Nerve injuries

DEFINITION

Partial or complete interruption of normal physiology

of the nerve.
NERVE CONDUCTION IS AFFECTED.
 Epineurium
Nerve trunk
Perineurium

Endoneurium

Fascicles

Nerve fiber

Axon

Node of Ranvier

Schwann cell
Myelin
Histology of a
nerve unit
Anaesthesia: no sensation
• The complete lack of any stimulus detection and
stimulus perception, including mechanoreceptive &
nociceptive stimuli

Paresthesia: altered sensation

• An alteration in sensibility in which there is abnormal
or occasionally normal stimulus detection and stimulus
perception that may be perceived as unpleasant but is
NOT painful
Dysesthesia: painful sensation

• An alteration in sensibility in which there is abnormal

stimulus detection and stimulus perception that may
be perceived as unpleasant and painful

• Allodynia: a specific type of dysesthesia

characterized by a sharp, first pain perception
elicited by a light touch stimulus

• Hyperpathia: type of dysesthesia characterized by a

dull, second pain elicited by a pressure stimulus. Pain
lingers or has an after-image that persists even after
the pressure stimulus is removed

• Associated with neuromas, entrapment, compression and

sympathetically maintained pain
 Causes of Nerve injury

• Obstruction of the blood flow

• Toxic substances

• Pressure over the fibre- crushing of the fibre

• Transection of the fibre

 Wallerian degeneration
• The proximal stump refers to the end of the injured neuron that is still
attached to the neuron cell body; is closest to the spinal cord and is still
in communication with the central nervous system (brain and spinal
cord). it is the part that regenerates.

• The distal stump refers to the end of the injured neuron that is still
attached to the end of the axon; is farther away from the spinal cord
and has lost communication with the CNS. it is the part of the neuron
that will degenerate but that remains in the area toward which the
regenerating axon grows.

• The degenerative changes the distal segment of a peripheral nerve fiber

(axon and myelin) undergoes when its continuity with its cell body is
interrupted by a focal lesion is called wallerian degeneration.
Classification of nerve injuries

• Seddon
• Sunderland
 Seddon classification:

• Based on the severity of tissue injury, prognosis for recovery, and

time frame for recovery

Neuropraxia
Axonotmesis
Neurotmesis
• Neuropraxia :
• Local conduction block causing anesthesia

• Continuity of axons is preserved

• No wallerian degeneration

• Block persists until local myelin repair

• Weeks to months

Epineurium
Perineurium
Endoneurium
Axon
• Axonotmesis:
• Loss of continuity of axons at the level of the lesion- wallerian
degeneration

• Endoneurial tubes are intact

• Advanced nerve compression or traction injury

• Time required for recovery related to length of axon injured

• Correct orientation of growing fibres since endoneurial tubes are

preserved

• Regeneration: 1 mm per day (approx. 1 inch per month)

• Good prognosis
• Neurotmesis:

• The word is used to describe the state of the

nerve that has either been completely severed
or is so disorganised by scar tissue that
spontaneous regeneration is out of question

