aires: Ediciones Journal; 2013:19–32
[6] Pro A. Anatomía Humana de Latarjet-Ruiz Liard. Buenos Aires:
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Lapierre F. Bases anatomiques des voies d’abord chirurgicales des
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[8] Rouviere H, Delmas A. Anatomía humana. Tomo 3: Miembros.
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11th ed. Mexico: Masson; 2005:525–644
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Deep Fibular Nerve Based Approach. New York, NY: Thieme; 2008:163–166
[12] Viswanathan A, Kim DH, Reid N, Kline DG. Surgical management of
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originates in the peroneal tunnel. From there, it follows a 65(4)(Suppl):A44–A51
[13] Cook D, Midha R. Meralgia paresthetica. In: Midha R, Zager EL, eds.
descending path to enter the anterior compartment of
Surgery of Peripheral Nerves. A Case-Based Approach. New York, NY:
the leg. It then runs alongside the anterior tibial artery Thieme; 2008:167–170
that passes above the interosseous ligament. In the ante- [14] Mattera D, Martinez F, Soria V, et al. Surgical anatomy of the lateral
rior compartment of the leg, the nerve supplies the femoral cutaneous nerve in the groin region. Eur J Anat. 2008; 12(1):
muscles of the region (tibialis anterior, extensor digito- 33–37
[15] de Ridder VA, de Lange S, Popta JV. Anatomical variations of the
rum, and extensor hallucis longus), becoming superficial
lateral femoral cutaneous nerve and the consequences for surgery.
as the muscle bodies become tendons. Within the inferior J Orthop Trauma. 1999; 13(3):207–211
third of the leg, it is located between the tibialis anterior [16] Peri G. The “critical zones” of entrapment of the nerves of the lower
and extensor hallucis longus, where it gives off articular limb. Surg Radiol Anat. 1991; 13(2):139–143
[17] Kitagawa R, Kim D, Reid N, Kline D. Surgical management of obtura-
branches to the tibiotarsal joint and passes beneath the
tor nerve lesions. Neurosurgery. 2009; 65(4)(Suppl):A24–A28
superior extensor retinaculum. It terminates in a medial [18] Spiliopoulos K, Williams Z. Femoral branch to obturator nerve
and lateral branch. The former is considered a continua- transfer for restoration of thigh adduction following iatrogenic injury.
tion of the deep fibular nerve and follows the axis of the J Neurosurg. 2011; 114(6):1529–1533

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Surgical Anatomy and Approaches to the Nerves of the Lower Limb

[19] Huang JH, Whitmore RG, Zager EL. Obturator nerve injury and repair. Parte 1: Nervio ciático y sus ramas (nervios peroneos y tibial poste-
In: Midha R, Zager EL, eds. Surgery of Peripheral Nerves. A Case- rior). In: Wolfla CE, Resnick DK, eds. Atlas de procedimientos neuro-
Based Approach. New York, NY: Thieme; 2008:171–174 quirúrgicos. Columna y nervios periféricos. Caracas: Segunda Edición,
[20] Kapandji AI. Cuadernos de fisiología articular. Tomo II: Miembro Amolca; 2009:372–377
inferior. 5th ed. Madrid: Panamericana; 2007 [24] Martínez F, Pinazzo S, Moragues R, et al. Neuropatía del nervio pero-
[21] Straja A. Anestesia locorregional del miembro inferior. In: Lafaye PG, neo secundaria a paraganglioma paraneural. Reporte de caso. Rev
ed. Anestesia Regional. Barcelona: Masson; 1986:109–128 Chil Neurocirugía. 2013; 39:61–64
[22] Socolovsky M. Estudio anatómico y microquirúrgico del abordaje [25] Van den Bergh FRA, Vanhoenacker FM, De Smet E, Huysse W.
transmuscular a la porción proximal del nervio ciático mayor. Tesis Verstraete KL. Peroneal nerve: Normal anatomy and pathologic
de Doctorado, Facultad de Medicina de la Unidad de Buenos Aires; findings on routine MRI of the knee. Insights Imaging. 2013; 4(3):
2010:76 287–299
[23] Steinmetz MP, Mason AM, Lastra-Powera JJ, Benzel EC. Abordaje
quirúrgico de los nervios periféricos de la extremidad inferior.

17
Nerve Injuries: Anatomy, Pathophysiology, and Classification

3 Nerve Injuries: Anatomy, Pathophysiology, and


Classification
Bassam M. J. Addas

Abstract Keywords: peripheral nerves, traction injury, laceration


Understanding the normal anatomy and the pathophysi- injury, entrapment neuroma in continuity
ology of peripheral nerve injury is of paramount impor-
tance to the clinician who deals with peripheral nerves.
This knowledge allows reaching the optimal recovery. 3.1 Anatomy of the Peripheral
The causes of nerve injuries are many; however, they
share common basic pathophysiological processes. Trac-
Nerves
tion and laceration injuries are the commonest traumatic The basic anatomy of the peripheral nerves is illustrated
mechanism with completely different approach to treat- in ▶ Fig. 3.1a, b. In simple terms, the axon is the basic unit
ment. Entrapment neuropathy is the commonest non- of the peripheral nervous system, surrounded by myelin
traumatic nerve injury encountered in clinical practice. that is produced by Schwann cells. Axons are grouped
Rare forms of nerve injuries are briefly addressed in this together in a fascicle, and the fascicles constitute the
chapter. Overall, this chapter focuses mainly on the prac- main nerve trunk. Endoneurium surrounds the axons,
tical approach to different pathological processes involv- perineurium surrounds the fascicles, and epineurium sur-
ing peripheral nerves based on well-established basic rounds the main nerve trunk. Epineurium (fibrovascular
pathophysiological knowledge. stroma) is the most outer layer of the peripheral nerve

Fig. 3.1 (a) Schematic drawing of the basic


structure of normal peripheral nerves.
(b) The essential elements of the three
layers of peripheral nerves.

18
Nerve Injuries: Anatomy, Pathophysiology, and Classification

trunk, composed mainly of collagen type I and III. Epineu- and Sunderland. Seddon2 first described three well-defined
rium gives the nerve trunk its flexibility, allowing stretch types of nerve injury: neuropraxia (conduction block),
up to 15 to 20% of its length. Thickness of the epineurium axonotmesis (neuroma-in-continuity), and neurotmesis
varies from one nerve to the other and it is generally (nerve division). Sunderland3 followed Seddon by a five-
more abundant near joints. Major nerve blood vessels, point grading system in ascending order of severity with
lymphatics, mast cells, and fibroblasts can be seen in this both anatomical and functional correlations (▶ Table 3.2).
layer. Perineurium is a specialized layer formed by multi- These injuries may not be of uniform severity. Different
ple layers of flattened perineurial cells and acts as a diffu- grades can be present in the same segment of the nerve
sion barrier. It also provides a protective environment to and different grades can be present along the course of
the underlying endoneurium. Endoneurium is the most the nerve. This classification is based on the effect of the
inner compartment that surrounds axons, Schwann cells, injury on the nerve and not necessary the mechanism of
macrophages, and capillaries. The tight junctions of the injury, as this pattern can be caused by stretch, thermal,
endoneurium capillaries form the “blood–nerve barrier.” or ischemic mechanisms.
Schwann cells, the most essential component of regener- Sunderland grade I (neuropraxia) is characterized by
ation of axons, are present only in the endoneurium.1 conduction block, with usually an excellent recovery.
Nerves are subjected to trauma by many different Early in the process, the involved muscles are weak/
mechanisms, traction and laceration injury being the paralyzed, and sensory loss is evident, particularly for
most common traumatic mechanisms. Different, less touch and proprioception; pain is usually more resistant.
common, and rare forms of injury can also lead to signifi- Autonomic function is usually not affected. Wasting of
cant nerve dysfunction, pain, and disability (▶ Table 3.1). muscles is not common and is a useful clinical clue.
To be able to offer the best management in a timely The exact duration of neuropraxia is debatable; however,
fashion, it is essential to understand the different patho- it may range from 1 to 4 months, with an average of
physiological processes related to each mechanism of 2 months in most cases.
injury. Sunderland grade II nerve injury is characterized by
loss of axons with preservation of the endoneurial tube.
Clinically, this is manifested by complete loss of motor,
3.2 Traction Injury sensory, and autonomic functions. Because of the intact
endoneurium, the regenerating axons find its old path
Traction injury is a common mechanism of injury affecting and reach their targets. The time to recovery depends
peripheral nerves; traumatic and birth-induced plexus on the level of injury—the more proximal the lesion, the
injuries represent classical examples of traction injury. longer the time for recovery. Regenerating axons travel in
According to the severity of injury in form of traction, a speed of 1 to 3 mm/day. Tourniquet injury is believed to
pathological changes take place within the nerve. The be a combination of grade I and II.4,5
grading of nerve injury is classically accredited to Seddon Sunderland grade III nerve injury combines grade II
and endoneurial tube disruption. The perineurium is
intact or minimally involved. This pattern means that
Table 3.1 Mechanisms of nerve injuries
the fascicles are preserved as tubes but their inside is
● Traction (stretch, rupture, and avulsion) “messed up.” Trauma inside the fascicles may cause
● Laceration (sharp and blunt) hemorrhage, edema, ischemia, and eventually fibrosis.
● Entrapment Fibrosis constitutes the main barrier for the regenerating
● Pressure axons. The scar created also can cause rerouting of the
● Ischemic/compartment regenerating axons, not reaching their original targets;
this is more evident in mixed fascicles with motor and
● Injection injury
sensory axons compared to pure motor fascicles. This
● Radiation injury
nature of mixed nerve can explain why grade III injury
● Electrical
of the median nerve (mixed nerve) at the arm level is
● Thermal different from grade III injury of the radial nerve (mostly

Table 3.2 Grading of peripheral nerve injuries


Sunderland grade Seddon grade Pathological features Clinical outcome
I Neuropraxia Conduction block, myelin loss Excellent
II Axonotmesis Axon loss Very good
III Grade II and endoneurium loss Variable
IV Grade III and perineurium loss Poor/no recovery
V Neurotmesis Nerve trunk disruption No recovery

19
Nerve Injuries: Anatomy, Pathophysiology, and Classification

Fig. 3.2 Intraoperative photograph depicting the cut section in


the middle of nonconducting neuroma of the sciatic nerve
showing complete loss of internal architecture with the
formation of dense fibrous scar.

motor) at the same level. In proximal lesions, retrograde Fig. 3.3 Intraoperative photograph demonstrating the
technique of slicing the nonconducting neuroma starting from
neuronal degeneration is more pronounced compared to
the center and going proximally and distally until reaching the
grade II, making recovery of grade III injuries significantly
normal fascicular pattern for repair.
worse. Also, the chance for axonal misdirection is higher,
affecting the extent and quality of recovery.
Sunderland grade IV nerve injury (fascicular disrup- and retract and adhere to the underlying tissues. Both
tion) occurs in nerves subjected to higher forces, with ends may remain attached by thin, fibrous tissue or
complete and more severe disorganization of the fascicles normal part of the partially preserved fascicles (▶ Fig. 3.4).
(▶ Fig. 3.2), with no or very little recovery that is usually Retraction can progress with time because of limb move-
nonfunctional. ment, and usually stopped by the next distal branch. Sig-
Sunderland grade V nerve injury (neurotmesis) repre- nificant retraction is usual in median and ulnar nerve
sents a severed, discontinuous nerve. This mode of injury injuries at the arm level because of lack of branches of
is not commonly seen in traction injuries at the level of both nerves at this level. Both stumps usually remain in
the nerve trunk and is usually caused by lacerations. the same plane but may change location according to the
Grades I and II are not surgical lesions and usually adherence to nearby tissues (▶ Fig. 3.5). In blunt lacera-
recover spontaneously. They can be found in association tions caused by blunt objects (motor blades, machinery,
with more severe lesions of grades III and IV (neuroma- chainsaw), irregular, ragged tears of the nerve trunk
in-continuity) involving other nerves. They usually show occur; this causes bruises and hemorrhages along both
positive nerve action potential (NAP) following external ends for some distance, making identification of healthy
neurolysis. In cases of neuroma-in-continuity (grade III end difficult (▶ Fig. 3.6). It is a good practice to explore
and IV), the affected nerve segment is isolated; if no NAP sharp injuries causing complete loss of function of the
or nerve stimulation is present, the neuroma is resected underlying nerves, as this gives the best chance for good
and either primarily repaired or grafted (▶ Fig. 3.3). recovery. In cases of blunt lacerations or contaminated
wounds or large wounds with soft-tissue loss, delayed
3.3 Laceration Injury repair (4–6 weeks) is advised allowing the edematous,
bruised ends of the nerve to heal and therefore delineat-
It has been estimated that laceration injury to the limbs, ing the zone between the normal and the abnormal parts
caused by knifes or sharp objects, causes transection of of the nerve, allowing better reconstruction with either
the underlying nerves in 30% of the cases.6,7 This percent- end-to-end or, more commonly, graft repair.
age depends on the injury location. Volar wrist laceration
injury will cause median or ulnar nerve injury in the
majority of cases. Sharp injuries to different areas of the 3.4 Compression/Pressure
body may not necessary transect the underlying nerve,
yet can cause a temporary loss of function depending on
Injury
the degree of injury. In clean sharp lacerations, there is a Carpal tunnel and cubital tunnel syndromes are the
minimal contusive injury, bruises, or hemorrhage in the most common surgical conditions that surgeons face on a
proximal and distal stumps. Both stumps form neuromas regular basis. Abnormal compression of nerves as they

20
Manual of Peripheral Nerve Surgery | 25.07.17 - 10:00

Nerve Injuries: Anatomy, Pathophysiology, and Classification

Fig. 3.4 Intraoperative photograph of sharp,


near-completely lacerated common pero-
neal nerve 1 month following injury, show-
ing minimal distal and proximal stump
changes.

Fig. 3.5 Exposure of the common peroneal


nerve following gunshot wound to the
popliteal fossa showing the proximal stump
(P) ends into an attenuated, fibrous scar at a
different plane from the distal end (D).

Fig. 3.6 Blunt laceration of the ulnar nerve


at the forearm level caused by a chainsaw.
Note the severely lacerated, contused,
hemorrhagic, and edematous ends making
meaningful repair difficult.

21
Nerve Injuries: Anatomy, Pathophysiology, and Classification

run in their natural courses can lead to dysfunction. inside the epineurium, acute edema takes place, followed
Deficit depends mainly on the degree and the duration of by inflammatory changes and eventually necrosis. This
the compression. Ischemia and mechanical distortion produces a scar, creating axonal block and nerve dysfunc-
are found to be the most common responsible mecha- tion. Blood–nerve barrier is also disrupted, worsening the
nisms.8,9,10 When severe and prolonged ischemia produce damage and further allowing more edema formation.
axonal loss and Wallerian degeneration, Lundborg had Injections outside the epineurium are usually less damag-
found that if the ischemia is prolonged for more than ing to the nerve architecture, but may evoke an inflam-
8 hours, an irreversible damage will take place.11 Chronic matory response and cause scar formation and adhesions
compression of the nerves produces a characteristic to the overlying gluteal muscles. Leakage of the injected
changes that are quite unique in form of alteration in par- material from the site of injection to the vicinity of the
anodal myelination, axonal thinning, and segmental nerve may be the explanation of the delayed symptoms
demyelination.12 Severe and neglected compression will that some patients report. Most cases show improvement
eventually lead to Wallerian degeneration. Generally, in on conservative management.17 The tibial component
entrapment syndromes, symptoms start with pain, and recovers more quickly than the common peroneal com-
only if compression is prolonged, muscle weakness ponent. Exploration is advised if no improvement is
becomes evident. Recovery of nerve compression varies; evident in 6 months’ time. Usually, the sciatic nerve is
generally, most of the pressure neuropathies caused by grossly normal with or without NAP recorded. The
anesthesia positioning will eventually recover without surrounding tissue usually does not show much of any
surgical intervention.13 This is also true for most of neu- reaction. Moderate to severe adhesions are rarely seen sur-
ropathy produced by the use of tourniquets. Pressure rounding the nerve. In some cases, the nerve is stuck to
neuropathies caused by hematomas because of anticoa- the posterior surface of the gluteal muscle. Primary or sec-
gulant therapy represents a dilemma, and surgical ondary repair is rarely needed in the author’s experience.
decision should be evaluated according to every case.
Delaying evacuation and repair of pseudoaneurysms
causing compression and producing new neurological 3.6 Rare Forms of Peripheral
symptoms may produce long-lasting deficits.14
Compartment syndrome is the most severe form of
Nerve Injuries
compression and produces ischemic necrosis that extends 3.6.1 Electrical Injuries
beyond the nerves and involves muscles, tendon, and soft
tissues—the commonest scenario being brachial artery This type of injury is commonly associated with high-volt-
injury in children with supracondylar fractures. If the age injuries that result in death, and peripheral nerve
flow of the brachial artery is not restored in a timely fash- injury is usually the least of the concerns; this makes the
ion, ischemia to the forearm nerves and muscles of the available cases of nerve injury rare, and therefore no uni-
volar forearm surface will occur, and if fasciotomy is not form or clear strategy of management is available. Electri-
performed urgently, the already swollen muscles and sur- cal current produces tissue damage by heating tissue. The
rounding structures, including swollen nerves, will more the current and the duration of exposure, the more
become necrotic. Necrosis of nerves usually involves long the heat generated and therefore the damage. Resistance
segment, making nerve repair options less realistic.15 of tissues increases in the following order: nerves, blood
vessels, muscles, skin, tendons, fat, and bones, nerves being
the most vulnerable.18,19 The commonest clinical scenario
encountered is a young boy electrocuted following holding
3.5 Injection Injury a high-voltage wire. The electrical current burns his hand
Although it seems largely avoidable and preventable, and exits from the forearm or the trunk, with the median
injection injury to the peripheral nerves remains a com- and ulnar nerves being the commonly affected nerves
mon problem particularly in the developing countries. (▶ Fig. 3.7). The principal pathological change in the nerve
Extremes of age groups are usually the victims.16 Because is coagulative necrosis, which is subsequently replaced by
the gluteal muscle is the commonest site of injection, the fibrous scar. When indicated, surgical exploration follow-
sciatic nerve is clinically the commonest nerve involved. ing a period of no recovery will delineate the zone of
The two most important determinants of the degree of injury, and the prognosis of recovery will depend on the
injury are the site of injection (outside epineurium vs. length of the segment involved. If there is a large area of
inside epineurium) and the nature of the injected mate- soft-tissue loss, including muscles, muscle or tendon trans-
rial. The puncture injury of the needle is wrongly blamed fers may be a more logical surgical option.
for the cause of the injury. Pathological changes vary
according to the injected material as there are some
highly toxic chemicals such as penicillin, gentamicin, and
3.6.2 Thermal Injury
diazepam. Less toxic chemicals can also produce signifi- Burning nerves by flames or hot metals may result is neu-
cant damage if injected in large quantities. When injected ral damage. This depends on the level of the heat and the

22
Nerve Injuries: Anatomy, Pathophysiology, and Classification

benefit some patients.24 Nerve transfer can be used in a


few selected cases.25

References
[1] Scheithauer B, Woodruff J, Erlandson R, eds. Atlas of Tumor Pathol-
ogy: Tumors of the Peripheral Nervous System. 1st ed. Washington,
DC: Armed Forces Institute of Pathology; 1999
[2] Seddon HJ. Three types of nerve injury. Brain. 1943; 66(4):237–288
[3] Sunderland S. A classification of peripheral nerve injuries producing
loss of function. Brain. 1951; 74(4):491–516
[4] Ochoa J, Danta G, Fowler TJ, Gilliatt RW. Nature of the nerve lesion
caused by a pneumatic tourniquet. Nature. 1971; 233(5317):265–
266
[5] Ochoa J, Fowler TJ, Gilliatt RW. Anatomical changes in peripheral
nerves compressed by a pneumatic tourniquet. J Anat. 1972;
113(Pt 3):433–455
[6] Kline DG. Physiological and clinical factors contributing to the timing
of nerve repair. Clin Neurosurg. 1977; 24:425–455
[7] Sunderland S. Nerve and Nerve Injuries. Baltimore, MD: Williams &
Wilkins; 1968
[8] Eames RA, Lange LS. Clinical and pathological study of ischaemic
neuropathy. J Neurol Neurosurg Psychiatry. 1967; 30(3):215–226
[9] Williams IR, Jefferson D, Gilliatt RW. Acute nerve compression during
limb ischaemia–an experimental study. J Neurol Sci. 1980; 46(2):
199–207
[10] Lundborg G. Nerve Regeneration. Nerve Injury and Repair. London:
Churchill Livingstone; 1988:149–195
[11] Lundborg G. Ischemic nerve injury. Experimental studies on intra-
neural microvascular pathophysiology and nerve function in a limb
subjected to temporary circulatory arrest. Scand J Plast Reconstr Surg
Fig. 3.7 Electrical injury in a young boy following holding of a
Suppl. 1970; 6:3–113
high-current metal wire, burning the palm of both hands and
[12] Aguayo A, Nair CP, Midgley R. Experimental progressive compression
exiting from the volar aspect of the distal forearm causing
neuropathy in the rabbit. Histologic and electrophysiologic studies.
partial median and ulnar nerve injury. Arch Neurol. 1971; 24(4):358–364
[13] Addas BM. An uncommon cause of brachial plexus injury. Neuro-
sciences (Riyadh). 2012; 17(1):64–65
[14] Roganović Z, Misović S, Kronja G, Savić M. Peripheral nerve lesions
duration of exposure. The nerve can be compressed ini- associated with missile-induced pseudoaneurysms. J Neurosurg.
tially because of edema and fasciotomy may be neces- 2007; 107(4):765–775
[15] Spinner M. Injuries to the Major Branches of Peripheral Nerves of the
sary.20 Compression of neural elements may occur later
Forearm. 2nd ed. Philadelphia, PA: WB Saunders; 1978
following fibrous tissue development. Patients with cir- [16] Villarejo FJ, Pascual AM. Injection injury of the sciatic nerve (370
cumferential burns will be the most susceptible group for cases). Childs Nerv Syst. 1993; 9(4):229–232
this form of compression neuropathy as the surrounding [17] Kline DG, Kim D, Midha R, Harsh C, Tiel R. Management and results of
fibrosis may produce a tourniquet-like effect. sciatic nerve injuries: a 24-year experience. J Neurosurg. 1998; 89(1):
13–23
[18] DiVincenti FC, Moncrief JA, Pruitt BA, Jr. Electrical injuries: a review
3.6.3 Radiation Injury of 65 cases. J Trauma. 1969; 9(6):497–507
[19] Grube BJ, Heimbach DM, Engrav LH, Copass MK. Neurologic conse-
With the refinement of the radiotherapy techniques, this quences of electrical burns. J Trauma. 1990; 30(3):254–258
[20] Salzberg CA, Salisbury RE, Gelberman RH. Thermal Injury of Periph-
form of neuropathy is reduced. It is dose-dependent and
eral Nerve. Operative Nerve Repair and Reconstruction. Philadelphia,
more than 70% of patients who receive more than PA: J.B. Lippincott Company; 1991:671–678
6,000 rad will eventually suffer radiation neuropathy.21 [21] Powell S, Cooke J, Parsons C. Radiation-induced brachial plexus
It usually involves the upper part of brachial plexus in injury: follow-up of two different fractionation schedules. Radiother
patients receiving radiation for breast cancer treat- Oncol. 1990; 18(3):213–220
[22] Bowen BC, Verma A, Brandon AH, Fiedler JA. Radiation-induced
ment.22,23 Symptoms may start few months to several
brachial plexopathy: MR and clinical findings. AJNR Am J Neurora-
years following the treatment. The pathological changes diol. 1996; 17(10):1932–1936
consist of extensive endoneurial fibrosis, with axonal [23] Clodius L, Uhlschmid G, Hess K. Irradiation plexitis of the brachial
degeneration. Changes in blood vessels are universal. Sur- plexus. Clin Plast Surg. 1984; 11(1):161–165
gery is indicated if there is a question between metastatic [24] Lu L, Gong X, Liu Z, Wang D, Zhang Z. Diagnosis and operative treat-
ment of radiation-induced brachial plexopathy. Chin J Traumatol.
and radiation brachial plexopathy. Pain is another indica-
2002; 5(6):329–332
tion for surgery when medical treatment fails. External [25] Addas BM, Midha R. Nerve transfers for severe nerve injury.
neurolysis with excision of the surrounding scar may Neurosurg Clin N Am. 2009; 20(1):27–38, vi

23
Clinical Aspects of Peripheral Nerve Lesions in the Upper Limb

4 Clinical Aspects of Peripheral Nerve Lesions in the


Upper Limb
Javier Robla Costales, Luis Domitrovic, David Robla Costales, Javier Fernández Fernández, and Javier Ibáñez Plágaro

Abstract All the peripheral nerves in the upper limb originate in


An accurate physical examination of a patient with a the brachial plexus. Excluding branches, there are four
peripheral nerve injury provides enough information to nerves: the musculocutaneous nerve, the median nerve,
establish the level of the lesion and the nerve(s) that is the ulnar nerve, and the radial nerve.
(are) affected. Peripheral nerves in the upper limb origi-
nate from the brachial plexus, and they are the musculo-
cutaneous nerve, the median nerve, the ulnar nerve, and 4.2 Musculocutaneous Nerve
the radial nerve. This chapter offers a concise summary of
the information and key points needed to do an accurate Transformation of the medial and lateral cords of the bra-
physical examination of the peripheral nerves of the chial plexus into their terminal branches is M-shaped.
upper limb. The lateral leg of the letter M is the musculocutaneous
nerve (▶ Fig. 4.1).
Keywords: peripheral nerve injury, brachial plexus, periph- The first muscle that the musculocutaneous nerve
eral nerve surgery, physical examination, upper limb innervates is the coracobrachialis muscle. It assists the
anterior deltoid with shoulder flexion (lifting the arm for-
ward in front of one’s body), and it also stabilizes the
4.1 Introduction humerus during elbow flexion. The coracobrachialis can-
not be isolated or readily palpated. Therefore, it is not
An accurate physical examination of a patient with a examined clinically.
peripheral nerve injury generally provides enough infor- After passing through and then deep to the coracobra-
mation to establish the level of the lesion and identify chialis, the musculocutaneous nerve innervates the bra-
which nerves are affected. It is also important to monitor chialis muscle and the biceps brachii muscle (▶ Fig. 4.2).
any improvement in nerve function over the course of The biceps brachii, with the assistance of the brachialis
follow-up. and brachioradialis (innervated by the radial nerve),
This chapter offers a concise summary of the informa- flexes the elbow. The biceps brachii is also a strong
tion and key points needed to perform an accurate phys- supinator of the forearm when the elbow is flexed. To test
ical examination of the peripheral nerves in the upper the biceps brachii and brachialis, have the patient flex a
limb. Anatomy of peripheral nerves in the upper limb is fully supinated forearm against resistance. Contribution
only mentioned as needed to explain certain issues; a from the brachioradialis (radial nerve) is minimized by
thorough review of upper limb nerve anatomy is pro- performing this test with the patient’s forearm in full
vided in Chapter 1. supination (▶ Fig. 4.3).

Fig. 4.1 Anatomy of brachial plexus and


peripheral nerves.

24
Clinical Aspects of Peripheral Nerve Lesions in the Upper Limb

Fig. 4.2 Anatomy of the musculocutaneous


nerve.

The brachialis muscle receives some innervation from ness. These findings need to be clinically differentiated
the radial nerve (in addition to its main innervation from from a biceps tendon rupture, as well as from a C6 radi-
the musculocutaneous nerve). However, this innervation culopathy. Following a tendon rupture, the biceps still
is usually not enough to flex the arm in the presence of contracts and can be felt rolling up the arm. A C6 radicul-
musculocutaneous nerve palsy. opathy is identified not only because of the radicular
Distal to the branches to the biceps brachii and the bra- pain, but also because of possible weakness in other, non-
chialis muscle, the musculocutaneous nerve continues as musculocutaneous innervated C6 muscles, including
the lateral antebrachial cutaneous nerve. The territory the brachioradialis and latissimus dorsi. Furthermore,
of this sensory nerve includes, as the name implies, the C6 radiculopathies usually cause numbness confined to
lateral half of the forearm (▶ Fig. 4.4). the thumb and index finger, whereas the sensory cover-
Isolated musculocutaneous palsies are rare, but can age of the lateral antebrachial cutaneous nerve stops
occur following shoulder trauma or dislocation. These at the wrist. Focal damage to the lateral antebrachial
patients present with numbness on the surface of their cutaneous nerve can occur during venipuncture in the
anterolateral forearm, along with elbow flexion weak- antecubital fossa.

25
Clinical Aspects of Peripheral Nerve Lesions in the Upper Limb

Fig. 4.4 Musculocutaneous nerve. Lateral antebrachial


cutaneous nerve innervation.

hand, the median nerve gives out a pure sensory


branch—the palmar cutaneous branch—which runs
Fig. 4.3 Musculocutaneous nerve. Biceps brachii examination. superficial to the carpal tunnel and ramifies over the
thenar eminence.
The median nerve passes through the center of the
wrist within the carpal tunnel. After it passes through the
4.3 Median Nerve carpal tunnel, the median nerve gives a branch off on its
radial side: the thenar motor branch (or recurrent thenar
The median nerve is derived from the lateral and motor branch). Next, in the deep palm, the median nerve
medial cords of the brachial plexus, with the lateral splits into two divisions: radial and ulnar. The radial divi-
cord providing mostly sensory axons from C6 and C7, sion divides into the common digital nerve to the thumb
and the medial cord mostly motor axons from C8 and and the proper digital nerve to the radial half of the index
T1 (▶ Fig. 4.1). finger. The common digital nerve to the thumb subse-
The median nerve remains slightly lateral and superfi- quently divides into the two proper digital nerves to the
cial to the brachial artery as it travels down the arm. thumb. The ulnar division of the median nerve divides
About halfway down the upper arm, the median nerve into the common digital nerves of the second and third
crosses over the top of the brachial artery, to lie just web spaces, which also subsequently divide into proper
medial to it by the time it passes under the bicipital apo- digital nerves.
neurosis (lacertus fibrosis) in the proximal forearm. The
median nerve travels down the center of the forearm deep
to the flexor digitorum superficialis, but superficial to the
4.3.1 Motor Innervation
underlying flexor digitorum profundus (FDP; ▶ Fig. 4.5). The median nerve innervates no muscles in the upper
About one-third to halfway down the forearm, an arm. However, it innervates numerous muscles in the
important branch of the median nerve exits: the anterior forearm and hand that control forearm pronation, wrist
interosseous nerve (AIN). Once formed, the AIN passes flexion, flexion of the digits (especially the first three),
deeper within the forearm and terminates in the distal and thumb opposition and abduction. To facilitate memo-
forearm deep to the pronator quadratus. As the median rization, these muscles can be separated into four groups:
nerve continues down the forearm, it becomes superficial proximal forearm, anterior interosseous, thenar motor,
about 5 cm proximal to the wrist. Before entering the and terminal group.

26
Clinical Aspects of Peripheral Nerve Lesions in the Upper Limb

Fig. 4.5 Anatomy of the median nerve.

The Proximal Forearm Group tendon can be observed and palpated proximal to the
wrist.
Four muscles form this group: the pronator teres, flexor The palmaris longus corrugates the palmar skin. This
carpi radialis, flexor digitorum superficialis, and palmaris muscle is not readily examined for muscular strength; in
longus. fact, it is absent in roughly 15% of the population.
The pronator teres is the main pronator of the forearm The flexor digitorum superficialis flexes all the fingers,
and the first muscle innervated by the median nerve. except the thumb, at their proximal interphalangeal joint.
Branches to the pronator teres exit the median nerve in To assess proximal interphalangeal joint flexion, each
the lowest part of the upper arm, before the median nerve finger is tested separately. Placing your fingers between
passes between the two heads of the pronator teres. To the single finger to be tested and the remaining fingers
test this muscle, the elbow should be extended with the isolates this movement (▶ Fig. 4.6c). This position places
forearm fully pronated. The patient is then instructed to the finger to be tested in mild flexion at the metacarpal–
resist forced supination by the examiner (▶ Fig. 4.6a). phalangeal joint and stabilizes the remaining fingers in
The flexor carpi radialis is the more important wrist extension, a position that allows for isolation of the flexor
flexor. Wrist flexion is done through contraction of the digitorum superficialis.
flexor carpi radialis (median nerve) and flexor carpi ulna-
ris (ulnar nerve). Loss of flexor carpi radialis function
The Anterior Interosseous Group
severely limits wrist flexion, but not toward the ulnar
side. Test the flexor carpi radialis by having the patient The AIN innervates three forearm muscles: the FDP (to
flex the wrist toward the anterior aspect of the forearm the second and third digits), the flexor pollicis longus,
(▶ Fig. 4.6b). During wrist flexion, the flexor carpi radialis and the pronator quadratus. Although the AIN gives

27
Clinical Aspects of Peripheral Nerve Lesions in the Upper Limb

Fig. 4.6 Median nerve. The proximal fore-


arm group: (a) pronator teres, (b) flexor
carpi radialis, (c) flexor digitorum super-
ficialis.

sensory innervation to the distal radioulnar, radiocarpal, consequently, instead of the fingertips touching, the volar
intercarpal, and carpometacarpal joints, it provides no surfaces of each distal phalanx make contact (▶ Fig. 4.7d).
cutaneous innervation. The third muscle innervated by the AIN is the prona-
The median and ulnar nerves innervate the FDP. The tor quadratus. This is a significantly weaker forearm
median nerve controls flexion of the distal interphalangeal pronator than the pronator teres. In fact, weakness of
joint of the second and, partly, the third digits; the ulnar the pronator quadratus is often not readily apparent
nerve controls this muscle’s action upon the third (partly), when the pronator teres is strong. However, fully flexing
fourth, and fifth digits. Distal interphalangeal joint flexion the forearm at the elbow removes the mechanical advant-
of the third (or long) digit has variable dominance, in age of the pronator teres; and, in this position, weakness
terms of innervation from the median versus ulnar nerve. of the pronator quadratus should be detectable when
Therefore, to assess median innervation of the FDP in iso- compared against the normal arm (▶ Fig. 4.7c).
lation, one must concentrate on the index finger. To do so,
hold the metacarpophalangeal and proximal interphalan-
geal joints immobile and have the patient flex the distal
The Thenar Group
phalanx against resistance (▶ Fig. 4.7a). The thenar motor branch of the median nerve innervates
The flexor pollicis longus flexes the distal phalanx of three muscles: the abductor pollicis brevis, the flexor
the thumb at the interphalangeal joint. Assess the flexor pollicis brevis, and the opponens pollicis.
pollicis longus by immobilizing the thumb, except for the There are two types of thumb abduction: palmar
interphalangeal joint, and asking the patient to flex the abduction away from the plane of the palm (mediated by
distal phalanx against resistance (▶ Fig. 4.7b). A quick the abductor pollicis brevis) and radial abduction away
way to assess both FDP and flexor pollicis longus innerva- from the line of the forearm (mediated by the abductor
tion from the AIN is to ask the patient to make an okay pollicis longus). Therefore, even with complete palsy of
sign by touching the tips of the thumb and index finger the abductor pollicis brevis, radial abduction of the
together. When these muscles are weak, the distal thumb can still occur. To test the abductor pollicis brevis,
phalanges of the thumb and index finger cannot flex; resist movement of the thumb away from the plane of

28
Clinical Aspects of Peripheral Nerve Lesions in the Upper Limb

Fig. 4.7 Median nerve. The anterior


interosseous group: (a) flexor digitorum
profundus (to the second and third digits),
(b) flexor pollicis longus, (c) pronator
quadratus, (d) okay sign.

Fig. 4.8 Median nerve. The thenar group: (a) abductor pollicis brevis, (b) flexor pollicis brevis, (c) opponens pollicis.

the palm (palmar abduction) while the hand is immobi- your other hand to immobilize the first metacarpal to
lized (▶ Fig. 4.8a). reduce substitution by the opponens pollicis. Because
The flexor pollicis brevis has both a deep and super- the flexor pollicis brevis is dually innervated, some
ficial head. The superficial head is innervated by the thumb flexion can still occur with median nerve
median nerve and the deep head by the ulnar nerve. palsy.
This muscle flexes the thumb at the metacarpophalan- To assess the opponens pollicis, have the patient forci-
geal joint. To test the flexor pollicis brevis, immobilize bly maintain contact between the fingertips of the thumb
the thumb’s interphalangeal joint and have the patient and fifth digit while you try to pull the first metacarpal
flex at the metacarpal–phalangeal joint (▶ Fig. 4.8b). away from the fifth digit (▶ Fig. 4.8c). Although the
Make certain that the distal interphalangeal joint is median nerve independently controls thumb opposition,
blocked for flexion because, if it is allowed, substitu- a combination of thumb adduction (adductor pollicis;
tion by the flexor pollicis longus may occur. Also use ulnar nerve) and thumb flexion (flexor pollicis brevis;

29
Clinical Aspects of Peripheral Nerve Lesions in the Upper Limb

deep head, ulnar nerve) may mimic thumb opposition 4.3.3 Martin-Gruber and
when median nerve palsy is present.
The key to exploring motor function in the thumb is to Riche-Cannieu Anastomoses
compare it against the normal hand. This is because, even Anastomoses between the ulnar nerve and either the
after complete loss of median nerve function, some median nerve or its anterior interosseous branch may
movement of the thumb may occur either secondary to occur in the hand and in the forearm. Many variations are
true muscle action via radial and ulnar innervations or possible, and minor and major shifts in motor innervation
through substitution by adjacent muscles. of the hand may occur through these two potential routes
of communication: the Martin-Gruber and Riche-Cannieu
anastomoses.
The Terminal Group
In up to 15% of limbs, a Martin-Gruber anastomosis is
The terminal group consists of the first and second present that involves the median nerve–innervated thenar
lumbricals, which are innervated by the terminal radial muscles (opponens pollicis, abductor pollicis brevis, and
and ulnar divisions of the median nerve, respectively. To flexor pollicis brevis). With this variation, nerve fibers
examine the first lumbrical, stabilize the index finger in a destined for these three muscles run down the anterior
hyperextended position at the metacarpophalangeal joint interosseous branch and are transferred to the ulnar
and then provide resistance as the patient extends the nerve. Within the palm, these fibers are finally transferred
finger at the proximal interphalangeal joint (▶ Fig. 4.9). back to the thenar motor branch, innervating their respec-
tive muscles. This distal communication between the deep
ulnar branch and the thenar motor branch in the palm is
4.3.2 Sensory Innervation termed the Riche-Cannieu anastomosis.
The median nerve carries cutaneous sensory information Therefore, in patients with a low median nerve injury
from the radial two-thirds of the palm and the volar in the wrist or distal forearm in whom a Martin-Gruber
surfaces of the first, second, third, and radial half of the anastomosis is present, thenar motor function can para-
fourth digits (▶ Fig. 4.10). Dorsal fingertip sensation is doxically be spared. In the same way in these patients,
also carried by the median nerve, including the dorsum damage to the ulnar nerve near the wrist can cause more
of the ulnar half of the distal phalanx of the thumb. severe deficits in intrinsic hand function than typically
Explore sensation over the thenar eminence to assess the expected.
palmar cutaneous branch, and sensation over the distal It is important to remember that, whenever strange
portion of the second and third digits to assess the sen- deficit patterns are evident following a median or ulnar
sory fibers that are carried by the median nerve through nerve injury, one should always consider these potential
the carpal tunnel. anastomoses.

Fig. 4.9 Median nerve. The terminal group: first and second
lumbricals. Fig. 4.10 Median nerve. Sensory innervation.

30
Clinical Aspects of Peripheral Nerve Lesions in the Upper Limb

4.3.4 Clinical Findings tor quadratus. This results in the inability to perform a
pinch-type maneuver with the affected hand (patients
The Upper Arm have a positive “okay sign”). Weak forearm pronation will
also frequently be present, but is difficult to demonstrate
Severe injury to the median nerve in the upper arm
because the pronator teres remains functional. To con-
affects the entire distribution of the nerve, with sensory
firm a pure AIN palsy, all other muscles innervated by
loss and lost function in all of the muscles innervated.
the median nerve, as well as sensation, must be normal.
The branch to the pronator teres (the first muscle
Variations and incomplete syndromes are common.
innervated by the median nerve) often arises above the
Consequently, many other etiologies may mimic this
elbow. Loss of pronator function suggests injury to
condition.
the median nerve at or above the elbow. Involvement of
AIN syndrome is a pure motor nerve palsy. Inability to
the flexor carpi radialis also suggests median nerve injury
perform a pinch maneuver should alert the physician to
at or above the elbow.
this diagnosis, as this is almost pathognomonic.
When examining for complete median nerve palsy, the
following pitfalls must be considered. The brachioradialis
(innervated by the radial nerve), aided by gravity, may The Wrist: Carpal Tunnel Syndrome
pronate the forearm from full supination. Next, you may
observe thumb opposition via the indirect actions of the In cases of median nerve injury at the wrist, objective
flexor pollicis brevis (its deep muscle head) and the sensory testing over the thenar eminence should be nor-
adductor pollicis (both innervated by the ulnar nerve). mal, because sensation is transmitted via the palmar
cutaneous branch, which does not pass through the car-
pal tunnel (▶ Fig. 4.5). However, the thenar muscular
The Forearm group (the abductor pollicis brevis, the flexor pollicis bre-
Pronator Teres Syndrome and Sublimis vis, and the opponens pollicis) will be affected. Rarely,
the thenar motor branch is affected selectively.
Arch Syndrome
The median nerve may be compressed or pinched where
it passes between the two heads of the pronator teres. 4.4 Ulnar Nerve
The only median-innervated muscle that is not affected
As stated previously, the transformation of the medial
by this syndrome is the pronator teres itself. This is
and lateral cords into their terminal branches is M-
because branches from the median nerve destined for
shaped, lying over the anterior aspect of the axillary
this muscle originate proximal to where the median
artery. The lateral leg of the letter M is the musculocuta-
nerve passes underneath it. Median-innervated hand
neous nerve, while the medial leg is the ulnar nerve. The
sensation is often normal; and motor function may be
ulnar nerve is an extension of the medial cord of the bra-
difficult to ascertain because of pain. Nonetheless, weak-
chial plexus (▶ Fig. 4.1).
ness is occasionally seen during flexion of the second and
Until it reaches the forearm, the ulnar nerve gives off no
third digits.
branches to any muscle (▶ Fig. 4.11). Below the elbow, the
A fibrotic arch between the two heads of the flexor dig-
first branches are destined for the flexor carpi ulnaris.
itorum superficialis may also compress the median nerve
Then, the ulnar nerve passes deep to the two proximal
as it passes underneath. This ridge has been called the
heads of the flexor carpi ulnaris, where it provides just a
sublimis arch. Clinical manifestations of this entrapment
single major branch to the FDP (the ulnar portion of the
are quite similar to those of pronator teres syndrome,
FDP). Two sensory branches originate from the ulnar nerve
except that forceful flexion of the proximal interphalan-
in the distal half of the forearm—the dorsal ulnar cutane-
geal joints of the second to fifth digits, which is mediated
ous nerve and the palmar ulnar cutaneous nerve—which
by contraction of the flexor digitorum superficialis
arise approximately 5 to 10 cm proximal to the wrist
muscle, may precipitate symptoms.
crease. In some cases, the dorsal ulnar cutaneous nerve
may branch from the superficial sensory radial nerve.
Anterior Interosseous Nerve Palsy The ulnar nerve enters the hand via Guyon’s tunnel.
An isolated palsy affecting the AIN may occur secondary Distally in Guyon’s tunnel, the nerve divides into a deep
to trauma, fractures, Parsonage–Turner syndrome, anom- motor branch and a superficial sensory branch. From the
alous muscles and/or tendons, or without any known deep branch of the ulnar nerve originates a small branch
cause. Patients usually complain of weakness or clumsi- that innervates the hypothenar muscles. The deep
ness grasping objects with their first two digits. There are (motor) branch supplies all the muscles innervated by the
usually no complaints of pain; and, because this nerve ulnar nerve in the hand. The superficial branch splits into
contributes nothing to cutaneous sensation, no numbness digital nerves destined for the fourth and fifth digits.
occurs. There is weakness of the FDP (involving the This mixed nerve supplies muscles of the forearm and
second and third digits), flexor pollicis longus, and prona- hand and provides sensation over the fourth and fifth

31
Clinical Aspects of Peripheral Nerve Lesions in the Upper Limb

Fig. 4.11 Anatomy of the ulnar nerve.

digits, as well as in the palm (ulnar side) and over the proximal to the wrist. Flexor carpi ulnaris contraction
dorsal (ulnar side) surface of the hand. stabilizes the pisiform, so the abductor digiti minimi can
abduct the fifth digit (▶ Fig. 4.12a). Then, instruct the
patient to flex the wrist against resistance in an ulnar
4.4.1 Motor Innervation direction, which is the primary action of this muscle
The ulnar nerve innervates no muscles in the upper (▶ Fig. 4.12b).
arm. The muscles innervated by the ulnar nerve may be The FDP to the fourth and fifth digits is tested as its
grouped into: a forearm group (flexor carpi ulnaris, median-innervated half, focusing on the fifth digit. Immo-
FDP); a hypothenar group (palmaris brevis, abductor bilize the proximal interphalangeal joint while the pa-
digiti minimi, flexor digiti minimi, opponens digiti tient flexes the distal interphalangeal joint (▶ Fig. 4.12c).
minimi); intrinsic muscles of the hand (the third and Although the median nerve’s anterior interosseous
fourth lumbricals, and the palmar and dorsal interos- branch may occasionally control distal interphalangeal
sei); and the thenar group (adductor pollicis, flexor joint flexion of the ring finger, the ulnar nerve always
pollicis brevis). controls this movement in the fifth digit.

Forearm Group Hypothenar Group


Testing the flexor carpi ulnaris is a two-step process. The palmaris brevis is located within the roof of Guyon’s
First, while the patient is abducting the fifth digit, tunnel. When it contracts, it corrugates the hypothenar
observe and palpate the flexor carpi ulnaris tendon just skin. To test this muscle, have the patient forcibly abduct

32
Clinical Aspects of Peripheral Nerve Lesions in the Upper Limb

Fig. 4.12 Ulnar nerve. Forearm group:


(a,b) flexor carpi ulnaris, (c) flexor digitorum
profundus.

Fig. 4.13 Ulnar nerve. Hypothenar group:


(a) palmaris brevis, (b) abductor digiti minimi,
(c) flexor digiti minimi, (d) opponens digiti
minimi.

the fifth digit and “contract” the hypothenar eminence. The opponens digiti minimi is tested by the examiner
Skin corrugation (wrinkling) should occur (▶ Fig. 4.13a). trying to force the patient’s distal fifth metacarpal
The abductor digiti minimi is tested by having the pa- away from the thumb, while the patient holds the volar
tient abduct his or her fifth digit against resistance pads of the distal thumb and fifth digit together
(▶ Fig. 4.13b). (▶ Fig. 4.13d).
Immobilizing the interphalangeal joints of the fifth
digit and instructing the patient to flex the metacarpo-
phalangeal joint against resistance assesses the flexor dig-
Intrinsic Muscles of the Hand
iti minimi (▶ Fig. 4.13c). One cannot isolate this muscle’s The hand’s intrinsic muscles can be organized into three
function entirely, because flexion of the fifth digit’s meta- groups: lumbricals, palmar interossei, and dorsal interos-
carpophalangeal joint is also performed by the fourth sei. The lumbricals assist with flexing the metacarpopha-
lumbrical and the interossei. langeal joints and extending the proximal interphalangeal

33
Clinical Aspects of Peripheral Nerve Lesions in the Upper Limb

joints when the metacarpophalangeal joints are immobi- The deep head of the flexor pollicis brevis is innervated
lized in a hyperextended position. The dorsal interossei by the ulnar nerve. However, as stated previously, its
abduct or spread the fingers. Conversely, the palmar inter- superficial head is innervated by the median nerve. Test-
ossei adduct or close the fingers. ing this muscle is not very useful because of its dual
The deep branch of the ulnar nerve innervates the third innervation. However, some weakness relative to the
and fourth lumbricals (to the fourth and fifth digits), as other hand may occur with ulnar lesions. To test this
well as all of the palmar and dorsal interossei muscles. muscle, have the patient flex the thumb’s metacarpopha-
To test the third and fourth lumbricals, immobilize the langeal joint while the interphalangeal joint is main-
metacarpophalangeal joints of these two fingers in tained in extension to minimize compensatory action by
hyperextension, and then test extension of the proximal the flexor pollicis longus (▶ Fig. 4.15b).
interphalangeal joints against resistance (▶ Fig. 4.14a).
A simple way to test the palmar and dorsal interossei is
by abducting the index finger against resistance (first
4.4.2 Sensory Innervation
dorsal interosseous) (▶ Fig. 4.14b) and adducting the The ulnar nerve has three sensory branches, which
index finger against resistance (second palmar inteross- together provide sensory innervation to the medial third
eous) (▶ Fig. 4.14c). of the hand (▶ Fig. 4.16).
The dorsal ulnar cutaneous nerve innervates the dorso-
medial third of the hand. It also innervates the dorsum of
Thenar Group the fifth finger and the medial half of the fourth. How-
The ulnar nerve innervates two muscles within the the- ever, the skin under and surrounding the fingernail is
nar eminence: the adductor pollicis and the deep head of innervated by the superficial sensory division of the ulnar
the flexor pollicis brevis. nerve. Sensory testing of the dorsal ulnar cutaneous
The adductor pollicis can be tested by the examiner by nerve should take place on the dorsal surface of the
trying to separate the thumb from the lateral border medial third of the hand.
of the palm while having the patient adduct a straight- The palmar ulnar cutaneous nerve provides sensory
ened thumb (▶ Fig. 4.15a). innervation to the whole medial third of the palm.

Fig. 4.14 Ulnar nerve. Hand intrinsic muscles: (a) third and fourth lumbricals, (b) first dorsal interosseous, (c) second palmar
interosseous.

Fig. 4.15 Ulnar nerve. Thenar group: (a)


adductor pollicis, (b) flexor pollicis brevis.

34
Clinical Aspects of Peripheral Nerve Lesions in the Upper Limb

The Elbow
Cubital tunnel syndrome is the second most frequent
nerve entrapment in the body after carpal tunnel syndro-
me. This ulnar nerve entrapment is localized most fre-
quently within the postcondylar groove. Even though
branches to the flexor carpi ulnaris often originate from
the ulnar nerve distal to the postcondylar groove
(▶ Fig. 4.11), weakness of this muscle in cubital tunnel
syndrome is rare. This has been attributed to the sensory
and intrinsic hand muscle motor fibers in the ulnar nerve
at the elbow being more superficial and, therefore, more
prone to injury. If flexor carpi ulnaris weakness is present
or occurs early, a lesion more proximal to the postcondy-
lar groove should be considered. In other kinds of injury
Fig. 4.16 Ulnar nerve. Sensory innervation.
not associated with entrapment at the elbow, the flexor
carpi ulnaris will always be affected, and the clinical find-
ings can be the same as when the site of injury is located
However, because of variations in sensory territory, in the upper arm.
the best area to test this nerve’s function is over the
hypothenar eminence.
The superficial sensory division of the ulnar nerve car-
The Forearm
ries sensation from the volar surface of the fifth finger Injuries in the forearm that occur distal to the elbow but
and the medial half of the fourth, including the dorsal proximal to the wrist present with normal function of
aspect of the distal phalanges (fingernails). The digital the FDP and flexor carpi ulnaris muscles. Depending on
nerves carry sensation from the fingers to the superficial the location of the injury along the course of the ulnar
sensory division. The best area to test sensation for this nerve, hand sensation can be more or less affected—
nerve is over the volar surface of the fifth digit. for example, if the dorsal and palmar cutaneous nerves’
origins are proximal versus distal to the injury site.
Where the ulnar sensory branches originate is most
4.4.3 Clinical Findings valuable in localizing ulnar nerve lesions. Sensory loss
that includes the palmar or dorsal aspect of the hand
The Upper Arm
implies that the lesion is proximal to Guyon’s tunnel
Injuries to the ulnar nerve in the upper arm can pro- (▶ Fig. 4.11). Distal to Guyon’s tunnel, the ulnar nerve
duce complete ulnar nerve palsy. This includes lost sen- divides into superficial and deep branches. The superficial
sation over the hypothenar eminence (palmar ulnar (sensory) branch supplies skin over the hypothenar
cutaneous branch), the volar surface of the fifth and eminence, as well as sensation to the entire fifth (little)
half of the fourth digit (superficial sensory division), finger and the ulnar half of the fourth (ring) finger.
and the dorsomedial third of the hand and fingers (dor-
sal ulnar cutaneous nerve). If sensory loss extends
more than 2 cm proximal to the wrist crease, one
The Wrist
should consider involvement of the medial antebrachial Ulnar lesions in the wrist generally spare flexor carpi
cutaneous nerve and therefore the medial cord of the ulnaris and FDP function, and also spare sensation over
brachial plexus (▶ Fig. 4.1). the palm and dorsum of the hand.
Wrist flexion in the ulnar direction will be absent. The Ulnar nerve compression at the wrist (Guyon’s tunnel)
distal phalanges of the fourth and especially the fifth digit is rare. Three variations in clinical presentation have been
will not flex secondary to FDP weakness. Marked intrinsic described (purely motor, purely sensory, or mixed),
weakness of the hand can occur, with residual function because compression can occur within three zones:
provided by the thenar muscles innervated by the ● Zone 1: With compression of the ulnar nerve before it

median nerve. There will be lost finger abduction and divides within Guyon’s tunnel, sensory loss occurs over
adduction from paralysis of the dorsal and palmar inter- the volar surfaces of the fifth and medial half of the
ossei, respectively. However, some finger abduction or fourth finger, including the nail beds (superficial sen-
adduction can still occur due to compensation by the long sory division). Sensation to the hypothenar eminence is
finger flexors and extensors. The so-called ulnar claw commonly spared because the palmar ulnar cutaneous
hand is characteristic of an ulnar nerve palsy. nerve is unaffected. Patients can have intrinsic hand

35
Clinical Aspects of Peripheral Nerve Lesions in the Upper Limb

muscle weakness, including a claw hand, a Wartenberg radial nerves (▶ Fig. 4.17). The location of this bifurcation
sign, and a Froment paper sign. is variable. The radial nerve provides motor innervation
● Zone 2: When compression only affects the deep motor to the brachioradialis and extensor carpi radialis longus 2
branch, no cutaneous sensory loss is evident. However, to 3 cm proximal to the elbow. The branch to the extensor
the motor deficits seen are similar to those of a zone 1 carpi radialis brevis originates from the radial nerve near
lesion. To confirm that the superficial sensory division its bifurcation.
is spared, one can test for palmaris brevis contraction. The superficial head of the supinator muscle forms a
The superficial sensory division innervates this small pocket into which the posterior interosseous nerve (PIN)
muscle; therefore, if this muscle contracts, one knows descends. The edge of this pocket can be fibrous and is
that this division is at least partially functional. termed the arcade of Fröhse. The superficial sensory radial
● Zone 3: When compression only affects the superficial nerve remains superficial to both heads of the supinator.
sensory division, the best area to test for sensory loss is The PIN is a pure motor nerve. It enters the supinator
over the volar surface of the fifth digit. Motor function pocket deep to the arcade of Fröhse. Once between the
is normal. two heads of the supinator muscle, the PIN travels later-
ally, entering the extensor compartment of the forearm.
Remember that the intrinsic muscles of the hand may be After emerging from between the two heads of the
intact in some patients with a Martin-Gruber or Riche- supinator muscle in the extensor compartment of the
Cannieu anastomosis. forearm, it then ramifies into a large number of branches,
which are often called the cauda equina of the forearm,
which run sequentially over the abductor pollicis
4.5 Radial Nerve longus, the extensor pollicis longus, and the extensor pol-
Distal to the origins of the thoracodorsal and axillary licis brevis (the three thumb muscles that are innervated
nerve branches, the posterior cord of the brachial plexus by the radial nerve).
becomes the radial nerve (▶ Fig. 4.1). The superficial sensory branch continues under the
The radial nerve in the arm courses around the hume- brachioradialis muscle until approximately two-thirds of
rus and pierces the lateral intermuscular septum. In the the way down the forearm. In the lower third of the
lateral arm, it lies between the brachialis and brachiora- forearm, it becomes superficial and branches toward the
dialis muscles and enters the antecubital fossa under the dorsolateral aspect of the hand.
cover of the brachioradialis, the extensor carpi radialis
longus, and the extensor carpi radialis brevis, which
sequentially arcade over the nerve. This arcade of muscles
4.5.1 Motor Innervation
is referred to as the radial tunnel. The radial nerve innervates four muscle groups: the
Distal to the elbow joint, the radial nerve bifurcates triceps group (triceps muscle, three heads), the lateral
into the posterior interosseous and superficial sensory epicondyle group (brachioradialis, extensor carpi radialis

Fig. 4.17 Anatomy of the radial nerve.

36
Clinical Aspects of Peripheral Nerve Lesions in the Upper Limb

longus and brevis, and supinator muscle), the PIN- ceps muscle, support the limb with the elbow half-
superficial group (extensor carpi ulnaris, extensor extended and instruct the patient to extend the elbow
digitorum communis, and extensor digiti minimi), and the against resistance (▶ Fig. 4.18).
PIN-deep group (abductor pollicis longus, extensor pollicis
longus, extensor pollicis brevis, and extensor indicis). Lateral Epicondyle Group
Branches to the brachioradialis muscle originate proxi-
Triceps Group mal to the lateral epicondyle. To test this muscle, have
The triceps has three heads (long, medial, and lateral), the patient flex the elbow against resistance with the
which act together to extend the forearm. To test the tri- forearm halfway between pronation and supination
(▶ Fig. 4.19a). With contraction, the brachioradialis
muscle becomes prominent and can be both observed
and palpated.
The extensor carpi radialis longus and brevis are tested
together by having the patient extend and abduct the
wrist against resistance while you stabilize the distal
forearm (▶ Fig. 4.19b). With the forearm pronated, these
muscles can be seen lateral to the brachioradialis. Most
branches to the extensor carpi radialis longus originate
from the radial nerve above the lateral epicondyle,
whereas branches to the extensor carpi radialis brevis
usually arise below the lateral epicondyle.
In the proximal forearm, the PIN innervates the supina-
tor before it passes under the arcade of Fröhse. The supi-
nator muscle supinates the forearm. Although the biceps
muscle is also a strong forearm supinator, it can be placed
at a mechanical disadvantage by extending the elbow.
Therefore, to isolate supinator function, it should be
Fig. 4.18 Radial nerve. Triceps muscle examination.
tested with the elbow extended (▶ Fig. 4.19c).

Fig. 4.19 Radial nerve. Lateral epicondyle


group: (a) brachioradialis muscle,
(b) extensor carpi radialis longus and brevis,
(c) supinator.

37
Clinical Aspects of Peripheral Nerve Lesions in the Upper Limb

Posterior Interosseous Nerve—Superficial digit (▶ Fig. 4.20c). This digit is usually quite weak and
should be compared against the normal hand.
Group
After passing through the supinator and entering the Posterior Interosseous Nerve—Superficial
extensor compartment, the PIN supplies the superficial
group of extensor muscles, often through a common
Group
branch. This group includes the extensor carpi ulnaris, The deep group of muscles is usually innervated by two
the extensor digitorum communis, and the extensor digiti separate branches from the PIN. This group includes
minimi. muscles that act upon the thumb and index finger: the
Test the extensor carpi ulnaris by stabilizing the distal abductor pollicis longus, extensor pollicis longus, exten-
forearm and having the patient extend and adduct the sor pollicis brevis, and extensor indicis. They are the most
wrist, bent in an ulnar direction (▶ Fig. 4.20a). This distal, radial nerve–innervated muscles.
muscle’s tendon can be observed and palpated at the The abductor pollicis longus abducts the thumb in
wrist. a radial direction (remember that the abductor polli-
The extensor digitorum communis extends the second cis brevis is responsible for palmar abduction of
to fifth digits at the metacarpophalangeal joints. To evalu- the thumb). To test the abductor pollicis longus, the
ate this muscle, have the patient extend each finger at the patient should maintain an extended thumb away
knuckle joint while you apply resistance just proximal from the index finger in the plane of the palm
to the proximal interphalangeal joint (▶ Fig. 4.20b). (▶ Fig. 4.21a).
The patient should not be allowed to simultaneously Thumb extension can be tested with the hand in a
flex the wrist because this will extend the fingers secon- fist, resting with its ulnar surface on some flat surface
dary to a tenodesis effect. The second and fifth digits have (like a table or the patient’s thigh). The thumb is
supplementary extensors: the extensor indicis and digiti actively extended away from the other fingers. The exten-
minimi. sor pollicis longus extends the interphalangeal joint
The extensor digiti minimi acts in a similar fashion to (▶ Fig. 4.21b), while the extensor pollicis brevis extends
the extensor digitorum communis, but only upon the fifth the metacarpophalangeal joint (▶ Fig. 4.21c).

Fig. 4.20 Radial nerve. Posterior


interosseous nerve—superficial group:
(a) extensor carpi ulnaris, (b) extensor
digitorum communis, (c) extensor digiti
minimi.

38
Clinical Aspects of Peripheral Nerve Lesions in the Upper Limb

Fig. 4.21 Radial nerve. Posterior


interosseous nerve—superficial group:
(a) abductor pollicis longus, (b) extensor
pollicis longus, (c) extensor pollicis brevis.

The extensor indicis acts only upon the index finger


and is examined like the extensor digitorum communis,
as described earlier.
Rarely, the PIN can communicate with the deep motor
branch of the ulnar nerve and control the first dorsal
interossei muscles. This anomalous communication is
called the Froment–Rauber nerve.

4.5.2 Sensory Innervation


Deficits involving the radial nerve’s sensory branches can
help localize the level of injury (▶ Fig. 4.22).

Posterior Cutaneous Nerve to the Arm


The posterior cutaneous nerve to the arm is the first sen-
sory branch of the radial nerve. It originates in the axilla.
Sensory loss in this territory is indicative of a radial nerve
lesion proximal to the spiral groove.

Lower Lateral Cutaneous Nerve to the


Arm
The lower lateral cutaneous nerve to the arm originates
from the radial nerve in the spiral groove. The sensory
territory of this branch includes the lower lateral arm
below the deltoid. Sensory loss here, with preserved pos-
terior arm sensation (via the posterior cutaneous nerve to

Fig. 4.22 Radial nerve. Sensory innervation.

39
Clinical Aspects of Peripheral Nerve Lesions in the Upper Limb

the arm), may indicate injury of the radial nerve within axilla. When a high radial palsy in the axilla occurs, it can
the spiral groove. cause both triceps weakness and posterior arm sensory
loss (from injury to the posterior cutaneous nerve to the
arm), two deficits that distinguish this location from
Posterior Cutaneous Nerve to the
more common radial nerve injuries occurring at the spiral
Forearm groove.
The posterior cutaneous nerve to the forearm originates Injuries affecting the proximal radial nerve in the axilla
at the brachial-axillary angle, proximal to the origin may be differentiated from posterior cord involvement by
of the lower lateral cutaneous nerve to the arm. The confirming normal deltoid and latissimus dorsi strength
posterior cutaneous nerve to the forearm runs with the (innervated by the axillary and thoracodorsal branches of
radial nerve in the spiral groove, and pierces the brachial the posterior cord, respectively). Patients with C7 palsies
fascia with the lower lateral cutaneous nerve to the arm can be distinguished from posterior cord or radial nerve
near the lateral intermuscular septum. Then it passes injuries because they usually have numbness on both the
posterior to the lateral epicondyle and lateral to the ole- volar and dorsal surfaces of the third digit. Furthermore,
cranon. Its sensory territory includes the dorsolateral C7 muscles innervated by the median nerve (i.e., pronator
aspect of the forearm. teres and flexor carpi radialis longus) would also be
weak.
Consequently, the hallmark of a radial nerve injury in
Superficial Sensory Radial Nerve the axilla is triceps weakness, whereas radial nerve inju-
The superficial sensory radial nerve provides sensation to ries in the arm from the spiral groove through the distal
the dorsolateral half of the hand, as well as the proximal humerus and elbow spare the triceps muscle, but lead to
two-thirds of the second, third, and lateral half of the weakness involving the remaining muscles, including the
fourth digits. The more lateral portion of the thumb is brachioradialis.
also part of the sensitive territory of this nerve. It is not Due to brachioradialis palsy, elbow flexion may be a bit
clear which area is the most specific for testing a lesion weak relative to the normal side. There is wrist drop from
affecting this nerve; areas that have been proposed extensor carpi radialis (longus and brevis) and extensor
include the anatomical snuff box, the first dorsal web carpi ulnaris weakness. The fingers cannot extend at the
space, and the area over the distal half of the second metacarpophalangeal joint. Supination is somewhat
metacarpal bone (▶ Fig. 4.23). However, variations in and weak, with residual supination performed by the biceps
overlap between sensory territories are frequent with the brachii. The wrist and hand appear flaccid, with the fin-
superficial sensory radial nerve, the dorsal ulnar cutane- gers semiflexed and the metacarpal bone of the thumb
ous nerve, and the lateral antebrachial cutaneous nerve. ventral to the palm (▶ Fig. 4.24).
Sensory loss differentiates injury in the spiral groove
from injury at the distal humerus. Loss of sensation
4.5.3 Clinical Findings along the lower lateral arm and posterior forearm usu-
ally occurs with spiral groove radial nerve injuries, due
The Arm to associated injury of the lower lateral cutaneous
Triceps palsy is rare in radial nerve injuries in the arm, nerve to the arm and posterior cutaneous nerve to the
because branches to these muscles originate high in the forearm.

Fig. 4.23 Sensory innervations in the hand. Fig. 4.24 Wrist drop sign.

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Clinical Aspects of Peripheral Nerve Lesions in the Upper Limb

The Forearm most of the branches to this muscle originate from the
PIN proximal to where this nerve passes under the arcade
The hallmark of injury to the radial nerve in the forearm of Fröhse.
is normal strength of the brachioradialis muscle. In summary, isolated PIN palsy is confirmed by docu-
In the proximal forearm, the radial nerve divides into menting normal brachioradialis and superficial sensory
the superficial sensory radial nerve and the PIN. radial nerve function.
Injuries of the PIN cause a purely motor neuropathy; Isolated damage to the superficial sensory radial nerve
since this nerve carries no cutaneous sensory fibers, sensa- can also occur in the forearm, resulting in hypoesthesia or
tion remains normal. PIN palsy has two characteristics: anesthesia in its territory, but no motor deficits.
wrist extension weakness in an ulnar direction (radial
wrist extension remains normal, mediated by the extensor
carpi radialis longus and brevis that are innervated more Further Readings
proximally by the radial nerve) and finger extension weak-
Birch R. Surgical Disorders of the Peripheral Nerves. 2nd ed. London:
ness at the metacarpophalangeal joints. Of note is that
Springer-Verlag; 2011
these patients do not present with a wrist drop because Midha R, Zager EL. Surgery of Peripheral Nerves: A Case-Based Approach.
the extensor carpi radialis muscles are unaffected. New York, NY: Thieme Medical Publishers, Inc.; 2008
Supinator and extensor carpi radialis brevis weakness Russell SM. Examination of Peripheral Nerve Injuries. An Anatomical
may occur from PIN palsy if the injury is proximal to the Approach. 2nd ed. New York, NY: Thieme Medical Publishers Inc.; 2015
Slutsky DJ, Hentz VR. Peripheral Nerve Surgery: Practical Applications in the
arcade of Fröhse. As such, weakness of the supinator is
Upper Arm. London: Churchill Livingstone, Elsevier Inc.; 2006
classically not evident in supinator syndrome because

41
Clinical Aspects of Traumatic Peripheral Nerve Lesions in the Lower Limb

5 Clinical Aspects of Traumatic Peripheral Nerve


Lesions in the Lower Limb
Yuval Shapira and Shimon Rochkind

Abstract The lumbar plexus originates from the ventral rami of


Knowledge of neuroanatomy and the clinical exam is of spinal nerve roots T12–L4 deep to the psoas muscle
paramount importance for accurate diagnosis and opti- emerging through and lateral to the border of the muscle.
mal management of nerve injuries in the lower extremity. Major components of the lumbar plexus include iliohypo-
When evaluating patients with peripheral nerve lesions gastric, ilioinguinal, genitofemoral, and lateral femoral
in the lower limb, it is important to exclude differential cutaneous nerves together with the femoral nerve and
diagnosis. In cases where the injured nerves do not the obturator nerve. The anterior division of L4 joins the
recover spontaneously, the surgeon has several treatment ventral rami of L5 to form the lumbosacral trunk, which
modalities. Selecting the correct treatment depends on contributes to the sacral plexus. The sacral plexus com-
the diagnosis and other specific factors such as the level prises spinal nerve root segments (L4–S3) and lies deep
of injury, the current neurological status, the existence of within the pelvis. The anterior divisions of L4–S3 join to
neuropathic pain, the time since the injury, and other form the tibial nerve, whereas posterior divisions of L4–
specific factors related to the expected recovery. S2 comprise the common peroneal nerve. The tibial and
peroneal nerve merge in a common epineural sheath to
Keywords: lumbosacral plexus, sciatic nerve, peroneal form the sciatic nerve, as it exits the pelvis via the greater
nerve, tibial nerve, obturator nerve, femoral nerve, sciatic foramen inferior to the pyriformis muscle together
saphenous nerve with the posterior cutaneous nerve to the thigh, the infe-
rior gluteal nerve, and the pudendal nerve most medially.
Less common, the sciatic nerve passes through or even
superior to the piriformis muscle.
5.1 Introduction Injury to the lumbosacral plexus may occur following
high-energy trauma (e.g., motor vehicle accident or high
When evaluating patients with peripheral nerve lesions
fall), gunshot wound, or as a complication of spine or
in the lower limb, it is important to exclude spinal lumbar
orthopaedic surgery.3
radiculopathy and nonstructural neuropathies.1,2,3,4,5,6,7
Generally, femoral neuropathy should be differentiated
from L2–L4 radiculopathy. L5 radiculopathy should be
excluded in patients presenting with symptoms related
5.3 Sciatic, Tibial, and Peroneal
to peroneal neuropathy, whereas S1 radiculopathy should Nerve
be excluded from symptoms related to tibial neuropathy.
Other nonsurgical processes such as lumbosacral plexitis 5.3.1 Anatomy
(amyotrophic neuralgia), proximal diabetic neuropathy,
The sciatic nerve is the main output from the lumbo-
and neoplastic and postradiation neuropathy should also
sacral plexus and originates from nerve roots L4–S3
be considered. The diagnosis and management are based
after receiving a contribution from the lumbar plexus
on the clinical history and physical examination together
through the lumbosacral trunk. The sciatic nerve exits
with imaging studies and electrodiagnostic findings. The
the pelvic at the sciatic notch together with the poste-
extent of injury and distance to the target, together with
rior cutaneous nerve via the greater sciatic foramen,
the interval of time since the injury, are the most impor-
deep to the gluteus magnus muscle and inferior to the
tant prognostic factors for recovery.
piriformis muscle. The sciatic nerve continues along
Here, we briefly describe applicable neuroanatomy and
the posterior aspect of the thigh as two branches, tibial
clinical aspects to support the management and surgical
(medial aspect) and peroneal (lateral aspect), joined by
treatment of peripheral nerve lesions in the lower limb.
a common epineurium up to the sciatic bifurcation at
the lower third of the thigh just superior to the popli-
teal fossa. The tibial nerve originates from the ventral
5.2 Lumbosacral Plexus rami of the anterior divisions of L4–S3. The posterior
All motor and sensory innervation of the lower limbs divisions of L4–S2 supply the common peroneal nerve.
originate from the lumbar and sacral nerve roots, which The tibial nerve runs along the medial aspect and
together form the lumbosacral plexus. Anatomy of the the peroneal nerve runs along the lateral aspect of the
lumbar and sacral plexus and corresponding nerves are sciatic nerve and they both innervate muscles as
presented in ▶ Fig. 5.1, ▶ Tables 5.1 and ▶ 5.2. described in ▶ Table 5.2.

42
Clinical Aspects of Traumatic Peripheral Nerve Lesions in the Lower Limb

T12 Fig. 5.1 Lumbosacral plexus illustration


depicting the major components of the
lumbosacral plexus with its spinal nerve root
L1
segments. Note relationship of the lumbar
and sacral plexus through the lumbosacral
trunk.
L2
(T12—L1)
lliohypogastric n.
(L1)
llioinguinal n.

L3

Lumbar (L1—L2)
Genitofemoral n.
plexus
L4
(L2—L3)
Lateral femoral Lumbosacral
cutaneous n. trunk
L5
(L2—L4)
Femoral n.
(L2—L4)
Obturator n.

S1

(L4—S4) S2
Superior gluteal n.
(L5—S2)
Inferior gluteal n. S3

(L4—S2)
Common fibular n. S4
Sacral (L4—S3)
Tibial n.
plexus (L4—S3)
Sciatic n.
(S4—S3)
Posterior femoral
cutaneous n.

(S2—S4)
Pudendal n.

5.3.2 Injuries second-degree damage from which it will recover sponta-


neously and completely. However, the nerve might be
Nerve Lesions due to Open Injuries subjected to such abrupt and violent deformation that
extensive third- and fourth-degree damage involves con-
Partial or complete loss of function in the distribution of
siderable lengths of the nerve. In particularly severe inju-
the sciatic nerve or one of its divisions, following a deep
ries, the nerve may be ruptured.
penetrating wound from a sharp object, suggests a high
Other serious closed lesions are those in which the
probability of a partially or completely severed nerve. The
common peroneal nerve is subjected to prolonged unre-
nerve is injured as a result of a direct hit or, more impor-
lieved compression at the head or neck of the fibula.
tantly, by the destructive forces created by the passage of
This leads to irreversible changes in the nerve in the
a high-velocity missile through the limb though it misses
form of a destructive fibrosis, which blocks all attempts
the nerve, subjects it to tremendous deforming forces
of spontaneous regeneration. The prognosis in these
leading to extensive stretch lesions over a considerable
cases is poor.
length of the nerve. Shrapnel injury has been shown to be
more destructive for nerve tissue than gunshot injuries.8
Stretch Injuries
Nerve Lesions due to Closed Injuries The most serious nerve lesions are those due to traction,
In general, closed injuries are traction or compression mostly occurring when the nerve is violently displaced in
lesions. With mild trauma, the nerve sustains first- or severe injuries to the limb.

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Table 5.1 Nerves of the lumbar plexus


Nerve (spinal root) Muscle innervation Sensory branch
Lateral cutaneous (iliac)
Iliohypogastric (T12–L1) Internal and transverse abdominal
Anterior cutaneous (hypogastric)
Ilioinguinal (L1) Internal oblique Anterior scrotal/labial
Femoral
Genitofemoral (L1–L2) Cremaster (male)
Genital
Lateral femoral cutaneous (L2–L3) – LFCN
Iliopsoas
Pectineus Anterior cutaneous
Femoral (L2–L4)
Sartorius Saphenous
Quadriceps femoris (RF, VL, VM, VI)
External obturator
Obturator (L2–L4) Adductor (longus, brevis, magnus) Medial cutaneous
Gracilis
Accessory obturator (30%) Pectineus –
Abbreviations: LFCN, lateral femoral cutaneous nerve; RF, rectus femoris; VI, vastus intermedius; VL, vastus lateralis; VM, vastus medialis.

Table 5.2 Nerves of the sacral plexus


Nerve (spinal root) Muscle innervation Sensory branch
Superior gluteal (L4–S1) Gluteus medius –
Gluteus minimus
Tensor fasciae latae
Inferior gluteal (L5–S2) Gluteus maximus –
Biceps femoris SH
Tibialis anterior (DPN)
Lateral sural cutaneous
EDL and EDB (DPN)
Lateral dorsal cutaneous (DPN)
Common peroneal (L4–S2) EHL and EHB (DPN)
Intermediate dorsal cutaneous (DPN)
PT (DPN)
Medial dorsal cutaneous (SPN)
Peroneus longus (SPN)
Peroneus brevis (SPN)
Semitendinosus
Semimembranosus
Biceps femoris LH
Adductor magnus
Gastrocnemius
Popliteus
Soleus
Plantaris Medial sural cutaneous
Tibialis posterior Calcaneal
Tibial (L4–S3)
FDL and FHL Medial plantar
Abductor hallucis (MP) Lateral plantar
FDB and FHB (MP)
Lumbricals (MP)
Quadratus plantae (LP)
FDM (LP)
Adductor hallucis (LP)
Interossei and lumbricals (LP)
ADM foot (LP)
Inferior cluneal
Posterior femoral cutaneous (S1–S3) –
Perineal branch
Abbreviations: ADM, abductor digiti minimi of foot; DPN, deep peroneal nerve; FDL and FDB, flexor digitorum longus and brevis; FHL and
FHB, flexor hallucis longus and brevis; LH, long head; SH, short head; SPN, superficial peroneal nerve.

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Obstetrical and Birth Injuries the sciatic nerve, which may also be injured during
attempts to reduce the dislocation. Damage to the sciatic
These are nerve lesions in the mother and infant caused nerve can occur during operations on the hip joint and
by trauma during obstetrical delivery. The lumbosacral femur.
trunk in the mother may be injured where it crosses the
pelvic rim during the application of forceps in a difficult
delivery. Pressure inadvertently applied to the lateral The Popliteal Fossa and Knee Joint
aspect of the knee during delivery may result in a com-
Considering the two terminal divisions of the sciatic
pression lesion of the common peroneal nerve. More
nerve, the tibial is more deeply placed and better pro-
common are the stretch lesions of the sciatic and pero-
tected in the popliteal fossa.
neal nerves, which result from traction on the limb of
The common peroneal nerve is intimately related to the
forcible intrauterine manipulations to assist delivery.
knee joint. In this position, the nerve may be stretched,
torn, or ruptured in traumatic dislocations of the joint.
5.3.3 Common Sites and Types
of Nerve Lesions The Head and Neck of the Fibula
The Pelvis: Sacral Plexus Compression The common peroneal nerve is closely related to the
and Traction Lesions superior tibiofibular joint and to the head and neck of
the fibula. The nerve may be damaged in several ways,
Sciatic nerve lesions associated with pelvic fractures including the following:
are severe injuries which involve the sacroiliac joint and ● Fractures of the neck of the fibula.
fracture of the bones constituting the posterior and post- ● Blows on the lateral side of the knee.
erolateral walls of the pelvis cavity. These are traction ● Superficial lacerations affecting the upper end of the
and/or compression nerve lesions involving one or a com- fibula.
bination of the lumbosacral trunk and the sciatic nerve ● Posterior dislocation of the tibiofibular joint.
itself. ● The stretched nerve may be damaged by being forcibly

angulated around the head of fibula.


The Gluteal Region ● Pressure from an improperly applied plaster, leg braces,

or thigh bondage.
The sciatic nerve is at risk in the gluteal region because
the buttock is a common site for therapeutic injections.
Besides, the nerve is intimately related to the hip joint 5.3.4 Symptoms and Signs
and it may be involved in orthopaedic injuries affecting of Common Peroneal Nerve Injury
that joint.
Symptoms and signs of common peroneal nerve involve-
ment include the following:
Injection Injury ● Paresthesia and pain down the outer aspect of the leg

They are lesions caused by the injection of sclerosing and and dorsum of the foot and ultimately hypoesthesia in
toxic agents in or around the sciatic nerve. the cutaneous distribution of the superficial and deep
The nerve may be damaged by the needle, by the agent peroneal nerves.
used, by pressure from a hematoma, or later by the ● In common peroneal lesions, cutaneous sensation

scarring which follows tissue reaction to the external is defective over the outer aspect of the leg and the
material. Sciatic nerve injury originating in this way has dorsum of the foot.
been reported after intragluteal injections in premature ● Tenderness to deep pressure over the neck of the fibula.

infants, children, and adults. Pain during or immediately ● Progressive weakness of the peronei and tibialis

following the injection is both severe and generalized, anterior muscles in particular, which may proceed to a
though it may be confined to the sciatic field. Signs and foot drop.
symptoms are maximal in the common peroneal nerve
distribution with a foot drop and varying degrees of
The Motor Disability
sensory loss along the outer line of the leg and dorsum
of the foot. With more severe and extensive damage, all ● Eversion of the foot. The peronei can be seen and felt to
movements below the knee are grossly affected or lost. contract when the foot is everted against resistance.
● Dorsiflexion of the foot. A paralyzed tibialis anterior is
too weak to dorsiflex the foot against gravity.
Injuries about the Hip Joint ● Extension of the toes. Deceptive extension of the toes is
Injuries fracturing the acetabulum and/or dislocating the observed in complete lesions of the common peroneal
head of the femur posteriorly may result in damage to nerve.

45
Clinical Aspects of Traumatic Peripheral Nerve Lesions in the Lower Limb

5.3.5 Symptoms and Signs of Tibial longus muscle medially.5 The femoral nerve splits into an
anterior and posterior branch distal to the femoral trian-
Nerve Injury gle. The cutaneous branches include intermediate femoral
● Plantar flexion of the foot resulting in paralysis of cutaneous, medial femoral cutaneous, and the saphenous
gastrocnemius and soleus muscles. Plantar flexion of nerves. The saphenous nerve runs distally with the femo-
the foot should be tested with gravity eliminated and ral vessels parallel to the sartorius muscle to provide sen-
against resistance. sory coverage to the medial leg, medial malleolus, and
● Inversion of the foot in plantar flexion, a movement arch of the foot. The lateral femoral cutaneous nerve is a
which is performed by the tibialis posterior muscle. separate branch coming off directly from the lumbar
● Flexion in the toes. In complete lesions of the tibial plexus. The femoral nerve gives motor innervation to the
nerve, the toe may be feebly plantar flexed. quadriceps (rectus femoris, vastus lateralis, vastus inter-
● Intrinsic muscles of the foot. Paralysis of the intrinsic medius, and vastus medialis), sartorius, and pectineus
muscles is revealed by a claw deformity. muscles.
● Abnormal sensation in the tibial aspect of the leg and
inner aspect of the foot. The most serious sensory loss 5.5.2 Femoral Nerve Lesions
involves the sole, the main weight-bearing area.
Open Injuries
The nerve may be damaged in penetrating injuries such
5.4 Obturator Nerve as in gunshots and other missile wounds, stab wounds,
and by penetrating fragments of glass and other sharp
5.4.1 Anatomy objects. In lesions of the nerve immediately below the
The obturator nerve originates from the lumbar plexus, inguinal ligament, the iliacus and psoas muscles are not
arising from the anterior divisions of L2–L4 ventral rami. affected, but all other muscular and cutaneous branches
The nerve runs posterior to the psoas major muscle along are involved. Penetrating injuries involving the midthigh
its medial border and exits the pelvis through the obtura- and the adductor canal may involve the saphenous nerve
tor foramen in the obturator canal. The obturator nerve and the branch to the vastus medialis.
gives motor innervation to the adductor muscles of the
lower extremity (obturator externus, adductor longus,
Closed Injury as a Result of External
adductor brevis, adductor magnus, gracilis) and the pecti-
neus (only in 30% by the accessory obturator nerve). The Trauma
obturator nerve gives sensory innervation to the medial A femoral nerve palsy may follow a severe fall, usually on
aspect of the thigh. the side or back, or an injury received in a road accident
or sporting activity. Nerve damage is due to:
● Rupture of the iliacus or iliopsoas muscles with hemor-
5.4.2 Injuries rhage into the iliacus compartment producing pressure
Lesions of the obturator nerve are uncommon. The nerve over the nerve.
may be damaged in this region during total hip arthro- ● Acute stretching of the nerve due to forced extension of

plasty. The lesion is caused by pressure exerted by the the limb.


cementing material. Obturator nerve lesions may also ● A fractured pubis.

occur as a result of a pelvic fracture.

5.5.3 Saphenous Nerve Lesions


5.5 Femoral Nerve Lacerations and surgical incisions involving the medial
aspect of the knee may divide branches of the saphenous
5.5.1 Anatomy nerve given off where the nerve becomes cutaneous.
The largest and most important of these branches is the
The femoral nerve is the largest branch of the lumbar
infrapatellar. Transection of these nerves can result in the
plexus. It originates from the posterior divisions of L2–L4
formation of a painful neuroma, which in this region can
ventral rami (▶ Fig. 5.1, ▶ Table 5.1) posterior to the psoas
be very troublesome and disabling.
major muscle. The nerve runs inferiorly and laterally
under the pelvis major and passes over the iliacus muscle
in the pelvic.4 The nerve enters the anterior thigh at the 5.5.4 The Symptoms and Signs
femoral triangle lateral to the femoral artery, outside the
femoral sheath and deep to the iliacus fascia, where it is
of Femoral Nerve Involvement
bordered by the inguinal ligament superiorly, the sartor- Atrophy of the quadriceps muscle mass gives an obvious
ius muscle laterally and inferiorly, and the adductor wasted appearance to the anterior part of the thigh.

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The Motor Disability vital for tailoring the optimal treatment plan and achiev-
ing the best possible functional outcome in lower limb
● Paresis or paralysis of the iliopsoas and rectus femoris peripheral nerve injuries. In cases where the injured
is reflected in weakness in flexion of the thigh. nerves are not able to recover spontaneously, surgical
● Paresis or paralysis of the quadriceps muscle results in approach allow for potential recovery.
weakness or an inability to extend the leg. The limb is
unstable. Walking and many other activities and
movements involving strong extension at the knee are References
severely disabled.
[1] Wilbourn AJ. Plexopathies. Neurol Clin. 2007; 25(1):139–171
● Quadriceps function is readily tested by asking the
[2] Planner AC, Donaghy M, Moore NR. Causes of lumbosacral plexop-
patient to extend the leg against gravity or resistance, athy. Clin Radiol. 2006; 61(12):987–995
or holding the leg in an extended position against [3] Kutsy RL, Robinson LR, Routt ML, Jr. Lumbosacral plexopathy in pelvic
resistance. trauma. Muscle Nerve. 2000; 23(11):1757–1760
[4] Reinpold W, Schroeder AD, Schroeder M, Berger C, Rohr M,
Wehrenberg U. Retroperitoneal anatomy of the iliohypogastric,
Sensation ilioinguinal, genitofemoral, and lateral femoral cutaneous nerve: con-
sequences for prevention and treatment of chronic inguinodynia.
Paresthesia or a deepening numbness affecting the ante- Hernia. 2015; 19(4):539–548
rior and medial aspect of the thigh and extending down [5] Choy KW, Kogilavani S, Norshalizah M, et al. Topographical anatomy
the inner side of the leg and foot to the big toe. of the profunda femoris artery and the femoral nerve: normal and
abnormal relationships. Clin Ter. 2013; 164(1):17–19
[6] Mackinnon SE, ed. Nerve Surgery. New York, NY: Thieme; 2015

5.6 Conclusion [7] Sunderland S, ed. Nerves and Nerve Injuries. 2nd ed. Edinburgh:
Churchill Livingstone; 1978
[8] Rochkind S, Strauss I, Shlitner Z, Alon M, Reider E, Graif M. Clinical
Anatomical knowledge and understanding the pathophy-
aspects of ballistic peripheral nerve injury: shrapnel versus gunshot.
siological process, depending on the nature of injury, is Acta Neurochir (Wien). 2014; 156(8):1567–1575

47
Electrodiagnostic Pre-, Intra-, and Postoperative Evaluations

6 Electrodiagnostic Pre-, Intra-, and Postoperative


Evaluations
Carlos Alberto Rodríguez Aceves, Miguel Domínguez Páez, and Victoria E. Fernández Sánchez

Abstract Understanding this structure allows one to appreciate


Electrodiagnostic studies are considered an extension of the pathophysiological substrate of nerve injuries, the
the clinical examination for peripheral nervous system degeneration/regeneration process, and the degree of
diseases and injuries. They started to be included as a injury.1,2,3,4
part of the diagnostic protocol for nerve injuries after the In the PNS, effector information is transmitted through
Second World War. Since then, they have been used rou- motor units (MUs), each of which is composed of an alpha
tinely to evaluate damaged peripheral nerve function, motor neuron, its axon, and whatever number of extra-
regardless of etiology (e.g., trauma, chronic compression, fusal muscle fibers it innervates. Afferent information is
tumors, neuropathies, etc.). integrated through sensory receptors; its axons and cell
Currently, electrodiagnostic studies are a very useful bodies are located in the dorsal root ganglia.5
tool for peripheral nerve surgery during pre- and intra-
operative evaluations and postoperative follow-up. For
this purpose, all professionals involved (neurophysiolo-
6.1.2 Physiological Characteristics
gists, anesthesiologists, neurosurgeons, and rehabilitation At rest, nerve fibers maintain their resting membrane
specialists) should be part of a multidisciplinary team potential. Generation of a stimulus of supramaximal
and maintain continuous communication. intensity results in changes in ion flow from the exterior
Different techniques are available to assess nerves’ to the interior of the axon. This increases positivity
functional status, including: sensory and motor nerve within the interior of the nerve fiber, decreasing the
conduction studies; electroneurography; electromyogra- potential difference between the inside and outside to
phy; somatosensory and motor evoked potentials; and transmit the impulse that generates an action potential
nerve action potentials with direct stimulation of the (AP).5 Electrodiagnostic studies (EDSs) evaluate the
nerve trunk. impulse conduction of thicker and more myelinated
This chapter will examine general aspects of nerve nerve fibers (i.e., the most rapid ones), which are classi-
impulse conduction, current recording techniques and fied as type A fibers, as per Erlanger and Gasser.6,7
their utility, clinical correlations, and the perioperative
use of these techniques for peripheral nerve surgery.
6.2 Pathophysiology
Keywords: electrodiagnostic studies, peripheral nerve
Two pathophysiological processes—axonal damage and
surgery, nerve injury, nerve conduction studies, electro-
demyelination—occur individually or concurrently in a
neurography, electromyography, somatosensory evoked
damaged nerve that are independent of the etiology and
potentials, motor evoked potentials, neuroma-in-
mechanism of injury.
continuity, nerve action potential, multimodal intraope-
rative monitoring
6.2.1 Axonal Damage
Any injury that causes disruption in an axon’s integrity
6.1 Basic Considerations results in degeneration of the distal segments through a
process called Wallerian degeneration (WD), which is
6.1.1 Anatomical Characteristics completed within 3 weeks of an injury. This degeneration
Axons are extensions of neuronal cell bodies. They trans- process can also occur in the cell body (chromatolysis),
mit nerve impulses and are enveloped by myelin. Myelin proximal axon, and distal target organs.
is produced by Schwann’s cells (SCs) in the peripheral Its broad etiology includes the following mechanisms:
nervous system (PNS); its function is to isolate axons crush, transection, stretch, and intrinsic neuropathy.8,9
from each other and optimize the transmission of nerve
impulses through periodic gaps called nodes of Ranvier.
Individual axons are surrounded by connective tissue
6.2.2 Demyelination
called the endoneurium. Axons are bundled together in Demyelination is the loss of the myelin layer, either iso-
groups called fascicles, each one covered by a connective lated or associated with axonal damage. In the latter case,
tissue sheath known as the perineurium. Fascicles are there is some alteration of the myelin sheath, but not of
grouped together in bundles that together constitute a the SCs. As such, the lack of myelin around any axon seg-
nerve trunk, which also is surrounded by epineurium. ment only requires SC division for remyelination to occur

48
Electrodiagnostic Pre-, Intra-, and Postoperative Evaluations

within that segment. Etiologies include compression inju- ● Recording equipment is composed of: (1) an amplifier
ries with ischemia, edema, and intrinsic neuropathies.8,9 to eliminate potential interference, (2) recording
channels, (3) enough sensitivity to measure the
amplitude of potentials, which range from 1 µV to
6.3 EDSs for Preoperative 10 mV, (4) filters to reduce distortion and interference,
Evaluations measured in hertz (Hz; ranging from 2 to 10,000 Hz),
(5) a display screen, (6) an audio amplifier and AD
During this stage of evaluation, EDSs are useful to com- converter, and (7) a printer.
plement the clinical examination of patients, detect signs ● A stimulator with which stimulus intensity, frequency,
not confirmed by neurological examination, and guide in and duration can be controlled; generally, this will
the diagnosis and therapeutic management of patients. entail the use of surface electrodes (adhesive, flat metal,
However, EDSs will never replace a thorough medical his- and/or ring surface electrodes).
tory and physical examination. In general, EDSs help to ● Recording electrodes: this usually would involve flat
safely: (1) pinpoint the site of injury (i.e., anterior horn, surface electrodes (adhesive, flat metal, and/or ring)
root, plexus, terminal nerve, neuromuscular junction); or concentric or Teflon-coated monopolar needle
(2) identify the underlying pathophysiological process electrodes for EMG, and an active electrode and
(i.e., demyelination and/or axonal damage); (3) establish reference electrode for SNCS.7
the timing, severity, and extent of injury; (4) generate a
list of possible diagnoses (e.g., compression syndrome, Recording is performed with the patient lying on an
mononeuropathy, diffuse neuropathy); and (5) assess examination table or in a bed. Electrodes are then
progression, which allows for some estimate regarding placed at sites that are specific to the study being per-
the prognosis for functional recovery10,11 (▶ Table 6.1). formed. The process begins with stimulating a specific
EDSs performed at different time points over the site via an electrical current until a desired potential is
course of follow-up help establish whether axonal regen- reached. EMG recording is obtained by introducing
eration is present or not, thereby assisting with predict- the concentric needle into the muscle being tested
ing prognosis, as well as the need and timing of surgical (▶ Fig. 6.1).7
intervention. It should be noted that the optimal timing
for performing EDSs is 2 to 3 weeks post injury (i.e., after
Equipment and Electrodes
the WD process is completed), because none of the elec-
trical changes that define a nerve injury are likely to be All data are recorded based on parameters that will be
evident earlier. reviewed later, with internationally standardized values
Sensory nerve conduction studies (SNCSs), motor available for each potential. Patients may feel some dis-
nerve conduction studies (MNCSs), and electromyogra- comfort or experience a tingling sensation. However,
phy (EMG) are among the studies recommended during these studies are generally well tolerated.
this assessment phase.
6.3.2 Nerve Conduction Studies/
6.3.1 Technical Considerations Electroneurography
The same equipment is used for both EMG and SNCS and Nerve conduction studies are performed by applying
should meet the following specifications: some supramaximal electrical stimulus that triggers the
activation of all fibers through a percutaneous electrode
Table 6.1 Electrodiagnostic studies (EDSs): preoperative and placed over a specific nerve. This generates an AP, which
intraoperative EDS techniques are demonstrated is recorded by other surface electrodes applied at a
Preoperative Intraoperative defined distance. Based on whether it is a sensory or
NCS Evaluation of spontaneous activity: motor study, electrodes are placed in a sensory innerva-
● Sensory ● Continuous EMG tion territory or into a specific muscle innervated by the
● Motor Evaluation of evoked responses: nerve under study, respectively.6,7,11,12,13
EMG ● Stimulated EMG
● SSEP Motor Nerve Conduction Studies
● MEP MNCSs evaluate the muscular response or compound
● NAP motor action potentials (CMAPs) by electrically stimulat-
Abbreviations: EMG, electromyography; MEP, motor evoked ing the nerve that should innervate the muscle. The
potentials; NAP, nerve action potential; NCS, nerve conduction CMAP is the summation of AP from all the MUs
studies; SSEP, somatosensory evoked potentials.
(▶ Fig. 6.2).6,7,11,12,13

49
Electrodiagnostic Pre-, Intra-, and Postoperative Evaluations

Fig. 6.1 Equipment and electrodes. Left:


The recording equipment consists of one
amplifier, recording channels, sensitivity, a
display screen, filters, an audio amplifier,
and a printer. Right: Recording electrodes:
stimulator (A), ring (B), surface (C), and
monopolar needle (D). (Source: Neuro-
physiology Department archives, American
British Cowdray Medical Center.)