• Surgical repair is required

• Poor prognosis
Sunderland classification

• Based on degree of tissue injury

• Considerable overlap with Seddon classification

• 6 types
First-degree injury

• Similar to neurapraxia

• Axonal conduction is temporarily blocked and all tissue

components are intact

• Result of ischemia or mechanical demyelination

• Causes anesthesia or paresthesia

• 3 sub-classes
Axonotmesis Epineurium
Perineurium
Endoneurium
Axon
Type 2

Neurotmesis
Type 3

Type 4

Type 5
Second-degree injury

• The afferent or efferent fibres (axon) are damaged

and undergo degeneration and regeneration

• Endo, peri & epineurium remain intact

• Generalized paresthesia with a localized area of

anesthesia

• Surgical intervention is usually not necessary unless

there is a foreign body irritant
Third-degree injury

• Intrafascicular tissue components, the axons and

endoneurium are damaged

• Perineurium intact

• Loss of nerve conduction at level of injury and within

distal nerve segment

• Endoneurium pathways disrupted and disoriented,

bleeding and edema lead to scarring

• Axonal misdirection

• Surgery may be required

Fourth-degree injury

• Fascicular disruption

• Only epineurium is intact

• Loss of nerve conduction at level of injury and within distal nerve

segment

• Poor prognosis for sensory recovery

Fifth-degree injury

• Transection or rupture of the entire nerve trunk

• Loss of nerve conduction at level of injury and within

distal nerve segment

• Soft tissue nerve injury has poor prognosis

• Requires surgical adaptation

Sixth-degree injury

• Added by Mackinnon & Dellon

• A combination of Sunderland’s five degrees

• Within the same nerve trunk, some fascicles may exhibit normal
function and others will have varying degrees of nerve injury
Acute or early repair is indicated for:

• Observed transection injuries of nerves located within

soft tissue

• Transection of nerves located within a bony canal

• Anaesthesia that persists for 3 months with a high

index of suspicion for severe nerve injury and poor
prognosis of spontaneous sensory recovery, e.g. crush
injury

• Presence of foreign body irritant, e.g. endosseous

implant compressing inf alv nerve
Clinical neurosensory examination:
• Noninvasive:
• Pin pressure nociception- mediated by small-diameter nerve
fibres with & without myelin

• Two-point detection- large myelinated axons

• Directional stroke determination mediated by specific receptors

innervated by larger myelinated nerve fibres- tests for rapidly
adapting mechano-receptors

• Weinstein-Semmes static light pressure- tests slowly adapting

mechano-receptors

• Examination for Tinel’s sign- shooting pain distally or pain

directed when palpating over surgical site or lingual alveolus
Nerve injuries in OMFS setting:

• Third molar surgery

• Orthognathic surgery

• Osseointegrated implants

• Rhytidectomy

• Trauma
Third molar surgery
• Inferior alveolar and lingual nerve

• Direct forces
- Anesthetic injections
- Crush injuries
- Due to instruments

• Indirect forces
- Root infections
- Pressure from hematomas
- Post-surgical edema
Orthognathic surgery
• Inferior alveolar nerve:
- BSSO
- BSSO + RIF= 0% - 75%
- BSSO + genioplasty: double-crush injury
• Lingual nerve:
- BSSO: occasionally
• Infra-orbital nerve:
- Le fort I osteotomy
- Traction and compression
• Descending/greater palatine nerve:
- Le fort I osteotomy
Osseo-integrated implants
• Incidence- 0.6 – 36%
• IAN:
- Direct mechanical damage
- Compression
- Damage to vessels with bleeding into canal
- Formation of traumatic neuroma

Risk factors:
- use of nerve repositioning or lateralization
procedures
- severely atrophic mandible
Rhytidectomy

• Transient numbness or hyperesthesia

• Temporary, diffuse cutaneous numbess

• Great auricular nerve

Trauma

• Penetrating injuries

• Crush injuries
MEDICAL MANAGEMENT
• Primary or first line agents:
1. Peripheral blocking agents
- Lidocaine, bupivacaine, capsaicin
2. Anti convulsant agents
- Carbamazepine (Tegretol), phenytoin (dilantin), valproic acid (baclofen)
3. Anti depressant – anxiolytic agents
4. Opioids
• Systemic corticosteroid, systemic NSAIDS are the most widely used
drugs.
• Topical transdermal, transmucosal systems that deliver lidocaine,
adrenocorticosteroids, capsaicin, clonidine have shown mild to
moderate efficacy for treating neuropathic pain.
SURGICAL MANAGEMENT
• Micro neuro surgery – 1st principle of micro suturing phase is to
determine the alignment of fascicles.
• Three techniques to repair a peripheral nerve
• Epineural
• Fascicular (perivascular)
• Fascicular group repair
 Definitions
• Primary Repair - that which occurs within 1-3
weeks after the injury
• Secondary Repair - after 3 weeks of injury
• Nerve Conduit - tube used to span the gap
between nerve ends (vein, artery, synthetic,
collagen)
• Nerve allograft - cadaveric nerve
• Nerve autograft - taken from elsewhere to
span the gap
 Golden Rule

Nerve Repair should occur in a

timely manner with a well
vascularized tissue bed and no
tension!