Fig. 6.2 Motor nerve conduction studies.


Recording of motor action potentials for
the ulnar nerve. (Source: Neurophysiology
Department archives, American British
Cowdray Medical Center.)

Fig. 6.3 Sensory nerve conduction studies.


Recording of sensory action potentials for
the ulnar nerve. (Source: Neurophysiology
Department archives, American British
Cowdray Medical Center.)

Sensory Nerve Conduction Studies velocity (NCV) is measured by stimulating only a single
point (▶ Fig. 6.3).6,7,11,12,13
SNCSs assess sensory nerve action potentials (SNAPs),
which are the summation of APs from sensory fibers of
the nerve produced by stimulation. Contrary to MNCSs,
Parameters to Be Evaluated
the amplitude is measured in µV. SNAPs can be either The following parameters of the generated potentials are
orthodromic or antidromic, and nerve conduction analyzed:6

50
Electrodiagnostic Pre-, Intra-, and Postoperative Evaluations

● Latency is the time interval between the moment of Delayed Responses: F-Wave and H-Reflex
nerve stimulation and the onset of the resulting poten-
tial. It is measured in milliseconds (ms) and represents Late responses may be evaluated when lesions affect the
the velocity of transmission. proximal segments of the nerve structure, making it
● Amplitude is the maximum voltage difference between impossible to use conventional electroneurography.
two points (i.e., the intensity of the impulse) expressed
in millivolts (mV) for motor studies and in microvolts F-Wave
(µV) for sensory studies. It is measured from baseline to After a stimulus is applied, it travels antidromically to the
maximum peak, and is related to the number of acti- anterior horn of the spinal cord where neurons generate
vated fibers. small APs that travel back (orthodromically), thereby acti-
● Area provides information on the number of axons vating the muscle and generating a small-amplitude res-
being stimulated. ponse (less than 10%), which is not elicited in all stimuli.
● NCV is calculated by dividing latency into the distance Latency may be variable, so it is advisable to repeatedly
between the stimulation and recording points. NCV is apply series of 10 to 20 stimuli. F-wave studies are useful
measured in meters per second (m/s), and reflects mye- for identifying proximal lesions in nerves; but they are
lin integrity. only of limited value for diagnosing radiculopathies and
● Duration reflects the degree of synchrony between of no use assessing posterior roots.14
nerve fibers.
● Wave morphology: In general, waves show a mono-
phasic or biphasic configuration. A polyphasic configu-
H-Reflex
ration denotes chronodispersion (▶ Fig. 6.4). The H-reflex is the electrophysiological analogue of the
stretch reflex; hence, it assesses sensory and motor fibers
Unlike demyelinating lesions, which frequently exhibit at a specific metameric level. It is initiated with a sub-
increased latency with a resulting decrease in NCV, sen- maximal stimulus. In adults, it is consistently evoked
sory, motor, and mixed axonal injuries characteristically from the flexor carpi radialis muscle by stimulating the
display some reduction in the amplitude of APs.13 median nerve at the elbow; and from the flexor muscles
of the foot by stimulating the tibial nerve in the popliteal
fossa. In these contexts, it is only useful for C7 and S1 rad-
iculopathies, respectively.

6.3.3 Electromyography
EMG is the group of recording techniques that assesses
electrical activity within skeletal muscles. The selection
of muscles depends on the patient’s clinical picture.
The examination involves a single-use concentric needle
electrode, which is introduced into the muscle, where it
records four phases of muscular activity. The signals are
displayed on a digital screen, and can also be converted
into an audible acoustic file. The following phases are
examined:12,15
● Insertion phase: This is derived from some needle-

induced mechanical irritation stimulus, and character-


ized by the presence of small-amplitude potentials and
a crackling sound.
● Resting phase: This phase is characterized by a flat

trace (electrical silence) under normal conditions.


“Plate activity” can occasionally be detected due to
irritation of the neuromuscular plate; but this does not
imply pathology.
● Mild contraction phase: This phase evaluates the con-

Fig. 6.4 Parameters. Latency, amplitude, area, conduction


figuration of the MU potential (MUP), which represents
velocity, duration, and phases are evaluated for each potential. the summation of APs for each MU fiber. The contrac-
tion force is determined by the number and frequency

51
Electrodiagnostic Pre-, Intra-, and Postoperative Evaluations

Fig. 6.5 Electromyography phases.


(a) Normal pattern and (b) neurogenic
pattern. Phases of the EMG include:
(1) insertion, (2) resting, (3) mild
contraction, (4) maximal contraction. The
image in (a) shows a normal pattern for
each phase, and in (b), the pattern
secondary to a nerve lesion.

with which simultaneous activated MUs are fired. The However, innervation MUPs are short and smaller in
following MUP parameters are examined: amplitude. In the maximal contraction phase, the recruit-
○ Duration: This is determined by the synchrony of ment pattern is incomplete which, from higher to lower
discharges and ranges from 8 to 14 ms. severity, can be: high-intermediate, low-intermediate,
○ Amplitude: This reflects the number and synchrony simple, or absent (▶ Fig. 6.5).7,15
of discharging fibers and ranges from 0.5 to 2 mV.
○ Phases: The phases represent the section of a wave
Registry Errors and Other Considerations
that falls between two baseline crossings; they can be
either biphasic or triphasic. EDSs may yield false-positive or false-negative results. As
● Maximal contraction phase: This phase determines age is among the factors commonly associated with
MUP recruitment, which is called spatial recruitment if altered results, it is necessary to remember that children
MUPs are increasing in number, and temporal recruit- complete myelination at 4 to 5 years of age, and that CV
ment if they are increasing in frequency. This makes it begins to decline at roughly 60 years of age. At tempera-
difficult to identify the individual MUs, as well as the tures below 33 °C, CV slows down to 1.5 to 2.5 m/s; and
baseline, and is known as an interference pattern (the latency increases by 0.2 ms per degree reduction. Tissue
normal muscle recruitment pattern). resistance can reduce amplitude. Results may be altered
by technical factors such as the improper placement of
recording electrodes, increased tissue impedance (resist-
Neurogenic Pattern on ance), the wrong nerve being stimulated, or the presence
Electromyography of an anastomosis not previously detected (e.g., Martin-
Gruber or Riche-Cannieu anastomosis).6,7
EMG findings are not pathognomonic of any nosological
Although EMG is a low-risk procedure and complica-
entity; nevertheless, it is possible to differentiate between
tions are rare, it is important to know if a patient has a
normal, neurogenic, and/or myogenic patterns. There is a
central catheter, pacemaker, or a coagulation disorder
high level of concordance (greater than 90%) between
before conducting such a study.12
EMG and muscle biopsy findings. Accordingly, EMG can
be useful for the diagnosis of peripheral nerve lesions
when a neurogenic pattern is present. During denerva- 6.4 Electrophysiological
tion, since there is an increase in fiber excitability, the
activity of the insertion phase also increases. However, Findings with Different Types
this may decline due to fibrotic changes in the muscle.
The resting phase of the neurogenic pattern is character-
of Nerve Injury
ized by the presence of spontaneous activity, indicated by Peripheral nerve pathologies exhibit neurophysiological
fibrillation, fasciculations (spontaneous, repetitive, short, changes that correlate well with ED records. For example,
biphasic discharges), and acute positive waves. This phase during the initial phases of chronic compression, CV is
commonly starts 3 weeks after the injury and tends to reduced by the demyelination–remyelination process.
disappear over time because of reinnervation or fibrosis. In the case of a distal lesion, distal latency is increased
Repetitive complex discharges may also be present. The and can coexist with decreased CMAP amplitude due to
presence of fasciculations is suggestive of a proximal le- chronodispersion (increased potential duration); except
sion (anterior horn or anterior nerve root). In the mild with severe compression, the EMG does not exhibit any
contraction phase, MUPs are polyphasic and greater in changes, due to the absence of axonal damage.
duration and amplitude; these characteristics become With acute compression, conduction block due to seg-
more pronounced as the process becomes more chronic. mental demyelination is a common finding. Recovery

52
Electrodiagnostic Pre-, Intra-, and Postoperative Evaluations

Table 6.2 Clinical correlation: correlating electrophysiological findings with nerve lesions
Grade injury Neurapraxia I Axonotmesis II–IV Neurotmesis V
Conduction block with decreased First day: proximal CMAP amplitude Absent proximal CMAP. After 4 days,
NCS amplitude that is restored within a reduced. After 4 days, distal CMAP absent distal CMAP
few weeks amplitude reduced
No spontaneous activity First day: recruitment decreased. First day: absent MUP with no spon-
Normal MUP After 3 weeks: spontaneous activity, taneous activity. After 3 weeks:
Recruitment decreased of MU that is abnormal MUP spontaneous activity, absent MUP.
EMG restored within a few weeks If reinnervation: polyphasic and Reinnervation signs only if recon-
prolonged MUP structive surgery successful; other-
If recovery: fewer denervation signs wise spontaneous activity disappears
and increased recruitment by fibrosis
Abbreviations: CMAP, compound motor action potential; EMG, electromyography; MU, motor unit; MUP, motor unit potentials;
NCS, nerve conduction studies.

is observed after a number of days or weeks. NCSs with


evidence of reduced amplitude or CMAP area between
6.6 EDSs for Intraoperative
proximal and distal stimulation points are useful tools. Evaluations
WD manifests as the loss of MUs and presence of sponta-
neous activity (fibrillations and positive acute waves). Appreciating that the different neurophysiological record-
These findings indicate neurapraxia. ing techniques used for routine preoperative evaluation
The pathophysiological substrate of acute traction or may also be used during surgical procedures has enabled
transection lesions and severe entrapment is WD, since it clinicians to integrate them into multimodal intraopera-
implies the loss of nerve fiber continuity. In such cases, tive monitoring (MIOM). Using different neurophysiologi-
EMG shows evidence of fibrillations and positive acute cal techniques adapted to each procedure permits the
waves due to increased spontaneous activity, with lost objective and continuous identification and quantification
MU proportional to the degree of degenerated fibers. (with unique time resolution) of certain parameters that
NCSs show reduced amplitude or absence of CMAP. Dur- indicate the functional status of nerve structures at risk
ing the first 48 to 72 hours, the distal segment maintains during surgery. Results are compared against preestab-
function and can respond to a stimulus. However, since lished reference values so that possible changes can be
conduction capacity is lost after this time, it is impossible evaluated during surgery based on the structure being
to differentiate conduction block from axonotmesis in monitored. Since these changes are detected early, perti-
early EDSs.7,16 nent measures can be taken to restore function and avoid
Most of the time, different degrees of lesion severity potential adverse consequences. In 1960, Kline and De
coexist within the same segment. In the EMG, reinnerva- Jonge were the first to report using evoked nerve poten-
tion data show longer-duration, low-amplitude polypha- tials to evaluate nerve lesions.17,18
sic potentials (▶ Table 6.2). MIOM has two major functions: the continuous moni-
toring of a specific nerve pathway’s functional integrity
to aid in the early detection of variations that might
require changes in surgical management; and mapping
6.5 When Are EDSs Indicated? for the timely identification of nerve structures that
The distal segment of the damaged nerve becomes non- should be preserved.
excitable after 5 to 7 days for motor fibers, and after 7 to Recording techniques follow the same principles
10 days for sensory fibers. Since the denervation process applied during the preoperative phase, except that
is complete after 3 weeks, EDSs are not indicated before monopolar needles are used for EMG recording. More-
that time. This is because, even though they may provide over, all the recording and stimulation electrodes in the
data about location, they yield no information about the surgery field must remain sterile.
extent or severity of injury. Subsequent monitoring dur-
ing preoperative evaluations depends on the type of
lesion and should be individualized. The first monitoring
6.6.1 Lesions-in-continuity
evaluation should be conducted at 3 months, when EDSs A neuroma-in-continuity is a disorganized tissue mass
tend to exhibit spontaneous innervations.11 that contains axons, connective tissue, and different types

53
Electrodiagnostic Pre-, Intra-, and Postoperative Evaluations

prepare the surgical field, and perform intraoperative


manipulation of the nerve under study.
Currently, the following intraoperative recording tech-
niques can be considered for PNS, divided based on
bioelectrical signals: (1) spontaneous activity: EMG and
(2) evoked responses: somatosensory evoked potentials
(SSEPs), evoked EMG (muscle APs), and nerve action
potentials (NAP). The recorded responses can be obtained
from the cerebral cortex, spinal cord, muscle, or the periph-
eral nerve itself. The study selected will depend on the
structure and function that must be evaluated.21,22,23,24,25

Continuous Intraoperative
Electromyography
Fig. 6.6 Lesion-in-continuity. With a neuroma-in-continuity, the
Continuous intraoperative EMG is the continuous record-
external anatomical integrity of nerve remains unchanged, so
the viability of the nerve trunk is evaluated through NAP ing of the electrical activity of the muscle(s) of interest
conduction. The black arrow demonstrates the anatomical (depending on the surgery). It is useful to prevent nerve
(but not necessary functional) integrity of the nerve after a trunk damage during surgical manipulation, which is
traumatic event. manifested as increased muscle activity due to irritation
of the nerve. Surgical manipulation should be altered or
interrupted in the presence of sustained tonic activity
of cells, including macrophages, fibroblasts, and SC. It can that does not disappear immediately after the surgical
be caused by a variety of mechanisms which result in the manipulation that triggered it is discontinued. The EMG
nerve failing to regenerate adequately. activity generated by irritating the nerve is displayed on
Lesions-in-continuity develop in up to 70% of nerve a digital screen; and an audible signal can be used to alert
lesions. As suggested by the name, anatomical continuity the surgeon as to when the nerve is in proximity.26,27
is preserved within the nerve trunk. However, this does
not imply that the internal structure is preserved. In Stimulated Intraoperative
some cases, function can be spontaneously restored;
but this is not the rule, and the prognosis is difficult to
Electromyography
establish. Stimulated intraoperative EMG is the application of a
It is for this specific type of lesion that using MIOM stimulus with subsequent recording of a compound
permits practitioners to evaluate peripheral nerve func- muscle AP, using the same electrodes as for continuous
tion and determine the potential for spontaneous func- EMG recording. It is a mapping technique used to detect
tional recovery, since observation and palpation are nerves of interest.
insufficient to determine the functional viability of a It is useful for the evaluation of neuromas-in-continuity
nerve trunk during surgery. Therefore, the different intra- near the target muscle, or large nerve trunk lesions on
operative recording techniques are the only ways to pre- their way to the innervated muscle (▶ Fig. 6.7).26,27
serve the function of a nerve, since external appearance
does not correlate with histology (▶ Fig. 6.6).19,20
Somatosensory Evoked Potentials
Evoked potentials are electrical signals generated by
6.6.2 Intraoperative Monitoring the nervous system in response to a specific external
stimulus. Measuring SEPs entails applying a peripheral
Techniques stimulus to the nerve trunk and subsequently recording
MIOM is especially useful for some peripheral nerve the response at the cortical level of the sensory pathway
lesions that pose interesting surgical challenges. Unlike or at upward relay stations (e.g., Erb’s point, the popliteal
other studies, MIOM provides real-time functional data. fossa, or the cervical cord). Responses are compared with
For this reason, it is essential to know, in detail, the reference values obtained before the surgical procedure is
patient’s medical history and baseline neurological status, begun. Wave morphology, amplitude, and latency are
as well as the regional anatomy, surgical goals, and type evaluated. In the upper limbs, the response is elicited by
of anesthesia used, since the data obtained can alter the stimulating the median and/or ulnar nerve; and in the
course of the surgical procedure (as in the specific case of inferior limbs, the response is elicited by stimulating the
a lesion-in-continuity). The multidisciplinary team must posterior tibial nerve and/or peroneal nerve. The intra-
know how to position the electrodes, apply the stimulus, operative interpretation of results relies on the detection

54
Electrodiagnostic Pre-, Intra-, and Postoperative Evaluations

Fig. 6.8 Intraoperative somatosensory evoked potentials.


Intraoperative recording of SSEP via stimulation of the median
and radial nerves after an infraclavicular brachial plexus injury.
(Source: Neurophysiology Department archives, American
British Cowdray Medical Center.)

Fig. 6.7 Intraoperative electromyography. Intraoperative EMG


recording during neurolysis of the ulnar nerve for neurotization
of the musculocutaneous nerve. (Source: Neurophysiology
Department archives, Hospital Regional Universitario de
Málaga.)

of reliable, significant changes, such as a > 50% decrease in


amplitude or a > 10% decrease in latency.
SEPs are useful for the evaluation and recording of pre-
ganglionic lesions involving the supraclavicular brachial
plexus when combined with recording of SNAPs. Gener-
ally, it is possible to determine which nerve roots are in
continuity with the central nervous system, thereby
avoiding extensive, time-consuming dissections in cica-
tricial or difficult-access areas (▶ Fig. 6.8).28,29

Motor Evoked Potentials


MEPs are obtained using high-voltage, short-duration
repetitive stimulations, with electrodes placed on the
scalp to evaluate motor responses within the muscles
Fig. 6.9 Nerve action potential. Direct nerve stimulation for the
being monitored. Similar to SSEP, this technique enables
recording of NAP after neurolysis of the median nerve.
the evaluation of more proximal segments of the nerve
trunk.
to carry out more complex reconstruction procedures. It
Nerve Action Potentials is also possible to use quadrant mapping to differentiate
healthy areas of the nerve trunk, so only partial recon-
The use of NAPs involves direct stimulation of the nerve structions are performed (▶ Fig. 6.9).19,30,31,32
trunk proximal to the area of the lesion, so as to obtain
the NAP distal to the lesion using recording electrodes.
At least 4,000 myelinated nerve fibers are required to Intraoperative Monitoring Limitations
evoke NAPs. Stimulation electrodes have two tips, while The main limitations of NAPs relates to technical prob-
recording electrodes have three J-shaped tips to be in lems. EMG is affected by the use of muscle relaxants,
direct contact with the nerve and reduce propagation of since it requires the partial preservation of functioning
the stimulus, thereby preventing artifacts. This technique MU to elicit a motor response. Moreover, it only assesses
is useful for the evaluation of lesions-in-continuity, since the segment from the point of stimulation to the muscle;
it permits clinicians to identify impulse transmission but there can be conduction block proximal to the stimu-
within the nerve trunk, in this way determining the need lation point. Using MEPs can partially solve this problem.

55
Electrodiagnostic Pre-, Intra-, and Postoperative Evaluations

6.6.3 Surgical Procedures 6.7 EDSs for Postoperative


When a lesion’s pathogenesis involves partial injury to Evaluations
the nerve trunk or the development of lesions-in-
continuity due to either extraneural cicatricial tissue Utilizing different EDS techniques to monitor patients
or a neuroma-in-continuity, MIOM plays a key role in after surgery depends on the type of procedure per-
determining the most suitable technique to restore formed. The main goals are to establish the procedure’s
nerve function. effectiveness (due to the presence of electrical signs
Neurolysis is a surgical procedure that entails remov- which precede clinical recovery), as well as the final out-
ing any cicatricial tissue that is pressing on the nerve. come of the technique used. The major interest of these
This is the only surgical procedure indicated when studies lies in the follow-up of nerve reconstruction (neu-
there is evidence of nerve impulse transmission after rorrhaphy with or without grafting).
decompression using NAP recordings. In the absence of The timing of the first clinical and neurophysiological
conduction, it is recommended that one resect the dam- manifestations of functional recovery of a nerve graft is
aged segment and perform reconstruction with a highly variable, as late as 1 to 2 years post reconstruction.
graft.33 Similarly, with severe lesions of the brachial Motor recovery, from a clinical and electrophysiological
plexus involving radicular avulsion, it is of vital impor- perspective, occurs before sensory recovery. Sometimes,
tance to identify the functionality of the proximal clinical evolution is disproportional to neurophysiologic
stumps of the damaged roots (i.e., that they remain con- evolution. Whereas in some cases this relationship is
nected to the spinal cord). This is because, if integrity is acceptable and concordant, in others clinical recovery is
maintained, they can be used as axon donors for recon- completely disproportionate to the slowness of NCV.
struction. This is not possible in the case of pregan- Thus, it is necessary to highlight the importance of the
glionic involvement.6,19 individual evaluation in each particular case.35
Furthermore, MIOM can be used to identify specific Despite this limitation, EDSs provide data that permit
groups of fascicles with the aim of performing nerve clinicians to evaluate whether the intervention adopted
transfers. This procedure consists of donating the proxi- has been successful or not.
mal end or fascicles of a healthy nerve to the distal end The first step involves knowing when to order EDSs;
of a damaged nerve. A well-known example is the Ober- and this depends on the time that is likely to elapse
lin technique, with which the fascicles that innervate before reinnervation of target muscle occurs. This, in
the flexor carpi ulnaris muscle are used to anastomose turn, relates to the distance between the neurorrhaphy
with the muscular branches of the musculocutaneous area and the motor end plate of the muscle that is being
nerve to the biceps, in patients with paralysis of the reinnervated. The following factors should be considered:
elbow secondary to an incomplete brachial plexus (1) axons grow approximately 1 to 3 mm/day; (2) axon
injury.34 growth generally begins about 7 days after anastomosis;
Based on the recording technique used, MIOM in the and (3) only 60% of fibers cross the first suture line, and
PNS enables surgeons to: (1) identify damaged nerves not all fibers reach the intended muscle.36 Therefore,
or specific areas of injury within a nerve trunk; (2) when performing neurotization (as with the Oberlin pro-
establish the severity and location of the nerve injury; cedure) using direct neurorrhaphy (wherein the distance
(3) prevent possible nerve injury from intraoperative from the area of neurorrhaphy to the target muscle is less
manipulation; (4) guide surgical practice for the appli- than 10 cm in most cases), the first signs of reinnervation
cation of different reconstruction techniques (decom- may occur within 3 to 6 months. Three to six months
pression, neurolysis, or resection and application of a postoperative is therefore a reasonable time at which to
graft); (5) identify the presence of radicular avulsions; order neurophysiological studies. Electrical and clinical
(6) identify nerve topography to allow for the safe col- recovery with more proximal injuries—as with recon-
lection of nerve biopsy specimens; (7) identify healthy structions with grafts in the primary upper trunk of the
fascicles that are susceptible to sectioning; and (8) pro- brachial plexus—are not expected to occur until at least
vide information regarding the prognosis of a nerve 9 months have elapsed.
injury.25 Some authors37 argue that the first ED examination
In some situations, using MIOM is not essential, as in should be performed between 3 and 4 months after the
late injuries beyond 1 year of evolution, for which there surgical procedure, with the aim of recording the first
would be limited likelihood of restoring nerve function electrical signs of reinnervation. The presence of low-
using different reconstruction techniques. The reason amplitude, short-duration MUPs is the first sign of
for this is that they present irreversible changes in the regeneration detected by EMG. MUPs with better syn-
nerve trunk and effector organs after the degeneration chronization, greater amplitude, and shorter duration
process.19 develop over time. Moreover, the spontaneous activity

56
Electrodiagnostic Pre-, Intra-, and Postoperative Evaluations

caused by denervation during rest gradually disappears. follow-up, even though, in some cases, the clinical findings
If at the time of the first examination, there are no signs are inconsistent with their electrical counterparts.
of reinnervation, one must repeat the study within a
period no longer than 2 months. It also is advisable to
examine several muscles innervated by the same nervous References
structure that was repaired. Reinnervation commonly [1] Rodríguez-Aceves CA, Cárdenas-Mejía A. Experiencia de un año en el
occurs first in more proximal muscles, but there are Hospital General “Manuel Gea González” en las lesiones nerviosas
exceptions (e.g., with lesions involving the primary upper del miembro superior y plexo braquial. Arch Neurocien. 2013; 18(3):
trunk, reinnervation of biceps sometimes precedes that 120–125
[2] Kim DH, Midha R, Spinner RJ. Kline y Hudson. Lesiones Nerviosas.
of the deltoid). When there is no electrical sign of rein-
Philadelphia, PA: Elsevier; 2010
nervation at the time of this second postoperative evalua- [3] Llusá M, Palazzi S, Valer A. Anatomía quirúrgica del plexo braquial y
tion, surgical exploration should be considered, due to de los nervios de la extremidad superior. Panamericana; 2013
the likelihood that the initial nerve restoration was [4] Mackinnon S. Nerve Surgery. 1st ed. New York, NY: Thieme; 2015
[5] Guyton CG, Hall JE. Textbook of Medical Physiology. 11th ed.
unsuccessful. This being said, some authors advise against
Philadelphia, PA: Elsevier; 2006
such exploration, since very late nerve regeneration [6] Kimura J. Electrodiagnosis in Diseases of Nerve and Muscle: Princi-
sometimes does occur. ples and Practice. 4th ed. Oxford: Oxford University Press; 2013
It is considered advisable to perform a subsequent [7] Iriarte-Franco J, Artieda-González J. Manual de Neruofisiología
examination 6 months after nerve repair when studies Clínica. 1st ed. Editorial Panamericana; 2013
[8] Oh SJ. Color Atlas of Nerve Biopsy Pathology. 1st ed. Boca Raton, FL:
show electrical signs of reinnervation, this time focusing
CRC Press; 2001
on more distal muscles within the denervated area. [9] Cuccurullo S. Physical Medicine and Rehabilitation Board Review.
A further evaluation 1 year after surgery is also recom- New York, NY: Demos; 2004
mended. However, it should be considered that regener- [10] Fuller G, Bone I. Neurophysiology. J Neurol Neurosurg Psychiatry.
2005; 76 S2:ii1
ating fibers are initially amyelinic, so CV will generally
[11] Chémali KR, Tsao B. Electrodiagnostic testing of nerves and
be much lower than normal during the early phases of muscles: when, why, and how to order. Cleve Clin J Med. 2005; 72
postoperative recovery. Rarely, physiological velocities (1):37–48
are achieved post neurorrhaphy. One final examination, [12] Gooch CL, Weimer LH. The electrodiagnosis of neuropathy: basic
which is often not performed, can be done 3 to 4 years principles and common pitfalls. Neurol Clin. 2007; 25(1):1–28
[13] Mallik A, Weir AI. Nerve conduction studies: essentials and pitfalls
after surgery to establish the degree of recovery and
in practice. J Neurol Neurosurg Psychiatry. 2005; 76 Suppl 2:ii23–
resulting sequelae. ii31
In some cases, EDSs show evidence of reinnervation, [14] Fisher MA. H reflexes and F waves. Fundamentals, normal and abnor-
but significant motor function is not achieved. Although mal patterns. Neurol Clin. 2002; 20(2):339–360, vi
the cause of such failure is unknown, it may be related to [15] Mills KR. The basics of electromyography. J Neurol Neurosurg
Psychiatry. 2005; 76 Suppl 2:ii32–ii35
the preoperative prognosis and/or to the inability of the
[16] Llusá M, Palazzi S. Anatomía quirúrgica del plexo braquial. Panameri-
motoneuron to induce maturation within the new MU cana; 2013
structures.38 [17] Zouridakis G, Papanicolau A. A Concise Guide to Intraoperative
Monitoring. Boca Raton, FL: CRC Press LLC; 2012
[18] Galloway GM. The preoperative assessment. In: Galloway GM, Nuwer

6.8 Conclusion MR, Lopez JR, Zamel KM. Intraoperative neurophysiologic monitor-
ing. New York, NY: Cambridge University Press; 2010:10–18
Undoubtedly, EDSs enable surgeons to identify nerve [19] Socolovsky M, Siqueira M, Malessy M. Introducción a la Cirugía de los
Nervios Periféricos. Argentina: Ediciones Journal; 2013
injuries, differentiate the underlying pathophysiological
[20] Flores LP. The importance of the preoperative clinical parameters and
mechanisms, and assess injury severity and time course. the intraoperative electrophysiological monitoring in brachial plexus
Moreover, they assist with intraoperative decision-making, surgery. Arq Neuropsiquiatr. 2011; 69(4):654–659
particularly with surgical procedures indicated for the [21] Sclabassi RJ, Balzer J, Crammond D, et al. Technological advances
in intraoperative neurophysiological monitoring. In: Dauber JR,
treatment of traumatic injuries or tumors. The reason for
Maguiere F, Nuwer MR, et al., eds. Handbook of Clinical Neurophysi-
this is that they permit the surgical team to establish the ology, Intraoperative Monitoring of Neural Function. New York, NY:
need to perform more complex nerve reconstructions that Elsevier; 2008:464–480
involve resection of the damaged segment and application [22] Jameson LC, Sloan TB. Neurophysiologic monitoring in neurosurgery.
of a graft, as opposed to decompression by simple neuroly- Anesthesiol Clin. 2012; 30(2):311–331
[23] Kim SM, Kim SH, Seo DW, Lee KW. Intraoperative neurophysiologic
sis. Accordingly, modifying surgical management to require
monitoring: basic principles and recent update. J Korean Med Sci.
less complex surgical intervention significantly reduces 2013; 28(9):1261–1269
surgical time, limits the risk of excessive manipulation [24] Slimp JC. Intraoperative monitoring of nerve repairs. Hand Clin.
of nerve tissue (decreasing the probability of iatrogenic 2000; 16(1):25–36
lesions), and provides insights into the functional status of [25] Wang H, Spinner R. Intraoperative testing and monitoring during
peripheral nerve surgery. In: Nuwer M, ed. Handbook of Clinical Neu-
nerve trunks involved in the lesion and their effector
rophysiology. New York, NY: Elsevier BV;2008:764–773
organs. Moreover, long-term functional prognosis can be [26] Holland NR. Intraoperative electromyography. J Clin Neurophysiol.
established with data collected during postoperative 2002; 19(5):444–453

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[27] Malessy M, Pondaag W. Electromyography, nerve action potential, potential recordings in patients with obstetric brachial plexus lesions.
and compound motor action potentials in obstetric brachial plexus J Neurosurg. 2008; 109(5):946–954
lesions: validation in the absence of a “gold standard”. Neurosurgery. [33] Robla J, Domínguez M, Socolovsky M. Técnicas modernas en micro-
2009; 65(4):A153–A159 cirugía de los nervios periféricos. Argentina: Ediciones Journal; 2014
[28] Salengros JC, Pandin P, Schuind F, Vandesteene A. Intraoperative [34] Rodríguez-Aceves CA, Collado-Ortíz MA, Correa-Márquez LI. Moni-
somatosensory evoked potentials to facilitate peripheral nerve toreo intraoperatorio multimodal y su aplicación en cirugía de
release. Can J Anaesth. 2006; 53(1):40–45 nervios periféricos: ¿Cuándo es de utilidad? An Med (Mex). 2016; 61
[29] Sutter M, Eggspuehler A, Muller A, Dvorak J. Multimodal intraopera- (2):123–131
tive monitoring: an overview and proposal of methodology based on [35] Portillo R, Rojas E, Vera J, Concha G. Seguimiento neurofisiológico en
1,017 cases. Eur Spine J. 2007; 16 Suppl 2:S153–S161 injertos de nervios periféricos. An Fac Med. 2003; 64(1):63–70
[30] Wang H, Bishop AT, Shin AY. Intraoperative testing and monitoring [36] Brown WF. Negative symptoms and signs of peripheral nerve disease.
during brachial plexus surgery. In: Nuwer M, ed. Handbook of Clinical In Brown WF, Bolton CF, eds. Clinical Electromyography. 2nd ed.
Neurophysiology. New York, NY: Elsevier BV;2008:720–730 Boston, MA: Butterworths; 1993:95–116
[31] Everett R, Happel LT. Intraoperative nerve action potential record- [37] Montserrat L. Lesiones traumáticas del nervio. Rehabilitación. 1993;
ings: technical considerations, problems and pitfalls. Neurosurgery. 27:44–55
2009; 65(4)(Suppl):A97–A104 [38] Parry GJ. Electrodiagnostic studies in the evaluation of peripheral
[32] Pondaag W, van der Veken LP, van Someren PJ, van Dijk JG, Malessy nerve and brachial plexus injuries. Neurol Clin 1992;10(4):921–934
MJ. Intraoperative nerve action and compound motor action

58
Magnetic Resonance Neurography and Peripheral Nerve Surgery

7 Magnetic Resonance Neurography and Peripheral


Nerve Surgery
Daniela Binaghi and Mariano Socolovsky

Abstract contrast media may not be required, though patterns of


Magnetic resonance neurography has become the imag- contrast enhancement can distinguish between patholo-
ing modality of choice for identifying and characterizing gies that have similar noncontrast appearances.
pathology within the peripheral nervous system. It pro- MRN imaging evaluates nerve anatomy, signal inten-
vides vital information for patients in whom surgical in- sity, internal pattern, and course, as well as the surround-
tervention is being contemplated. ing tissues and innervated muscles. Normal peripheral
nerves appear isointense to muscle on T1-weighted
Keywords: magnetic resonance neurography, peripheral (T1w) images and iso- to slightly hyperintense on T2-
neuropathy, peripheral nerve trauma, nerve entrapment, weighted (T2w) images—depending on the amount of
peripheral nerve tumor endoneural fluid—revealing a fascicular pattern. Mean-
while, normal nerves do not exhibit enhancement after
gadolinium administration because of the nerve–blood
7.1 Introduction barrier (▶ Fig. 7.1). On DTI, normal nerves show fractional
anisotropy values greater than 0.4 to 0.5.1
Peripheral neuropathy is a commonly encountered disor-
der. Although clinical examination and electrophysiologi-
cal studies are the traditional mainstay of the diagnostic
work-up, magnetic resonance imaging (MRI) has recently
7.2 Trauma
become an important component of this process, facilitat- Most patients with acute nerve transection do not
ing operative interventions, including: targeted fascicular require MRN imaging. Nevertheless, in patients without
biopsies; making surgical exploration faster and more nerve transection—which accounts for the majority of
straightforward; and enhancing neurological outcomes. serious injuries—it might be difficult to distinguish
Furthermore, a new MRI technique called diffusion tensor between those injuries that will and those that will not
imaging (DTI) is becoming available, allowing for the recover spontaneously and may require surgery. MRN
assessment of axonal integrity in neural tissues and ena- imaging plays an essential role in this subset of patients.
bling three-dimensional (3D) reconstruction to evaluate In an attempt to classify the physical and functional
neural tracts (diffusion tensor tractography [DTT]). state of damaged nerves, Seddon2 introduced the terms
Unfortunately, however, DTI–DTT is a time-consuming neurapraxia, axonotmesis, and neurotmesis. Sunderland3
technique with technical difficulties that need to be over- refined this classification, based on the recognition that
come. In addition, data interpretation requires experience axonotmetic injuries had widely variable prognoses,
and further comparisons with surgical and histological depending on the degree of connective tissue involve-
findings. ment. These terms and this classification system are
The term magnetic resonance neurography (MRN) was useful, because they indicate the pathological status of
introduced in the early 1990s to describe the application the nerve, predict the prognosis if the injury is left
of high-resolution sequences to visualize peripheral untreated, and provide a guide to management. MRI
nerves and surrounding soft tissues. It requires the use can aid in distinguishing between these lesions, provid-
of a high-field MR system (1.5-T or 3-T) and dedicated ing vital information for management and surgical
radiofrequency coils. Depending on the clinical picture, planning.

Fig. 7.1 Normal median nerve within the


carpal tunnel. On axial T1w (a), it is
isointense to muscle (flexor carpi ulnaris,
asterisk) and exhibits a fascicular
appearance; on STIR (b), it exhibits mildly
high signal intensity (arrows).

59
Magnetic Resonance Neurography and Peripheral Nerve Surgery

Table 7.1 MRN findings in traumatic nerve injuries


Seddon classification Sunderland classification MRN findings
Nerve: increase SI on FSS
Neurapraxia First degree
Muscle: mild atrophy, no denervation
Axonotmesis Nerve: enlargement, increased SI on FSS
Second degree
Muscle: signs of denervation
Nerve:
● Acute: enlargement, increased SI on FSS, loss of fascicular appearance
Third degree
● Subacute/chronic: neuroma-in-continuity

Muscle: signs of denervation


Nerve: enlargement, increased SI, loss of fascicular appearance, blockage
Fourth degree of axoplasmic flow on DTT
Muscle: signs of denervation
Nerve:
● Acute: gap shows high SI on FSS
Neurotmesis Fifth degree
● Chronic: terminal neuroma

Muscle: signs of denervation


Abbreviations: DTT, diffusion tensor tractography; FSS: fluid-sensitive sequences; SI, signal intensity.

ities in muscle signal intensity, except for mild atrophy


secondary to disuse.
MRI findings in axonotmetic lesions include neural
enlargement and transient increases in nerve signal
intensity on T2w and short tau inversion recovery (STIR)
images, combined with loss of the normal fascicular
appearance, blurring of the perifascicular fat, and signs of
muscle denervation (appearing within 24–48 hours); this
is followed by muscle volume reduction and fatty atrophy
if nerve regeneration does not occur. MRN is further able
to distinguish axonotmetic injuries as subclassified by
Sunderland. With a type III injury, the endoneurium
is disrupted, intrafascicular fibrosis takes place, and a
neuroma-in-continuity (▶ Fig. 7.3) is formed that appears,
on MRN imaging, as a fusiform enlargement with inter-
mediate to high signal intensity in fluid-sensitive images
Fig. 7.2 Neurapraxia. On coronal STIR, note increased signal with variable contrast enhancement. With Sunderland
intensity in the C5 (arrow) and C6 roots (arrowhead) of the type IV injuries, only the epineurium is intact, so MRN
brachial plexus. images demonstrate lost fascicular appearance, increased
nerve signal intensity on T2w and STIR sequences, and
blockage of the axoplasmic flow on DTT (▶ Fig. 7.4),
which is an emerging MRN technique that generates a 3D
With neurapraxia, the nerve is intact, but cannot trans- image of neural tracts, thereby allowing clinicians to
mit impulses. With axonotmesis, the axon is damaged or assess axonal integrity.6
destroyed, but most of the connective tissue framework During the acute stage of a neurotmetic injury, MRN
is maintained. Meanwhile, with neurotmesis, the nerve is can demonstrate nerve discontinuity (▶ Fig. 7.5), the gap
disrupted and the connective tissue framework is either filled with fluid and granulation tissue5 that, over time
totally lost or badly distorted. On MRN imaging, these (1–12 months), will form proximal “bulbous-end” thick-
three classes of injury look different4,5 (▶ Table 7.1). Typi- ening with intermediate signal intensity on T1w images,
cal MRN imaging findings in neurapraxic injuries and inhomogeneous intermediate to high signal intensity
(▶ Fig. 7.2) and Sunderland´s first-degree nerve lesions on T2w images; contrast enhancement is variable and
are a focal increase in nerve signal intensity on fluid- dependent on the level of maturity of any fibrotic and
sensitive sequences, combined with no signal abnormal- regenerated nerve tissue involved in the repair. Diagnosis

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Magnetic Resonance Neurography and Peripheral Nerve Surgery

Fig. 7.3 Neuroma-in-continuity in the


elbow, distal to the cubital tunnel.
(a) Sagittal STIR and (b) axial proton density
(PD) images show fusiform enlargement
and a slight increase in signal intensity
(arrows).

Fig. 7.4 Peroneal injury secondary to knee dislocation. On axial PD images (a), the peroneal nerve (arrow) shows loss of fascicular
appearance. On fiber tract images (b), blockage of peroneal axonal flow is seen, while the tibial nerve displays normal axonal flow
(arrowhead). After surgery (c), axonal flow is restored (arrow).

Fig. 7.5 Root avulsion. (a) An axial


reformatted T2w 3D image shows complete
left brachial plexus root avulsion (dashed
circle). (b) Tractographic image of the
lumbosacral plexus overlaid on coronal T2w
MRN demonstrates avulsion of L5 (arrow)
and S1 (arrowhead) right-sided nerves, but
normal contralateral nerves (dotted arrows).

61
Magnetic Resonance Neurography and Peripheral Nerve Surgery

Fig. 7.6 Terminal ulnar nerve neuroma in


the distal forearm. (a) Sagittal T2w shows
fusiform enlargement of the nerve (arrow)
consistent with a terminal neuroma.
(b) Axial STIR exhibits the gap (arrowheads).
R, radial bone; U, ulnar bone.

Fig. 7.7 Carpal tunnel syndrome secondary


to radial bursitis. (a) Axial PD-SPIR image
shows radial bursa (asterisk) contacting with
the median nerve, which is normal in
appearance (arrow). (b) Tractographic
image overlaid on axial PD exhibits
decreased axonal flow (dotted arrow) in
fascicles close to the bursitis.

of a stump neuroma is not always straightforward. For may also be evident in advanced cases. MRN imaging
this reason, MRN should be performed as soon as possi- criteria used to determine the presence of compression
ble, before repair tissue covers the gap, after which time are: (1) close contact with the compressive structure,
imaging becomes very difficult (▶ Fig. 7.6). (2) disappearance of the fat plane around the affected
nerve, and (3) change in the normal nerve appearance.
MRN imaging is particularly valuable in complex cases
7.3 Entrapment Neuropathies with discrepant nerve function test results, when a sec-
ondary cause is suspected (▶ Fig. 7.7), and in patients
Compression neuropathies encompass a heterogeneous
who require postsurgical evaluation (▶ Fig. 7.8).
group of focal neuropathy syndromes characterized by
peripheral nerve compression. Nerve compression results
in pain, paresthesias, and lost function of the affected
nerve. The term entrapment neuropathy defines a pressure-
7.4 Tumors
induced chronic compression injury. Developing a classification system and nomenclature for
Although nerves may be injured anywhere along their peripheral nerve tumors has been difficult and confusing.
course, they are more prone to compression, entrapment, However, advances in MRN imaging have improved the
or stretching as they traverse anatomically vulnerable diagnostic work-up, helping to delineate the various
regions, such as superficial or geographically constrained differential diagnostic possibilities and determining
spaces.4 Compression may be episodic and may have a whether lesions are intra- or extraneural. These advances
cumulative effect. The nerves affected by dynamic or have implications for safe and complete resection of both
fixed compressive neuropathy have an injury-related common and less common neurogenic and nonneuro-
abnormal appearance, indicators of compression or swel- genic tumors, as well as for targeted fascicular biopsy.
ling, as well as high signal on fluid-sensitive sequences, a The diagnosis of benign neurogenic tumors and
sign of intraneural edema. Muscular denervation changes pseudotumors can be suggested from their imaging

62
Magnetic Resonance Neurography and Peripheral Nerve Surgery

appearances and characteristics; luckily, they are more


common than secondary involvement in systemic malig-
nancies and malignant peripheral nerve sheath tumor
(MPNST).
The clinical appearance of a neurogenic tumor is usu-
ally that of a soft-tissue mass that might be associated
with symptoms related to the involved neural structures.
The most common benign peripheral nerve tumors are
schwannomas and neurofibromas. It is usually difficult,
if not impossible, to reliably differentiate these two
lesions on the basis of MRN imaging features, despite
their different pathological characteristics. The typical
MRN appearance (▶ Fig. 7.9) of a benign peripheral nerve
tumor is that of a well-defined oval lesion, usually in con-
tinuity with the nerve of origin, which is less than 5 cm in
diameter, isointense to muscle on T1w images, and
hyperintense on T2w images, while exhibiting prominent
enhancement after contrast administration. Often, there
is an area of low signal on T2w images, which usually
does not enhance, representing the classic “target sign” of
a benign neurogenic tumor, caused by peripheral myxoid
material and central fibrous tissue. On DTI, these lesions
are associated with high apparent diffusion coefficient
(ADC) values (> 1.1–1.2 × 10–3 mm/s2).7 Also, DTT can be
used to visualize the 3D course of nerve fibers and
bundles, which are displaced in the presence of schwan-
nomas, but infiltrated by neurofibromas. DTT can also
identify a “safe zone” in which dissection can be per-
formed while avoiding damage to normal fascicles.
MPNSTs are an extremely rare group of malignancies.
Unfortunately, MRN differentiation of benign versus
MPNSTs remains challenging.8 It has been suggested that
a combination of two or more of the following MRI fea-
tures can serve as indicators of malignancy: ill-defined or
invasive margins; peritumoral edema; largest diameter
greater than 5 cm; and heterogeneous signal intensity on
T1w and T2w images.9 Low diffusivity values (ADC) indi-
cate malignancy on DTI, while, on DTT, there will be par-
tial or complete disruption of tracts.10 Even in the absence
of such findings, malignancy must be suspected in
patients who have tumors that have increased rapidly in
size, become progressively painful, or produced a new
neurological deficit.

7.5 Conclusion
Fig. 7.8 Peroneal nerve entrapment, which developed after MRN imaging plays an essential role in the diagnostic
lateral ligament reconstruction surgery. (a) Sagittal T2w of the work-up of peripheral neuropathies. It helps to establish
peroneal head shows the peroneal nerve (asterisk) passing the cause of the condition; confirms, locates, and charac-
through a constrained space. (b) Axial PD-SPIR demonstrates an terizes the pathological process; and provides crucial
altered fascicular pattern and increased nerve signal (arrow).
information that may alter the choice of treatment or
BT, biceps tendon; LCL, lateral collateral ligament.
surgical plan.

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Magnetic Resonance Neurography and Peripheral Nerve Surgery

Fig. 7.9 Schwannoma versus neurofibroma. Axial PD (a, c) shows focal neural enlargement (arrow) with a similar image appearance.
Tractographically reconstructed images demonstrate, in the first case (b), displaced tracts consistent with schwannoma (arrowhead),
while in the second case (d) the mild disorganization (arrowhead) of tracts suggests neurofibroma. Both cases were confirmed
histologically.

[6] Lehmann HC, Zhang J, Mori S, Sheikh KA. Diffusion tensor imaging to
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64
Ultrasound in Peripheral Nerve Surgery

8 Ultrasound in Peripheral Nerve Surgery


Maria Teresa Pedro and Ralph W. König

Abstract neurologists or nerve surgeons a readily available and


High-frequency ultrasound (HFU) has become an indis- deeper insight into the nerve, including its surrounding
pensable diagnostic tool in peripheral nerve surgery. soft tissue.
Progress in technical equipment made it possible to
depict peripheral nerves in high resolution, up to 500 µm. 8.2 How to Start
Especially concerning “failed surgeries” of compression
neuropathies, HFU is able to capture morphological path- (Basic Principles)
ologies (scars, nerve kinking, partial neuroma, cysts).
One of the basic principles of US is the fact that high fre-
It provides essential information for the medical evalua-
quency (17–15 MHz; ▶ Fig. 8.1) leads to high resolution
tion of recurrent surgery.
but low tissue penetration. Therefore, the visualization of
HFU has also changed the time frame in treating trau-
superficial peripheral nerves is decently feasible. How-
matic nerve lesions since loss of continuity of damaged
ever, for the presentation of deeper lying nerves (for
nerves are depicted right away. During reconstructive
instance, sciatic nerve), the application of lower fre-
nerve surgery, intraoperative HFU has a direct impact on
quency transducers (10–12 MHz) becomes necessary.
the surgeon’s decision, since tissue differentiation and
To start examination, the authors would recommend
pathologies becomes immediately visible. Nerve surgeons
obtaining transverse US images. At the beginning, it is dif-
can take a look into the affected nerve and decide which
ficult to distinguish nerves from tendons (i.e., median
microsurgical technique could be optimally applied.
nerve at the wrist) (▶ Fig. 8.2). However, when the US
For the diagnostic evaluation of peripheral nerve
probe is slightly tilted, nerves will not change their
tumors, magnetic resonance imaging (MRI) is the gold
shape, while tendons will become either hyperechoic or
standard, but nevertheless misinterpretations are fre-
hypoechoic. The typical transverse picture of a healthy
quent, in particular, concerning rare nerve tumors.
peripheral nerve is similar to a honeycomb, meaning that
Multimodal ultrasound (power Doppler, superb micro-
single fascicles are hypoechoic, those are surrounded by
vascular imaging, contrast-enhanced ultrasound) offers
hyperechoic membranes of the perineural sheath. The
additional morphological knowledge. However, further
whole nerve is coated by epineural tissue, which is also
expertise and studies are necessary to evaluate these
results first.

Keywords: high-frequency ultrasound, compression neu-


ropathy, traumatic nerve lesions, peripheral nerve tumor,
multimodal ultrasound

8.1 Introduction
Regular application of ultrasound (US) as a medical diag-
nostic tool goes back to the 1960s. However, it was
not earlier than 1988 when Fornage1 first described the
ultrasonographic visualization of peripheral nerves.
Nowadays, as a consequence of an ongoing combined
development of US transducers and image processing
software (i.e. compound imaging, tissue harmonic imag-
ing), high-frequency/high-resolution ultrasound (HFU/
HRU) has become a highly versatile diagnostic tool for the
diagnostic evaluation of peripheral nerve problems in
general.2 In particular, its intraoperative implementation
provides valuable additional information for surgery of
peripheral nerve trauma and tumors.3
Nowadays, US, besides the medical history, a complete
clinical examination, and electrophysiological studies,
can be considered as a valuable standard in the diagnosis Fig. 8.1 The 15-MHz transducer, called ice hockey stick
of peripheral nerve pathologies. US, rather than magnetic (left-hand side); the 17 MHz transducer (right-hand side).
resonance neurography (MRN), is capable of offering

65
Ultrasound in Peripheral Nerve Surgery

ology are indispensable and usually sufficient. However,


if the visualization of the affected nerve becomes neces-
sary, for instance, in cases of suspected recurrence, HRU
is the suitable diagnostic tool to provide additional mor-
phological information.
Historically, the first HRU studies were dealing with CTS
and CUTS. Already in 1991, only 3 years after Fornage first
described a neural structure in US, Buchberger and his
colleagues4 published their findings in patients with CTS.
The study group pointed out that the median nerve
appeared enlarged before entering the entrapment zone.
One possible pathological explanation for the develop-
Fig. 8.2 Transversal plane of the median nerve. RCFT, flexor ment of this swelling is postulated to be caused by com-
tendon of the M. carpi radialis muscle; RF, retinaculum pression of the vasa nervorum. As a result, an ischemia
flexorum.
and venous congestion may occur, which in turn leads to
neural edema.5 This suspicious surface area has to be com-
pared to the more proximal or distal parts of the nerve.
hyperechoic. Note that the real anatomical existing num-
If the ratio is 2:1, one can speak of a pseudoneuroma
ber of fascicles is usually much higher. It does not corre-
(▶ Fig. 8.3a–c). Kele et al6 examined 110 median nerves of
spond to the number of fascicles depicted by HRU.
patients suffering from CTS via US. A cross-sectional area
The investigator should start US at an anatomical rele-
(CSA) of > 0.11 cm2 was considered to be highly predictive
vant area, where the nerve is lying superficially or nearby
for the diagnosis of CTS (sensitivity 89.1% and specificity
a typical bone structure, for example:
98%). Therefore, diagnostic accuracy of HRU is comparable
● Median nerve: carpal tunnel/wrist.
to electrophysiological studies in CTS.7 Another group
● Ulnar nerve: cubital tunnel/elbow.
reported that by combining HRU with nerve conduction
● Radial nerve: humerus/middle upper arm.
studies, sensitivity and specificity increased to 98 and
● Peroneal nerve: fibula/knee joint.
91%, respectively, in patients with CUTS.8
● Tibial nerve: tarsal tunnel/medial malleolus.
For all other rare entrapment syndromes of the upper
limb, such as, supinator syndrome, thoracic outlet syndro-
HRU should be a dynamic examination. It is important to
me, Guyon’s syndrome, etc., HRU is even more essential,
examine the whole or at least a long trail of the nerve,
and it provides helpful additional information (existence
sometimes even to compare the healthy side of the body
of cysts, lipoma, cervical ribs) since electrophysiology
with the lesioned one. By slightly increasing the pressure
examination is often challenging in those cases.
of the transducer, the investigator can even provoke a Tinel
sign; or by asking the patient to flex and stretch the elbow,
a subluxation or complete luxation of the ulnar nerve can 8.3.2 Compression Neuropathies
be seen by HRU. Last but not least, one should also evalu-
of the Lower Limb
ate the structure of the different surrounding tissues, i.e.,
muscles, bones, and tendons, especially in trauma. Entrapment syndromes of the lower limb are quite rare,
but peroneal and tibial nerves in particular can be com-
pressed by extraneural or intraneural cysts. Therefore, for
Note:
surgical planning, HRU is extremely helpful (▶ Fig. 8.4).9
High frequency means less tissue penetration. Even Morton’s neuroma of the interdigital plantar nerve
Start examination in transverse plane on an anatomical can be visualized as a spherical swelling. Also, a hypoe-
relevant area. choic enlargement of the lateral femoral cutaneous nerve
(LFCN) is a secure sign of entrapment at the anterior
HRU is a dynamic examination, keep moving.
superior iliac spine in patients with meralgia paresthe-
tica, but since those patients are often obese, an examina-
tion via HRU is in general difficult.10 Infiltrations of the
8.3 Compression Neuropathies LFCN as a nonsurgical treatment option are firmly per-
formed by US guidance.11
8.3.1 Compression Neuropathies
of the Upper Limb 8.3.3 Recurrent Compression
Bearing in mind that the carpal and the cubital tunnel
Neuropathies
syndrome (CTS and CUTS) are the most frequent entrap- HRU is of great importance and indispensable in cases of
ment syndromes, clinical examination and electrophysi- recurrent entrapment syndromes. Before a surgical redo

66
Ultrasound in Peripheral Nerve Surgery

Fig. 8.3 Transversal plane of the ulnar nerve of a patient suffering of CUTS. (a) At the level of the epicondylus medialis, showing a
hypoechoic enlargement of 0.146 cm2. (b) At the middle of the upper arm with a CSA of 0.068 cm2. (c) At the middle of the forearm
next to the ulnar artery with a CSA of 0.067 cm2.

Fig. 8.4 Tibial nerve next to an extraneural cyst at the malleolus


medialis.

Fig. 8.5 Median nerve of a symptomatic patient, who was


surgery is decided, the visualization of new postoperative previously operated for CTS, showing epineural fibrosis.
morphological changes, such as, scars, epineural fibrosis
(▶ Fig. 8.5), partial neuromas, cysts, nerve kinking after
transposition, etc. have to be depicted and evaluated. Also after CTS surgery in asymptomatic patients, postulating
the CSA of the pseudoneuroma before and after surgery that after decompression the swelling of the affected
can be compared. Tas et al12 described a decrease in CSA median nerve is reversible.

67
Ultrasound in Peripheral Nerve Surgery

can be measured, so that the needed length of nerve


Note:
grafting can be determined and surgery can accordingly
Pseudoneuroma means CSA 2:1. be performed at an early stage.
Indirect nerve lesions may lead to incomplete neuro-
HRU is above all useful for “failed surgery” and rare com-
logical deficits, which makes it often more difficult to
pression neuropathies of the upper or lower limb (e.g.,
find the right decision whether to operate or not. Mor-
detection of cysts).
phological findings in HRU do help to understand the
pathogenic mechanism and to better evaluate nerve’s
damage. The affected nerve may lose its fascicular struc-
8.4 Trauma ture and become swollen and hypoechoic, epineural
tissue may be fibrotic, or scar tissue may lead to compres-
8.4.1 Preoperative HRU sion (▶ Fig. 8.9).
HRU in the recent past had a significant impact on periph-
eral nerve surgery, especially in peripheral nerve trauma.
Besides medical history, clinical examination, and elec-
8.4.2 Intraoperative HRU
trophysiological studies, HRU provides morphological High-frequencies transducers (e.g., 17 MHz) in HRU
information of the lesioned nerve segment and its sur- achieve a spatial resolution of up to 500 µm, but tissue
rounding tissues (bone, tendons, muscles). Before, clinical penetration is restricted to few centimeters. Especially in
and electrodiagnostic examination were the only tools enlarged extremities due to lymphedema or hematoma,
to evaluate patients. In some instances, MRN was per- the tissue differentiation may become difficult. Lee was
formed, but in the majority of cases, due to the presence the first who used HRU intraoperatively to localize
of osteosynthetic material, nerve structures could hardly directly a neuroma in situ.17 To exploit maximal spatial
be recognized. resolution, our study group evaluated HRU findings in
Now, via HRU, the injured area can be examined as a traumatic lesioned nerve segments in an intraoperative
whole. Tendons, muscles, bones, osteosynthetic material, setting (iHRU) in 2011. After external neurolysis, the
hematoma, and nerves become visible.13 injured nerve segment was embedded in sterile US gel
Since morphological nerve damage is visualized and cushions and the affected part of the nerve was visualized
registered by HRU, this diagnostic tool has obtained an via a 15- or 17-MHz transducer (▶ Fig. 8.10a,b). These
outstanding role especially in regard to iatrogenic nerve findings were compared to the results of compound
lesions14 (▶ Fig. 8.6a,b). nerve action potentials (cNAP) and, in the case of the
It is now possible to distinguish between direct (sharp neuroma being resected, also compared to histopathol-
transection) and indirect nerve lesions (compression due ogy. Morphological alterations correlated well with
to scar tissue, osteosynthetic material, hematoma).15 The intraoperative recording of cNAP and therefore with
cause is determined as well as the exact localization of functionality.3
the nerve damage is registered. This enables the physi- Focusing on neuroma-in-continuity surgical manage-
cians to make a proper decision whether to operate or to ment, especially in cases with partial neurological regen-
wait for reinnervation.16 Furthermore, surgical approach eration, becomes challenging. Even after microsurgical
and skin incision can be precisely targeted (▶ Fig. 8.7a–c). exposure, neuromas involving the complete internal
In the case of a sharp transection with discontinuity of structure are hard to be distinguished from partial neuro-
the nerve, HRU depicts neuroma as large hypoechoic mas. Frequently, different morphological alterations
enlarged stumps (▶ Fig. 8.8). The distance between them merge into one another and thus the complete extent of

Fig. 8.6 (a) Preoperative ultrasound revealing the exact location where the radial nerve slides under the screw. (b) Intraoperative picture
of osteosynthesis after a fracture of the left humerus; radial nerve is lying under a screw.

68
Ultrasound in Peripheral Nerve Surgery

Fig. 8.7 Patient with humeral fracture after osteosynthesis with loss of hand extension. (a) Transversal plane of radial nerve lying on
osteosynthetic material. (b) Transversal plane of the radial nerve slipping over a screw as over a hypomochlion. (c) Through preoperative
HRU detection of the location of damage and planning the further incision (red lines and red arrows, former scars, suspected location of
nerve damage at the elbow level; black line, new incision).

In summary, pre- and intraoperative HRU merge into


one another. Both have changed peripheral nerve surgery,
especially in traumatic nerve lesions. They are comple-
mentary diagnostic tools to electrodiagnosis and clinical
examination. All of them together enable us to achieve
important knowledge about morphology and function of
an affected nerve.
The implementation of both techniques is shown in the
trauma flowchart (▶ Fig. 8.11).

Note:
Preoperative HRU locates and depicts nerve damage at
an early stage.
Intraoperative HRU helps determine the best micro-
surgical technique that should be employed in each
case.

Fig. 8.8 Longitudinal scan of a dissected sciatic nerve (stump)


in a child of 10 years.
8.5 Tumors
Peripheral nerve tumors (PNTs), especially schwannoma
lesion gets exposed. Via iHRU, the inner architecture of and neurofibroma, each account for 5% of all soft-tissue
the affected nerve segment becomes visible, and by this tumors. Magnetic resonance imaging (MRI) as a diag-
means, it has a direct influence on the surgical procedure nostic tool has been the gold standard until now.
(▶ Table 8.1). However, nevertheless, misinterpretations, especially
Nowadays, HRU is a fixed component in the operating concerning rare peripheral nerve tumors, are frequent.18
room during peripheral nerve surgery. A secure differentiation between benign and malignant

69
Ultrasound in Peripheral Nerve Surgery

Fig. 8.9 Longitudinal scan of a median


nerve being compressed from above by a
scar tissue.

Fig. 8.10 Intraoperative HRU. (a) Sterile-draped 15-MHz probe, while the ulnar nerve is embedded in a sterile gel cushion. (b) IHRU
picture of a peroneal nerve via 17 MHz, honeycomb structure clearly visible.

peripheral nerve sheath tumors (BPNST and MPNST), impressive US result. Histopathology defined it as a B-cell
despite advances in MRI sequences, containing MR lymphoma. Until now, a second case of lymphoma could
enhanced neurography or diffusion tensor imaging, and be examined and the same criteria were depicted
18F-fluorodeoxyglucose positron emission tomography (▶ Fig. 8.13).
(FDG PET), is not yet possible.19,20 Nowadays, HRU has The third group came out to be grossly inhomogeneous
become a further additional promising diagnostic me- in their pathological examinations, although iHRU
dium, but concerning PNTs, experience is still limited revealed no large differences within this group. The
and until now with only a few published studies.21,22 affected nerves showed large hypoechoic tumor masses
Our study group first started to perform iHRU in PNTs and no affected fascicles were displaced or hardly distin-
in 2010. The first step was to obtain maximal morpholog- guishable. Cysts or even areas with hyperechoic solid
ical knowledge, by using high-frequency transducers parts were seen. Ancient benign schwannomas, as well as
(17 MHz) to gain a resolution of up to 500 µm. MPNST, were hardly distinguishable (▶ Fig. 8.14).
In summary, due to US findings, three different groups However, depending on pathological results, surgical
(A–C) were described. management differs widely, ranging from complete enu-
In the first group, the examined nerves revealed cleation of the tumor mass under strict neurological pres-
enlarged hypoechoic fascicles. Their inner architecture ervation (e.g., schwannoma) to biopsy of one fascicle (e.g.
per se was definable (▶ Fig. 8.12). After biopsy of one perineurioma) and complete resection of the tumorous
conspicuous fascicle, pathological examination revealed nerve taking into account a loss of function (e.g., MPNST).
very rare tumor entities, such as amyloidoma and peri- To date, it is still a long-awaited requirement to improve
neurioma, or tumorlike lesions, such as multifocal diagnostic accuracy within preoperative classification.
acquired demyelinating sensory and motor (MADSAM) Since tissue penetration is limited in HRU, further US
neuropathy. modalities such as contrast-enhanced US, power Doppler,
The second group consisted of one case with a giant and superb microvascular imaging are being used for pos-
sciatic nerve, showing in iHRU huge, dense, enlarged iso- sible PNT differentiation (▶ Fig. 8.15a–c) in ongoing
echoic fascicles. In 2015, only one case revealed this research.21,23

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Ultrasound in Peripheral Nerve Surgery

Table 8.1 Trauma classification via iHRU


Type I Normal

Type II Epineural fibrosis Epineurotomy

Type III Intraneural fibrosis Epineurotomy and intraneural dissection

Type IV Partial neuroma Split repair

Type V Complete neuroma (in continuity) Nerve grafting

Trauma Fig. 8.11 Trauma flowchart. In case of


traumatic nerve lesions, HRU should be
performed as soon as possible to depict
nerve’s continuity. Depending on nerve’s
HRU
regeneration, early-staged surgery should be
carried out. iHRU enables visualization
of nerve’s damage. Together with nerve
Lost Continuity Continuity action potentials, it helps determination
of nerve’s lesion in a trauma classification
Follow up (I–V). HRU, high-resolution ultrasound;
Surgery
iHRU, intraoperative high-resolution
ultrasound; NAP, nerve action potential.
− Regeneration + Regeneration

Follow up
Time

Stagnant Ongoing
regeneration regeneration

Surgery

3 months
iHRU NAP

I II III IV V

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Ultrasound in Peripheral Nerve Surgery

Fig. 8.12 Transversal plane of an ulnar


nerve, showing hypoechoic enlarged fas-
cicles next to smaller regular ones. Classical
picture of an amyloidoma.

Fig. 8.13 Transversal plane of sciatic nerve of a B-cell


lymphoma. Fascicles are enlarged, dense, isoechoic; the inner
architecture is distinguishable. Fig. 8.14 Longitudinal HRU picture of a schwannoma of a
median nerve. Hypoechoic cystic tumor displaces no affected
fascicles. No fascicles distinguishable in the tumor mass.

Fig. 8.15 Multimodal HRU. (a) Preoperative ultrasound of a schwannoma of a sciatic nerve (left side). Same picture examined via superb
microvascular imaging showing a positive perfusion on the upper part of the tumor (right side). (b) Intraoperative contrast-enhanced
ultrasound of those two schwannoma of the right tight, directly after intravenous application intravenous application, showing no inner
enhancement. (c) Same patient after 20 seconds, revealing a homogenous complete enhancement.

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Ultrasound in Peripheral Nerve Surgery

ment in 20 consecutive patients. J Ultrasound Med. 2011; 30(10):


Note: 1341–1346
[12] Tas S, Staub F, Dombert T, et al. Sonographic short-term follow-up
MRI is the gold standard for PNT. after surgical decompression of the median nerve at the carpal tun-
Ongoing research for multimodal HRU in PNT. nel: a single-center prospective observational study. Neurosurg
Focus. 2015; 39(3):E6
[13] Kele H. Sonographie der peripheren Nerven. In: Reimers CD,
Gaulrapp H, Kele H, eds. Sonographie der Muskeln, Sehnen und
Nerven. Köln: Deutscher Ärzteverlag; 2004:271–280
References [14] Antoniadis G, Kretschmer T, Pedro MT, König RW, Heinen CPG,
Richter HP. Iatrogenic nerve injuries: prevalence, diagnosis and treat-
[1] Fornage BD. Peripheral nerves of the extremities: imaging with US. ment. Dtsch Arztebl Int. 2014; 111(16):273–279
Radiology. 1988; 167(1):179–182 [15] Gruber H. Traumatic nerve lesions. In: Peer S, Bodner G, eds. High-
[2] Beekman R, Visser LH. High-resolution sonography of the peripheral resolution sonography of the peripheral nervous system. Berlin:
nervous system – a review of the literature. Eur J Neurol. 2004; 11 Springer-Verlag; 2008:123–149
(5):305–314 [16] Gruber H, Glodny B, Galiano K, et al. High-resolution ultrasound
[3] Koenig RW, Schmidt TE, Heinen CP, et al. Intraoperative high- of the supraclavicular brachial plexus–can it improve therapeutic
resolution ultrasound: a new technique in the management of decisions in patients with plexus trauma? Eur Radiol. 2007; 17(6):
peripheral nerve disorders. J Neurosurg. 2011; 114(2):514–521 1611–1620
[4] Buchberger W, Schön G, Strasser K, Jungwirth W. High-resolution [17] Lee FC, Singh H, Nazarian LN, Ratliff JK. High-resolution ultrasonogra-
ultrasonography of the carpal tunnel. J Ultrasound Med. 1991; 10 phy in the diagnosis and intraoperative management of peripheral
(10):531–537 nerve lesions. J Neurosurg. 2011; 114(1):206–211
[5] Bodner G. Nerve compression syndromes. In: Peer S, Bodner G, eds. [18] Kransdorf MJ, Murphey MD. Radiologic evaluation of soft-tissue
High-Resolution Sonography of the Peripheral Nervous System. masses: a current perspective. AJR Am J Roentgenol. 2000; 175(3):
Berlin: Springer-Verlag; 2008:71–122 575–587
[6] Kele H, Verheggen R, Bittermann HJ, Reimers CD. The potential value [19] Koenig RW, Coburger J, Pedro MT. Intraoperative Findings in Periph-
of ultrasonography in the evaluation of carpal tunnel syndrome. eral Nerve Pathologies. In: Prada F, Solbiati L, Martegani A, DiMeco F,
Neurology. 2003; 61(3):389–391 eds. Intraoperative Ultrasound (IOUS) in Neurosurgery: From Stand-
[7] American Association of Electrodiagnostic Medicine, American Acad- ard B-mode to Elastosonography. Heidelberg: Springer; 2016:71–79
emy of Neurology, and American Academy of Physical Medicine and [20] Ferner RE, Golding JF, Smith M, et al. [18F]2-fluoro-2-deoxy-D-
Rehabilitation. Practice parameter for electrodiagnostic studies in glucose positron emission tomography (FDG PET) as a diagnostic tool
carpal tunnel syndrome: summary statement. Muscle Nerve. 2002; for neurofibromatosis 1 (NF1) associated malignant peripheral nerve
25(6):918–922 sheath tumours (MPNSTs): a long-term clinical study. Ann Oncol.
[8] Beekman R, Van Der Plas JP, Uitdehaag BM, Schellens RL, Visser LH. 2008; 19(2):390–394
Clinical, electrodiagnostic, and sonographic studies in ulnar neuropa- [21] Pedro MT, Antoniadis G, Scheuerle A, Pham M, Wirtz CR, Koenig RW.
thy at the elbow. Muscle Nerve. 2004; 30(2):202–208 Intraoperative high-resolution ultrasound and contrast-enhanced
[9] Visser LH. High-resolution sonography of the common peroneal ultrasound of peripheral nerve tumors and tumorlike lesions. Neuro-
nerve: detection of intraneural ganglia. Neurology. 2006; 67(8): surg Focus. 2015; 39(3):E5
1473–1475 [22] Capek S, Hébert-Blouin MN, Puffer RC, et al. Tumefactive appearance
[10] Onat SS, Ata AM, Ozcakar L. Ultrasound-guided diagnosis and treat- of peripheral nerve involvement in hematologic malignancies: a new
ment of meralgia paresthetica. Pain Physician. 2016; 19(4):E667– imaging association. Skeletal Radiol. 2015; 44(7):1001–1009
E669 [23] Loizides A, Peer S, Plaikner M, Djurdjevic T, Gruber H. Perfusion
[11] Tagliafico A, Serafini G, Lacelli F, Perrone N, Valsania V, Martinoli C. pattern of musculoskeletal masses using contrast-enhanced ultra-
Ultrasound-guided treatment of meralgia paresthetica (lateral femo- sound: a helpful tool for characterisation? Eur Radiol. 2012; 22(8):
ral cutaneous neuropathy): technical description and results of treat- 1803–1811

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Surgical Repair of Nerve Lesions: Neurolysis and Neurorrhaphy with Grafts/Tubes

9 Surgical Repair of Nerve Lesions: Neurolysis and


Neurorrhaphy with Grafts or Tubes
Sudheesh Ramachandran and Rajiv Midha

Abstract peripheral nerve repair have originated from the infor-


Peripheral nerve injuries are devastating, and manage- mation gleaned from numerous animal models. This
ment is complex. Microsurgical repair forms the mainstay chapter attempts to provide an overview of the surgical
of treatment, which includes direct repair, nerve grafting, techniques currently used for peripheral nerve repair
nerve transfers, and nerve tubes. This chapter elaborates with special emphasis on grafting, tubulization techni-
on the technical nuances of surgical repair and critically ques, and recent advances such as cell-based supportive
analyses the evidence for various surgical modalities. therapies.
Advances in tissue engineering provide considerable
promise in the future as alternative/adjunct to existing
management strategies. 9.2 Evaluation and Approach
A thorough understanding of the nerve injury is impera-
Keywords: nerve surgery, nerve injury, neurorrhaphy,
tive following a clinical diagnosis. This is because subse-
conduits, functional outcome
quent management strategies are strongly based on the
type of insult sustained. We now know that a regenera-
tive cascade of events begins immediately after a nerve
9.1 Introduction injury. When the neural elements are disrupted, each
axon forms several filopodia, which steadily and slowly
Peripheral nerve injuries (PNIs) are disturbingly frequent, advance toward the distal nerve stump in an attempt to
affecting around 2.8% of the trauma population.1 Most of bridge the gap. The recovery time is dependent on the
them occur as a consequence of motor vehicle accidents regeneration rate, which averages 1 mm/day.8 When
or injuries at home/workplace, resulting in substantial endoneurial tubes are intact (pure axonotmesis injury),
and often permanent morbidity and disability. The strict there is an excellent chance of an uninhibited regenera-
enforcement of the use of seat belts and crash helmets in tive process culminating in satisfactory reinnervation.
many countries has significantly reduced the mortality; However, when there is a partial or complete internal
however, a simultaneous increase in the incidence of PNI rupture, the advancing and regenerating axons become
has been an undesirable offshoot.2 Most of our under- tangled in disrupted internal architecture and scar tissue,
standing of PNIs come from the First and Second World often resulting in a neuroma-in-continuity. The recovery
Wars’ experience in the 20th century. However, the con- in axonotmesis largely depends on the ability of the
cepts of nerve repair and regeneration were described as regenerating axons to bridge the gap and establish func-
early as 7th century by Paul of Aegina. In 1850, Augustus tional continuity without being impeded by the scarring
Waller threw some light on the pathophysiology of nerve process. Neuropraxia recovers spontaneously, and neuro-
injury by describing anterograde myelin and axonal tmesis requires surgery. In complex clinical scenarios,
degeneration.3 The first successful nerve regeneration multiple levels and types of injuries can coexist, giving
after surgical repair was reported by Cruikshank in 1795. rise to a therapeutic challenge.
Primary epineurial suturing and nerve suturing techni- The timing of intervention for nerve repair is largely
ques were described by Heuter in 1871 and Mikulicz in dependent on the type of nerve injury sustained, condi-
1882, respectively.4 Albert in 1876 pioneered nerve graft- tion of the wound, and vascular supply of the nerve
ing procedures to bridge the gaps, and Loebke in 1884 bed.9,10 Early surgery is indicated when there is a lacera-
elaborated on bone-shortening procedures to reduce tion with concurrent neurological deficit, where the pos-
nerve tension during repair. Many of these techniques sibility of a nerve transection is quite high. These types of
were further refined in the 20th century, resulting in tre- injuries are typically caused by knife wounds, lacerations
mendous advances in the realm of PNI management. from glass, or razor blade. Spinner and Kline recom-
To date, the clinical recovery following PNI is incom- mended action with end-to-end repair within 72 hours
plete. The timing of repair, severity and extent of injury, in such scenarios of sharp lacerating injuries.10 On the
fascicular anatomy and realignment, mechanism of other hand, a bluntly transected nerve is best managed at
injury, patient age and comorbidities, and early psycho- 3 to 4 weeks so that the neuromas and scarred portions
logical stress are some of the few factors known to impact of the nerve are more obvious at the time of repair. These
outcome. The technical skill of the surgeon, as well as the portions are resected and then the nerve is reapproxi-
surgical technique used, is also one of the key influences mated with or without grafts. If such an injury is identi-
on functional recovery.5,6,7 Various surgical techniques for fied during an early exploration, the contused and ragged

74
Surgical Repair of Nerve Lesions: Neurolysis and Neurorrhaphy with Grafts/Tubes

ends of the nerve are tacked to the adjacent fascial or


muscular planes to minimize retraction and to aid an
9.4 Neurolysis
elective end-to-end repair. Delayed exploration with Neurolysis has paramount importance in surgical repair
possible repair is indicated in traction injuries, partial of nerve injuries. In this context, the authors are referring
nerve defects, infected wounds, and poor patient’s status. to external neurolysis which essentially involves dissec-
These are typically performed at 3 to 4 months to allow tion outside the epineurium to release it from points of
time for spontaneous recovery or complete evaluation of compression or tethering due to scarring, particularly in
the nerve function with serial clinical and electrophysio- cases of delayed exploration. This will enable sufficient
logical assessments.11 When there is no nerve tissue loss mobilization of the nerve, which is a critical step prior to
and ends can be approximated without undue tension, an any form of coaptation. Sufficient exposure of the injured
end-to-end repair should be attempted. In case of injuries segment, both proximal and distal, is mandatory prior to
resulting in defects less than 3 cm, autografting or tubuli- neurolysis. Dissection is preferably performed toward the
zation techniques are attempted, whereas in larger injury site from a normal segment of the nerve. Adequate
defects nerve grafting with autografts (rarely allografts) neurolysis is believed to act in concert with a healthy vas-
is recommended.12 Nerve transfer repairs are especially cularized bed to improve nerve vascularity, thus enhanc-
indicated in brachial plexus injuries, proximal intrafora- ing the results of nerve repair.
minal injuries, spinal cord root avulsion injuries, and in
cases with delayed presentation and redo brachial plexus
injuries. They are covered in detail in other chapters. 9.5 Direct Repair
This type of repair is attempted when the severed ends
can be approximated without tension and when the gap
9.3 General Principles of Nerve is minimal. A better outcome is observed when the
Repair nerves are exclusively motor or sensory and also when
the amount of intraneural connective tissue is relatively
The general principle of nerve repair is based on the fol- less.14 Several technical principles should be strictly
lowing: a thorough knowledge of the gross anatomy of followed in every case of direct nerve repair. The
the limbs and peripheral nerves; clinical evaluation importance of adequate visualization of relevant neural,
including a detailed history and a complete physical vascular, and musculoskeletal structures during surgical
examination; electrophysiological studies; and relevant exposure cannot be overemphasized. External neurolysis
imaging. Following determination of the type of nerve should be performed without causing neural damage, as
injury and formulation of a surgical plan, patients should mentioned earlier. The repair should be achieved with
be adequately informed about the surgical procedure and minimal tension. Numerous authors have reported that
expected outcome. Proper positioning of the limb, pad- excessive tension is detrimental to nerve vascularity and
ding of pressure points and draping to allow full exposure functional outcome.15,16,17 Due to the elastic nature of
of the nerve, and assessment of distal muscle function are nerves, some degree of tension is expected in every
crucial. Microsurgical techniques should be used for repair. The amount of acceptable tension is, however, not
nerve repair, including the use of microsurgical instru- properly defined. De Medinaceli and colleagues reported
ments and an operating microscope or magnifying that failure to hold an end-to-end repair with single 9–0
loupes. A short-acting muscle relaxant is typically used suture is a sign of excessive tension.18 Whenever there is
because intraoperative stimulation may be required to excess tension at repair site, nerve grafting is preferred.
test for muscle contraction from nerve stimulation during
surgery. The injured nerve should be exposed well proxi-
mal and distal to injury, in addition to the injury zone, in
9.5.1 End-to-End Repair
a thorough and meticulous manner. As mentioned earlier, This is one of the most widely used techniques for direct
the damaged nerve must be resected until a normal fas- nerve repair. Numerous authors have described different
cicular pattern is observed, as the repair will fail unless techniques to achieve an end-to-end repair.
healthy tissues are approximated. Bleeding occurring ● Epineural repair: This technique is commonly used

from the sectioned surface of the stump can be controlled when there is a sharp injury to the proximal portion of
by using a piece of Gelfoam or muscle, whereas arterial the nerves without nerve loss and also in cases of par-
bleeding is controlled using fine-tipped bipolar electro- tial injuries with good fascicle alignment. It is highly
cautery visualized using a microscope. To summarize, a effective for monofascicular and diffusely grouped poly-
technically perfect nerve repair must consist of four fascicular nerve repairs.19 The primary goal is to
parts: (1) complete debridement to healthy nerve tissue, achieve continuity of the nerve stumps without ten-
(2) nerve approximation without tension, (3) end-on sion, along with proper alignment of the fascicles.
alignment of fascicles, and (4) atraumatic and secure The correct fascicle positioning is confirmed by aligning
mechanical coaptation of nerve ends.13 the longitudinal blood vessels in the epineurium.20

75
Surgical Repair of Nerve Lesions: Neurolysis and Neurorrhaphy with Grafts/Tubes

The coaptation is performed using 8–0 or 9–0 nylon


sutures under magnification. To begin with, two orient-
ing epineural sutures are taken 180 degrees apart to
avoid rotational displacement during mobilization. It is
important to avoid injury to the perineurium; however,
a small amount of internal epineurium should be taken
in the suture for appropriate fascicular coaptation.
Following placement of the first suture, its tail is held
using an instrument such as a fine hemostat, to facili-
tate the rotation of the nerve for coaptation on the
opposite side. Additional interrupted sutures may be
placed 90 degrees away from the initial sutures for
added strength. Minimal number of sutures (usually
four) for accurate coaptation are preferred to reduce the
Fig. 9.1 Intraoperative photograph showing matching fascicles
scarring process.19,20,21 Many surgeons will augment during nerve repair to enhance functional recovery.
repair using fibrin glue to further minimize the number
of microsutures.
● Grouped fascicular repair: This technique is used in
magnification by placement of sutures, usually two to
mixed motor and sensory nerves where the fascicles
three 10–0 or 11–0 nylon sutures 120 to 180 degrees
serving specific functions are well formed and easily
apart, in the perineurium. It is important to avoid
recognized (e.g., ulnar nerve at wrist, radial nerve
injury to the endoneurium during suture placement.
above elbow before giving rise to posterior interosseous
Excessive tension produces lateral protrusion of the
nerve, and superficial sensory radial nerve). Contrary to
interfascicular contents and disappearance of spiral
epineural repair, grouped fascicular repair is a more
bands of Fontana.23 Should this occur during repair, the
accurate but technically demanding method of coapta-
surgeon should reassess the tension at the repair site.
tion. Resection of the damaged nerve ends is imperative
Unlike epineural repair, both grouped fascicular and
to precisely delineate fascicular anatomy. The external
fascicular coaptation provides better alignment of the
epineurium is reflected back to organize the fascicles.
fascicles, thereby reducing misdirection of axons
Fascicular coaptation is achieved with placement of
(▶ Fig. 9.1). Nevertheless, the additional dissection and
sutures in the interfascicular epineurium and perineu-
increased sutures involved in this technique could
rium with 8–0 to 10–0 nylon sutures. As mentioned
potentially lead to increased scarring and disruption
earlier, not more than two to three sutures per group
of blood supply.20,21 Studies have found no significant
are preferred to reduce scarring.22 It is imperative to
difference in functional outcome when individual or
keep the tension at the repair site to the utmost mini-
grouped fascicular repair techniques were used com-
mum as the interfascicular epineurium is not as tough
pared to simple epineural repair.24,25,26
as the external epineurium. Excessive tension could
also contribute to malalignment of the fascicles and
increased scarring.
9.5.2 End-to-Side Repair
● Fascicular repair: This technique is used in a clean lac- End-to-side or terminolateral neurorrhaphy involves con-
erating injury, where the motor and sensory fascicles necting the distal stump of a transected nerve, referred to
can be easily identified, in the partially damaged nerve. as the acceptor nerve, to the side of an intact adjacent or
This involves coaptation of the individual fascicles for neighboring nerve, referred to as the donor nerve. This
optimal alignment, and hence this is a more technically technique is particularly useful in sensory nerve transfers
difficult repair. Following dissection of the interfascicu- and facial nerve reanimation. The advantage of this tech-
lar epineurium, the fascicles are identified using the nique is that there is no length limitation and also that
spiral bands of Fontana in the perineurium. These there is recovery of injured nerve without compromising
bands are instrumental in maintaining proper fascicular the function of donor nerve. The mechanism of functional
structure and elastic properties of the perineurium.23 If recovery in the acceptor nerve is not entirely clear. Rovak
there is protrusion of the intrafascicular material in the et al opined that nerve fibers invade from the donor
perineural edge, it should be carefully trimmed prior to axons damaged during nerve preparation for coapta-
suturing. The external epineurium is stripped for tion.27 Zhang et al, based on double-labelling studies,
lengths approximately twice the cross-sectional diame- found that collateral sprouting occurs from the undam-
ter of the nerve. Care should be taken to preserve the aged donor nerve.28
surrounding paraneurial tissue as it contains blood Since its introduction by Viterbo et al in 1992, many
vessels, and this can be used to cover the repair site. studies on end-to-side repair have shown that outcomes
Fascicular coaptation is achieved under high range from poor to modest but rarely excellent. However,

76
Surgical Repair of Nerve Lesions: Neurolysis and Neurorrhaphy with Grafts/Tubes

Mennen demonstrated good sensory or motor recovery 9.6.1 Autografts


in a large cohort of 50 patients with various peripheral
nerve injuries. Excellent results were seen in facial Although many options exist for bridging the gap, an
reanimation procedures, where end-to-side facial to autograft is used whenever possible. Several technical
hypoglossal nerve anastomosis was performed with an principles influence the success of nerve grafting. The
interpositional jump graft.29,30 This technique was also proximal and distal nerve stumps are meticulously
used with good results for the repair of dysesthesia after inspected, and any damaged portion or neuroma is
removal of the sural nerve, as well as to connect the resected. The epineurium is cut in a longitudinal fashion,
phrenic nerve to the brachial plexus. End-to-side repair and the fascicles are closely inspected under magnifica-
has been used to link the nerve gap after ulnar nerve tion. All fibrotic tissue amid these fascicles is removed
injury, with median nerve as donor nerve, in addition to using sharp dissection. The surgeon must make sure that
phrenic and spinal accessory nerve neurotization, and the proximal and distal nerve stumps are tension-free
coaptations of palmar digital nerves and select cases of even when the extremity is moved along its full range.
brachial plexus trauma. Viterbo and Ripari reported good The harvested graft should be kept moist and handled
outcome when they tried to restore lower limb sensation carefully to prevent injury. To avoid fascicular malalign-
in paraplegics, thereby reducing the chances of formation ment, the interfascicular tissue is retracted and the fas-
of pressure sores, by linking the intercostal nerves cicles are defined in groups akin to fingers. The sensory
above the site of injury and sciatic nerve in an end-to- or motor components should be matched as accurately as
side fashion using sural nerve graft.31 However, Bertelli possible (▶ Fig. 9.2). However, this is practically feasible
and Ghizoni reported poor results using this technique to in only distal nerves. The number and length of the graft
repair radial nerve, C5 or C6 root rupture, and common depend on the cross-sectional area and the bridging gap,
peroneal nerve lesion.32 It now appears that end-to-side respectively. In general, the graft length should be 10 to
repair would be ideal only in specific and limited clinical 20% longer than the gap, to provide room for retraction
scenarios. and shrinkage. The cross-sectional area of the graft is
With microscopic magnification, following adequate preferably smaller than the recipient nerve. Smaller
mobilization of the recipient nerve, a small epineural diameter grafts are associated with better results as larger
window is created matching the size of recipient nerve grafts have compromised vascularity in their core, thus
end. As with other techniques, any terminal neuromas leading to necrosis and greater scar formation. The small-
on the recipient nerve stump should be excised and diameter nerves obtain nourishment from their surface.36
healthy fascicles be properly visualized prior to coapta- Owing to this, it would be ideal to use multiple small
tion, which is achieved with two to three microsutures diameter nerves for grafting major nerves (▶ Fig. 9.3).
placed 180 degrees apart through the epineurium. Sutures are taken through the epineurium in the host
stump 180 degrees apart, to the interfascicular epineu-
rium and perineurium of the isolated fascicles, spreading
9.6 Nerve Grafting the cross section of the graft in a fish mouth pattern.
Fibrin glue may be used to reinforce the repair. The
Nerve grafting is recommended whenever a direct
surgeon must revisit all repair sites at the end of the
repair is likely to result in excessive tension at the
repair site.33 In the past, nerve stretching, bone shorten-
ing, extremity positioning, and stump mobilization
were some of the procedures used to shorten the bridg-
ing gaps, most of which are now obsolete. In current
clinical practice, the ideal choice to circumvent such
a scenario is to use a nerve graft. Tubulization techni-
ques may be used for smaller gaps (< 3 cm), but larger
defects need nerve grafts.34,35 Split repair is a technique
which is used when there is partial injury to the nerves
with damage to only a portion of the fascicles with rela-
tive sparing of the rest. In these conditions, the healthy
fascicles are dissected from the injured ones and nerve
action potential (NAP) recording is used. Usually, the
Fig. 9.2 Intraoperative photograph demonstrating the
NAP is recordable from the healthy fascicles and absent
technique of fish mouthing in the proximal segment (P) of a
in the injured ones. The injured fascicles are then
repaired common peroneal nerve using two grafts of sural
resected till normal fascicular anatomy is visualized nerve, to include all the outgoing axons to reach the distal
and then coapted with a graft using an interfascicular segment, in an attempt to maximize the functional recovery.
technique.10

77
Surgical Repair of Nerve Lesions: Neurolysis and Neurorrhaphy with Grafts/Tubes

Fig. 9.3 Intraoperative photograph depicting coaptation of Fig. 9.4 Local sensory nerves can be used when the major
three sural nerve grafts from C5 nerve root healthy stump to injured neighboring nerves requires repair. In this case, the
upper trunk elements (suprascapular nerve, posterior and median nerve (M) was reconstructed using graft obtained from
anterior divisions of upper trunk). C6 nerve root was avulsed in the adjacent medial antebrachial cutaneous nerve of the arm
this case. UT, upper trunk. (MACN).

procedure, as they can get distracted when repair is per- different region, thus increasing morbidity, operative
formed elsewhere. It is important to place the repair on a time, and chances of wound complications. Moreover,
healthy vascularized bed to promote healing and reduce harvesting of a nerve adjacent to the injured nerve would
scarring. result in clinically unacceptable sensory loss.
The functional outcome is believed to be inversely pro- The sural nerve is one of the most commonly used
portional to the length of the graft, with poorer results donor nerve grafts. It supplies cutaneous sensation to the
with the use of longer grafts. Though seemingly true, this posterior and lateral aspect of the lower one-third of
has to be viewed in a different light. Longer grafts are the leg and also lateral aspect of the foot and heel. It can
used when there is a greater nerve tissue loss, which in be easily harvested from the posterolateral lower leg. The
turn is usually seen in extensive and more proximal inju- sural nerve has a diameter of 2.5 to 4 mm proximally and
ries. This is also associated with loss of neurons in the 2 to 3 mm distally with around 9 to 14 fascicles fed by
spinal cord or dorsal ganglia, which would substantially robust nutrient artery and veins. This contributes to the
contribute to the negative outcome. Hence, the use of faster graft revascularization and better healing. The sural
longer grafts is associated with more severe injuries and nerve can easily provide 30 to 50 cm of graft, making it
greater reinnervation time. the first choice when repairing large gaps. It is harvested
Siemionow et al described the single fascicle method of with the patient in supine position with the lower
nerve repair. In experimental models, they could demon- extremity internally rotated and flexed at the hip, flexed
strate faster regeneration and better functional outcome at the knee, and dorsiflexed at the ankle. A longitudinal
when single fascicle repair was performed on rat sciatic incision or multiple-step incisions may be used to obtain
nerve covering 25 to 59% of the cross-sectional area of the nerve. The morbidity associated with this procedure
the nerve. They believed that this technique reduced for- includes calf tenderness, numbness along the lateral
eign body reaction, intraneural fibrosis, and donor-site aspect of the foot, neuroma formation, and intolerable
morbidity by reducing the amount of graft material pain. In a study, 6.1% had clinically symptomatic neuro-
required.37 Clinical application, however, has not been mas and 9.1% were found to be dissatisfied with the
reported. numbness in the foot.38
The commonly used donor nerve grafts are sural nerve,
medial antebrachial cutaneous nerve above and below
elbow, lateral antebrachial cutaneous nerve below elbow,
9.6.2 Allografts
superficial sensory radial nerve, dorsal cutaneous branch Allografts from cadaveric donors have been used rarely
of ulnar nerve, and lateral femoral cutaneous nerve of when the bridging gap is exceedingly high so that avail-
thigh. The graft choice depends on site of nerve injury able autografts would not suffice.39 With allografts, sur-
and surgeon’s preference. Whenever possible, the graft geons have an unlimited length of nerve tissue available
should be harvested from the same limb so that the sur- for grafting. They provide guidance and viable donor
gery can be performed under regional anesthesia and an Schwann’s cells (SCs) to regenerating host axons. Allograft
additional incision can be avoided (▶ Fig. 9.4). However, nerve is not as immunogenic as skin or muscle, but cer-
most often, sufficient graft length is not available from tainly requires immunosuppressive therapies to prevent
the injury site, leading to incision and exploration of the rejection. Without such therapies posttransplantation, the

78
Surgical Repair of Nerve Lesions: Neurolysis and Neurorrhaphy with Grafts/Tubes

donor nerves blood–nerve barrier is broken down, graft is


revascularized, and infiltration of immune cells occurs,
9.7 Nerve Tubes
ultimately leading to graft rejection.40 However, Midha Despite being the gold standard in bridging the gap in
et al reported that the immunogenicity of allografts steadily peripheral nerve injuries, autologous nerve grafts come
decreased over time as the process of SC exchange from with several disadvantages such as donor-site neurologi-
donor to host proceeds.41,42 The following are the strategies cal deficit, need for additional incisions and chances of
available today to prevent graft rejection: wound complications, neuroma formation and neuro-
● MHC matching: MHC matching leads to better results, pathic pain, limited availability, and so on. Only 40 to 50%
similar to any organ transplantation. Mackinnon et al, of autologous nerve grafting show useful degree of func-
in a study of seven patients, demonstrated a return of tional recovery.50 These issues have paved the way to the
sensory and motor function in six patients when ABO study and use of nonnerve grafts as a conduit for axonal
blood type matched donor allografts were used. Despite regeneration. A tube works by encasing the distal and
being covered with immunosuppressive medications, proximal nerve ends, guiding axons sprouting from the
one of these patients experienced rejection.39 regenerating nerve end, protecting them from fibrous tis-
● Nerve allograft preparation: Several methods of allog- sue, and providing a path for diffusion of neurotropic and
raft preparation are reported in literature. Irradiation neurotrophic factors from the injured nerve stump.51
and freeze drying techniques were used initially in the An ideal conduit should be biodegradable and nontoxic
1960s. Subsequently, cryopreservation (10% dimethyl to axons, produce minimal foreign body reaction and
sulfoxide at -196 °C in liquid nitrogen) and lyophiliza- scarring, semipermeable, have an internal structure simi-
tion techniques were used. In cold storage technique, lar to the architecture of the nerve fascicle, provide pro-
allografts were harvested within 24 hours of death and tective environment to the nerve regeneration, and be
were stored in university of Wisconsin cold storage sol- easy to manipulate.52,53,54 Some biomaterials used for
ution at 5 °C for 1 week. This decreased the antigenic tubulization are prone to swelling in vivo, which, if exces-
load and hence the chances of rejection. Moreover, the sive, may block the tunnel and prevent nerve regenera-
doses of immunosuppressive agents could be reduced tion through it. Therefore, the tube diameter should
following cold storage.43 exceed the nerve diameter by 20%. Conduits are expected
● Immunosuppression: Most of the data for immuno- to be resorbed gradually with the completion of axonal
suppressive strategies come from experimental models. regeneration. Should this happen too fast, there will be
Cyclosporine, which is a calcineurin inhibitor, was one focal inflammation and swelling. On the other hand, if it
of the first drugs to be tried with nerve allografts. It is too slow, it can cause compression of the regenerated
worked by blocking the transcription of interleukin-2, nerve and chronic immune rejection.55
which played a significant role in the inflammatory cas- Technique: The healthy nerve stumps are inserted into
cade of rejection. Subsequently, tacrolimus (FK-506, the tube. Following this, a nonabsorbable microsuture is
also a calcineurin inhibitor) was found to be better than placed in a “U” fashion—outside to inside of the tube, then
cyclosporine in terms of functional recovery and axonal through the epineurium 1 to 2 mm behind the stump edge,
regeneration. The graft pretreatment in cold storage then again from inside to the outside of the tube to tie a
substantially reduced the therapeutic doses of these knot after pulling the stump into the lumen (▶ Fig. 9.5).
drugs, thereby bringing down the undesirable side
effects.43 Unlike cyclosporine, tacrolimus can rescue
grafts within 10 days of onset of rejection.44

When decellularized allografts are used, immunosup-


pressive medications are not required as they are devoid
of living SCs. These allografts act like a scaffold provided
by the extracellular matrix for axon regeneration.45,46,47
In a study by Karabekmez et al, 10 sensory nerve gaps in
seven patients were reconstructed with AxoGen nerve
allografts (decellularized allograft), the lengths of which
ranged between 5 and 30 mm. Five patients achieved
excellent results, and the other five patients had good
results.47 AxoGen allografts are thought to have better Fig. 9.5 A 1.5-cm gap in the deep peroneal nerve in the dorsum
results when compared to type 1 collagen conduits.48 of the foot is shown being repaired with a 2-cm long collagen
tube. The nerve at the proximal end has already been
Despite the lack of living SCs, several uncontrolled studies
approximated within the lumen of the tube with a single
have reported good results with decellularized grafts.47,49 9–0 microsuture, while the two branches distally are shown
The authors do not advise use of decellularized allograft inserted within the tube, awaiting microrepair.
or tube repairs for gaps exceeding 3 cm (see Chapter 9.7).

79
Surgical Repair of Nerve Lesions: Neurolysis and Neurorrhaphy with Grafts/Tubes

The interior of the lumen is then filled with saline, using a fibrotic reaction, and compression necessitating the
small-gauge needle and syringe, to flush out any air bub- removal of the conduits in many of them. This gave rise
bles. Fibrin glue is used to reinforce the ends. At present, to the popularity of several other semipermeable and bio-
tubulization techniques are indicated only for shorter nerve compatible conduits such as polyglycolic acid polymer
gaps (< 3 cm).35,56 (PGA), polylactide-caprolactone polymer (PLCL), type 1
collagen, polyglycolic acid coated with cross-linked colla-
9.7.1 Autologous Conduits gen, and decellularized porcine submucosa tubes, with
silicone being reserved for shorter gaps (1 cm). Mackinnon
Autologous nonnerve grafts constitute a natural and non-
and Dellon pioneered the use of polyglycolic acid con-
toxic alternative to autologous nerve grafts. These include
duits in 1990.56 They reported a series of 15 patients with
arteries, veins, mesothelial chambers, skeletal muscle or
digital nerve injuries, with gaps ranging from 5 to 30 mm.
muscle basal lamina, human amniotic membrane, and
They found that 13 patients had good to excellent results
epineural sheath. Arterial grafts were initially used, but
after a follow-up of 11 to 32 months. Weber et al con-
subsequently fell into disfavor due to morbidity, poorer
ducted a large, prospective, randomized study in which
outcome when compared to nerve grafts, and lack of dis-
PGA conduits were compared to direct coaptation or
pensable arteries. Vein grafts have been studied exten-
autologous nerve grafting.64 They reported similar results
sively by many authors. Wang et al demonstrated faster
in both groups; however, PGA conduits fared better when
conduction velocities and greater axon counts with
the gaps were longer than 4 mm. In a recent experimental
inside-out vein grafts compared to autologous nerve
study by Costa et al, the differences between autografts,
grafts in experimental models.57 The adventitia of these
PGA conduits, and autografts enveloped with PGA con-
vessels provides a conduit which is rich in collagen, lami-
duits were analyzed. They showed greater number of
nin, and SCs, thereby creating a milieu ideal for axonal
regenerated myelinated axons in autografts enveloped
regeneration. Some authors have used vein grafts filled
with PGA group; however, there was no demonstrable
with muscle to prevent collapse of the conduit.58 Similar
difference in functional outcome.65
to a nerve graft, the SCs migrate and proliferate very early
PLCL tubes are transparent polymer-based tubes allow-
in these types of grafts. Karacaoglu et al, in a study of 40
ing visualization of the nerve stumps within. This mate-
rats, compared nerve grafts, vein grafts, and epineural
rial degrades by hydrolysis and is fully resorbed by 3 to
grafts.59 They found that the functional outcome with
24 months. They swell circumferentially post implanta-
epineural grafts was similar to that of the nerve grafts
tion, thereby having an impact on the selection of the size
and was significantly better than the vein grafts. They
of the conduit. Bertleff et al compared PLCL tubes with
concluded that the use of epineural graft, which is a read-
autologous grafts in a randomized study of 30 patients
ily available conduit, could potentially eliminate the use
and found no significant difference in the outcome
of nerve grafts and the morbidity associated with them.
between the two groups.66 However, they reported com-
Another biological conduit of historical interest is the ten-
plications such as irritation and extrusion from the
don autograft; however, with the absence of clinical stud-
wound, necessitating revisions in two of their patients.
ies, it is unclear whether autologous tendons are useful in
Chiriac et al reported 29 patients who have undergone
human nerve repair.60,61
repair with PLCL conduits in sensory and mixed nerves,
with gaps ranging from 2 to 25 mm. They found recovery
9.7.2 Artificial Conduits of useful function in only 31% of sensory nerves and 8% of
Over the past few decades, several authors have explored mixed nerves, with a 30% complication rate necessitating
the potential of synthetic biocompatible conduits for axo- explantation in some of them. The unsatisfactory out-
nal regeneration. Lundborg et al,62 with their landmark come and safety profile prompted them to advise against
work on silicone tubes, threw light on this novel treat- the use of PLCL conduits in hand surgeries.67
ment strategy. The mechanism by which these conduits Collagen conduits are being used by numerous authors
aid axonal regeneration was elucidated. The fluid exuding in many arenas of peripheral nerve repair. Outcomes
from the transected nerve ends is known to create a were first reported by Lohmeyer et al in 2009 in 15 digital
fibrin matrix which would act like a cable for cell migra- nerve repairs with a mean nerve gap of 12.5 ± 3.7 mm.
tion. Subsequently, a regenerating core is formed which They achieved good to excellent results in nine of these
eventually matures to form a pseudonerve sheath with patients, but did not recommend its use in gaps more
microfascicles. With longer gaps, thin cables are formed, than 15 mm.68 Haug et al also reported the results of 45
resulting in contraction of the fibrin matrix, thus limiting digital nerve repairs in 35 patients with a mean defect
axonal regeneration. Lundborg et al reported a series of length of 12 mm. The recovery of sensory function at
mixed nerve injuries in the forearm, with gaps less than 12-month follow-up was found to be good to excellent in
5 cm, treated with silicone tubes.63 These patients suf- 25 patients. They also reported 40% return of static two-
fered a constellation of problems secondary to the use of point discrimination in gaps up to 20 mm. In their opin-
silicone tubes such as superficial soft-tissue irritation, ion, the positive prognostic factors were age < 50 years

80
Surgical Repair of Nerve Lesions: Neurolysis and Neurorrhaphy with Grafts/Tubes

and distance of the lesion to the fingertip < 5 cm.69


Recently, in a prospective two-center cohort study,
9.9 Tissue Engineering and
Lohmeyer et al analyzed 49 digital nerve repairs using Future of Nerve Repairs
type 1 collagen in 40 patients, with gaps ranging from
5 to 25 mm.70 They had good to excellent results in Due to an improved understanding of the pathophysio-
20 patients (based on two-point discrimination), whereas logical processes of axonal regeneration in the past few
9 patients achieved no sensibility. They added that gaps decades, there has been a stupendous advance in the sur-
less than 10 mm performed significantly better than gical management of PNI. However, the management of
those more than 10 mm, which was a change from their PNI with defects > 30 mm still remains a challenge. The
previous recommendation of 15 mm. Boeckstyns et al use of autologous grafts, despite being a gold standard
compared collagen conduits and conventional neurorrha- strategy, comes with significant associated morbidity, as
phy in a prospective randomized controlled trial in mentioned earlier. As a result of this, focus is now
32 patients.71 They concluded that collagen conduits gave invested on tissue engineering techniques to enhance
useful recovery of sensory and motor functions similar to nerve regeneration on a larger scale. Autologous cell
conventional neurorrhaphy at 2-year follow-up when the transplantation has gained a lot of attention in the last
gap was less than 6 mm. They also observed that the two decades. Glial cell transplantation is known to play a
operating time was significantly shorter for collagen con- significant role in axonal regeneration, in addition to
duits. However, collagen conduits are also not immune to myelinic and amyelinic ensheathing of axons.74 SCs and
complications. Two papers have reported complications olfactory ensheathing cells (OECs) are cell types which
such as failure of resorption of the conduit, classic hour- have been extensively studied experimentally. In the
glassing of the fibrin matrix, fibrosis, scarring, neuroma event of a PNI, SCs express cell adhesion molecules and
formation, and foreign body reaction on histological play an integral role in forming the endoneurial sheath,
assessments.72,73 In the authors’ opinion, commercially thus creating a microenvironment conducive to axonal
available tubes and decellularized allografts should be regeneration. On the basis of this, some authors have
restricted to gap lengths of 25 mm with no larger than tried to enrich conduits with SCs hoping to achieve
30 mm tubes used. All other gap repairs should be regeneration over a larger distance.75,76 They could dem-
repaired with nerve autografts. onstrate improvement in the rate and quality of regener-
ation. Strauch et al reported that SC-seeded vein conduits
enabled regeneration over longer gaps (6 cm) in rabbits.77
9.8 Post-op Management SCs are derived from the bone marrow, fresh/banked
human umbilical cord or neural crest pluripotent, and
Post-op care is a critical phase in the management of stem cells found in sites of gliogenesis such as the sciatic
peripheral nerve injuries. A thorough and meticulous nerve and dorsal root ganglia. Recently, Kumar et al dem-
attempt for adequate hemostasis should be made to avoid onstrated that adult skin–derived precursor SCs exhibited
operative site hematoma. Suction drains may be avoided superior myelination and regeneration properties com-
as much as possible to avoid potential injury to the nerve pared to the chronically denervated SCs.78 Reid et al
repair during drain removal. The strength of a nerve reported that transdifferentiated adipose-derived SCs
repair usually plateaus by the third week. Hence, all limb expressed a range of neurotrophic factors conducive to
movements should be exercised with caution during axonal regeneration.79 These are convenient alternatives
this time period, with special attention to avoid over- to conventional techniques of SC harvest. SCs are also
stretching, abduction, or extension. Most nerve repairs known to influence the macrophage response follow-
are performed in extension to avoid suture distraction ing PNI, thus impacting myelin debris clearance and
postoperatively. A bulky operative site dressing usually regeneration. Stratton et al have reported the positive
serves as a reminder to avoid excessive movements in the immunomodulatory and regenerative properties of adult
early post-op period. Shoulder immobilization or sling is skin–derived precursor SCs.80 Recently, OECs derived
used for brachial plexus repair. After 3 weeks, the degree from the olfactory nerve have triggered a lot of interest in
of limb excursions and ambulation should be gradually axonal regeneration research. Its applicability in central
escalated with the help of physiotherapy and occupa- and peripheral nervous system makes it unique. It is
tional therapy. It is important to mobilize the extremity believed that OEC transplantation at the time of micro-
to promote healing and to avoid joint contractures. Clini- surgical repair would act like a scaffold and also provide
cal evidence of target muscle innervation is usually not trophic and directional cues for axonal regeneration.74
apparent for several months postoperatively, depending The therapeutic benefits of cell transplantation are
on the regeneration distance. Once reinnervation occurs, tainted with several setbacks which would essentially
more focus is invested on strengthening measures. Sen- hamper their translation to clinical practice. The primary
sory symptoms and neuropathic pain could be alleviated issue has been preservation of cell viability after thawing
by pharmacotherapy. In case of refractory pain, referral to and insertion into the conduit.81 Other concerns are aber-
pain services or neurostimulation may be considered. rant, nonlinear axonal growth, possibility of malignancy,

81
Surgical Repair of Nerve Lesions: Neurolysis and Neurorrhaphy with Grafts/Tubes

and influence of donor conditions such as age, smoking, [20] Ogata K, Naito M. Blood flow of peripheral nerve effects of dissection,
stretching and compression. J Hand Surg [Br]. 1986; 11(1):10–14
and diabetes on regeneration. Tissue engineering may be
[21] Brushart TM, Tarlov EC, Mesulam MM. Specificity of muscle reinner-
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tion,82 manual stimulation,83 and photostimulation.84 The [22] Trumble TE. Peripheral nerve injury: Pathophysiology and repair.
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NY: McGraw-Hill; 1999: 2048–2053
axonal regeneration is still in progress. In the future, we
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can envision targeted cellular and adjunctive approaches (1):1–20
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nerve injuries. versus conventional repair of median and ulnar nerves in the human
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419–424 ral labeling of Schwann cells: in vitro characterization and in vivo
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hand. J Hand Surg Am. 2005; 30(3):513–518

83
Timing in Traumatic Peripheral Nerve Lesions

10 Timing in Traumatic Peripheral Nerve Lesions


Leandro Pretto Flores

Abstract otherwise, operate later in order to be completely sure


Surgical timing is one of the most important decisions to about the lack of potential for spontaneous recovery, and
take in the operative management of traumatic injuries assuming the risk that the mechanisms of muscle dener-
of peripheral nerves. It depends on a number of factors vation and atrophy that follows a nerve injury may
such as associated injuries, patient stability, level and become so intense that the surgery may become useless.
degree of injury, medical comorbidities, and even the Hence, determining the optimal surgical timing of each
available operative resources. This chapter aims to dem- patient is one of the most important decisions to take in
onstrate the proper timing for surgical intervention of the operative management of traumatic injuries of
the different types of traumatic injuries of peripheral peripheral nerves. The operative timing is variable and
nerves. Open wounds due to laceration mechanism depends on a number of factors such as associated inju-
deserve urgent attention, and sharp injuries are best ries, patient stability, level and degree of injury, medical
treated within the first 72 hours after the trauma; blunt comorbidities, and even the available operative resources.
open injuries need a short delay of 3 to 4 weeks before The knowledge about nerve regeneration, mechanism of
exploration, aiming to avoid further nerve shortening injury, nerve injury classification, and neuropathology
and scar tissue formation into the suture site. Gunshot may be helpful in order to guide the surgeon in taking
wounds should be treated conservatively for 4 to the appropriate decision.1 This chapter aims to summa-
6 months, as most of these injuries do not result in direct rize the most available modern data from the medical lit-
nerve hit. The majority of the closed injuries are explored erature about the proper timing for surgical intervention
from the third month after the trauma, and surgery is of the different possible types of traumatic injuries that
indicated for patients who do not demonstrate signs of affect peripheral nerves. Discussion about surgical timing
spontaneous recovery of the critical muscles. for brachial plexus and facial nerve injuries has been
excluded, because these issues will be further detailed in
Keywords: nerve injury, timing, microsurgery, trauma specific chapters.

10.1 Introduction 10.2 Basic Science as an Aid for


Peripheral nerve injury is a dramatic event that signifi-
Taking an Important Decision
cantly affects the daily-living activities of victims sus- There are three critical temporal factors that may affect
taining such type of trauma. Although the appropriate the decision of when to operate and also when to avoid
treatment is individually based, some general considera- surgery. Resolution of segmental demyelination requires
tions may help in guiding the physician to optimize the 8 to 12 weeks, so deficits that persist beyond that period
proper therapy for a specific case. The main mechanisms of time indicate that there has been axonal damage, not
that provoke injuries to the nerves of the neck or the only neuropraxia (Grade I injury). Under ideal conditions,
limbs are very well known, i.e., traction, compression, lac- axon regrowth occurs at 1 to 3 mm/day, or 1 inch/month.
eration, and gunshot wounds. However, the clinical deci- The time after which irreversible muscle atrophy has
sion about when to operate can be, sometimes, difficult. occurred and operation cannot provide benefit ranges
For the cases of sharp and clean penetrating injuries, it from 18 to 24 months, depending on: (1) the type of
seems logical that an immediate nerve repair shall be injury, (2) the injured nerve, and (3) the proposed techni-
indicated. However, if the surgeon performs such acute que for reconstruction. The Schwann cells and the endo-
repair in a penetrating injury associated with blunt neurial tubes remain viable for 18 to 24 months after
trauma, the result may be disastrous. It is even worse for injury. If they do not receive a regenerating axon within
cases of traction injuries, because the decision about this time span, the tubes degenerate. Reinnervation must
when to operate the patient may be one of the most occur not only before the muscle undergoes irreversible
important factors that will determine the final outcome. changes, but also before the endoneurial tubes will no
For these last cases, the surgeon faces a clinical dilemma: longer support the nerve regrowth. Hence, the time-
to operate early, aiming to decrease the time of muscle distance equation has two primary variables: irreversible
denervation, and at the same time taking the risk of oper- changes in critical target structures after 18 to 24 months,
ating (and occasionally transecting) a given nerve that and axon regrowth rate at 1 to 3 mm/day from the site of
would have a potential for spontaneous regeneration; or, injury or from the site of the surgical repair.2

84
Timing in Traumatic Peripheral Nerve Lesions

timing is mainly dictated by type of the lesion. However,


10.3 Initial Evaluation of a there are a number of different possible causes that has
Peripheral Nerve Injury the potential to damage the peripheral nervous system,
named as follows:
The injuries that involve the nerves of the head, neck, and ● Stab wounds are characteristically open lesions that
limbs are classified generally as closed (those caused by result from clean and sharp lacerations. They are more
stretch or compression mechanisms) and open or pene- often provoked by objects with a cutting edge in one or
trating (consequence of laceration or missile wounds). both of its borders, such as a knife or a glass. Neurologi-
The most frequent type of injury observed in civilian cal deficits associated with such type of injury are
practice are closed tractions injuries resulting from vehic- always associated with nerve transection (partial or
ular accidents; the injuries provoked by gunshot wounds total) or neurotmesis (Sunderland Grade V injury). Lit-
and those that occurs secondary to blunt penetrating tle trauma to the nerve stumps and minimal local tissue
mechanism are less frequent, but still not uncommon; trauma is the rule in most of these cases.
and lesions from sharp and clean divisions of peripheral ● Open injuries secondary to lacerations may also be
nerves are usually very uncommon (in this last group, caused by blunt trauma. In these cases, the nerve is div-
iatrogenic injuries may be very incidental).3 ided by jagged metal or saws, especially chain saws,
The surgical timing and the management of closed and where a ragged, torn skin wound is usually observed.
open injuries are different, and the type of the injury Local damage is often more extensive in such type of
must always be determined at the moment of the initial injury, and associated vascular or bone trauma may also
evaluation. It is apparent in the majority of the cases, and be present. It is not infrequent that the wound may
specific details about the circumstances of the aggression show gross contamination. The extension of the nerve
or the trauma itself should be sought, as this kind of in- injury is usually longer than those associated with stab
formation may have prognostic value. For example, the wounds, and it is usually difficult to evaluate it in the
severity of the trauma is usually roughly proportional to first days that follow the trauma. Moreover, these inju-
the degree of damage to the involved nerves. ries are associated with a large amount of scar tissue
Evaluating the postinjury neurological status following formation following the healing process, and this fibro-
a peripheral nerve trauma—i.e., whether the deficit is sis may prevent appropriate nerve regeneration if an
improving, static, or worsening—has paramount impor- early nerve suture is attempted.5
tance for the decision-making process that finally will ● Gunshot wounds are open injuries with little or no tis-
allow the surgeon to determine who are going to be oper- sue exposure, with some unique features that require
ate or when one must be operated. Moreover, close atten- different approach from the other wounds provoked by
tion to the progression of the neurological recovery in penetrating mechanism. Such lesions have a variable
such cases will provide additional data about the severity degree of intraneural derangement. Most of the missile
of the lesion and will aid in establishing a working prog- trajectories are associated with neural injury that do
nosis. Immediately following the injury, nearly all of the not directly strike the nerve, but instead provide a near
patients will show a specific neurological loss (it is very miss. The projectile may provoke contusive forces that
rare a progressive neurologic deficit following a periph- result in dual stretching to the neural tissue: as the mis-
eral nerve injury that initiate hours or days after the sile approaches the nerve, the nerve explodes away
trauma; however, they may be observed occasionally in from the missile’s trajectory and then implodes back
clinical practice, for example, in injection injuries). Some when the missile passes by. Such damage extends over
of the patients will improve, and the prognosis of such a length of the nerve, and produces a swollen and hem-
lesions is good for the great majority of them. Other orrhagic neural segment. These forces may produce a
patients will not improve, and eventually they will need a combination of conduction block, axonotmesis, or neu-
surgical intervention in order to obtain a better recovery. rotmesis, and a neuroma-in-continuity is often
However, some deficits may become worse in time—what observed. The proportion of axonotmetic and neurot-
may indicate a continued or progressive increasing pres- metic changes will determine the potential for useful
sure onto the involved nerve (e.g., the development of a regeneration. These injuries may also result in vascular
pseudoaneurysm in a nearby artery; or the presence of a and bone trauma, and the formation of acute hema-
clot on a tunnel nerve area) and may demand an urgent toma, traumatic pseudoaneurysm, or arteriovenous fis-
surgery for decompression.4 tula has the potential to determine nerve compression.6
● Bone fractures may also be implicated as a cause of

10.4 Causes of Traumatic injury to adjacent nerves. The dislocation of a bony


fragment may result in lesion by mechanism of stretch-
Peripheral Nerve Injury ing, direct compression, or ischemia. In all of these situ-
As described earlier, traumatic peripheral nerve injuries ations, the injury is considered and managed as closed.
are basically classified as closed or open, and operative Good examples are the classical pattern of radial nerve

85
Timing in Traumatic Peripheral Nerve Lesions

palsy that follows a fracture of the middle third of the ultimate level of nerve injury until the local inflammation
humerus, or an injury of the suprascapular nerve asso- declines.9 However, with the progressive advance of the
ciated with fractures of the scapula. microsurgical techniques and electrophysiology, early
● There are cases in which the lesion is promoted by a repairs become increasingly advised. Currently, delayed
mechanism of ischemia of the nerve. It is a mechanism reconstruction is done when nerve continuity is uncertain
of injury that is frequently linked to deformations asso- or when it is suspected that the natural recovery could be
ciated with nerve compressions. In these cases, a quick better than surgery. One of the major precepts of periph-
nerve recovery should be expected. The most common eral nerve surgery is that incomplete lesions do better
example is the so-called Saturday night palsy, associ- without surgery. The major disadvantages of late nerve
ated with a radial nerve compression. However, more reconstructions include the progressive collapsing of the
serious injuries may be associated with the mechanism endoneural tubes and the continuous progression of
of ischemia: Volkmann’s contracture that follows the muscular denervation, factors that can downgrade the
vascular injuries may result in disastrous lesions in final outcome.10 An end-to-end suture maximizes the
even more than one nerve at once, which are often axonal offer to the distal stump of the transected nerve;
associated with poor recovery. however, this type of repair needs some extra length of
● The most common cause for closed injuries is traction nerve mobilization, which is only possible during the first
or stretching. These lesions have the potential to result few days that follows the trauma.11
in a number of different nerve damage, which include Early or late repair can be indicated based on the type
neuropraxia, axonotmesis, and neurotmesis. The forma- of injury associated with the nerve trauma, as discussed
tion of a neuroma-in-continuity is frequently noted, next.
and the prognosis will be dictated by the severity of the
damage to the cover layer of the nerve. Although this
type of lesions are more frequently observed in associa-
10.5.1 Open Wounds: Laceration
tion with brachial plexus trauma, stretching injuries of Mechanism
distal nerves are also very often observed as a conse-
In stab wounds, the associated neurological deficit is
quence of vehicular accidents. Traction may also pro-
assumed as being a consequence of a nerve transection,
voke lesions to nerves at some points, where they run
and recovery will not occur without repair. Still, there is
under a tunnel area, for example, the axillary nerve at
a small but realistic chance that the nerve has not been
the level of the quadrangular space or the musculocuta-
divided, as the wounding agent may only contused or
neous nerve at the level of the coracobrachialis tunnel.7
stretched the nerve rather than transected it; however,
● Injection injuries are closed lesions that deserve atten-
early exploration of the involved nerve is always advised.
tion. This type of injury is caused by a needle placed
Although most of the authors agree that a clean and
into or close to a nerve, and the damage is a conse-
sharp injury (knife, blade, glass, etc.) may require imme-
quence of the neurotoxic chemical of the agent injected.
diate repair in order to optimize the final outcome, there
The extension of the injury varies, depending on
is no reason to treat it as a surgical emergency. A delay of
whether the toxic substance is injected in the nerve or
24 to 72 hours is acceptable if the general conditions of
not, and the degree of neurotoxicity of the agent. In
the patient need some further stabilization or if the ideal
10% of the cases, the symptoms may be delayed hours
resources for the nerve suture are still not available.
or days before their onset. The most common neural
When the repair is done within few days, an end-to-end
injection site is the level of the buttocks, damaging the
suture of the nerve stumps is possible once the elasticity
sciatic nerve; however, injection injuries may involve
of the epineurium allows that the stumps may be drawn
every major nerve of the body.8
together. If the nerve is not repaired acutely, there is
● Indirect mechanism of nerve injury, such as thermal,
retraction of the proximal and distal stumps, and the scar
radiation, and electrical, are closed lesions that promote
tissue will fix the nerve ends at their retracted lengths.
very extensive and diffuse damage to nerves. Moreover,
These mechanisms increase the probability that grafting
these aggressors also result in extensive fibrosis forma-
will be needed to bridge the gap, lessening the likelihood
tion in the surroundings soft tissues, and managing
of a good outcome.12
these cases is usually very difficult.
Technical conditions in performing the surgery is
another important issue that must be taken into consid-
10.5 Specific Surgical Timing eration when deciding for an early repair: this implies the
use of microscope magnification, 9.0 or 10.0 caliber
For many years, there was a strong tendency to favor sutures, and a careful manipulation of nerve structures
delayed repair in traumatic nerve injuries. This bias has its using microsurgical instrumental. Any attempt to suture
origin from the experience obtained with wartime inju- the nerve beyond these conditions will result in unneces-
ries, in which considerable soft-tissue trauma was fre- sary damage to nerve tissue, increasing local fibrosis reac-
quently associated, preventing a clear demarcation of the tion and worsening the functional results at long-term

86
Timing in Traumatic Peripheral Nerve Lesions

follow-up. Hence, it is better to wait until ideal technical Vascular and soft-tissues injuries are relatively common
conditions for nerve repair are available before deciding to in association with these injuries. If an acute vascular or
explore the wound.13 bone repair is necessary, the affected nerve must be
Lacerations associated with blunt trauma require a dif- inspected for signs of visible macroscopic discontinuity.
ferent approach. If the wound is torn, contused, or conta- If this is the case, no attempt should be made to repair it
minated, it is better to delay the repair until the affected immediately—because the extent of damage to the nerve
site becomes cleaned and uninfected. Moreover, under ends cannot be determined—and, as in blunt lacerations, it
these conditions it is uncertain what length of the nerves is better to wait 3 to 4 weeks for a second approach, when
is really damaged, or to predict how much scar tissue is the longitudinal extent of the injury is more clearly demar-
going to deposit into the injury site. Early surgery may cated. If the nerve is found in anatomical continuity, con-
lead to poor outcomes, as scar tissue may form within the servative treatment, as described earlier, is recommended.
nerve and also at the suture site, blocking the axonal Associated pain syndromes with poor medical and conser-
regeneration. Delayed (not late) surgery is the rule for vative control may also require earlier surgery.18
such scenarios. The best approach to these injuries is to
identify the stumps of the affected nerve during the ini-
tial surgery (i.e., surgery for soft-tissue debridement, sta-
10.5.3 Closed Injuries: Traction
bilization of fractures, vascular repair, etc.) and to tack or Compression
them down to tissue near each other. Any attempt of
Closed injuries are more frequently associated with nerve
primary suture under tension must not be done, even
injuries in continuity, i.e., characterized by an absence of
temporarily, as this maneuver will lead to increased scar
gross nerve rupture. The decision to explore a nerve in
formation at the nerve stumps. Tacking down the nerve
such scenarios is made by determining whether the
stumps during the acute exploration of the wound will
neurological deficit is due to a neurotmetic nerve injury—
limit the shortening of the nerve ends, allowing further
transection or severe internal disrupture—or due to axo-
reconstructions with shorter grafts. Hence, blunt and
notmesis. All efforts are directed toward establishing as
contuse penetrating traumas to nerves are best managed
precisely as possible whether the nerve is injured com-
by waiting 3 to 4 weeks before performing the definitive
pletely or partially, and whether or not it is recovering.
nerve suture. The repair can be done after resection of
A common approach when the nerve continuity is
the damaged nerve back to areas of healthy tissue
uncertain is to wait and to search for signs of clinical or
appearance and where viable fascicles can be identified,
electrophysiological evidence of reinnervation. If no rein-
decreasing the chance of excessive fibrosis formation at
nervation has occurred by 3 to 4 months after the injury,
the suture site.14
exploration should be considered. This time delay allows
any component of neuropraxia or axonotmesis to be
10.5.2 Open Injuries: Gunshot resolved, confirmed by signs of recovery on the target
muscles. This is true for most of the injuries of the large
Wounds compound nerves of the body, because their first target
These are penetrating injuries that require different treat- muscles are frequently placed no more than 10 cm far
ment from the other open nerve wounds. In most of the from the site of the injury, and their recovery can be
cases, the missile does not strike the nerves directly, but observed in such time frame. However, this may not be
it causes much more contusion and ischemia. The true to very proximal lesions of long nerves in which
involved nerves may be damaged over a long extension, the critical muscles are located far from the injury site
although many of them are found in gross anatomical (such as the ulnar nerve or the peroneal nerve); particu-
integrity. Hence, the best way to manage such lesions is larities of the surgical managing of such lesions will be
to consider them as closed, and due to the high incidence discussed in Chapter 10.5.4. Exploration may be delayed
of injuries in continuity—with implies likelihood of spon- some few more months later if the injury is considered
taneous recovery—conservative initial treatment is incomplete or if the circumstances of the lesion indicate
advised.15 Most of the authors advocate that a 4 to 6 relative minor trauma, but it should not be delayed for
months’ wait before surgical exploration should be indi- more than 6 months. Waiting beyond this time frame will
cated for such patients. Data from wartime records show impact negatively on the degree of recovery if the lesion is
that military wounds (high-velocity missiles) result in complete and requires repair, once all time lost prior to the
nerve lesions that are characterized by a prolonged recov- surgical treatment is counted, and the total time required to
ery period, and a longer period of clinical observation is reinnervate the paralyzed muscles is additioned.19
advised (6 months).16 In civilian practice, the low-velocity Electrodiagnostic studies are also useful in planning
missile wounds usually result in more focal nerve inju- the timing for the surgery in such cases. A measurement
ries, and it is recommended to shorten the period of con- is made from the injury site to the most critical muscle
servative treatment, exploring the nerve in 3 to 4 months to reinnervate, assuming that, if surgery is necessary,
following the trauma.17 sprouts from the repair site must reach the muscle before

87
Timing in Traumatic Peripheral Nerve Lesions

irreversible changes occur. At 1 inch/month for axonal It is also important to define the time when the nerve
regeneration velocity, it important to calculate the time repair has little or nothing to offer. Although this limit
required for the sprouts from the injury site to reach the may vary, because some nerves and muscles may recover
first target muscle in line for reinnervation. If the first tar- better than others, most of the authors agree that nerve
get muscle does not reinnervate on time, exploration surgery should be avoided when the duration of the total
is advised.20 On the other hand, in recent years high- muscle denervation exceeds 18 to 24 months. Exceptions
resolution ultrasonography has been used with increas- to this rule may occur in a group of patients with lesions
ingly frequency for the study of nerve injuries. It has that maintained some distal axonal continuity, and when
demonstrated to be a very useful tool to anticipate the the main goal of the surgery is to recover only sensory
operative timing for closed injuries (and also for missile function (e.g., lesions of the digital nerves). It is also
wounds), as it allows disclosing focal nerve abnormalities important to recognize when the distance between the
(such as focal enlargement) and evaluating the degree of nerve injury and the muscles is too great that the nerve
intraneural damage (the amount of scar tissue formation reconstruction cannot predict any degree of functional
within the nerve, and the arrangement and viability of recovery. One of the best examples for such situations is
the fascicles). Ultrasound is also useful to differentiate the suture of the ulnar nerve at the level of the axilla: the
posttraumatic neuroma-in-continuity from nerve discon- distance between the injury site and the critical muscles
tinuity with end-bulb neuroma, which can guide the sur- is so far that no intrinsic recovery is predicted, even
gical planning for an earlier nerve repair.21 with early exploration and optimal repair. In these cases,
There are some specific situations in which closed inju- tendon transfers or distal nerve transfer techniques
ries can or must be managed acutely: should be elected as the primary approach for restoring
● The first scenario corresponds to those cases in which motor function.24
the involved wound needs to be explored for correction
of fractures or vascular or other soft-tissue lesions. In
these cases, the nerve can be inspected for its integrity. 10.5.4 Closed Injuries: Special
If the nerve is intact, clinical observation is advised and
a second exploration is indicated for the individuals in
Situations
which no signs of nerve regeneration can be registered ● Injections injuries: There is considerable controversy
3 to 4 months after the trauma. If the nerve is discon- regarding the treatment of nerve injection injuries.
tinued, the stumps are tacked down near each other, If the complication is noted immediately, acute open
and the repair is delayed for 4 weeks or until the heal- irrigation with normal saline has been advocated in an
ing of the fracture. Nerve suture should be avoided in attempt to dilute the drug and thereby to prevent per-
patients with poor or no bone fusion.22 manent neuropathy. Although logical, such treatment is
● Surgery may also be anticipated when it becomes nec- rarely practical as patients are infrequently seen acutely
essary for treating some poorly controlled painful syn- and widespread experience with this method is lacking.
dromes associated with nerve injuries. Although this Early exploration (within 3 to 4 weeks), aiming to per-
kind of complication is more frequently observed in as- form a thorough external neurolysis, has also been
sociation with missile wounds, they can be noted in advised. However, most of the authors recommend
patients suffering from traction injuries of nerves with exploration of those nerve injection injuries that are
extensive sensory component, such as the median or complete and show no or little recovery at 4 to
the posterior tibial nerve. If the surgery is indicated for 6 months.25
controlling the pain, intraoperative electrophysiological ● Proximal injuries of long nerves: injuries of a complex
studies (in special nerve action potentials [NAP]) must nerve in a position above the elbow or above the knee
be employed to guide the optimal decision regarding are problematic—because of the long distance that the
the type of technique to repair the nerve (neurolysis or sprouts must travel—making it difficult to reinnervate
grafting).23 critical distal muscles before irreversible changes occur.
● Finally, there are cases in which the closed trauma The clinical decision regarding exploration must occur
occurred at an area of possible nerve entrapment (such over a much shorter time frame. In these cases, it is
as carpal tunnel, cubital tunnel, and peroneal tunnel), advisable to wait 8 to 12 weeks for any component of
resulting in acute nerve compression manifested by irra- neuropraxia to resolve. Early surgery (3 months) is
diated pain or partial or complete neurological deficit. acceptable and recommendable for these patients, in
These cases must be urgently evaluated by imaging tech- order to allow proper time for distal motor and sensory
niques, aiming to identify the local elements with poten- reinnervation. However, the use of intraoperative NAP
tial for compression of the nerve, such as hematomas or recording is mandatory during such surgeries: if a NAP
dislocated bone fragments. Such scenarios demand acute can be recorded across the lesion, then external neurol-
exploration, appropriate nerve decompression and cor- ysis is performed; otherwise, repair by means of nerve
rection of the underlying condition if possible. grafting or by distal nerve transfer is advised.26

88
Manual of Peripheral Nerve Surgery | 25.07.17 - 10:01

Timing in Traumatic Peripheral Nerve Lesions

[6] Kline DG. Civilian gunshot wounds to the brachial plexus. J Neuro-
10.6 Conclusion surg. 1989; 70(2):166–174
[7] Kline DG. Physiological and clinical factors contributing to the timing
Injuries of peripheral nerves may result in severe neuro- of nerve repair. Clin Neurosurg. 1977; 24:425–455
logical deficits that can be improved if a proper manage- [8] Kretschmer T, Antoniadis G, Braun V, Rath SA, Richter HP. Evaluation
ment strategy is adopted. The surgical timing and a of iatrogenic lesions in 722 surgically treated cases of peripheral
careful microsurgical technique are the most important nerve trauma. J Neurosurg. 2001; 94(6):905–912
[9] Smith JW. Factors influencing nerve repair. II. Collateral circulation of
factors that will determine the outcomes of such lesions.
peripheral nerves. Arch Surg. 1966; 93(3):433–437
Open wounds due to laceration mechanism deserve [10] Hudson AR, Hunter D. Timing of peripheral nerve repair: important
urgent attention: sharp injuries are best treated within local neuropathological factors. Clin Neurosurg. 1977; 24:391–405
the first 72 hours, while blunt injuries need a short delay [11] Millesi H. Reappraisal of nerve repair. Surg Clin North Am. 1981; 61
(2):321–340
of 3 to 4 weeks to avoid further nerve shortening and scar
[12] Robinson LR. Traumatic injury to peripheral nerves. Muscle Nerve.
tissue formation into the suture site. Gunshot wounds 2000; 23(6):863–873
should be treated conservatively for 4 to 6 months, as [13] Martins RS, Bastos D, Siqueira MG, Heise CO, Teixeira MJ. Traumatic
most of this type of lesion does not result in nerve trans- injuries of peripheral nerves: a review with emphasis on surgical
ection. The majority of the closed traction, compression, indication. Arq Neuropsiquiatr. 2013; 71(10):811–814
[14] Sunderland S. The anatomic foundation of peripheral nerve repair
or stretching injuries must be explored from the third
techniques. Orthop Clin North Am. 1981; 12(2):245–266
month after the trauma, and surgery are indicated for [15] Katzman BM, Bozentka DJ. Peripheral nerve injuries secondary to
patients who do not demonstrate signs of spontaneous missiles. Hand Clin. 1999; 15(2):233–244, viii
reinnervation of the target muscles. The best outcomes [16] Roganović Z, Savić M, Minić L, et al. Peripheral nerve injuries during
the 1991–1993 war period [in Serbian]. Vojnosanit Pregl. 1995; 52
are obtained if the nerve is treated within the sixth
(5):455–460
month that follows the trauma; thus, all effort must be [17] Nicholson OR, Seddon HJ. Nerve repair in civil practice; results of
directed to properly manage such patients within this treatment of median and ulnar nerve lesions. BMJ. 1957; 2(5053):
time limit. Surgery is still indicated for lesions more than 1065–1071
6 months old; however, the outcomes associated with [18] Stanec S, Tonković I, Stanec Z, Tonković D, Dzepina I. Treatment of
upper limb nerve war injuries associated with vascular trauma.
such procedures are frequently less than optimal. The
Injury. 1997; 28(7):463–468
neurological surgery is not advisable for cases with fixed [19] Kline DG. Timing for exploration of nerve lesions and evaluation of
deficits resulting from injuries more than 2 years old, and the neuroma-in-continuity. Clin Orthop Relat Res. 1982(163):42–49
secondary procedures (such as tendon transfers) should [20] Aminoff MJ. Electrophysiologic testing for the diagnosis of peripheral
be offered as primary option for these patients. nerve injuries. Anesthesiology. 2004; 100(5):1298–1303
[21] Koenig RW, Pedro MT, Heinen CP, et al. High-resolution ultrasonogra-
phy in evaluating peripheral nerve entrapment and trauma. Neuro-
surg Focus. 2009; 26(2):E13
References [22] Amillo S, Barrios RH, Martínez-Peric R, Losada JI. Surgical treatment
of the radial nerve lesions associated with fractures of the humerus.
[1] Kline DG, Hackett ER. Reappraisal of timing for exploration of civilian
J Orthop Trauma. 1993; 7(3):211–215
peripheral nerve injuries. Surgery. 1975; 78(1):54–65
[23] Dworkin RH, Backonja M, Rowbotham MC, et al. Advances in neuro-
[2] Liuzzi FJ, Tedeschi B. Peripheral nerve regeneration. Neurosurg Clin N
pathic pain: diagnosis, mechanisms, and treatment recommenda-
Am. 1991; 2(1):31–42
tions. Arch Neurol. 2003; 60(11):1524–1534
[3] Selecki BR, Ring IT, Simpson DA, Vanderfield GK, Sewell MF. Trauma
[24] Hubbard JH. The quality of nerve regeneration. Factors independent
to the central and peripheral nervous systems: Part I: an overview of
of the most skillful repair. Surg Clin North Am. 1972; 52(5):1099–
mortality, morbidity and costs; N.S.W. 1977. Aust N Z J Surg. 1982;
1108
52(1):93–102
[25] Clark WK. Surgery for injection injuries of peripheral nerves. Surg
[4] Höke A. Mechanisms of disease: what factors limit the success of
Clin North Am. 1972; 52(5):1325–1328
peripheral nerve regeneration in humans? Nat Clin Pract Neurol.
[26] Spinner RJ, Kline DG. Surgery for peripheral nerve and brachial
2006; 2(8):448–454
plexus injuries or other nerve lesions. Muscle Nerve. 2000; 23(5):
[5] Rochkind S, Filmar G, Kluger Y, Alon M. Microsurgical management
680–695
of penetrating peripheral nerve injuries: pre, intra- and postoperative
analysis and results. Acta Neurochir Suppl (Wien). 2007; 100:21–24

89
Outcomes in the Repair of Nerve Injuries

11 Outcomes in the Repair of Nerve Injuries


Lukas Rasulic and Miroslav Samardzic

Abstract adolescents still better than those attained in adults.


Grading systems for nerve function are needed not only On the other hand, there is no significant difference in
to evaluate individual motor and sensory function, but the outcomes obtained between different age groups
also to assess entire nerves or plexus elements. Most among adults. No critical age at which outcomes tend to
major nerves innervate one or more proximal muscles, decline has been established, though other factors may
a group of distal muscles, and a distal sensory field of play a more significant role in the elderly.
variable functional importance. The most widely accepted Possible explanations for the enhanced results that
system for grading nerve function loss and recovery children typically experience are: (1) the earlier initiation
was introduced by the British Medical Research Council of regeneration; (2) an increased rate of neural regenera-
(MRC). Since then, several modifications have been made, tion; (3) greater stability of the neuromuscular junction
but these have not altered the original concept, especially after denervation; (4) shorter extremities; and (5)
regarding functional priorities. increased adaptability and ability for other nonaffected
Keeping this in mind, the results of nerve repairs for muscles to substitute or modify their motor function to
complex nerve structures—such as the brachial plexus compensate for muscles that have been paralyzed.1
and proximal sciatic nerve—should be analyzed in a
somewhat different way than for individual nerves. This
chapter focuses on the analysis of prognostic factors and 11.1.2 Characteristics of the Nerve
grading systems for individual peripheral nerves, and
It is obvious that repair outcomes vary between different
how they should be modified for more complex nerve
nerves, even within the heterogeneous series that have
structures.
been reported. Generally, repair of a pure motor or sen-
sory nerve is technically simpler, and its results are better
Keywords: brachial plexus, nerve injury, operative out-
than for combined motor–sensory nerves because of the
come, prognostic factors, sciatic nerve
diminished likelihood of axonal mixing. Discrepancies in
repair outcomes between nerves in the upper and lower
11.1 Prognostic Factors extremities have also long been described, as well as
greater recovery in the tibial nerve versus the peroneal
Several factors influence the final outcome following nerve, and better outcomes with radial nerve versus
nerve repair, most of them independent of the surgeon. median and peroneal nerve repairs. Most investigators
These factors can be subdivided as follows: have been unable to detect any meaningful difference in
● Patient age. recovery potential between the median and ulnar nerves,
● Characteristics of the nerve, including: though opposing claims also exist in favor of either one
○ Topography of the motor neurons. or the other. The reasons for differences in motor recov-
○ Nerve microanatomy. ery potential include the topography of motor neurons
○ Main muscle effectors. in the spinal cord, characteristics pertaining to the
● Characteristics of the nerve injury, including: nerve’s microanatomy, and the nature of the main muscle
○ Mechanism. effectors.2
○ Level. Examining the topography of motor neurons within
○ Length of the nerve defect. the anterior horns of the spinal cord, peroneal nerve neu-
○ Associated injuries. rons are found to be numerous and scattered, while
● Surgery. radial nerve neurons are concentrated over a small area
● Postoperative rehabilitation. within the cross-section of the anterior horn. The topog-
raphy of the neurons for other nerves is between these
two extremes.
11.1.1 Patient Age Considering the characteristics of nerve microanatomy,
It has been generally accepted that a patient’s age is the the following may contribute to different nerve recovery
most important predictor of outcome following nerve potentials:
repair, with significantly better results generally observed ● A great proportion of intraneural connective tissue

in children and teenagers. The prognosis for functional (e.g., within the peroneal nerve) makes it difficult for
recovery is the best in children younger than 10 years, regenerating axons to grow into empty endoneurial
with good to excellent results in more than 90% of cases. tubes.
This compares with 75% in patients between 10 and ● A greater proportion of sensory fibers (e.g., within the

20 years old, with results in older children and median, ulnar, and tibial nerves) is a risk factor for poor

90
Outcomes in the Repair of Nerve Injuries

recovery, because of the potential for cross motor– Contrary to the peroneal nerve, only one to three risk
sensory reinnervation. factors exist for nerves with the best recovery potential
● An oligofascicular pattern within the nerve and sparse (e.g., the radial, musculocutaneous, femoral, and axillary
connections between the bundles increase the proba- nerve), while four to six risk factors are present among
bility of good recovery (such are characteristics of the nerves with moderate motor recovery potential (e.g., the
radial, musculocutaneous, and axillary nerve, but not of median, ulnar, and tibial nerve).
the tibial and peroneal nerves).
● Inadequate vascularization in some regions (e.g., the 11.1.3 Characteristics of the Nerve
peroneal nerve as it passes by the fibular neck).
Injury
With respect to main muscle effector characteristics, Final repair outcomes are influenced considerably by the
repair outcomes tend to be better in the following cases: mechanism of injury and the severity of trauma. In par-
● If the main effectors receive their input relatively proxi- ticular, nerve injuries resulting from projectiles/missiles
mal within the limb (e.g., the main effectors for the and from traction have a poorer prognosis than other
musculocutaneous, axillary, radial, tibial, and femoral types of injury, because they involve longer segments of
nerves). nerve.
● If functionally useful reinnervation of the main effec- Numerous authors have also recognized the influence
tors requires relatively few nerve fibers (e.g., the tibial of the repair level on the outcome (▶ Table 11.1). Poor
and radial nerves), as opposed to the lion’s share of the prognosis after high-level repairs can be attributed to
regenerating axons (e.g., the ulnar nerve). variations in nerve mapping, especially in cases of nerve
● If complete return of muscle strength is not necessary tissue loss, and to the irreversible degeneration of sensor-
for good functional recovery (e.g., contraction of finger imotor effectors. Muscle atrophy starts within 3 weeks
extensors with only 20% of maximal strength results in of denervation, with almost complete replacement of
minimal functional disability after radial nerve repair). the muscle with fibrous tissue over the next 2 years. If
● If it is not necessary to restore precise or coordinated the calculated reinnervation period for the main muscle
muscle contractions; such contractions only need to be effectors is longer than that, nerve repair cannot be
restored by median, ulnar, and peroneal nerve repairs. accompanied by motor recovery, because of irreversible
● If any major disability can be precluded or alleviated muscle fibrosis (e.g., useful reinnervation of hand muscles
by muscles supplied by an uninjured nerve; only inju- cannot be expected after ulnar nerve repair in the axilla).
ries to the peroneal, ulnar, and radial nerve lack such Conversely, after high radial nerve repairs, regenerating
potential. axons grow into distal effectors early enough to prevent
irreversible muscle fibrosis (for thumb extensors, within
Reviewing these factors, it is clear that risk factors por- 16–18 months). Such limitations do not apply to sensory
tending poorer motor recovery are especially numerous recovery, which can be anticipated even after delayed and
for the peroneal nerve, which is likely why the peroneal high-level nerve repairs (▶ Table 11.1 and ▶ Table 11.2).
nerve must be considered, among the major nerves, The length of nerve defect—which is determined by
probably the worst candidate for graft repair. The pero- both the extent of the initial trauma and the passage of
neal nerve also has less connective tissue and is less vas- time (due to stump distraction)—impacts outcomes more
cularized than the tibial nerve, which is also protected by than the length of the graft. In principle, shorter grafts do
fatty tissue in the popliteal fossa. better than longer ones. Several authors have claimed

Table 11.1 Establishing the level of injury in upper extremity nerves


Nerve High Medium Low
Above the lower margin of the
Median Above midarm Below the pronator teres muscle
pronator teres muscle
Ulnar Above midarm Above the middle third of the forearm Middle and lower third of the forearm
Radial Above midarm Above the nerve bifurcation Posterior interosseous nerve
Above the biceps-brachialis Below the biceps-brachialis muscle
Musculocutaneous –
muscle space space

Table 11.2 Establishing the level of injury in lower extremity nerves


Nerve High Medium Low
Peroneal Above midthigh Above the final division Peroneus profundus
Tibial Above midthigh Above the soleus muscle arc Below the soleus muscle arc
Femoral Above Poupart’s ligament Below Poupart’s ligament –

91
Outcomes in the Repair of Nerve Injuries

that nerve grafts longer than 5 to 10 cm considerably


limit the probability of a good outcome, even though
11.2 General Grading Systems
experimental data indicate that certain other factors (e.g., As stated at the outset, grading systems are needed not
the concomitant damage of effectors) also may be respon- only for individual muscle and sensory functions, but also
sible for the poor results typically observed with long for the evaluation of entire nerve or plexus elements.
nerve grafts.3 Most nerves and plexus elements innervate one or more
Combined nerve injuries, particularly simultaneous proximal muscles, a group of distal muscles, and also
lesions affecting the ulnar and median nerve, are fre- some distal sensory field, the functional importance of
quent, especially after projectile-caused wounds. Although which may vary.4 The British Medical Research Council
opposing claims also exist, most authors consider that (MRC) system for grading loss or the return of motor
such injuries almost always result in a nonfunctional function after nerve injury and repair was originally
hand, warranting additional corrective measures. based on grading systems developed to evaluate paralysis
Comorbid injuries in the repair region (e.g., bone frac- associated with poliomyelitis (▶ Table 11.3 and ▶ Table 11.4).
tures, injuries to main arteries, and soft-tissue defects) To expand the scale, grade 4 subdivisions were introduced,
influence repair outcomes through ischemia, perineural as follows: (4–) slight movement without resistance; (4)
scarring, and defects involving the effectors. Useful motor moderate movement against resistance; and (4 +) strong
recovery is more frequent among patients with less local movement against resistance. Paternostro-Sluga et al intro-
damage. duced further modifications to this scale, including range of
movement (ROM) to indicate subgrades5:
● Grade 2–3: active movement against gravity over less
11.1.4 Surgery than 50% of the feasible ROM.
One of the most significant determinants of repair out- ● Grade 3: the same as 2–3, with feasible ROM over more

comes is the duration of time between the initial trauma than 50%.
and surgery. Progressive closing of distal endoneural ● Grade 3–4: active movement against resistance over

tubes, resulting in increasingly disproportionate sizes in less than 50% of the feasible ROM.
the proximal and distal nerve stumps, is the consequence ● Grade 4: the same as 3–4, with feasible ROM over more

of a prolonged preoperative interval. Delaying surgery than 50%.


beyond the aforementioned critical denervation period of ● Grade 4–5: active movement against strong resistance

24 months is particularly problematic, particularly for over the feasible ROM, but distinctly weaker than the
proximal repairs. According to some published data, contralateral side.
operations may be postponed safely for 4 to 6 months, ● Grade 5: normal power.

but further delay may endanger motor recovery. If the


preoperative interval is longer than 24 months, the out-
come is likely to be poor, though good results have been Table 11.3 Grading of the motor outcome—Highet’s
sporadically reported for surgeries performed 3 or more classification system
years after injury. Score Motor outcome
The choice of surgical procedure is directly influenced
0 Total paralysis
by the characteristics of the nerve injury and the timing
1 Muscle fibrillation
of nerve repair. Unquestionably, the best results are
obtained with neurolysis of lesions-in-continuity. In 2 Visible muscle contraction
nerve transections, the chances for useful functional 3 Movement against gravity
recovery are best following direct nerve suture. It should 4 Movement against gravity and some resistance
be emphasized that there is no significant difference in 5 Normal muscle function
the results obtained with direct epineural or fascicular
repair versus nerve grafting with nerve defects up to
Table 11.4 Scoring of motor recovery as recommended by the
5 cm in length. Certainly, other favorable circumstances British Medical Research Council
are necessary in these situations.
Motor recovery
M0 No contractions
11.1.5 Postoperative Rehabilitation M1
Visible or palpable contractions in the proximal
muscles
Consistent rehabilitation is also necessary for good recov-
Voluntary contractions of proximal muscles and trace
ery after nerve repair, particularly after repairs in the M2
or no contractions of distal muscles
upper extremity. Soon after surgery, the patient should M3 Some voluntary contractions of distal muscles
be encouraged to use his/her injured extremity as much
M4 Contractions of distal muscles against resistance
as possible to prevent contractures and achieve maximal
M5 Full and separate contractions of all distal muscles
functional recovery.

92
Outcomes in the Repair of Nerve Injuries

A similar grading system was introduced by the Louisiana 1976,11 which included the testing of two-point discrimi-
State University Medical Center (LSUMC), wherein move- nation (▶ Table 11.8). Sensory recovery is not a reliable
ment with gravity eliminated was excluded (▶ Table 11.4 sign of regeneration, however, mainly because of its late
and ▶ Table 11.5). Useful motor function was considered occurrence and difficulties associated with its clinical eval-
to be grade 3 with the MRC scale, versus grade 2 with the uation. It is functionally important after median and tibial
LSUMC rating system. nerve repairs in particular, because sensory loss that
For the grading of complete motor function in selected occurs in the sole of the foot predisposes patients to
nerves, no system has really superseded the one intro- recurrent trophic ulceration. Recovery is frequently fol-
duced by Highet in 19416 and proposed to the Nerve Inju- lowed by “sensory relearning,” which is a process of
ries Committee of the MRC in 1954.6,7 The definition of functional cortical reorganization caused by axonal
proximal and distal muscles varies depending on the misdirection at the repair site. Sensory recovery is less
height of repair. Proximal muscles include forearm important for the overall outcome of ulnar, radial, axillary,
muscles (for the median and ulnar nerves), the brachiora- peroneal, femoral, and musculocutaneous nerve repairs.
dial and triceps brachii muscles (for the radial nerve), Recovery of sweating in the autonomous zone may pre-
the triceps muscle of calf and posterior tibial muscle (for cede sensorimotor recovery by several weeks or months,
the tibial nerve), the anterior tibial and peroneus muscles because autonomic fibers are small in diameter and
(for the peroneal nerve), and the iliacus and pectineus regenerate more quickly. Finally, to grade the entire nerve,
muscles (for the femoral nerve). Distal muscles include including motor and sensory function, the LSUMC system
hand muscles (for the median and ulnar nerves), the dor- has been used in several studies (▶ Table 11.9).8,9,10
sal forearm muscles (for the radial nerve), the extensor/ The term “useful recovery” has been adopted fre-
flexor muscles of toes (for the peroneal/tibial nerve), and quently to reflect the functional impact of the repair and
the sartorius and quadriceps muscles (for the femoral variations from nerve to nerve. For the tibial nerve, useful
nerve). sensory recovery is defined as the return of superficial
For the grading of sensory function in the autonomous painful and some tactile sensation, without clear
zone of a nerve where there is minimal overlap from
adjacent nerves, there are also two systems: MRC and
LSUMC (▶ Table 11.6 and ▶ Table 11.7). Samardzic et al8,9,10
Table 11.6 Scoring of sensory recovery as recommended by the
used a grading system introduced by Millesi et al in British Medical Research Council
Sensory recoverya
S0 Absence of sensation
Table 11.5 Louisiana State University Medical Center grading
system for motor function S1 Recovery of deep cutaneous pain sensation
Individual muscle grade S2 Return of some degree of superficial pain and tactile
sensation
Grade Evaluation Description
S2 + Same as in Stage S2, with additional slight
0 Absent No contraction hyperresponsiveness
1 Poor Trace contraction S3 Further recovery of pain and tactile sensation, with no
2 Fair Movement against gravity only dysesthesia
3 Moderate Movement against gravity and some S3 + Same as Stage 3, with the addition of some two-point
resistance discrimination
4 Good Movement against moderate resistance S4 Complete recovery
5 Excellent Movement against maximal resistance aSensationshould be tested in the autonomous zone of a nerve,
where there is minimal overlap from adjacent nerves.

Table 11.7 Louisiana State University Medical Center grading system for sensory function
Sensory grade
Grade Evaluation Description
0 Absent No response to touch, pin, or pressure
1 Bad Testing yields hyperesthesia or paresthesia; deep pain recovery in autonomous zones
2 Poor Sensory response sufficient for grip and slow protection; sensory stimuli poorly localized with
hyperresponsiveness
3 Moderate Response to touch and pin in autonomous zones; sensation poorly localized and abnormal with some
hyperresponsiveness
4 Good Response to touch and pin in autonomous zones; response localized but sensation abnormal; no
hyperresponsiveness
5 Excellent Near-normal response to touch and pin in entire field including autonomous areas

93
Outcomes in the Repair of Nerve Injuries

Table 11.8 Grading of the sensory outcome—Millesi’s classification functional priorities, and the use of different methods to
evaluate functional recovery. For practical purposes, one
Score Motor outcome
can use the grading system for upper arm function that is
0 Anesthesia
based on the gradations published by Ploncard in 1982
1 Dysesthesia (▶ Table 11.10). The main reasons for this modification are
2 Protective sensation the significance of both nerves for upper arm function, the
3 2PD > 10 mm complexity of shoulder function involving several muscles,
4 2PD < 10 mm and the role of two muscles (biceps and brachialis) in
5 Normal function elbow flexion. Other reasons include the importance of
Abbreviation: 2PD, two-point discrimination. ROM, endurance, and the capacity for repetition.10 The
level of recovery is typically categorized as fair, good, or
excellent. With this grading system, good recovery roughly
localization (> S2). On the other hand, some restoration of corresponds to restoration of strength to the level of M2 or
two-point discrimination is also required after median higher using the LSUMC grading system, and to M3 or
and ulnar nerve repairs. Useful motor recovery (usu- higher according to the British MRC system. To establish a
ally > M3) after peroneal nerve repair means restoration final grade and level of recovery, the follow-up period
of dorsiflexion of the ankle to bring the foot into a neutral should be at least 2 years (▶ Table 11.10).
position (with or without some degree of foot eversion) Taking into consideration global upper arm function
because this means that a foot brace will no longer be that includes both shoulder abduction and elbow flexion,
needed for walking. Inability to regain toe extension is of functional results are graded as follows:
much less functional importance. Similarly, some plantar ● Poor: when there is absent elbow flexion with any

flexion must be present to consider the outcome after range of shoulder abduction, or fair elbow flexion in
tibial nerve repair useful. However, useful motor recovery the absence of shoulder abduction.
also requires some finger movements to be regained after ● Partial: when there is fair elbow flexion with any level

median and ulnar nerve repair. of shoulder abduction, or good and excellent elbow
flexion in the absence of active abduction—such
patients may be suitable for secondary reconstructive
11.2.1 Upper Extremity Repair procedures.
Generally, it is difficult to accurately assess the results of ● Useful, grade A: includes good or excellent elbow flex-

brachial plexus surgery (i.e., nerve transfers), due to poor ion with fair shoulder abduction—this grade of recovery
standardization of the complex injury patterns, varying enables normal daily activities.

Table 11.9 Louisiana State University Medical Center criteria for grading whole nerve injuries
Individual muscle grade
Grade Evaluation Description
0 Absent No muscle contraction, absent sensation
1 Poor Proximal muscles contract but not against gravity; sensory grade 1 or 0
2 Fair Proximal muscles contract against gravity; distal muscles do not contract; sensory grade,
if applicable, usually 2 or lower
3 Moderate Proximal muscles contract against gravity and some resistance; some distal muscles contract against
gravity; sensory grade is usually 3
4 Good All proximal and some distal muscles contract against gravity and some resistance; sensory grade is
3 or better
5 Excellent All muscles contract against moderate resistance; sensory grade is 4 or better.

Table 11.10 Grading of recovery for upper arm functions following nerve transfers
Result Elbow flexion Arm abduction Shoulder exorotation
Bad No movement or only movement without gravity
Movement against gravity with the ability to hold position
Fair Up to 45°
Up to 90° Up to 45°
Repeated movements against gravity
Good Up to 90°
Full range Over 45°
Excellent Near-normal function with preserved brachiothoracic pinch Over 90°

94
Outcomes in the Repair of Nerve Injuries

● Useful, grade B: includes good or excellent elbow flex- of cases (mean 58.2%). Similarly, crucial external shoulder
ion and shoulder abduction—this grade gives the pa- rotation has been obtained in 21.4 to 55% of cases, with
tient some capacity to do manual work with the ROM ranging from 16.7 to 118 degrees.
affected limb. The results of nerve transfers for the lower brachial
plexus are not as impressive, achieving M3-level recovery
Useful recovery, especially grade B, depends on hand func- in just 25 to 32% for the median, ulnar, and radial nerves.
tion, which may be partially or completely preserved in Kim12 reported rates of recovery of 84.2, 65.1, and
patients with a partial injury. In those with total brachial 45.9%, respectively, for neurolysis, direct repair, and graft-
plexus palsy due to avulsions of four to five spinal nerve ing with lacerations of the brachial plexus. The results for
roots, limited results for hand motion recovery can be gunshot wounds were in the same range, with 94, 70,
achieved with wrist arthrodesis or some other secondary and 54% of patients achieving at least an M3 level of
procedure or procedures; however, at best, the patient’s recovery. Previously reported results indicated lower
ability to perform any work with that hand will be poor. rates of recovery. The obtained results for upper nerve
The published rates of recovery vary depending on the elements were significantly better than for the lower ele-
type of nerve transfer and recipient nerve. Meta-analysis ments, with 95 versus 75% of patients achieving M3-level
data have been collected from 57 reports published over recovery.
the past 45 years and are presented in ▶ Table 11.11. Results for nerves of the entire upper arm are graded
Shoulder function has also been restored using spinal using the scales indicated in ▶ Table 11.12 and
accessory to suprascapular nerve transfers, with an M3 ▶ Table 11.13. A period of 2 to 3 years is required for
grade or more of arm abduction achieved in 36.4 to 92% maximal motor recovery after proximal nerve repairs,
while even longer periods are necessary for maximal sen-
Table 11.11 Rates of recovery of nerve transfers to the sory recovery (5–7 years). Clinical series dealing with
musculocutaneous and axillary nerves (meta-analysis data) nerve repairs are infrequent and differ in their outcome
assessment protocols, definition of repair levels, mecha-
Percentage of recovery
nisms of injury, patient age ranges, and other variables.
Nerve transfer Elbow flexion (%) Arm abduction (%)
▶ Table 11.14 summarizes the meta-analysis of data
Intercostal 42.8–100 33.8–87.5 reported over the past 40 years by 56 first authors in
Spinal accessory 44.4–100 61.5–67.0 77 well-documented papers, where the percentage of
Thoracodorsal 83.3–100 36.0–100 useful sensorimotor recovery is considered separately for
Medial pectoral 80.0–91 81.8–100 proximal-level and distal-level repairs. Literature reports
Oberlin procedure 75.0–100 on repairs of the median and ulnar nerves mostly include
Phrenic 29.4–100
wrist-level lesions. Series exclusively assessing proximal
repairs are rare and have mostly yielded discouraging

Table 11.12 Grading of functional recovery for complex structures of the brachial plexus
Nerve elements Function Good outcome Satisfactory outcome
I C5–C6 or upper trunk Elbow flexion M4–5 M3
Abductiona M3–5 M3
Wrist flexion M3–5 Mc
Sensory S3–4 S2
Extension M3–5 Mc
II C5–C7 or upper trunk and As for I As for I As for I
medium trunk Finger extension M3–5
Thumb abduction M3–5
III C8–T1 or lower trunk Finger flexion M4–5 M3
Hand muscles M3–5 Mc
Sensory M3–4 S2
IV Lateral cord Elbow flexion M4–5 M3
Wrist flexion M3–5 M3
Sensory M3–4 S2
V Medial cord As for III As for III As for III
VI Posterior cord Abductionb M4–5 M3
Wrist and finger extension M3–5 M3
Thumb abduction M3–5 Mc
Note: Lowest limitations, according to functional priorities, are as follows: aabduction innervated by the axillary nerve or suprascapular
nerve, or both; babduction innervated by the axillary nerve; cmotor outcome irrelevant for a satisfactory result.

95
Outcomes in the Repair of Nerve Injuries

Table 11.13 Grading of outcomes for peripheral nerves of the upper extremity (lowest limits)
Outcome Median nerve Ulnar nerve Radial nerve Musculocutaneous Axillary
nerve nerve
High Low High Low
Excellent M4–5 all M5 hand M4–5 all M3 hand M4–5 all M5 biceps M5 deltoid
muscles S4 muscles S4 muscles
S4 S4
Good M4–5 forearm M4 hand M4–5 forearm M4 hand M4–5 all M45 biceps M4–5 deltoid
M3 hand S3 M3 hand S3 muscles but
S3–4 S3–4 M3 of thumb
abduction
Satisfactory M3 forearm M3 hand M3 forearm M3 hand M3 all M3 biceps M3 deltoid
M0–3 hand S2 M3 hand S2 muscles but
S2 S2 M0–3 of
thumb
abduction
Poor M0–2 all M0–2 hand M0–2 all M0–2 hand M0–2 all M0–2 biceps M0–2 deltoid
muscles S0–1 muscles S0–1 muscles
S0–1 S0–1

Table 11.14 Percentage of useful sensorimotor recovery after nerve graft repairs of the upper extremity (meta-analysis data)
Repaired nerve Height of repair Useful motor recovery (%) Useful sensory recovery (%)
Median Proximal 40.1 61.7
Distal 67.3 71.9
Ulnar Proximal 35.0 66.0
Distal 66.4 72.8
Radial Proximal 75.5 –
Distal 90.7 –
Musculocutaneous All levels 87.1 –
Axillary All levels 79.4 –

results, though current reports on ulnar nerve repairs are Protective sensation is the first priority of surgical
more optimistic than in the past. repair. A second complication that must be addressed is
foot drop with an equinovarus deformity. Since adequate
functional improvement of the muscles innervated by the
11.2.2 Lower Extremity Repairs peroneal nerve is rare, the second functional priority of
The peroneal and tibial components should be evaluated restoration is plantar flexion. Recovery of plantar flexors
separately after sciatic nerve repairs. Generally, the tibial is essential to using an orthopaedic device or even the
division has exhibited the greater potential for recovery, restoration of active movements in the ankle joint by
even when lengthy grafts are necessary. Significant recov- anterior transfer of the tibialis posterior tendon. These
ery appears to be more difficult to achieve with the pero- two functions may be established by repairing the tibial
neal division, with data showing an average of only 36% division. Therefore, the best results can be obtained by
of patients reaching grade M3 or higher after suturing or successful nerve repair or grafting. In this case, even par-
graft repair.8,9 tial improvement may prevent contact sores; and with a
Motor function has been classified into six grades, from limited palliative procedure, this yields a good result.
M0 to M5, using Highet’s clinical scale. Sensory function Finally, a retarded vasomotor response with cyanosis and
was classified into five grades, from S0 to S4 (anesthesia, discomfort when the leg is in a vertical position is
dysesthesia, protective sensation, and two-point discrimi- another important complication, for which functional
nation above and below 10 mm). Patients experiencing restoration is a priority.
grade M3 recovery of plantar or dorsal flexors of the The results reported for the largest series on sciatic
foot and S2 sensory function were considered to have had nerve repairs, published by Kim and Murovic in 2008,13
useful functional recovery of the corresponding division. are similar to those reported by Samardzic et al.9 The cor-
The results of surgery for the sciatic nerve complex were responding rates of recovery, listed by surgical procedure
classified according to functional priorities (▶ Table 11.15). (neurolysis, split repair, grafting), were 74.3, 58.9, and

96
Outcomes in the Repair of Nerve Injuries

Table 11.15 Grading of outcome for peripheral nerves of the lower extremity (lowest limits)
Outcome Peroneal nerve Tibial nervea Femoral nerve Sciatic
nerve
Excellent M4–5 all muscles M4–5 all muscles M5 quadriceps Good VMF
S2 S3–4 T4
P2
Good M4–5 tibialis ant. peroneal group M4–5 triceps sure M4 quadriceps Good VMF
M3 finger extension M3 tibialis post., finger flexion T3
S2 S3 P1 (tendon transfer)
Satisfactory M3 tibialis ant. peroneal group M3 triceps sure M3 quadriceps Good VMF
M0–2 finger extension M0–2 tibialis post., finger flexion T2
S2 S2 P1 (orthopaedic aid)
Poor M0–2 all muscles M0–2 all muscles M0–2 quadriceps Poor VMF
S0–1 S0–1 T1
P1
Abbreviations: P, peroneus; T, tibialis; VMF, vasomotor function.
aGrading is only for lesions below Poupart’s ligament.

Table 11.16 Scoring of sensory recovery as recommended by the British Medical Research Council
Sensory recoverya
S0 Absence of sensation
S1 Recovery of deep cutaneous pain sensation
S2 Return of some degree of superficial pain and tactile sensation
S2 + Same as Stage S2, with slight additional hyperresponsiveness
S3 Further recovery of pain and tactile sensation, with no dysesthesia
S3 + Same as Stage 3, with the addition of some two-point discrimination
S4 Complete recovery
aThe sensation should be tested in the autonomous zone of a nerve, where there is minimal overlap from adjacent nerves.

36% for the peroneal nerve and 90.9, 87.5, and 72.7% for [5] Paternostro-Sluga T, Grim-Stieger M, Posch M, et al. Reliability and
validity of the Medical Research Council (MRC) scale and a modified
the tibial nerve, respectively. However, results were sig-
scale for testing muscle strength in patients with radial palsy. J Reha-
nificantly different for the buttocks and thigh. Excluding bil Med. 2008; 40(8):665–671
neurolysis, the difference was approximately 20% for the [6] Highet WB. Grading of Motor and Sensory Recovery in Nerve Injuries.
individual components. As could be expected, the rates of Report to the Medical Research Council. London: Her Majesty’s
recovery for nerve grafting were lower: 24.3 and 44.9%, Stationary Office; 1954
[7] Medical Research Council. Aids to Examination of the Peripheral
respectively. Therefore, this procedure is no less than
Nervous System. Memorandum No. 45. London: Her Majesty’s
questionable at the buttock level. Our own corresponding Stationery Office; 1976
rates of recovery, again by surgical procedure, were 73.3, [8] Samardzic M, Rasulić L. Repair of traumatic peripheral nerve lesions:
63.6, and 33% for the peroneal nerve, and 93.7, 93.3, and operative outcome after repair of complex nerve structures. In:
Siqueira MG, Socolovsky M, Malessy M, Devi I, eds. Treatment of
71.4% for the tibial nerve (▶ Table 11.16).
Peripheral Nerve Lesions. Bangalore: Prism Books Pvt Ltd; 2011:121–
126
References [9] Samardzic MM, Rasulić LG, Vucković CD. Missile injuries of the sciatic
nerve. Injury. 1999; 30(1):15–20
[1] Seddon H. Surgical Disorders of the Peripheral Nerves. 1st ed. New [10] Samardzic M, Rasulić L, Grujicić D, Milicić B. Results of nerve transfers
York, NY: Churchill Livingstone; 1975 to the musculocutaneous and axillary nerves. Neurosurgery. 2000;
[2] Roganovic Z. Repair of traumatic peripheral nerve lesions: operative 46(1):93–101, discussion 101–103
outcome. In: Siqueira MG, Sokolovsky M, Malessy M, Devi I, eds. [11] Millesi H, Meissl G, Berger A. Further experience with interfascicular
Treatment of Peripheral Nerve Lesions. Bangalore: Prism Books Pvt grafting of the median, ulnar, and radial nerves. J Bone Joint Surg Am.
Ltd; 2011:111–120 1976; 58(2):209–218
[3] Roganovic Z, Pavlicevic G. Difference in recovery potential of periph- [12] Kim D. Gunshot wounds to the brachial plexus. In: Kim D, Midha R,
eral nerves after graft repairs. Neurosurgery. 2006; 59(3):621–633, Murovic JA, Spiner R, eds. Kline and Hudsons: Nerve Injuries. Phila-
discussion 621–633 delphia, PA: Saunders; 2008:313–323
[4] Kline DG. Grading results. In: Kim DH, Midha R, Murovic JA, Spinner [13] Kim D. Murovic JA. Lower extremity nerve: sciatic nerve injuries. In:
RJ, eds. Kline and Hudson’s Nerve Injuries. 2nd ed. Philadelphia, PA: Kim D, Midha R, Murovic JA, Spiner R, eds. Kline and Hudsons: Nerve
Saunders; 2008:65–74 Injuries. Philadelphia, PA: Saunders; 2008:209–225

97
Gunshot and Other Missile Wounds to the Peripheral Nerves

12 Gunshot and Other Missile Wounds


to the Peripheral Nerves
Miroslav Samardzic and Lukas Rasulic

Abstract often attributable to shock waves and cavitation that


Gunshot or other missile injuries to the peripheral nerves, cause them to be compressed and stretched.9,10 These
and especially the brachial plexus, present a specific pro- extensive injuries also involve soft tissues, blood vessels,
blem with respect to their clinical and morphological and bones. Nerve structures, all or only in part, may be
characteristics, indications and timing of surgery, and damaged outside the projectile path, at the longer nerve
prognosis. Furthermore, missile injuries to the brachial segment or at multiple levels.1,9 Furthermore, different
plexus are difficult to explore and treat because of its degrees of injury usually coexist, and spontaneous recov-
complex anatomy, including the proximity of great ves- ery may or may not occur. In recent wars, the effects of
sels and their possible injury, which increases the risks of blast explosions from improvised explosive devices are
surgery. In the majority of cases, these injuries produce often devastating to the whole extremity, including the
lesions-in-continuity with incomplete functional loss and nerves.11
the potential for spontaneous recovery. Therefore, sur- The first large series of brachial plexus injuries were
gery should usually be postponed for 2 to 4 months after reported by Brooks in 19547 and Nulsen and Slade in
injury. After this time, surgery is indicated if there has 1956.8 Thereafter, no large series were published for
been no or only partial functional recovery, or if recovery about 30 years, until the reports made by Kline and Judice
plateaus over this period. In cases of missile injury to the in 19835 and Kline in 1989,4 who analyzed injuries in
lower brachial plexus elements and peroneal division of civilian practices. Generally, gunshot wounds to the bra-
the sciatic nerve, and particularly in patients with an chial plexus are infrequent in civilian practice, such that
extended nerve defect, the rationale for surgery is there have been only few large series published over the
unclear. past two decades.2,3,12 However, in recent military
This chapter summarizes experiences from extensive conflicts, these injuries constituted 2.6 to 14% of all
wartime and civilian practice series. peripheral nerve injuries.13,14
The largest surgical series on peripheral nerve
Keywords: brachial plexus, gunshot injury, missile inju- missile injuries have been based on war practice. In 1924,
ries, peripheral nerve Delageniere15 published his experiences from World War
I among 375 surgically treated penetrating injuries
(mostly gunshot injuries to the peripheral nerves). Pol-
lock and Davis16 reviewed their cumulative experiences
12.1 Introduction with 397 cases from the same war.16 After World War II,
Missile injuries to the brachial plexus and peripheral Seddon reported on the British experience with 699 mis-
nerves may be produced by both low- and high-velocity sile nerve injuries, 8.6% of which were treated with nerve
missiles. Low-velocity missile (less than 700 m/s) injuries grafts,17 while Woodhal and Beebe reported on American
are caused by hand guns, revolvers, and shell fragments experiences with 3,656 nerve injuries, but only 30 graft-
(for which the velocity is generally around 300 m/s), ing procedures.18 Thereafter, there were no large series
although some authors exclude the last of these three. In on this subject until the Vietnam War. At that time,
such cases, nerve elements are damaged by small shock Omer published a series of 917 injuries involving the
waves, by temporary cavitation, and sometimes by direct upper extremity peripheral nerves, 753 (66.6%) of which
impact. Thus, the lesions are largely neurapraxia, and were gunshot wounds, including 269 surgically treated
spontaneous recovery can take place, even in patients nerves.19 Similar experiences, with 135 nerve injuries
with severe neurologic deficits at presentation, unless the operated on during the Vietnam War, were reported by
nerve is transected by direct impact.1,2,3,4,5,6 These lesions Brown.20 Somewhat later, Samardzic et al reported a ser-
are characteristic of older military series7,8 and civilian ies of 90 missile injuries involving upper arm peripheral
practice.4 On the other hand, high-velocity missile (with nerves operated upon during the war which took place
velocities over 700 m/s, averaging 1,000 m/s) injuries, within the former country of Yugoslavia.21 Kline and Hud-
produced by modern rifles or machine guns, cause more son also published their series of 64 surgically treated
extensive damage. The destructive effects of these projec- gunshot injuries from civilian practice.22
tiles depend on the amount of energy that is released, Few reports have detailed the incidence and results of the
which in turn is determined by the mass, velocity, and surgical management of sciatic nerve injuries.22,23,24,25,26
angle of incidence of the bullet. Nerve elements are rarely Published opinions based on World War II experiences gen-
injured by direct impact; rather, these injuries are most erally were very pessimistic and led to the conclusion that

98
Gunshot and Other Missile Wounds to the Peripheral Nerves

nerve reconstruction should not be recommended, given severe disability, even though lesions-in-continuity are
that foot drop could be managed via tendon transfers, common.1,11,27 Most of these lesions are associated with
arthrodesis, or orthotic support.5 Similarly, Seddon reported complete functional loss.3,6 Kim et al documented com-
his experiences and concluded that there was no need to plete loss of function in 69% of the nerve elements, which
repair severe nerve lesions with lost substance.25 However, was clearly contradictory to older reports.3 Moreover,
a number of recent papers23,26 have challenged this tradi- Samardzic et al registered complete functional loss in the
tional approach, particularly one paper that described a distribution of all brachial elements in 62.9% of patients,
series of 324 patients with sciatic nerve lesions, including with spontaneous recovery noted only in 16.6%.9 A signifi-
surgically managed gunshot wounds that affected 43 tibial cant number of patients with upper trunk and posterior
and 42 peroneal divisions.22 cord injuries who present with only partial neurologic def-
As stated previously, the largest series of missile icits will recover spontaneously, but not those with injury
injuries to the peripheral nerves were drawn from war to the lower elements.10 Patients exhibiting signs of spon-
practice.15,16,17,18,19,20 However, these series are difficult to taneous recovery over the first 4 weeks are likely to have a
evaluate and compare, because they include heterogene- good or excellent outcome.27 It should be emphasized that
ous patient populations, especially regarding the charac- lesions-in-continuity, with functionally and electromyo-
teristics of the nerve lesions, timing of surgery, and graphically complete loss persisting for 3 months after
surgical techniques used. It should be remembered that injury, displayed nerve impulse transmission in 23% of the
magnification, delicate instruments, and less reactive elements, which meant that neurolysis was indicated as
suture materials only became available for use during the the surgical method of choice.28 Lesions affecting multiple
Vietnam War.19 Techniques such as interfascicular nerve levels of the brachial plexus are common, and will never
and modified cable grafting also were not used at that recover spontaneously.1
time.
Gunshot wounds to the brachial plexus are technically
difficult to explore and treat, since the anatomy is com- 12.2.2 Peripheral Nerves
plex, including great vessels that are close to the nerve
Spontaneous recovery may also occur in a significant
elements, such that intraoperative vascular injury is a
number of peripheral nerve missile injuries, though this
genuine risk during surgery. However, recently, there
recovery can be delayed for up to 11 months.29 Interest-
have been considerable advances in this respect, owing to
ingly, the noted rates of spontaneous recovery were
improved preoperative evaluations, intraoperative moni-
similar in the retrospective studies for World War I,
toring, and nerve repair techniques.
World War II, and Vietnam War missile injuries, ranging
from 67 to 69% of cases.

12.2 Clinical Characteristics


12.2.1 Brachial Plexus 12.3 Characteristics of Nerve
Older reports used to emphasize partial neurologic defi-
Lesions
cits in large numbers of patients, with the potential for
spontaneous recovery, especially in the upper trunk and
12.3.1 Brachial Plexus
posterior cord, but not with injuries affecting the lower In previously published series,4,5,7,8 a large majority of
elements.7,8 In the first published series that Brooks brachial plexus lesions preserved some nerve continuity.
reviewed, only 31.8% of 170 patients with open injuries Brooks identified division of some neural elements in
were operated upon.7 Nulsen and Slade reported a larger 29.6% of his patients who underwent surgical repair.7
number of operated-upon patients, 76% of their selected Meanwhile, Kline noted that 46.6% of the nerve elements
case group.8 Kline reported similar clinical characteristics had complete functional loss without any continuity.4
in his series.4 Complete or nearly complete functional loss Lesions-in-continuity were detected in 221 elements,
in the distribution of all nerve elements at the injured among which 75% exhibited complete functional loss.
level was present in only 19 patients (21%). Kline oper- Among nerve elements with incomplete loss, only seven
ated on 63.8% of his patients and stated that complete required nerve repair. Conversely, studies on intraopera-
injury to one element could recover spontaneously, but tive nerve action potentials confirmed signs of early
often did not. Meanwhile, incomplete functional loss in regeneration in 48 of these elements (28.9%), and only
the distribution of one element usually recovered sponta- neurolysis or a split repair had to be performed.
neously; but this did not guarantee that other elements Samardzic et al reported that 23.9% of the nerve elements
would experience the same recovery. lacked any continuity and, consequently, were associated
In recent years, it has been appreciated that many with complete functional loss.9 Among the remaining
missile injuries to the brachial plexus do not recover nerve elements, 15.3% were preserved but compressed
spontaneously; many, in fact, cause persistent pain and by an external scar, and 60.8% had lesions-in-continuity

99
Gunshot and Other Missile Wounds to the Peripheral Nerves

(fibrosis, a neuroma-in-continuity, or partial loss of con- Samardzic et al24 registered partial functional loss in only
tinuity). Recent series have confirmed the predominance 13.3% of their patients, while additional functional
of nerve lesions-in-continuity.3,6,14,27,28 improvement was observed in another 7.3%. However,
Gunshot wounds to this region may also injure the this partially preserved function involved either motor or
neighboring vessels (e.g., axillary and subclavian arteries sensory function, or only some of the muscles, and rarely
and veins), bones (e.g., clavicle, scapula, humerus, ribs), exceeded M2 or S2 in terms of the ultimate functional
and viscera (e.g., lung, pharynx, esophagus).6 Generally, grade attained.21
there is a high incidence of associated injuries. The most
frequent injuries are vascular, which are apparent in over
30% of patients. These vascular injuries are of two types.27
12.4 Indications for and Timing
The first results in major vascular interruption, while the of Surgery
second is manifested as a pseudoaneurysm, which is
often difficult to diagnose and treat.12 Bone fractures If there is a clean aseptic wound, a stable bone fracture,
increase the risk of nerve damage since the shattered and skin closure over neurovascular structures, there are
bone fragments become secondary projectiles and travel few reasons why surgery cannot be delayed.6 Other reasons
in almost all directions, causing extraneous damage to to delay surgery that pertain to the affected nerve elements
surrounding tissues.1,6 themselves include difficulty evaluating the extent of nerve
damage and the potential for spontaneous recovery.9,10
Generally, an operation is indicated if, at the time of
12.3.2 Peripheral Nerves follow-up clinical examination: there has been no recovery;
The radial nerve was the most commonly injured periph- there is nonanatomic recovery in distal but not proximal
eral nerve in World Wars I and II.16,17,18 Injuries were oth- muscles; or there is a complete functional loss in the distri-
erwise equally distributed among the rest of the upper bution of one or more nerve elements that has persisted
extremity nerves.19,20,21 It should be noted that, in 26% of for at least 3 months, a period that should permit sponta-
all patients, and in 32% of those with injuries to upper neous recovery from the first three grades of injury.3,8,24,27
extremity nerves, there were multiple injuries that Association with vascular injuries may warrant emergent
involved two or even three nerves.21 Proximal injuries surgery. Otherwise, the question arises as to whether bra-
predominate in all of the published series. Preserved chial plexus repair should be attempted or not. In most
nerve continuity was noted in roughly one-third of surgi- instances, it is much better to perform secondary repair of
cally treated cases from the Vietnam War19,29 and in the nerve injuries.1,30 Early exploration and nerve repair within
majority of cases drawn from civilian practice.22 In the the first 3 months are indicated in cases with progressive
series reported by Samardzic et al,21 nerve continuity was neurologic deficits because of an aneurysm or arteriove-
preserved at least partially in almost one-third of nous fistula, or in cases with noncausalgic pain that proves
patients, as well. For the large majority of nerve transec- resistant to conservative treatment, especially if bullet or
tions, surgeons performed nerve grafting, with 40% of the bone fragments are present.31 If lost nerve continuity is
nerve grafts over 6 cm in length. Direct nerve suturing documented upon early exploration, early secondary repair
was possible in only two instances. is indicated.9 It should be mentioned that, in these cases
Factors contributing to the partial extent of sciatic and in those with a proximal nerve stump that is either
nerve injuries include the large size of the nerve and the fibrotic or unavailable for grafting, there is the potential for
existence of two separate divisions. In the series reported performing nerve transfers.1,28
by Samardzic et al,24 nerve continuity was preserved at Surgery can be delayed for up to 6 months with no
least partially in 76.4% of sciatic nerve injuries and in unfavorable effect on outcomes. Within this period of
25.4% of patients with a neuroma-in-continuity or time, earlier repair is indicated if: there is no evidence of
fibrotic changes, with preserved fascicular patterns for anatomic recovery or such recovery plateaus over the first
both divisions. Finally, in 51% of partially transected few months; there is dissociated recovery, with a discrep-
nerves, one of the divisions was completely preserved in ancy between motor and sensory functional improve-
roughly one-third of cases.24 There was no significant dif- ment; or there is uneven functional recovery with regular
ference in the extent of injury between gunshot and shell chronology but the absence of improvement in certain
fragment wounds.24 Regarding the total number of muscles.9,10,24 Operative results have been proven to
injured divisions, 40.1% of divisions were completely decline if surgery is delayed for more than 1 year.4,5,9,10,21,24
transected, 24.5% were partially transected, and 35.4% Adult patients with lesions affecting the C8 and T1 spinal
had preserved continuity.24 In the series published by nerves, lower trunk, and medial cord and its outflows—
Kline and Hudson, preserved continuity was identified in especially the ulnar nerve—as well as the sciatic nerve are
approximately half of the divisions, but they provided no suited for conservative treatment unless associated pain is
data on the extent of transections. This variety in ana- intolerable and resistant to medication.10,21,24
tomical lesions may cause complete or, in many instances, Repairing sciatic nerve lesions that are accompanied by
partial functional loss that may improve spontaneously.22 the loss of substance was not recommended previously,

100
Gunshot and Other Missile Wounds to the Peripheral Nerves

because of the poor prognosis, risk of increased pain after depending on the different nerve segments. Repair of the
operation, and potential for spontaneous recovery. One C7 spinal nerve and middle trunk was associated with a
additional reason was that, following complete transec- 45% recovery rate after grafting. As far as the lower spinal
tion of the sciatic nerve, the patient still has control of nerves, lower trunk, and medial cord are concerned, only
the knee joint, owing to the preserved hamstring branch, medial cord to median nerve repairs generated useful
and is thereby able to walk using an orthotic to support recovery, which amounted to 66.6% with direct suturing
the foot and ankle.23,25,31 The main complication of such and 53% with a nerve graft. Citing these results, Kline and
injuries is the loss of sensation over the sole, which can Hudson22 concluded that nerve repair of brachial plexus
lead to trophic ulcer formation. Consequently, restoring injuries caused by gunshot wounds not only was possible,
sensory function is the priority of surgical repair. A sec- but also produced acceptable results. They further con-
ond major complication is foot drop, with an equinovarus cluded that end-to-end repairs were usually, though not
deformity. Since adequate functional improvement of the always, possible. More recent reports have confirmed
muscles innervated by the peroneal nerve is rare, the sec- their beliefs. For example, rates of recovery obtained by
ond functional priority for restoration is plantar flexion. neurolysis have ranged from 90 to 94%,9,14,32 with failures
Recovery of the plantar flexors is essential to using an mostly attributed to lesions involving the lower trunk or
orthotic device and even to the restoration of active the ulnar or radial nerve.31 Results were especially good
movements in the ankle joint by anterior transfer of the if the nerve element was compressed by scar or there
tibialis posterior tendon. These two functions may be was a neuroma-in-continuity.10 Approximately 70% of the
restored by repairing the tibial division. Therefore, the lesions repaired by direct suture experienced successful
best results can be obtained by its successful nerve repair functional recovery.2 Secer et al,10 meanwhile, obtained
or grafting.21 In such cases, even partial improvement functional recovery only 36.6% of the time with direct
may prevent pressure sores and, with a limited palliative sutures and 56.5% of the time using partial direct sutures.
procedure, yield a good result.26 A final important Nerve grafting was performed for lesions with lost con-
complication of sciatic nerve injuries that is a priority of tinuity, whether total or partial, and for lesions-in-continu-
surgical repair is a retarded vasomotor response, charac- ity without transmission of nerve action potentials.4,31 The
terized by cyanosis and discomfort when the leg is in a techniques used were interfascicular nerve grafting for
vertical position. split-nerve repairs, and the same technique or modified
cable nerve grafting for complete nerve transections.9 The
reported rates of recovery ranged from 70 to 89%,1,9,14,32
12.5 Results and Prognosis although Secer et al10 reported a total rate of recovery of
only 16.6%. Some of the factors portending favorable
12.5.1 Brachial Plexus results included the use of short nerve grafts,9 using a sig-
On the basis of obtained results, Brooks7 concluded that nificant number of split-nerve repairs,4,9 and surgery per-
surgery for gunshot wounds to the brachial plexus was formed within the first 3 months of injury. However, the
“rarely profitable and justifiable,” because recovery most important determinant of outcome was performing
occurred only after upper trunk or C5 and C6 spinal nerve nerve grafts for elements thought to have a favorable prog-
suture. Neurolysis of the other elements provided some nosis, such as the C5, C6, and possibly C7 spinal nerves,
pain relief, but rarely enhanced the functional outcome. upper trunk, lateral and posterior cords, and musculocuta-
Nulsen and Slade8 made similar observations. In their neous and axillary nerve.1,9,10,14,32 This has been especially
experience, recovery occurred after suturing the upper true with infraclavicular lesions involving the lateral cord
spinal nerves and trunk, and in the proximal muscles and musculocutaneous nerve, because the target muscles
after repair of the lateral and posterior cord. Surgical are closer than in other situations.30
repair of the lower elements and grafting procedures Neurolysis and repair of the lower nerve elements—
were not successful. Meanwhile, Kline and Hudson22 including the C8 and T1 spinal nerves, lower trunk,
obtained useful functional recovery in 92% of patients medial cord, and ulnar nerve—rarely result in functional
treated with neurolysis. The rate of recovery for elements improvement.9,10,14 However, such repair can help with
thought to have a favorable prognosis was 96%; for those pain relief.10 This being said, Siqueira et al30 obtained
with an unfavorable prognosis, it was much lower, at 79%. reinnervation of the wrist and digital flexors in 50 to 60%
Direct suture overall yielded a recovery rate of 69%, while of patients without reinnervating the intrinsic muscles of
nerve grafting was successful in just 54% of patients. the hand. Sensory restoration throughout the area inner-
The results of nerve repair have been especially favor- vated by the median nerve was achieved in 70 to 80%.6,30
able for the upper spinal nerves, upper trunk, and the lat- Noncausalgic pain may be related to partial transections,
eral and posterior cords and their nerves, together having especially with lower-level lesions, or to compression by
an overall rate of recovery of 83% with direct sutures scar. This pain responds well to both external and internal
and 66% with nerve grafting, ranging from 50 to 100% neurolysis.1

101
Gunshot and Other Missile Wounds to the Peripheral Nerves

12.5.2 Peripheral Nerves for peroneal nerve injuries, if all levels of injury and all
surgical procedures were included. Failures were mostly
Citing his series from World War I, Delageniere15 con- related to nerve grafting procedures and extensive nerve
cluded that the overall results in his 113 patients treated defects. Additionally, Kline and Hudson22 noted recovery
via neurolysis were not good; on the other hand, 122 of with peroneal nerve injuries following 43.8% of their graft
142 (85.9%) sutures were completely successful, while 16 procedures. In this series, patients achieving a lower level
were partial successes and there were only 4 failures. of M3-level strength were graded as having experienced
Pollock and Davis16 reported a success rate of 72% for useful recovery.
radial, 69% for median, and 57% for ulnar nerve repairs. Differences in the results achieved with nerve grafting
The use of nerve grafts was largely unsuccessful through- for gunshot wounds versus clean transections might be
out this period. attributed to the extensive and high-located nerve
Reviewing British experiences from World War II, injuries, as well as the extra surgical delay that is pre-
Seddon17 claimed that radial nerve injuries generally had dominant in the first group. Furthermore, it should be
more satisfactory outcomes than either median or ulnar remembered that the series of gunshot wounds reported
nerve injuries. He noted that 36.9% of his 114 radial nerve by Samardzic et al9 also included the results of nerve
repairs achieved grade M4–M5 strength. Furthermore, he grafting for peroneal nerve injuries, which have exhibited
noted that only 8.6% of median nerve injuries achieved a the lowest rate of recovery in all series.
satisfactory level of sensory function, while just 4.9% of In 1972, Kline published a series of 13 patients with
ulnar nerve injuries attained satisfactory motor function. gunshot wounds to the sciatic nerve. Functional improve-
Similar findings were documented by Woodhal and ment (without detailed gradations) was obtained in all
Beebe,18 who noted good motor function in just 21.3% of neurolysis cases for both divisions, in all sutured tibial
127 radial nerve repairs. Poor results with nerve grafting divisions, and in two-thirds of sutured peroneal divi-
during World War II were largely attributed to the sions.31 Likewise, Seddon in 1975 analyzed a series of 329
severity of nerve injuries, associated with large nerve patients, including 132 for whom some form of surgical
gaps, and to the use of trunk graft techniques without repair had been performed. He obtained useful functional
magnification. However, Seddon17 reported the successful recovery (first three grades, according to his classification
use of cable grafts for median nerve injuries. He noted system) in 64% of cases, but stated that recovery in the
motor recovery to grade M3–M4 in 54% and sensory long muscles of the leg was usually disappointing, except
recovery to S3–S3 + in 63% following median nerve graft- for the triceps surae.25 Millesi in 1987 published a series
ing procedures. of 39 injuries that included 6 injuries secondary to injec-
For the largest series of nerve injuries from the Viet- tions. He obtained useful functional recovery, according
nam War, Omer19 reported a total rate of recovery of to his own grading system, in 5 (83.3%) of the 6 patients
55% with external neurolysis, including 37.5% for high- who underwent neurolysis, in all 13 with combined neu-
velocity and 76.2% for low-velocity gunshot wounds. rolysis and nerve grafting, and in 10 (71.3%) of 14 who
Additionally, he noted a total rate of recovery of 25% in underwent grafting alone.23 Finally, Kline and Hudson
cases with epineural sutures, 20% for high-velocity and published their results of surgery for gunshot wounds
31.2% for low-velocity gunshots. Approximately 75% of affecting 43 tibial and 42 peroneal divisions. They
the successful nerve sutures were performed between 3 obtained functional recovery of tibial divisions in 93.3
and 6 months after the injury, and 80% of the patients and 69.2% post neurolysis and grafting, respectively,
were 20 years old or younger. Clinically significant func- while corresponding rates for the peroneal division were
tion was not observed after any of the 19 nerve graft pro- 86.2 and 25%.22
cedures. The techniques used included multiple cable Samardzic et al published a series of 45 patients with
grafts and two pedicle grafts. Omer concluded that there missile injuries to the sciatic nerve, in whom they
was no significant difference between the outcomes with obtained functional recovery in 86.7% for tibial divisions
the repair of gunshot nerve injuries during World War II and 53.3% for peroneal divisions.24 The rates of functional
and those of his own series. The high incidence of failures recovery, by surgical procedure, were also significantly
was attributed to the overall condition of the extremity, higher for tibial versus peroneal division repairs. These
the severity and level of nerve injury, and delayed sur- rates were 93.7 versus 68.7% for neurolysis, 93.3 versus
gery. Similar results with nerve sutures were reported by 63.6% for split repairs, and 71.4 versus 33.3% for nerve
Brown,20 with corresponding rates of recovery for the grafts. Graft failures for the tibial division were related to
ulnar nerve of 35%, for the median nerve of 50%, and for injuries at the gluteal level. The total rate of recovery
the radial nerve of 40%. across the whole sciatic nerve complex was 86.7%. The
Reporting their cumulative experiences with gunshot rates of recovery following neurolysis and repair of parti-
wounds to the peripheral nerves from civilian practice, ally transected nerves were similar: 90.9 versus 96.0%.
Kline and Hudson22 noted individual rates of recovery of The quality of recovery was better for partial transections
92.8% for radial, 89.2% for median, 64% for ulnar, and 80% if split repairs were performed for both divisions, or if

102
Gunshot and Other Missile Wounds to the Peripheral Nerves

neurolysis for one division was combined with split


repair of the other. The rate of recovery following nerve
References
grafting for both divisions was 55%, which is significantly [1] Bhandari PS, Sadhotra LP, Bhargava P, et al. Management of missile
lower than for the other two surgical procedures. injuries of the brachial plexus. Indian J. Neurotrauma. 2006; 3(1):49–
54
It should be emphasized that the final outcome is also
[2] Kim DH, Cho YJ, Tiel RL, Kline DG. Outcomes of surgery in 1019
influenced greatly by the existence of associated injuries, brachial plexus lesions treated at Louisiana State University Health
such as vascular lesions, bone fractures, and soft-tissue Sciences Center. J Neurosurg. 2003; 98(5):1005–1016
defects.3,6 Vascular lesions affect nerve elements through [3] Kim DH, Murovic JA, Tiel RL, Kline DG. Penetrating injuries due to
gunshot wounds involving the brachial plexus. Neurosurg Focus.
ischemia. Bone fragments can cause additional nerve
2004; 16(5):E3
damage or subsequent callus spread around the repaired [4] Kline DG. Civilian gunshot wounds to the brachial plexus. J Neuro-
nerve.10 surg. 1989; 70(2):166–174
[5] Kline DG, Judice DJ. Operative management of selected brachial
plexus lesions. J Neurosurg. 1983; 58(5):631–649

12.6 Conclusion [6] Secer HI, Daneyemez M, Tehli O, Gonul E, Izci Y. The clinical, electro-
physiologic, and surgical characteristics of peripheral nerve injuries
caused by gunshot wounds in adults: a 40-year experience. Surg
Drawing from the experiences of others, we can
Neurol. 2008; 69(2):143–152, discussion 152
determine several conclusions: [7] Brooks DM. Open wounds of the brachial plexus. In: Seddon HJ, ed.
● In a significant number of patients, gunshot wounds to Peripheral Nerve Injuries, Medical Research Council Special Report
the brachial plexus and peripheral nerves produce Series. London: Her Majesty’s Stationery Office; 1954
lesions-in-continuity, with either incomplete functional [8] Nulsen FE, Slade WW. Recovery following injury to the brachial
plexus. In: Woodhal B, Beebe GW, eds. Peripheral Nerve Regenera-
loss, with which spontaneous recovery is possible, or
tion: A Follow-Up Study of 3656 World War II Injuries. Washington,
complete loss, with which spontaneous recovery DC: Government Printing Office; 1956:389–408
typically does not occur. [9] Samardzic MM, Rasulic LG, Grujicic DM. Gunshot injuries to the
● Associated vascular injury is an indication for emergent brachial plexus. J Trauma. 1997; 43(4):645–649
[10] Secer HI, Solmaz I, Anik I, et al. Surgical outcomes of the brachial
surgical exploration.
plexus lesions caused by gunshot wounds in adults. J Brachial Plex
● The potential for spontaneous recovery and difficulties
Peripher Nerve Inj. 2009; 4:11
with the initial evaluation of nerve lesions are the main [11] Birch RM, Stewart MPM, Eadley WEP. War and gunshot wound
reasons for delaying surgery and nerve repair until 2 to injuries of the peripheral nerves. In: Tubbs S, Rizk E, Shoja M, Loukas
4 months postinjury. M, Barbaro N, Spinner R, eds. Nerve and Nerve Injuries. Vol. 2.
Amsterdam: Elsevier; 2015:629–653
● After this period, surgery is indicated (1) if there is
[12] Kim DH, Murovic JA, Tiel RL, Kline DG. Gunshot wounds involving the
complete functional loss; (2) if there is incomplete loss brachial plexus: surgical techniques and outcomes. J Reconstr Micro-
that does not improve spontaneously; (3) if recovery surg. 2006; 22(2):67–72
plateaus or only partial recovery is evident 6 months [13] Gousheh J. The treatment of war injuries of the brachial plexus. J
after the injury; or (4) if a pseudoaneurysm or fistula is Hand Surg Am. 1995; 20(3, Pt 2):S68–S76
[14] Stewart MP, Birch R. Penetrating missile injuries of the brachial
compressing nerve elements.
plexus. J Bone Joint Surg Br. 2001; 83(4):517–524
● Delaying surgery past 1 year is not justifiable.
[15] Delageniere H. A contribution to the study of the surgical repair of
● Neurolysis yields useful functional recovery for over peripheral nerves. Surg Gynecol Obstet. 1924; 39:543–553
90% of lesions with preserved nerve continuity. [16] Pollock LJ, Davis L. Peripheral nerve injuries. Am J Surg. 1932; 15:
● Similar results may be obtained by split repairs and 179–217
[17] Seddon H. Nerve grafting and other unusual forms of nerve repair.
nerve grafting on elements thought to be prognostically In: Seddon H, ed. Peripheral Nerve Injuries, Medical Research Council
favorable—such as the C5 and C6 spinal nerves, the Special Report, No 282. London: Her Majesty’s Stationery Office;
upper trunk, the lateral and posterior cord and their 1954:389–417
outflows (except the ulnar nerve), and the tibial nerve. [18] Woodhal B, Beebe GW. Peripheral Nerve Regeneration: A Follow-up
Study of 3656 World War II Injuries. Veterans Administration, Medi-
● Nerve grafting has a lower rate of recovery for
cal Monograph. Washington, DC: US Government Printing Office;
gunshot wounds than for clean transections, due to 1956
the predominance of more extensive and higher-level [19] Omer GE, Jr. Injuries to nerves of the upper extremity. J Bone Joint
injuries. Surg Am. 1974; 56(8):1615–1624
● For injuries affecting lower brachial plexus elements, [20] Brown PW. The time factor in surgery of upper-extremity peripheral
nerve injury. Clin Orthop Relat Res. 1970; 68(68):14–21
conservative treatment is usually warranted, except in
[21] Samardzic MM, Rasulic LG, Antunovic V, Grujicic DM. Missile injuries
patients with resistant noncausalgic pain. to the peripheral nerves. Eur J Emerg Surg Intensive Care. 1998; 21:
● The peroneal division of the sciatic nerve should not 173–178
be repaired if there is a long nerve defect, especially [22] Kline DG, Hudson A. Nerve Injuries. Philadelphia, PA: Saunders; 1995
[23] Millesi H. Lower extremity nerve lesions. In: Terzis JK, ed. Microre-
at the buttock level. The available donor nerves
construction of Nerve Injuries. Philadelphia, PA: Saunders; 1987:
should be saved for reconstruction of the tibial division, 239–251
which is the priority when the whole sciatic nerve is [24] Samardzic MM, Rasulić LG, Vucković CD. Missile injuries of the sciatic
injured. nerve. Injury. 1999; 30(1):15–20

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Manual of Peripheral Nerve Surgery | 25.07.17 - 10:01

Gunshot and Other Missile Wounds to the Peripheral Nerves

[25] Seddon H. Surgical Disorders of the Peripheral Nerves. 2nd ed. Edin- [29] Omer G. Nerve injuries associated with gunshot wounds of the
burgh: Churchill Livingstone; 1975 extremities. In: Gelberman RH, ed. Operative Nerve Repair and
[26] Sedel L. Surgical management of the lower extremity nerve lesions Reconstruction. Vol. 1. Philadelphia, PA: Lippincott; 1991:655–670
(clinical evaluation, surgical technique, results). In: Terzis JK, ed. [30] Siqueira MG, Martins RS. Surgical treatment of adult traumatic
Microreconstruction of Nerve Injuries. Philadelphia, PA: Saunders; brachial plexus injuries: an overview. Arq Neuropsiquiatr. 2011; 69
1987:253–265 (3):528–535
[27] Vrettos BC, Rochkind S, Boome RS. Low velocity gun shot wounds of [31] Kline DG. Operative management of major nerve lesions of the lower
the brachial plexus. J Hand Surg [Br]. 1995; 20(2):212–214 extremity. Surg Clin North Am. 1972; 52(5):1247–1265
[28] Kline DG, Tiel RL. Direct plexus repair by grafts supplemented by [32] Samadian M, Rezaee O, Haddadian K, et al. Gunshot injuries to the
nerve transfers. Hand Clin. 2005; 21(1):55–69, vi brachial plexus during wartime. Br J Neurosurg. 2009; 23(2):165–169

104
Compressive Lesions of the Upper Limb

13 Compressive Lesions of the Upper Limb


Gregor Antoniadis and Christine Brand

Abstract and palmar hand. The numbness may be intermittent or


Compressive lesions of the upper limb are widespread absent in an early stage, and, with time, symptoms
diseases. The most common entrapment neuropathy is increase. Usually, numbness occurs more frequently dur-
the carpal tunnel syndrome, followed by ulnar nerve ing sleep (nocturnal paresthesia)3,4 and disappeared by
entrapment at the elbow. Rare entrapment neuropathies hand activity. Shaking the hand or rubbing it alleviates
are the pronator teres syndrome and suprascapular nerve the symptoms. In later stages, burning pain occurs in the
entrapment at the upper limb. Direct pressure on periph- palmar hand, wrist, and forearm and is a major complain.
eral nerves leads to local ischemia, caused by reduced If CTS is burned out, the patient develops thenar atrophy,
blood flow in the vasa vasorum of the nerve. As a result weakness of thumb opposition, and persistent numbness
of chronic pressure, demyelination of the nerve and then with loss of texture discrimination and fine motor skills.5
scarring occur. Loss of function in late stages is the result In neurologic examination, Tinel’s sign (tingling is repro-
of chronic peripheral nerve compression. In most cases, duced by tapping the anterior aspect of the wrist with
peripheral nerves are entrapped in anatomical bottle- your fingers) may be positive above the carpal canal.
necks. Repetitive motions or a trauma may cause neuro- Phalen’s test (wrist flexion test) may be also present. Both
pathies. Diagnosis is easily established with the help of tests are less sensitive than the electrodiagnosis.3,6 In
medical history and clinical examination in most cases. most cases, physical examination is specific. To confirm
Electrophysiological testing can confirm the diagnosis. the diagnosis, electrophysiological evaluation is essen-
Further diagnostic measures are ultrasound and magnetic tial.7 In early stages, sensory nerve conduction studies are
resonance imaging (MRI), especially in cases of tumor, more sensitive than motor conduction studies.8 Electro-
ganglion cysts, and trauma. If conservative therapy fails, myograms (EMGs) are usually not needed.9 Ultrasound
surgery is an effective procedure. Decompression of the imaging is of value in the diagnosis of recurrent CTS10 or
nerve is mostly the treatment of choice. Internal neuroly- to exclude a tumor. Magnetic resonance imaging (MRI) is
sis is contraindicated by the first procedure. Prognosis is more expensive and not generally available. It is indicated
in general good. Poor outcome is mostly the result of in special situations.
incorrect diagnosis, incomplete decompression, or func-
tional loss in late stages. Timing
Keywords: peripheral nerve entrapment syndromes, Treatment options range from nonsurgical approaches, includ-
median nerve entrapment, ulnar nerve entrapment, ing activity modification, nonsteroidal anti-inflammatory
radial nerve entrapment, suprascapular nerve entrap- medication, splinting (full-time vs. nocturnal), and corticoste-
ment roid injections, to surgical decompression of the carpal tunnel
using a variety of methods.
Conservative management is used for patients with
mild symptoms in the absence of neurological deficits.
13.1 Median Nerve In case of nocturnal paresthesia, volar wrist splints can
temporary relieve the symptoms. Steroid injection into
13.1.1 Carpal Tunnel Syndrome the carpal canal can alleviate symptoms; however, it is
generally felt to be a temporary treatment.
Clinical Presentation The following circumstances indicate surgical interven-
Carpal tunnel syndrome (CTS) is caused by chronic com- tion in a timely manner:
pression of the median nerve within the carpal tunnel.1 ● Failure of nonsurgical therapy after a period of 8 weeks

Carpal tunnel is built by carpal bones (scaphoid, to relieve pain and/or progressive motor or sensory
trapezium, hamate) and is covered by the flexor retinacu- deficits.11
lum. Tendons of the flexor pollicis longus, flexor digito- ● Neurological deficits such as permanent numbness,

rum superficialis and profundus, and the median nerve weakness, loss of texture discrimination, and fine
pass through it. CTS is the most common upper limb motor skills.
nerve entrapment neuropathy. The estimated prevalence ● Absolute indications for carpal tunnel release include

of CTS is 6%.2 CTS is much more common in women than rapidly progressive or acute course.
men (3–4:1). In gravidity, obesity, and renal dialysis, the
incidence is higher than in normal population. Symptoms One year after surgical treatment, patients’ complaints
vary from numbness in the thumb, index, middle, and/or are relieved in almost all cases (90–95%).12 The results
radial half of the ring fingers to pain in the forearm, wrist, correlate with the degree of preoperative deficits and

105
Compressive Lesions of the Upper Limb

the duration of symptoms. The recurrent rate is low verse carpal ligament is divided through a shortened skin
(0.5–2.2%).12,13 incision of about 1.5 to 2 cm. This technique allows lim-
ited inspection of the carpal tunnel and may lead to
incomplete release of the ligament and iatrogenic nerve
Surgical Strategy
lesion by unexperienced surgeons.
Surgical carpal tunnel release can be performed under
general, regional, or local anesthesia on outpatient basis. Endoscopic Carpal Tunnel Release
Generally, we perform the procedure under local anes-
thesia on outpatient basis. Exceptional cases are patients There are two systems used for endoscopic carpal tunnel
under antiplatelet therapy, tumor as a cause of CTS, and release: the Agee single portal technique15 and the Chow
recurrent CTS. Open carpal tunnel release is the current dual portal system.16 In comparison to the open techni-
gold standard treatment. Endoscopic technique has been que, results do not differ relating to side effects, complica-
developed and in use for over 20 years. Release of the tions, and recovery time.17 Contraindications are prior
transverse carpal ligament is the aim of both techniques. surgery on the palmar hand, tumor, arthritis, or wrist
articulation rigidity.

Open Carpal Tunnel Release


Single-Portal Technique Described by Agee15
After subcutaneous infiltration with a local anesthetic, a
The requirements of this technique are the same as for
blood pressure cuff is applied to achieve ischemia. Inci-
the open technique (decompression performed under
sion is made in the proximal palm between the thenar
local anesthesia, ambulatory care). A tourniquet control is
and hypothenar creases with a total length of 3 to 4 cm
obligatory. Skin incision is made at the ulnar side of the
(▶ Fig. 13.1). Fatty tissue is removed to exhibit the palmar
tendon of the palmaris longus with a total length of 1 cm
fascia. At this stage of the surgery, you have to take care
(▶ Fig. 13.2). The palmar fascia is divided and the trans-
of the terminal branches of the palmar cutaneous nerves.
verse carpal ligament is visualized through an endoscope,
The palmar fascia is divided sharply and the transverse
which looks like a pistol (▶ Fig. 13.3). A specially designed
carpal ligament is shown distally to the rascetta. After-
blade through the open roof of the trocar is used to trans-
ward, the entire ligament is divided under direct vision.
ect the ligament from the distal to the proximal end
Additional motor branch decompression is usually not
(▶ Fig. 13.4). Visibility may be reduced by fatty tissue.
needed. Further manipulation, particularly, internal
neurolysis, may result in scar formation and has risk of
fascicle damage. No difference in results was reported
Two-Portal Technique Described by Chow16,18,19
either after internal neurolysis or after epineurotomy.14 Release of the transverse carpal ligament is performed
Reapproximation of the sectioned carpal ligament is not under tourniquet control and local anesthesia. Two skin
recommended. The skin is closed in a simple fashion. incisions are needed. The first incision is made like the
At the end of the surgery, the wrist should be bandaged. single-portal technique and the second in the palmar
Splinting is not necessary. hand (▶ Fig. 13.2). The endoscope is inserted from
A variation of this open technique is called “limited both sides after positioning a slotted cannula from the
open technique” or “mini-incision.” In this case, the trans- opposite skin incision (▶ Fig. 13.5). Retrograde blade cuts

Fig. 13.1 Skin incision for open surgery. Standard technique Fig. 13.2 Skin incision for endoscopic procedures. Single portal
(black line), mini-incision (red line). technique (black line), two portal technique (red lines).

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Compressive Lesions of the Upper Limb

Fig. 13.3 Inserted endoscope for splitting the retinaculum


flexorum (Agee’s technique).

Fig. 13.4 Endoscopic view of the retinaculum flexorum


(partially divided).

13.1.2 Median Nerve Entrapment


at the Elbow
Anterior Interosseous Nerve Syndrome
(Kiloh–Nevin Syndrome)
Clinical Presentation
Fig. 13.5 Two-portal technique according to Chow. The anterior interosseous nerve is a motor branch of the
median nerve and arises 4 to 8 cm distally to the elbow.
It penetrates the anterior interosseous membrane as the
last major branch of the median nerve and innervates the
the whole length of the ligament until fatty tissue pronator quadratus and flexor digitorum profundus to
protrudes. the index and long digits.
Typically, patients have a history of acute pain in the
elbow and forearm for a few hours, which terminates
Complications spontaneously. Corresponding to the nerves distribution,
Complications from surgical treatment of CTS must be a nerve lesion leads to inability to flex the distal pha-
attributed mainly to poor technique. Complication rate langes of the thumb and index finger and/or paralysis of
for the endoscopic technique is around 5.6%, meanwhile the distal interphalangeal joints of the long finger. There-
it is 2.8% for open release.20 The most common cause of fore, the patient is unable to form an “O” with their tips
failure of carpal tunnel release is incomplete sectioning of of the thumb and index finger (pinch sign) (▶ Fig. 13.6).
the transverse carpal ligament. Damage of motor and In addition, weakness of the pronator quadratus occurs.
sensory branches is rare; however, it can cause severe Sensory complaints are missing.
disability of hand function. The phenomenon of so-called Besides a tendon rupture, further differential diagnosis
pillar pain is controversial. Patients complain of pain in is a Parsonage–Turner syndrome (plexus neuritis). Cases
the palmar hand after surgical treatment. Symptoms usu- of nerve rotation located within the median nerve trunk
ally relieve after 4 to 6 months spontaneously. Complex or anterior interosseous nerve were described.
regional pain syndrome (CRPS I) after surgical treatment Electrophysiological testing is of value. Electromyogra-
is rare. Symptoms are edema, pain, circulatory disturb- phy shows denervation in the muscles supplied by the
ance, skin changes, and finally functional limitation of anterior interosseous nerve. Sensory nerve conduction
hand movement. Rosenbaum and Ochoa described CRPS I studies are normal, because this nerve has no primary
in 10 cases out of 7,000 surgeries.21 sensory component. In all these cases, MR neurography

107
Compressive Lesions of the Upper Limb

Fig. 13.7 Skin incision for the interosseous anterior syndrome.


Fig. 13.6 Interosseous anterior syndrome with paresis of the
flexor pollicis longus and flexor digitorum profundus muscles on
the right hand.

of the upper arm and brachial plexus region is recom- proximal forearm can be observed. Spinner described
mended. provocative tests to establish the level of compression: in
flexion and supination of the forearm against resistance,
Timing the pain can be triggered if the compression level occurs
at the level of lacertus fibrosus or the Struthers arcade. If
Decompression of the nerve should be done if conservative pain aggravates while extending the pronated forearm
treatment has not been successful after 12 weeks22,23,24 against resistance, the entrapment could occur beneath
and other causes for this pathology are excluded. Seror the pronator teres; and resisted middle finger sublimis
concluded that surgery should not be considered for a year, flexion suggests compression at the sublimis arch if
as late spontaneous recovery can occur.25 There have also these resisted movements trigger pain in the proximal
been reports that suggest no difference in outcome forearm.28 Electrophysiological testing may show dener-
between surgical and conservative treatment.26,27 vation of the median nerves’ supplied muscles. High-
resolution ultrasound can be of value.
Surgical Strategy There are doubts of the real existence of the inteross-
eous anterior and the pronator teres syndrome.
Surgery can be performed under general anesthesia and
tourniquet control. The skin incision is S-shaped along
the radial border of the pronator muscle (▶ Fig. 13.7).
Timing
Branches of the lateral and medial antebrachial cutaneous Treatment depends on the severity of the symptoms.
nerves must be protected. The lacertus fibrosus should be Avoiding triggering movements and the use of anti-
divided along the median border of the biceps tendon. inflammatory medication and splints at the elbow or
Struthers’ ligament, if present, should be cut through. wrist may be helpful. Surgical treatment is an option if
The nerve and its branches should be exposed in its symptoms persist longer than 6 to 8 weeks.
course more distally until the flexor superficial arch. Con-
strictive tissue like fibrous bands should be removed Surgical Strategy
when encountered.
The surgical approach is a gentle S-shaped incision in
both entrapment syndromes (▶ Fig. 13.7). The antebra-
Pronator Teres Syndrome chial cutaneous nerve should be treated with care. The
median nerve is easily found medial to the tendon of the
Clinical Presentation biceps. The lacertus fibrosus is excised. A possible supra-
Symptoms can be similar to the CTS. Nocturnal paresthe- condylar process of the humerus and/or a Struthers liga-
sia is usually missing. Patients describe pain in the area of ment should be resected. A high origin of the superficial
the elbow and proximal forearm aggravated by using the head of the pronator teres could be responsible for com-
arm (especially in activities where the forearm is sub- pressing the nerve: in this case, it must be divided.
jected to permanent pronation and supination). Sensory Branches that arise from the medial aspect of the nerve
complaints are inconsistent. Weakness may occur espe- and go into the muscle must be preserved. The next pos-
cially if the anterior interosseous nerve is involved. sible compression point is the deep head of the pronator
Tenderness on palpation over the median nerve in the teres on the lateral side of the median nerve, which build

108
Compressive Lesions of the Upper Limb

together with the superficial head a fibrous arch. After and first dorsal interosseous muscles, the patient is not
resecting this arch, dissection continues along the course able to hold the paper, compensating by flexing the flexor
of the median nerve. A more distal compression can also pollicis longus of the thumb to maintain grip pressure.
occur at an accessory long head of the flexor pollicis lon- The elbow flexion test36 is another clinical test for ulnar
gus muscle (Gantzer’s muscle), which must be resected. nerve dysfunction. Hypesthesia and tingling occur as a
After releasing all potentially structures, the nerve itself result of direct compression over the ulnar nerve at the
is observed. Pseudoneuromas, increased vascularization, elbow. In many cases, Tinel’s sign is positive as well.
and fibrotic areas may be detected at the compressions Electrophysiological testing is useful for diagnosis.
side. Motor nerve conduction velocity is decreased in the
elbow region (< 50 m/s). In comparison to the forearm re-
gion, motor nerve conduction velocity is reduced to about
13.2 Ulnar Nerve 10 m/s. Furthermore, there may be a significant ampli-
tude reduction of the motor response potential after
13.2.1 Ulnar Nerve Entrapment stimulation proximally—but not distally—at the cubital
tunnel of about 20%.
at the Elbow If there is a history of trauma, X-ray of the elbow is
Clinical Presentation helpful. Ultrasound of the ulnar nerve may show pseudo-
neuromas, tumors and ganglion cysts, scar tissue com-
The so-called cubital tunnel is a fibro-osseous tunnel pressing the nerve, and potential transposition of the
whose extension is about 10 cm. It begins approximately nerve in motion. In comparison to ultrasound, MRI is
6 cm proximal to the elbow where the ulnar nerve trans- more specific, but also more expensive.
verses the intermuscular septum from anterior to poste- C8 radiculopathy, Guyon’s syndrome, thoracic outlet
rior. Struthers described a ligament between the medial syndrome, and plexus brachialis lesions are potential dif-
triceps head and the medial intermuscular septum ferential diagnoses.
(“Struthers’ arcade”)29,30 as a potential compressive point.
Dellon could not verify the existence of this arcade in his
explorations.31 As it approaches the elbow, the ulnar Timing
nerve is located between the medial epicondyle of
The treatment decision is based on the degree and
the humerus and the olecranon, being bridged by an apo-
severity of symptoms, as in other entrapment syndromes.
neurosis called Osborne’s ligament (or ligamentum
For patients with mild and/or intermittent symptoms,
arcuatum).32 In 11% of all cases, a residual anconeus epi-
treatment is nonsurgical, including avoidance of repeti-
trochlearis muscle is identified instead of the Osborne lig-
tive movements (flexion and extension). Splinting has no
ament.33 The ulnar nerve transverses the two heads of
advantage.37 If development of atrophy or weakness is
the flexor carpi ulnaris underneath the deep fascia (sub-
detected, primary surgical treatment is indicated without
muscular membranes) 5 cm distally. This fascia contains
delay.
fibrovascular bands, which may also compress the ulnar
nerve at this point at the end of the tunnel. A further rea-
son for ulnar nerve entrapment is chronic subluxation or Surgical Strategies
luxation of the ulnar nerve. Cubitus valgus deformity There are various surgical techniques:
after a humeral fracture may be a cause years prior to the ● Simple in situ decompression (open and endoscopic).
onset of symptoms (tardy ulnar nerve palsy). Rare rea- ● Subcutaneous transposition.
sons are tumors or a ganglion cyst (see ▶ Fig. 13.9). ● Submuscular transposition.
Ulnar nerve entrapment at the elbow is the second ● Medial epicondylectomy.
most common entrapment syndrome.34 ● Intramuscular transposition.
Intermittent hypesthesia in the ulnar nerve distribu-
tion is the most common initial symptom. Furthermore, The last technique is not in use anymore, at least in our
patients report of pain in the region of the elbow and department.
forearm as well as shooting pain in the hand and digits.
Loss of fine motor skills, such as writing and turning
around a key, intrinsic muscle atrophy, and weakness
Simple In Situ Decompression
occur on later stages. Decompression is performed under local anesthesia on an
Positive Froment’s sign35 is a characteristic sign of ulnar in- or outpatient basis. Tourniquet control can be used.
nerve deficit. The patient is asked to take a piece of paper The incision is made slightly anterior to the medial
between the thumb and the index finger. The examiner condyle with a total length of 3 to 4 cm (▶ Fig. 13.8).
tries to move away the piece of paper. Because of the The posterior branches of the medial cutaneous nerve of
weakness of the adductor pollicis, flexor pollicis brevis, the forearm often have variable courses, so they have to

109
Compressive Lesions of the Upper Limb

Fig. 13.8 Skin incision for open decompression of the ulnar Fig. 13.9 Extended decompression of the ulnar nerve by
nerve at the elbow. compression neuropathy due to an extraneural ganglion cyst.

Fig. 13.11 Subcutaneous decompression of the ulnar nerve at


the elbow.

Fig. 13.10 Submuscular membranes (deep fascia) after


endoscopic decompression of the ulnar nerve at the elbow.

be protected when using this approach. The ulnar nerve Anterior Transposition
is identified proximally to the sulcus and dissected 5 cm
In comparison to the submuscular or deep transposition,
distally toward the condyle. To achieve this, the Osborne
the subcutaneous transposition of the ulnar nerve is less
ligament is divided. If the arcade of Struthers is found,
traumatic for the surrounding tissue. In both cases, the
it is also released. The ulnar nerve should be explored
ulnar nerve is removed out of its original environment to
between the two heads of the flexor carpi ulnaris muscle
protect the nerve from repetitive friction trauma and
and the submuscular membranes, and other constrictive
therefore from chronic neuropathy. If using the subcuta-
tissue around the nerve are released. Pseudoneuromas
neous technique, the skin incision is made above the
may be present proximally to the compression. Splinting
cubital tunnel. The ulnar nerve is exposed proximally
is not necessary after surgery. Endoscopic decompression
to the epicondyle and dissected circumferentially to
of the ulnar nerve was first described by Tsai in 1995.38
enable a transposition out of the ulnar groove, anterior
For this approach, the incision is up to 2 cm in length,
and superficial to the flexor pronator muscle mass
which is used as a port for the endoscope. Long-distance
(▶ Fig. 13.11). Muscular branches to the flexor carpi ulna-
decompression is possible for a length of up to 12 cm
ris should be mobilized before transposition is made.
from the retrocondylar groove and 6 to 8 cm proximally
The medial intermuscular septum and the deep fascia of
of the sulcus (▶ Fig. 13.9, ▶ Fig. 13.10).

110
Compressive Lesions of the Upper Limb

the flexor carpi ulnaris (submuscular membranes) must as screwdriver and pliers. Further reasons for ulnar neu-
be divided to avoid kinking of the ulnar nerve. After cre- ropathy are fractures of the hook of the hamate, metacar-
ating the new tissue bed, the surgeon must secure the pals, and pisiform, and ulnar artery thrombosis. Ganglion
nerve in his new anterior position by loosely suturing a cysts are also a common cause of compression of the
portion of subcutaneous tissue medial to the nerve. After ulnar nerve inside the Guyon’s tunnel.
the surgery, it is recommended to treat the elbow with
care in a 90-degree flexion position for 2 weeks.
Timing
Medial Epicondylectomy Traumatic lesions of the ulnar nerve caused by cycling,
for example, have a good prognosis to recover spontane-
In this procedure, there is no need to remove the nerve
ously. Ganglions, thrombosis of the ulnar artery, and
from its soft-tissue bed, which ensures the blood supply
other tumors should be removed. Fractured hook of the
to the nerve by sparing its feeding blood vessels. First, the
hamate bone should be excised and the ulnar nerve
ulnar nerve and its branches are exposed next to the epi-
released. Surgical therapy is indicated if symptoms do not
condyle. Second, the surrounding muscular masses are
improve or severe paresis and atrophy are present.
pushed aside and the diaphyseal–metaphyseal junction
of the medial epicondyle is exposed. Afterward, an
osteotomy is performed with a rongeur or an osteotome. Surgical Strategy
The muscle mass has to be refixed to the elbow in exten- The surgery can be performed under general or local anes-
sion. Impingement of the nerve has to be avoided, espe- thesia and tourniquet control. The incision is similar to the
cially in motion. Postoperative splinting is not necessary. one used for releasing the median nerve at the wrist, but
According to many comparative studies performed in just a bit longer at the distal end, toward the ulnar side,
the last two decades, the complication rate of simple in and angled at the wrist. The ulnar nerve is exposed radial
situ decompression is lower than anterior transposition, to the tendon of the flexor carpi ulnaris. Afterward, the
but the results of both techniques are equal,39,40 even for nerve is identified more distally. A possible existing
luxation of the ulnar nerve.41 palmaris brevis muscle is excised, as well as the volar car-
Recurrences can occur in all kinds of techniques, espe- pal ligament. The next step is to identify the level of the
cially after the intramuscular transposition.34 bifurcation of the ulnar nerve. The deep branch of the
ulnar nerve is tracked to the pisohamate ligament, which
has to be divided for reaching a complete decompression.42
13.2.2 Ulnar Nerve Entrapment
Finally, ganglions, if present, are identified and excised.
at the Wrist (Guyon’s Syndrome)
Clinical Presentation 13.3 Radial Nerve
The ulnar nerve is most frequently compressed at the
Compressions of the radial nerve are rare compared with
region of the wrist. The Guyon’s canal is built by the pisi-
the carpal and cubital tunnel syndromes. Lesions of the
form, the hook of hamate, the volar carpal, and the trans-
radial nerve in the upper arm are in most cases result of
verse carpal ligament. The ulnar nerve and the ulnar
humeral fractures or spontaneous compressions when
artery and vein pass through the tunnel. Tendons, unlike
the radial nerve pierces the lateral intermuscular septum.
in the carpal tunnel, are missing. Compression of the
nerve in the forearm is possible but rare. If the nerve is
affected at the wrist, patient’s complaints are both sen- 13.3.1 Radial Nerve Entrapment
sory and motor. Lesions of the nerve more distally may
lead to a purely motor deficit syndrome. Sensory
at the Elbow (Posterior Interosseous
branches are not affected. Clinical examination may show Nerve Syndrome)
atrophy and weakness of intrinsic muscles innervated by
the ulnar nerve, monkey or claw hand, and loss of sen-
Clinical Presentation
sory function. Tinel’s and Froment’s signs may be posi- The most common site of radial compression at the elbow
tive. Electrophysiological testing is helpful for localizing is the arcade of Frohse.43 The arcade is a fibrous arch from
the compression site. Distal motor latency is prolonged the supinator muscle tendon. The posterior interosseous
at the hypothenar and the first interosseous dorsalis nerve passes beneath this structure. At this level, the radial
muscle in isolated compressions of the deep (motor) nerve has already bifurcated into the sensory and deep
branch. Sensory action potentials are reduced or missing motor branch. That is the reason why patients present just
if the ulnar nerve is compressed more proximally. A com- motor deficits, especially paralysis of the extensor digito-
mon trigger for ulnar neuropathy at the wrist is chronic rum superficialis and the extensor pollicis longus muscles.
repetitive trauma. Examples for extrinsic trauma are The extensor carpi radialis is not involved, as the branches
long-distance cycling or chronic pressure from tools such that innervate this muscle are proximal to the compression

111
Compressive Lesions of the Upper Limb

site. Pain and sensory deficits are generally missing. Pain 13.3.2 Radial Sensory Nerve
on palpation in the region of the supinator tunnel may
occur, but this is meaningful only when the difference Entrapment (Wartenberg’s
with the opposite side is very evident. Syndrome, Cheiralgia Paresthetica)
Electrophysiological testing shows denervation in the
muscles supplied by the deep branch of the radial nerve. Clinical Presentation
Supinator and the extensor carpi radialis muscles are nor- The superficial radial nerve runs on the surface of the
mal. Sensory action potentials are normal. distal radial bone. Therefore, it is exposed to external
Further causes for radial nerve compression are tumors pressure (wristwatch, handcuffs) and fractures. Symp-
such as lipomas and cysts. Those can be detected by ultra- toms are hypesthesia at the dorsal radial aspect of the
sound or MRI. hand and first digit. Pain on palpation may be present at
the distal portion of the forearm. Sensory action poten-
Timing tials are missing in electrophysiological testing. Quer-
vain’s disease is the most common differential diagnosis.
If tumors, lipomas, or cysts are present, they should be
removed. Watch-and-wait strategy may be performed for
8 to 12 weeks. If there is no spontaneous recovery, sur- Timing
gery is indicated. Prognosis for complete recovery is good In most cases, it is sufficient to remove the source of
and can be expected within 2 to 6 months after surgery. external pressure (watch band, handcuff). In case of per-
sistent symptoms, exploration is useful.
Surgical Strategy
Surgery is performed under general or local anesthesia; Surgical Strategy
tourniquet control can be used. There are two possible The skin incision is made at the palmar and radial aspect
approaches: dorsal and anterior. In the former, the nerve of the distal forearm with a total length of 5 to 6 cm. The
is exposed to get access to the distal part of the supinator superficial radial nerve is exposed between the distal
tunnel. Therefore, the skin incision is made between the portion of the brachioradialis and the extensor carpi radi-
tendons of the extensor carpi radialis and extensor digito- alis muscles. The superficial radial nerve is released from
rum communis muscles. The anterior approach is used constrictive tissue such as fascia and scars.
more frequently. It begins proximally in the cubital fossa
between the brachialis and the brachioradialis muscles
(▶ Fig. 13.12). Then, the radial nerve is detected in the re- 13.4 Suprascapular Nerve
gion of the radial head, where the nerve bifurcates into
the superficial and deep branches. Crossing vessels (leash Entrapment
of Henry) are coagulated. The arcade of Frohse is exposed
and released. The deep branch of the radial nerve is 13.4.1 Clinical Presentation
directly observed up to the end of the supinator tunnel. If The suprascapular nerve is fixed within the scapular
present, tumors, ganglion cysts (▶ Fig. 13.13), or lipomas notch. This notch is covered by the superior transverse
are excised. scapular ligament. If the arm is abducted and the

Fig. 13.13 Interosseous posterior syndrome with compression


Fig. 13.12 Skin incision performed by interosseous posterior of the deep branch of the radial nerve due to a parosteal
syndrome. lipoma.

112
Compressive Lesions of the Upper Limb

Fig. 13.14 Prone position for decompression of the


suprascapular nerve. Skin incision (dashed line).

Fig. 13.15 Compressed suprascapular nerve (N) due to a


ganglion cyst (C) in the suprascapular notch.

shoulder is moved forward, the nerve is pushed against


the ligament. Repetitive motions may damage the nerve.
References
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[19] Chow JCY. Endoscopic carpal tunnel release. Two-portal technique. [36] Fine EJ. The ulnar flexion maneuver. Muscle Nerve. 1985; 8:612
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[20] Thoma A, Veltri K, Haines T, Duku E. A systemic review of reviews ulnar neuropathy at the elbow. Cochrane Database Syst Rev. 2011(2):
comparing the effectiveness of endoscopic and open carpal tunnel CD006839
decompression. Plast Reconstr Surg. 2004; 113:1184–1191 [38] Tsai TM, Bonczar M, Tsuruta T, Syed SA. A new operative technique:
[21] Rosenbaum RB, Ochoa JL, eds. Carpal Tunnel Syndrome and Other cubital tunnel decompression with endoscopic assistance. Hand Clin.
Disorders of the Median Nerve. Amsterdam: Butterworth Heine- 1995; 11(1):71–80
mann; 2002 [39] Barthels RH, Verhagen WI, van der Wilt GJ, Meulstee J, van Rossum
[22] Spinner M. The anterior interosseous-nerve syndrome, with special LG, Grotenhuis JA. Prospective randomized controlled study compar-
attention to its variations. J Bone Joint Surg Am. 1970; 52(1):84–94 ing simple decompression versus anterior subcutaneous transposi-
[23] Nigst H, Dick W. Syndromes of compression of the median nerve in the tion for idiopathic neuropathy of the ulnar nerve at the elbow: Part 1.
proximal forearm (pronator teres syndrome; anterior interosseous Neurosurgery. 2005; 56(3):522–530
nerve syndrome). Arch Orthop Trauma Surg. 1979; 93(4):307–312 [40] Gervasio O, Gambardella G, Zaccone C, Branca D. Simple decompres-
[24] Hill NA, Howard FM, Huffer BR. The incomplete anterior interosseous sion versus anterior submuscular transposition of the ulnar nerve in
nerve syndrome. J Hand Surg Am. 1985; 10(1):4–16 severe cubital tunnel syndrome: a prospective randomized study.
[25] Seror P. Anterior interosseous nerve lesions. Clinical and electrophy- Neurosurgery. 2005; 56(1):108–117, discussion 117
siological features. J Bone Joint Surg Br. 1996; 78(2):238–241 [41] Kraus A, Sinis N, Werdin F, Schaller HE. Is intraoperative luxation of
[26] Nakano KK, Lundergran C, Okihiro MM. Anterior interosseous nerve the ulnar nerve a criterion for transposition? Chirurg. 2010; 81(2):
syndromes. Diagnostic methods and alternative treatments. Arch 143–147
Neurol. 1977; 34(8):477–480 [42] Ombaba J, Kuo M, Rayan G. Anatomy of the ulnar tunnel and the
[27] Sood MK, Burke FD. Anterior interosseous nerve palsy. A review of 16 influence of wrist motion on its morphology. J Hand Surg Am. 2010;
cases. J Hand Surg [Br]. 1997; 22(1):64–68 35(5):760–768
[28] Spinner M, ed. Injuries to the Major Branches of Peripheral Nerves of [43] Frohse F, ed. Die Muskeln des Menschlichen Armes. Bardelebens
the Forearm. Philadelphia, PA: WB Saunders; 1978 Handbuch der Anatomie des Menschlichen. Jena: Fischer; 1908
[29] Struthers J. On a particularity of the humerus and humeral artery. [44] Antoniadis G, Richter HP, Rath S, Braun V, Moese G. Suprascapular
Month J Med Sci. 1948; 28:264–267 nerve entrapment: experience with 28 cases. J Neurosurg. 1996; 85
[30] Struthers J. On some points in the abnormal anatomy of the arm. Br (6):1020–1025
For Med Chir Rev. 1854; 14:170–179

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14 Compressive Lesions of the Lower Limb and Trunk


Christian Heinen and Thomas Kretschmer

Abstract The peroneal portion of the nerve is located laterally,


Compressive nerve lesions in the lower extremities are whereas the tibial portion remains medially. In varying
less frequent than in the upper limb. manifestations, a dividing groove between these two por-
Clinical features include pain, sensory impairment, and tions can already be seen at an infrapiriform level.
weakness. Its close relationship to the hip joint predisposes the
Due to symptomatic similarity, symptoms are prone to sciatic nerve to traumatic or iatrogenic lesions, the pero-
be misinterpreted and falsely attributed to the much neal portion being more frequently affected.
more common lumbar spine syndromes. One major drawback of a proximal sciatic nerve lesion is
Therefore, meticulous assessment and review of his- its very limited amenability to imaging and electrophysio-
tory, physical examination, and imaging and electro- logical preoperative work-up due to its deep localization.
physiology studies are mandatory to exclude spinal In patients with previous surgery, metal artefacts, e.g., may
genesis and confirm peripheral nerve compression. impair magnetic resonance imaging (MRI) neurography.
Common primary compression syndromes occur in the High-resolution neurosonography lacks depth of tissue
anatomically predefined narrow spaces of the lower penetration, impeding detailed nerve depiction.
extremity and trunk, such as at the infrapiriform fora- Therefore, frequently the exact level of compression or
men, at the anterior superior iliac spine, in the vicinity of lesion remains unclear, necessitating an explorative
the inguinal ligament and superficial inguinal ring, approach with intraoperative inspection and evaluation.
around the exit of Alcock’s and Hunter’s canal, around the This can be accomplished with minimal surgical morbid-
fibular head, and the anterior and posterior tarsal tunnel. ity by the endoscopic approach we described.2
They are discerned from secondary forms, which may In essence, a small entry port of 3 cm is used via
be caused by scarring, cysts, varices, muscle hypertrophy, the subgluteal fold to follow the nerve proximally by a
and acquired bony changes following trauma or medical retractor-held endoscope along its gluteal course. Simple
treatment. decompression from scar, adhesions, and venous tether-
In order to confirm diagnosis and choose the most ing can easily be accomplished by this route. The same
appropriate surgical strategy, we seek for anatomical port allows for exploration in the opposite caudal direc-
resolution of the presumed narrowing by the use of high- tion along the proximal thigh.
resolution magnetic resonance imaging (MRI) and neuro-
sonography imaging. In view of significant functional loss Deep Subgluteal Syndrome/Piriformis
and differing recovery potential of involved nerves, Syndrome
adequate timing of decompression is important.
There still is controversy concerning the proper diagnosis,
Keywords: entrapment, decompression, surgical techni- assessment, and treatment in piriformis syndrome.3
que, endoscopy, lower extremity, trunk, timing Some authors introduced the more adequate term of
deep subgluteal syndrome (DSS) encompassing different
causes for sciatic nerve entrapment.4
14.1 Nerves Aside from the “classic” piriformis syndrome caused by
a hypertrophic muscle or sharp tendinous muscle border,
14.1.1 Sciatic Nerve a large variety of pathologies have been reported—
compressive fibrous bands, anatomic variants or acquired
General Considerations changes of surrounding muscles such as obturator inter-
Being the largest nerve in the body, the sciatic nerve usu- nus, quadratus internus, and gemellus muscles or the
ally consists of L4–S3 contributions. hamstrings, and more. Inborn or acquired bony altera-
After its intrapelvic course in the vicinity of the sacrum, tions of the hip joint/ischial tuberosity or vascular abnor-
the bladder, the rectum, and the iliac vessels, it leaves the malities such as circumferential or penetrating varices
pelvis in the incisura ischiadica major between the piri- may be the underlying cause.
formis muscle and the gemellus superior muscle passing Clinical symptoms consist of deep gluteal pain and
the infrapiriform foramen. sensory-motor deficits involving tibial, peroneal, and dor-
Different courses above/within/beneath piriformis muscle sal cutaneous femoral nerve.
have been described.1 External rotation, hip flexion, and simultaneous knee
Despite appearing as one nerve, the sciatic is already extension may provoke the symptoms. Deep gluteal pal-
divided in its peroneal and tibial aspect with respective pation and pressure overlying the sciatic exit and course
root supply at an infrapiriform level. at its infrapiriform level in relaxed prone and in a lateral

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Compressive Lesions of the Lower Limb and Trunk

decubitus position with the hip flexed, the knee bent, Key to successful treatment will remain exclusion or
and the leg rotated inward (“quadripartite position”; identification of mechanical encroachment, which at
stretches sciatic and at the same time lifts the nerve to times may be hard to achieve. In cases of high degree of
a more superficial level) may provoke the typical pain. suffering or significant functional loss, (early) surgical
Frequently, patients have problems to sit on the affected exploration is justified.
half of the buttock and prefer to use an asymmetric sit-
ting position that releases pressure on this side.
In terms of imaging, MRI is the gold standard assessing
Surgical Strategy
or excluding space-occupying lesions. Different approaches have been described, such as infra-
High-resolution neurosonography with detailed depic- gluteal, transgluteal, and subgluteal (see ▶ Fig. 14.1a–e).2,7,8
tion of the intraneural anatomy is limited due to Position is usually prone; anatomical landmarks and
restricted tissue penetration. the course of the nerve are highlighted (midline, subglu-
Some reports on electrophysiology with pathologic teal skin fold, coccyx, posterior superior iliac spine) with
H-reflexes in different positions may underline DSS. Elec- a skin marker.
tromyogram (EMG) alone might be misleading if only the Using a small horizontal incision within the subgluteal
peroneal part of a lesioned sciatic nerve is affected. skin fold, the nerve can be easily and bluntly detected in
Conservative treatment consists of physiotherapy, the proximal thigh entering the space between the long
anti-inflammatory medication, and local injections of head of biceps femoris and the semitendinosus muscle.
corticoids or botulinum under ultrasound control into This access facilitates dissection of the nerve in both
the corresponding muscles. distal and proximal direction.
According to the literature, both conservative and sur- If necessary, an additional gluteal incision can be made,
gical treatment seem to be helpful,5,6 and classically only allowing for transgluteal exposure and decompression of
in conservative therapy refractory cases’ surgery is con- the nerve.
sidered. We think this very general approach should be Endoscopy via a subgluteal port enables dissection of
more nuanced. Fibrovascular compression or the above- the nerve along its gliding tissue and easy identification
mentioned secondary causes can only be relieved surgi- of the dorsal cutaneous branch. Even in big-framed
cally (see the next section on Surgical Strategy). patients, visualization of compressive tissue and thus

Fig. 14.1 (a) Indication in centimeters to demonstrate the possible range of triportal decompression starting at the subgluteal level;
white dots indicate infrapiriform foramen level. (b) Triportal decompression of the sciatic/peroneal nerve (arrows indicating surgical
accesses). (c) Identifying the sciatic nerve (asterisk) via the subgluteal incision. (d) Endoscopic view; elevated connective tissue (arrows)
compressing the sciatic nerve (asterisk). (e) Endoscopic view; decompressed sciatic nerve at the infrapiriform foramen level (asterisk).

116
Compressive Lesions of the Lower Limb and Trunk

targeted surgery up to the infrapiriform foramen level are This is the actual anatomic predefined notch.
possible. If the piriform muscle is the origin of symptoms, At this level, the nerve divides into three branches
it can be partially or completely dissected and incised (from medial to lateral): the tibiofibular joint branch, the
without subsequent gait impairment.6 deep branch, and the superficial branch.
This seems to account for gemelli muscles as well. In The deep branch innervates anterior tibial muscle and
case of a sudden stop and resistance of endoscopic the toe extensors including the hallux.
advancement that cannot be resolved and neurolyzed via It supplies the interdigital space between the hallux
this route, it is simple and fast to add a transgluteal and the second toe autonomously.
focused route in a second step during the same surgery. The superficial branch supplies the foot everting long
For this, we use an oblique incision at the buttock overly- and short peroneus muscles and the lateral lower leg as
ing the anticipated course of the sciatic nerve. well as the instep.
In case of substantial trauma, these two ports could
potentially still be connected to a flap resembling the Clinical Aspects
more classic large question mark–shaped skin incision
(classic approach according to Henry). This will provide The compression neuropathy of the peroneal nerve at the
a more extensile overview to the whole region at the fibular head is the most common neuropathy in the lower
price of massive gluteal muscle disinsertion. Access- extremity.10 Sudden nonpainful functional loss is the
related morbidity and muscle trauma, therefore, is a leading clinical symptom.
major drawback of this large approach, and even However, there seem to be no reliable data on inci-
in sciatic nerve reconstruction or tumor surgery at glu- dence.11
teal level, we do not see the need for this approach Unfamiliar physical activity, sustained work in a kneeling
anymore. position (“harvester’s palsy”), sitting with legs crossed,
We prevent cutting the gluteal muscles by atraumatic uncommon postures, and long periods of immobilization
blunt dissection in a more perpendicular trajectory with casts stress the peroneal nerve at its notch. By fortify-
directly overlying the nerve, which already has been ing an already (latently) existing compressive site, an edem-
identified via the subgluteal port. Muscle dissection is in atous nerve reaction will be induced that leads to further
line with the fiber orientation of the gluteus maximus rise in pressure and more edema in a vicious circle.
after sharp incision of the gluteal fascia. Care must be Furthermore, systemic illness such as diabetes and poly-
taken to avoid the plane of the gluteal nerve branches neuropathy predisposes peroneal neuropathy. If a patient
and vessels. Intermediate use of a nerve stimulator to presents with pain in an otherwise atraumatic lesion, tumor
detect branches is most helpful. or an intraneural ganglion cyst needs to be ruled out.
When treating big or very athletic patients, a fixed Intraneural ganglia play an important role in the com-
frame-retractor system with long blunt blades is useful. pression syndromes of the peroneal nerve.
Proximal intrapelvic compression syndromes within There are different theories on the origin of extra-/
the pelvis are rare. Cases of intrapelvic sciatic nerve com- intraneural or combined ganglia (degenerative/synovial/
pression syndromes have been reported, such as sciatic tumorous).
endometriosis (“catamenial syndrome”), ganglion cysts, In recent years, the “unifying articular (synovial) origin
varices, or postoperative scarring. of intraneural ganglia” was established.12
Treatment includes hormonal or anti-inflammatory In brief, it postulates that connection of tibiofibular
medication. joint synovia to articular nerve branches enables entry of
In case of surgery, transabdominal or minimal-invasive synovial fluid into the nerve’s internal structure and thus
methods can be used.9 paves the way for fluid extension within the intraneural
space. The progressive filling with synovial fluid and gel
leads to formation and rise of intraneural pressure, and
14.1.2 Peroneal Nerve as such to an “internal compression syndrome.”
Clinical symptoms may vary from complete/incomplete,
General Considerations whole/partial nerve, etc., and include foot/toe drop, weak-
ness of foot eversion, sensory impairments, and pain.
Anatomy Thorough physical examination usually gives clear
After emanating from the sciatic, the peroneal nerve hints to determine the lesion level (pattern of neurologi-
descends adjacent to the medial border of the biceps cal deficit, Hoffmann–Tinel sign, pain, palpable mass).
femoris muscle. Note that the posterior tibial muscle (foot inversion) is
It then turns laterally toward the fibular head lying a tibial nerve–innervated muscle.
superficially. Its proximity to the bones and knee as well This is of clinical importance discerning pure peroneal
as to the tibiofibular joint favors its vulnerability. from combined peroneal-tibial, sciatic, or L5 lesion.
The nerve enters the space between the two heads of Imaging usually encompasses MR neurography and
the long peroneus muscle at the fibular head. high-resolution neurosonography depicting caliber changes

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Compressive Lesions of the Lower Limb and Trunk

of the nerve at the compression site or space-occupying The patient is positioned prone, allowing for decom-
lesions such as intra/extraneural ganglia, varices, popliteal pression of the nerve in both cranial and caudal direction
aneurysms, and sesamoid bones (“fabella”). Nerve ultra- if necessary.
sound gives excellent resolution of lower extremity nerves Some authors prefer lateral or supine position with
up to a level of 1 mm, and is easy to apply. It enables quick flexed and slightly internally rotated leg.
differentiation of cyst from classic compression or tumor. A semilunar incision is placed on the fibular head ante-
Electrophysiology further enhances nerve lesion asses- rior to the nerve, avoiding a direct scar on the nerve.
sment and gives clues as to the nerve’s functional state by Already at a fascial level, the nerve can be detected dig-
using EMG and conduction studies (complete vs. incom- itally in its course medial and posterior to the fibular
plete lesion, absence of voluntary muscle potentials). head. The fascia is then incised and opened up.
Polyneuropathies and diabetes seem to promote com- Usually, the nerve is surrounded by a gliding fatty
pression; nonetheless, these patients benefit from surgery.13 tissue that should be maintained and not manipulated
or coagulated as it protects and provides the nerve with
vessels enabling passive motion during leg movement.
Surgical Strategy Following the nerve distally, the superficial fascia of
Surgical strategy is dictated by the underlying pathology. the long peroneal muscle inserting at the fibular head is
Timing of surgery depends on the severity of symptoms, verified, incised, and kept apart.
as the recovery potential of the peroneal nerve is limited. One should ensure not to open the superficial layer
With severe symptoms and definitely with complete only but also the deeper lamina.
foot drop, we favor prompt surgery. Then, the trifurcation of the nerve can be worked out
At the junction of incomplete traumatic nerve lesions once again respecting the surrounding gliding tissue.
and compressive elements (anatomic notch, constricted Electrostimulation is used to identify and test nerve
scar), external compression can prevent regeneration of response of the single branches.
otherwise intact internal nerve structure (Sunderland For verification of proper decompression, dissectors
lesions I to III, Millesi A and B). can be useful.
Decompression can enable or at least facilitate proper After wound closure, we prefer compression dressing
recovery in these cases. instead of wound drains.
This is why we are quite generous when it comes to Mobilization of the patient can start immediately
indicating simple decompression at the fibular head notch. avoiding novel adherences due to scarring.
The benefit can be enormous, the risk is minimal, and the Intraneural ganglia require a different approach and
surgery is simple. setting (see ▶ Fig. 14.2a–f).

Fig. 14.2 (a) Intraoperative view; irregular


shape of the distended nerve. (b) Evacua-
tion of the intraneural cyst after epineur-
otomy. (c) Identification of the feeding
articular branch. (d) Ligation of the feeding
articular branch. (e) Note the enlarged
lumen (arrow) of the dissected feeding
articular branch. (f) Decompressed peroneal
nerve.

118
Compressive Lesions of the Lower Limb and Trunk

Frequently, onset of sensorimotor impairments is quick Results


and substantial.
Timing is crucial and early surgery should be sched- For simple entrapment neuropathy, there are only a few
uled, as only few patients experience a spontaneous and systematic outcome studies. In addition, they refer to
sufficient recovery. small patient numbers. They report favorable surgical
We prefer prone position and a microsurgical setup outcome and low complication rates.14,15 This accounts
including microscope, electrostimulation, intraoperative particularly for patients with mild symptoms.16
electrophysiology, and neurosonography. Skin incision is Pain and motor weakness seem to benefit better than
determined by the lesion’s extension. sensory function.17
Exposition should comprise the whole lesion including a Results of surgery for intraneural ganglia differ from
healthy nerve segment proximal and distal to the lesion. simple decompression.
By doing that, the healthy nerve sections can be It has been reported that surgery improves pain in the
inspected and more importantly tracked into/within the majority of patients.
cystic part. Improvement of sensorimotor function is dependent on
The goal of surgery is to decompress the nerve by epi- the severity and duration of symptoms prior to surgery,
neurotomy and cyst fenestration. At the same time, a and the extent of lesion. It occurs in 50 to 64% of cases.18
recurrence is prevented by disconnecting the “feeding” A significant problem is recurrent cyst formation,
articular branch (“close the faucet”). This is accomplished which is reported in up to 24% of the patients.19 Discon-
by radical ligation and transection of the feeding branch nection of the feeding articular branch is the accepted
as close to the tibiofibular joint as possible. We prefer to measure to prevent recurrent ganglia.20
excise a larger segment for histopathology in order to The peroneal nerve has low regenerative capacity in
enlarge the distance between joint and nerve. general.21
Disconnection is regarded as the most effective meas- Therefore, in patients with only fair or insufficient
ure to prevent cyst recurrence; as multiple articular recovery, secondary procedures such as transfer of the
branches can occur, these also should be ruled out to tendon of posterior tibial muscle have a definite role to
minimize this risk. improve gait and should be considered in failed nerve
As the cystic wall cannot be dissected from the epineu- regeneration. There is a need to counsel patients in that
rium, an attempt to make a “radical resection” of the cyst regard and offer this type of treatment.
will definitively lead to fascicular damage and thus is con-
traindicated. The “cyst treatment” is limited to a micro-
Anterior Tarsal Tunnel
surgical fenestration of the cyst wall at a fascicle free site This rare entrapment syndrome affects the terminal
where it reaches the epineural surface. branch of deep peroneal nerve at the cruciform ligament
In some patients, there is one big communicating intra- or underneath the extensor hallucis brevis tendon.
neural, i.e., intraepineurial, cyst, compressing, dislocating, Both the medial (providing the first interdigital space)
and thinning out the fascicles. These cases can be treated and the lateral (providing the dorsum) branch can be
easily with one larger fenestration. affected, provoking different symptoms.
However, multiple and multilobular cysts can occur. Diabetic patients seem to be susceptible.
They complicate surgery in so far as more fenestrations Association with lumbosacral radiculopathy and foot
are needed and frequently not all cysts can be opened. deformities has been described.22
The recurrence rate is higher in such cases. Intraoperative Local and activity-related pain and paraesthesia are the
ultrasound can help to detect deep lying cyst chambers. main symptoms.
We try to avoid electrocauterization within the nerve Conservative treatment consists of anti-inflammatory
and prefer mild focused compression using cottonoids to medication, infiltration with local anesthetics or corticoids,
stop bleeding. and shoe orthoses.
In patients with underlying bony deformations in the When symptoms persist, the nerve can be surgically
form of exostosis, fragments, or additional bones (fabella), decompressed.
the surgical task consists of tissue-sparing bone removal, The longitudinal or transverse skin incision follows the
decompression, and creation of a new and smooth nerve dorsal pedis artery as the most important anatomic land-
bed using autologous fat pads to enable supple passive mark. After that, the cruciform ligament and the extensor
motion of the nerve during leg movements. tendon are dissected. Then, the nerve is identified and
Rarely intraneural varices are the underlying pathology decompressed by transecting the cruciform ligament.
of peroneal nerve deficit. They demand careful microsur- Rarely, part of the tendon needs to be notched. Surgery
gical interfascicular dissection and disconnection of the can greatly be eased if performed in a bloodless field. Pain
vessel after epineurotomy. relief can be achieved in up to 80%.23

119
Compressive Lesions of the Lower Limb and Trunk

Entrapment of the Superficial Peroneal Usually, L5–S2 account for tibial nerve function provid-
ing all foot and toe flexors including posterior tibial
Nerve
muscle (foot inversion) and sensation to the sole of the
Isolated entrapment of the superficial peroneal nerve foot and heel (calcaneal branch). The tibial nerve passes
distal to the fibular head is postulated to occur, at the the soleal sling at the knee level (two to three fingers’
site where the nerve perforates the deep fascia of the breadth below the flexor crease) to enter the tarsal tunnel
leg.24 distally behind the medial malleolus.
MRI and/or neurosonography help to detect compres- The calcaneal branch usually forks off the main branch
sive pathologies. before or within the tarsal tunnel.
Electrophysiology may display lowered conduction The tibial nerve then divides into the sensorimotor
velocities or pathologic EMG of the peroneal muscles. medial and lateral plantar nerve before or after entering
Skin incision is placed about 5 cm lateral to the lateral the flexor retinaculum. There are different anatomically
tibial border. given bottlenecks, with the most important one being
Then, the fascia is opened and the nerve decompressed. within the tarsal tunnel at the ankle.
Reports describe pain relief after surgery, with body mass
index being a negative predictor for successful surgical
treatment.25
Proximal Soleal Sling
A fascia connecting the tibial and fibular head of the sol-
Sural Nerve eus muscle can compress the tibial nerve. Aside from idi-
opathic causes, posttraumatic and diabetic forms have
Primary sural nerve entrapment is extremely rare. Com-
been described. Clinical presentation is calf pain and
pression can occur throughout the whole course of the
mostly sensory problems in addition to a Hoffmann–Tinel
nerve, with pain and sensory impairments being the clin-
sign. Weakness can afflict flexor hallucis longus muscle.
ical features. Due to its rather long course, the nerve can
MRI may help to confirm soleal sling syndrome by identi-
be damaged secondarily after fractures and their treat-
fication of nerve swelling and hyperintensity at this
ment. Conduction studies reveal pathologic sural nerve
location.29 As this entrapment syndrome is very rare,
values. Imaging using MRI and neurosonography may
symptomatic patients may have undergone tarsal tunnel
reveal bony or vascular anomalies or secondary scarring.
surgery prior to its diagnosis.
In case of failed conservative treatment, the nerve can
Surgery consists of a skin incision at the medial calf
easily be accessed between the lateral ankle and the
and dissection of the gastrocnemius fascia. After identifi-
Achilles tendon, and decompressed.26 Patients under-
cation of the space between the gastrocnemius and the
going diagnostic sural nerve biopsy harbor the risk of
most proximal aspect of the soleus muscle, the sling can
painful neuroma formation. As mostly only a few centi-
be divided.30
meters are harvested for histopathological exam, the
proximal neuroma often is located superficially and distal
to the fascia. Symptoms such as pain and dysesthesia Posterior Tarsal Tunnel Syndrome
occur in up to 19% of the patients on contact but also
A proximal tarsal tunnel syndrome (TTS) can be differen-
when moving.27 Conservative treatment consists of medi-
tiated from the distal one. In nearly 80% of the cases, an
cation, serial infiltrations under ultrasound guidance
underlying pathology such as perineural ganglia, lipoma,
using local anesthetics and/or corticoids.28 If conservative
and nerve sheath tumors account for TTS.
treatment fails, neuroma resection can be performed.
Clinically, the proximal TTS also affects the calcaneal
However, a new neuroma will form anyway. Superficial
branch and therefore includes sensory deficits at the heel.
neuromas are much more prone to ectopic nerve activity
This is in contrast to the distal TTS. Toe flexion and/or toe
and painful transformation. Surgery therefore aims at
spreading may be impaired. The surface of the sole can be
high-level nerve resection to bury the stump deep within
flattened. A Hoffmann–Tinel sign can be elicited along
the muscular compartment. This implies to extend the
the nerve’s course within the tarsal tunnel.31
resection above mid lower leg.
Imaging should include MR neurography and high-
resolution neurosonography.
14.1.3 Tibial Nerve Electrophysiologically, lowered conduction velocities
of the lateral and medial plantar nerves in combination
Anatomy with altered EMG of toe flexor may empower the
In contrast to the anatomic course of the peroneal nerve, diagnosis.
the tibial nerve proceeds in a straight line along with In primary TTS, conservative management with anti-
tibial artery to the lower leg before it changes direction inflammatory medication, physiotherapy, and splinting is
toward the dorsal aspect of the inner ankle to branch into of first choice.
a medial and a lateral plantar nerve that supply the sole Patients with persisting or worsening symptoms may
of the foot and its intrinsic muscles. undergo decompressive surgery.

120
Compressive Lesions of the Lower Limb and Trunk

The same accounts for secondary space-occupying tion and simultaneously applying pointed pressure on the
lesions provoking TTS. sole between the affected metatarsal bones.
A semilunar skin incision is placed along the course of MRI imaging confirms the diagnosis. High-resolution
the nerve dorsal the medial malleolus. ultrasound is also capable of detecting the mass.37
Dissection of the complete retinaculum flexorum In addition to medication, physiotherapy, and splinting,
should be performed assuring the decompression not diagnostic therapeutic blocks are indicated. Infiltration
only of the main trunk but also of the medial and lateral can easily be performed with or without ultrasound guid-
plantar nerve. This long incision, however, bears a rela- ance from a less painful dorsal interdigital approach.
tively high risk of impaired wound healing (skin tension, Serial infiltration with local anesthetic and corticoids
vascular insufficiency, tissue edema, venous insuffi- aims at reducing pain and inflammation. However, we
ciency). Therefore, we prefer one or two short horizontal think its potential to lead to long-lasting relief in severe
skin incisions—the first at the proximal and the second at Morton’s neuralgia is limited. Surgical excision of the
the distal end of the tunnel. The skin bridge can be lifted neuroma, in contrast, has a strikingly high success rate.
with a Langenbeck retractor, or alternatively a retractor- For surgery, a dorsal and a plantar approach have been
held endoscope can be used from a proximal to distal described.38 We have clear preference for the dorsal inter-
direction. Sparing of the calcaneal branch is of utmost digital “web-space” approach as it circumvents a very
importance. painful plantar incision that limits early weight bearing
Surgery can be performed openly or with endoscopic and has high potential for wound infection. Most authors
assistance.32 use the dorsal approach and either resect the pseudo-
Especially in patients with diabetes or venous insuffi- neuroma or decompress it.35 The pseudoneuroma is
ciency, preservation of veins and arteries is mandatory to located directly between the eminences of the metatarsal
prevent impaired wound healing. heads underneath the transverse metatarsal ligamentum
We usually advise the patients to intermittently elevate (TML).
the leg and ambulate on elbow crutches for the first 1 to A 3-cm longitudinal incision is placed from in-between
2 weeks of mobilization, avoiding full weight bearing on the bases of the affected toes to proximal. Once the meta-
the affected foot. tarsalgia have been identified, they are pushed apart by a
Results may vary significantly: patients with secondary small retractor placed on the bone to open the space. The
causes seem to benefit more frequently from the proce- visible TML builds the rooftop of the pseudoneuroma. It
dure contrasting with those with idiopathic origin.33,34 is either incised to approach the pseudoneuroma directly
from above or left intact to reach from a more anterior
trajectory. The conglomerate of pseudoneuroma, bursa,
Distal Tibial Nerve Compression and thickened sensory digital nerve endings in the pseu-
Syndromes doneuroma are dissected out and excised. Surgery is
For the sake of completeness, rare distal entrapments of greatly eased in a bloodless field and can be accomplished
the medial plantar nerve (“jogger’s foot”) as well as of the under local anesthesia.
lateral plantar nerve (“Baxter’s neuropathy”) are men- Results are very satisfying even in the long term.36,38,39,40
tioned in the literature.35

14.1.4 Lateral Femoral Cutaneous


Morton’s Neuroma Nerve (Meralgia Paraesthetica)
Even more distal and certainly more frequent is the The incidence of meralgia paraesthetica (MP) is estimated
entrapment of the terminal branches of the medial and at 4 to 10 per 10,000. Mean age of occurrence is 30 to 40
lateral plantar nerve. It affects mainly the nerves between years, and correlation with pregnancy and carpal tunnel
the second and third or third and fourth metatarsal syndrome has been reported.41 A total of 7 to 10% of the
bones. Chronic irritation of the nerve and adjacent bursa patients display bilateral manifestation.42 There seems to
intermetatarsophalangea may provoke a painful pseudo- be an association with positioning in surgery in prone
neuroma and chronic bursitis. Women are affected four position, weight change, tight clothing, etc.43 Being a pure
times more often, and multiple Morton’s neuromas are sensory nerve, patients with MP suffer from paresthesias
frequent. Association with foot deformities have been or dysesthesias in the anterolateral thigh depending on
reported.36 Arthritis and other degenerative osseous con- posture. Frequently, there is a burning and tingling com-
ditions should be excluded. ponent on the pain. Classic teaching states retroflexion
Patients often prefer to walk barefoot as narrow shoes (“inverse Lasègue”) as pain inflicting posture. In our
may provoke the symptoms. observation, we find both retroflexion and hip flexion or
Clinically, aside from pain and sensory deficits, the char- sitting to provoke pain. In clear cases, there is a punctum
acteristic Mulder’s sign is the main feature. It is performed maximum (PM) of the pain in the vicinity of the anterior
by compressing the arch of the foot in a mediolateral direc- iliac spine, where finger tapping can elicit the typical

121
Compressive Lesions of the Lower Limb and Trunk

painful sensations spreading to the anterolateral thigh. ligament centering the anterior superior iliac spine. Then,
The PM should be in accordance with the lateral femoral the aponeurosis of the external oblique muscles is split.
cutaneous nerve (LFCN) course and is the supposed point The fibers of the internal oblique and transversus
of compression. abdominis muscles are dissected to allow identification
Electrophysiology may show lowered conduction of the nerve underneath the iliac fascia heading toward
velocity of LFCN; imaging with high-resolution neuroso- the SAIS.50
nography can reveal the nerve and its compressive site. At this point, decompression can be performed.
In addition, MRI may help to exclude compressive Authors postulate a better feasibility of nerve detection51
pathologies in the nerve’s vicinity. by this more invasive approach. In case the nerve is trans-
Anatomically, the nerve arises from L1–L2 and then ected intra-abdominally, the stump should remain with-
takes its course beneath the iliac fascia in the retroperito- out any other compression deep in the abdominal space
neum toward the superior anterior iliac spine (SAIS).44 (e.g., iliac fascia).
At this point, the nerve bends nearly 90 degrees, enter- In conclusion, the majority of patients can be treated
ing the thigh usually below the inguinal ligament and lat- conservatively, and will only have transient symptoms. In
eral to the sartorius muscle border covered by the thigh refractory cases, surgery is an option. We prefer simple
fascia (85% of the cases).45 decompression at the inguinal level as the first surgical
There are several variants of the nerves’ course, from treatment option. In severe debilitating cases with prior
intrapelvic to infrainguinal. The LFCN can run underneath, recurrent surgery, we see intrapelvic transection as an
through, or above the ligament. It can also perforate the option. For this, we can also enter from below the liga-
sartorius muscle. At times, it will run above the iliac spine, ment. The nerve can be followed along its intrapelvic
and can have a bony roof or its own bony iliac canal.46 course by using a retractor or a retractor-held endoscope.
Differential diagnoses such as general neuropathy, spi- However, there still is ongoing debate whether the
nal problems, pathologies of the lumbar plexus, or intra- nerve should be approached from a supra- or infraingui-
pelvic causes have to be excluded. nal access.
In roughly 25% of patients, symptoms will resolve Moreover, there is disagreement whether decompres-
spontaneously especially if associated with pregnancy. sion or neurotomy is the most appropriate primary surgi-
Aside from weight reduction, change of clothing habits cal treatment.
and infiltrations using local anesthetics or corticoids can There are no reliable data assessing large patient
be applied with a high success rate.47 In patients with collectives favoring one or the other method.47,49
pain refractory to conservative treatment or intractable
pain, surgery is indicated. 14.1.5 Ilioinguinal Nerve/
There are two surgical techniques available: one is a
simple decompression at the inguinal ligament level, the
Iliohypogastric Nerve/Genitofemoral
other one is an intra-abdominal transection of the nerve. Nerve
None has proven significant superiority.48,49
These nerves are provided by T12–L3.
We prefer decompression as a first surgical step, leaving
Clinically, the supplied area may vary significantly,
transection for cases of failed decompression and massive
overlapping also with the pudendal nerve, complicating a
residual pain. After supine positioning, a 4-cm skin incision
clear diagnosis.
is placed transversely from SAIS in a medial direction. This
MRI and ultrasound may exclude space-occupying
allows for supra- and infrainguinal dissection. The subcuta-
masses.
neous tissue is bluntly separated freeing the fascia and
However, true entrapment syndromes of these nerves
enabling identification of the inguinal ligament, the lateral
are rarities.
sartorius muscle border, and the fascia lata.
Most of the neuropathies arise after iatrogenic manipu-
Once the fascia is opened, the LFC nerve usually can be
lation.52
found in a triangle between the SAIS laterally, the ingui-
When reoperating, it can be very difficult to find the
nal ligament above, and the sartorius muscle medially.
nerves within in the scar due to their small diameter.
The nerve is then followed proximally to its point of com-
In analogy to Morton’s neuroma or meralgia, a deep
pression toward the inguinal ligament.
nerve resection can be taken into account.
Now step-by-step decompression of the nerve is car-
ried out by nicking the inguinal ligament, sartorius
muscle or other compressive structures. Sometimes the
14.1.6 Femoral Nerve
nerve is covered by an own fascia layer on its way from The femoral nerve is built by L1–L4 contributions. It fol-
the abdominal space into the thigh, which than should lows the psoas muscle dorsally and laterally and clings to
also be incised. the femoral vessels entering the thigh underneath the
When accessing the nerve via a retroperitoneal route, inguinal ligament. At this point, there are variants in the
an incision is placed above and parallel to the inguinal branching pattern.

122
Compressive Lesions of the Lower Limb and Trunk

Although the space beneath the inguinal ligament is Otherwise, it can easily be extended into a semilunar
narrow, primary compression neuropathies of the femo- incision along the ventral iliac bone.
ral nerve are uncommon. After mobilizing the fat, the aponeurosis of the external
When it comes to traumatic or iatrogenic lesion due to oblique muscle, internal oblique muscle, and rectus
surgery, positioning, or compressive hematomas—either abdominis muscle can be split bluntly if needed.
inguinal or retroperitoneal—the nerve is highly suscepti- Once the peritoneum is identified, it can be retracted by
ble to secondary compression53 (e.g., by scar). self-holding systems giving view to the iliopsoas muscle.
Depending on the level of impairment, not only knee Usually, the femoral nerve can be found at its medial
extension but also hip flexion due to weakness of quadri- border within the muscle’s fascia.
ceps and iliopsoas muscle occurs. Psoas hematomas represent a cause of femoral nerve
Sensory areas comprise median femoral cutaneous and impairment: in those cases, fascial opening and evacua-
saphenous nerve. tion of the hematoma significantly improve the situation.
MRI and ultrasound rule out secondary causes. The nerve can be easily followed caudally to the ingui-
Electrophysiological assessment reveals depth of nal ligament.
nerve damage. As already detailed for the LFCN, the femoral nerve can
Treatment depends on the underlying pathology also be visualized from its extra- to intrapelvic course by
necessitating either trans/retroperitoneal or inguinal lifting the inguinal ligament. An endoscope with 30
approach for nerve decompression. degrees optics enables following its course from an
If compression in the vicinity of the inguinal ligament infrainguinal approach without the need to go transmus-
is suspected, an incision parallel to it allows exploring the cular via the abdominal wall (see ▶ Fig. 14.3).
nerve’s intra- and extrapelvic portion. Complete transection of the inguinal ligament is not
Usually, the nerve lies lateral to the femoral vein and recommended in order to avoid hernia formation requir-
artery. ing further surgical treatment.
By either palpation or ultrasound, the vessels can easily Fortunately, the femoral nerve has a high regeneration
be depicted and marked on the skin. potential.54
After incision, the subcutaneous fat is mobilized and Therefore, in patients with no spontaneous recovery,
the fascia identified. Incision of the fascia gives view on an attempt to decompress the nerve enabling proper
both vessels and the nerve. regeneration can be performed.
There is considerable variation of branching pattern
and level.
Saphenous Nerve
Thus, one has to be particular careful not to harm the
rather small-sized muscle and sensory nerve divisions The saphenous nerve is the terminal sensory branch of
and other nerves such as the femoral branch of the geni- the femoral nerve emanating shortly below the inguinal
tofemoral nerve. ligament level. It provides sensation to the medial distal
The inguinal ligament can now be partially incised for thigh as well as the calf.
proper decompression. One of its branches is the infrapatellar nerve, which
As the skin in the groin region is very flexible, the same detours the saphenous nerve slightly above the knee
skin incision suffices for a suprainguinal, i.e., retroperito- level, perforating the distal sartorius muscle. Compres-
neal, inspection and decompression of the femoral nerve. sion within the adductor canal (“Hunter’s canal”) as an

Fig. 14.3 (a) Endoscopic view; scar tissue


(arrows) compressing the femoral nerve
(asterisk). (b) Endoscopic view; decom-
pressed femoral nerve (asterisk).

123
Compressive Lesions of the Lower Limb and Trunk

anatomically given notch provokes pain or sensory


impairment in the provided region.
Ultrasound and MRI may exclude secondary causes
(varices/tumors).
If conservative treatment including anesthetic blocks
fails, a simple decompression by a small skin incision on
the anterior border of the sartorius muscle can help
improve the symptoms.55 The point of maximum discom-
fort should be marked prior to surgery, as this branch is
of small caliber (1–2 mm): a bloodless field greatly helps
its identification.
A true idiopathic entrapment neuropathy of the infra-
patellar nerve is very rare with only few reports, whereas
iatrogenic lesion is much more frequent.56,57

Fig. 14.4 Surgical access to obturator nerve (yellow loop)


14.1.7 Obturator Nerve identified between pectineus and adductor muscle.
The nerve arises from L2–L4 and heads caudally at the
medial border of the psoas muscle.
After exiting the pelvis through the obturator foramen,
the nerve divides into two main branches. Other authors described a laparoscopic decompression
The anterior branch supplies the gracilis, adductor lon- of the intrapelvic nerve portion.60 In cases of tumor or
gus, and brevis and pectineus muscle. perineural ganglia, the surgical approach can differ.
An articular branch provides the hip joint and the According to the extent of the lesion, even biportal
medial thigh. accesses (retroperitoneal—thigh) may be necessary.
The external obturator and adductor magnus muscles There are no reliable data on patient’s outcome
and the medial thigh above the knee are innervated by following surgery. Decision-making remains highly indi-
the posterior branch. vidual and the diagnostic work-up clearly should
Primary entrapment neuropathies of the obturator implement MRI imaging to rule out pelvic or lumbosacral
nerve are rare. neoplasia or inflammatory disease, and electrophysiology
Mainly in athletic persons, the thickened fascia of the should confirm affection of the obturator-innervated
adductor brevis muscle harbors the danger of obturator muscles.
nerve entrapment.58 Secondarily, tumors, ganglia, endo-
metriosis, and hypertrophic muscles can cause obturator
nerve compression. Furthermore, obturator nerve lesions 14.1.8 Pudendal Nerve/Pudendal
occur after hip or pelvic surgery.59 Neuralgia
Clinically, patients present with pain and sensory
impairment on the medial thigh as well as weakness of Usually, S2–S4 roots contribute to the pudendal nerve.
leg adduction. Being a mixed motor-sensory-autonomic nerve, it divides
Electrophysiology reveals rarefication of voluntary into three main branches: dorsal nerve of the clitoris/penis,
muscle action potentials in EMG of the adductor muscles. perineal nerve, and inferior anal nerve.
Imaging with MRI and neurosonography detects the They supply anal and urethral sphincters and the pelvic
site and cause of compression along the course of the floor muscles.
nerve from its origin in the retroperitoneum, to the pelvis The nerve provides sensation to genital (clitoral-vulvar-
and leg. vaginal/scrotal-testicular-penile) and perineal areas.61
Treatment depends on the underlying pathology. Different compression mechanisms have been described
The first option is NSAID medication and physiotherapy in primary pudendal neuralgia, including the sacrospinal
or avoidance of pain-provoking maneuvers. or sacrotuberal ligament (alone or combined), the falciform
If pain persists, sensorimotor deficits increase, and sec- process due to obturator fascia, the piriformis muscle, and
ondary causes are excluded, decompression of the the ischial spine.62
extrapelvic part of the nerve has been proposed.58 In addition, a more distal compression site within the
An oblique incision on the lateral aspect of the long Alcock’s canal was proposed.63
adductor muscle allows for blunt dissection of the nerve Clinical symptoms mainly consist of genital, perineal,
between the pectineus/long adductor and short adductor and anal pain and sensory deficits typically aggravated by
muscle. sitting.
It then can be followed in both directions facilitating Defecation and sexual intercourse are additional pain
proper decompression (▶ Fig. 14.4). triggers, having a deep impact on life quality.

124
Compressive Lesions of the Lower Limb and Trunk

Pain is characterized as burning, torsion, or foreign- The approaches include the decompression of the
body feeling. nerve by dissection of compressive portions of the sacro-
Most of the patients will not use the bike anymore but tuberal and sacrospinal ligament. This seems to have
feel some relief sitting on ringlike cushion. Sensory no impact on pelvic stability. Some authors perform a
impairments include all the above-mentioned areas, transposition of the nerve anterior to the ischial spine in
rending the clinical picture difficult to discern from syn- the same session.64
dromes of other nerves. Secondary nerve entrapments The direct anterior access is provided for the so-called
can be attributed to surgery, tumors, or trauma. distal entrapment syndrome within the Alcock’s canal.
Imaging mainly consists of MRI excluding other We prefer a transgluteal approach to the nerve.
inflicting pathologies such as tumors, varices, and bony An oblique 5- to 6-cm incision is placed 2 to 3 cm para-
alterations. median to the coccyx.
Electrophysiology may reveal altered conduction After blunt dissection of the gluteus maximus muscle,
velocity or EMG changes in sphincter or bulbospongiosus the sacrotuberal and sacrospinal ligament are identified.
muscle. The nerve can be found at the cranial border of the
Most authors insist on diagnostic-therapeutic blocks sacrotuberal ligament entering the space between the
using CT- or MRI-guided infiltrations of the nerve at its two ligaments.
origin at the spine as well as in Alcock’s canal.61 At this point, careful decompression can be performed
Surgery can be done in different ways: transgluteal, by sectioning both ligaments (▶ Fig. 14.5a–d).
transperineal, transabdominal (open or by laparoscopy), In our setting, we use intraoperative sphincter EMG to
or transischiorectal. confirm nerve identity.

Fig. 14.5 (a) Skin incision for pudendal nerve decompression. (b) Intraoperative view; retractor holding back the bluntly dissected
maximus gluteus muscle giving view on the sacrotuberal ligament. (c) Intraoperative view; partially dissected sacrotuberal ligament
(asterisk) with the pudendal nerve (arrow). (d) Intraoperative view; visualization of the pudendal nerve (arrow) after complete ligament
dissection.

125
Compressive Lesions of the Lower Limb and Trunk

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