Nerve Injury

Nerve injuries most frequently appear in the upper and lower extremities. These nerve injuries can be caused by either blunt trauma or sharp trauma. If the nerve remains intact, resting and careful observation may achieve recovery. More severe injuries require surgical reconstruction.

The physical exam is an assessment of the sensory and motor function in the affected nerves. A nerve conduction study called electromyography (EMG) can be performed to evaluate the electrical function of the nerves and muscles and to determine the location and the extent of the injury.

Surgical nerve repair requires removing injured tissue from the nerve endings so a nerve can be directly reconnected if there is enough length to allow for quality repair without further tension. An operating microscope offers the best alignment of the fiber bundle fascicles inside of the injured nerve. A conduit is an artificial tube that connects the nerve endings.

Nerve fiber repair process occurs slowly beginning to grow from the repair site toward the lost target tissues of skin and muscle to restore sensation and movement at a rate of 1 inch per month.

Brachial Plexus and Traumatic Nerve Injury

The brachial plexus is a network of nerves in the shoulder that provides movement and sensory signals from the spinal cord that allow feeling of the shoulder, arm and hand. The nerves supporting the arm exit the spinal column high in the neck and the nerves that support the hands exit lower in the neck.

Brachial plexus injuries typically stem from trauma to the neck, which presents with pain, weakness and numbness in the arms and hands. A brachial plexus injury may result in incomplete sensory and motor function of the involved arm. Patients who have been diagnosed with a brachial plexus injury may require surgery. For most patients, relief from the pain associated with brachial plexus injury is achieved at one or two years following surgery.

Microsurgery for Brachial Plexus

Treatment for brachial plexus and other complex nerve injuries often involves microsurgery. Microsurgery is the specialty of operating under a microscope with precise tools and materials that can not be viewed by the naked eye. Microsurgery procedures for nerve reconstruction includes neurolysis / nerve release, nerve repair, nerve grafts and nerve transfers. Specially trained surgeons use extremely precise customized instruments to reconnect and repair nerves.

Patients with complex nerve injuries may need a combination of procedures to achieve recovery of function.

Nerve Reconstruction

Nerve reconstruction is the term given to the various microsurgical techniques used to treat nerve injury.

Nerve reconstructive options include allograft and autograft nerve grafts, nerve transfers and nerve conduits to bridge digital sensory nerve gaps. The gold standard in nerve repair is primary end-to-end coaptation.
If damage to the nerve occurs too far away from the affected muscles, recovery is not possible with just nerve repair surgery.

Reconstruction procedures to restore lost function include tendon transfers that takes working muscles that are adjacent to a paralyzed muscle, and substituting the movement of one muscle for another by reconnecting the tendons from the uninjured muscle to the injured one. The new movement from the transferred muscle maximizes function in that specific area.

Early intervention is extremely important for obtaining a positive outcome. For the best results, nerve reconstruction should begin between 3-6 months after the injury.

Primary nerve reconstruction are optimally performed 3-6 months after injury.

Secondary reconstructive procedures include tendon transfers, free muscle transplants, pedicle muscle transfers, and fusions. These secondary procedures can often be done months or years after the injury.

Recovery from reconstructive nerve surgery is a lengthy process. Long-term physical therapy helps to preserve range of motion, strength, and flexibility in the affected area. Physical therapy also helps muscle atrophy.

Nerve Grafting

When there is too large of a gap for repair or a large quantity of tissue has to be removed from the nerve endings, nerve grafting takes a non-essential nerve from a separate location on the body and used to bridge the nerve gap. Nerve graft substitutes derived from donated nerve tissues are also appropriate for some patients.

Periodic exams after nerve repair are required to chart the progress of the regenerating nerve fibers. Signs of recovery include returning muscle tone and contraction and restore voluntary movement. The advancing nerve fibers within the recovering nerve will tingle when tapped.

Neurolysis

Neurolysis and nerve release are techniques used to remove scar tissue or compression areas on the nerve that can disrupt normal function and cause pain.

In a nerve repair coaptation, the surgeon lines up the nerve ends and reattaches the two ends of the severed nerve.

For a nerve graft, the surgeon takes a healthy piece of expendable nerve from another location on the patient’s body (autograft) and uses it to reconnect the two ends of the damaged nerve. Recovery begins when the nerve tissue starts to regenerate from either end of the original nerve connecting via the grafted nerve tissue.

For brachial plexus injuries, the sural nerve (a long nerve that extends from the ankle to the back of the knee) is often used and this removal from its original site does not harm the patient.

New technology and advances are using bioabsorbable material that provide a scaffolding on which the axons in the two nerves can reconnect.

Nerve Transfer

Nerve transfer involves moving working nerve branches from adjacent uninjured nerves to reconnect to an injured nerve close to its connection to muscle to restore function. Nerve transfers are able to restore function to muscles by placing the recovering nerve endings closer to the target muscle area before irreversible damage occurs.

Nerve transfers in many cases have replaced nerve grafting. Sensation can also be restored with nerve transfers of working sensory nerves to nonfunctioning sensory nerves in a related procedure.

When the nerve recovers, physical therapy is initiated to maximize the functional gains. Physical therapy will concentrate on retraining better function as the sensation returns. Physical therapy helps maintain flexibility and motion in the joints and muscles.

Nerve transfer procedure takes a donor nerve from another location in the patient’s body and connect it to the site of the damaged nerve to restore its function. The surgeon separates out the bundles of nerve fibers (fascicles) that deliver the important information. Nerve transfer reconstruction surgery offers advantages including the potential for a faster reconnection of the nerve tissue and muscles.

In addition to its use in brachial plexus injury, nerve transfers can be an effective treatment for other complex injuries to the peripheral nerves, especially nerve problems associated with fractures and dislocations, nerve lacerations, nerve tumors, and injuries from projectiles.

Surgeons refer to various types of nerve transfers based on the location of the donor nerve.

Intraplexal nerve transfers are done within the brachial plexus. One example is the intraplexal nerve transfer of the ulnar nerve to the biceps branch of the musculocutaneous nerve to help restore elbow function.

Extraplexal nerve transfers connects a donor nerve from a site that is outside the brachial plexus. Patients with injuries to multiple levels in the brachial plexus may require an extraplexal transfer, such as one involving the intercostal nerve in the rib cage to the biceps.

Distal nerve transfer utilizes nerve tissue below the elbow that can be moved to reinnervate the ulnar nerve and help restore function to the hand.

Depending on the nature of the injury, the surgeon may perform nerve transfers in combination with other nerve reconstruction procedures. Nerve transfers may also be called neurotization, heterotopic nerve suture, and nerve crossing.

Neurolysis, nerve repair, nerve grafting and nerve transfer are used to regain sensibility and to decrease neuropathic pain.

Periodic monitoring and electrodiagnostic testing is important to ensure that recovery is occurring.

Free muscle transfer

Free muscle transplantation is the transfer of a skeletal muscle and its own blood supply from one location in the body to another. In brachial plexus injury, the gracilis muscle (a long muscle on the inside of the thigh) that helps flex the knee and turn the hip inward is transplanted to the arm to restore the patient’s ability to bend the elbow and move the fingers.

Free muscle transplant may help restore certain types of function months or even years after the initial nerve injury.

Pedicle muscle transfer

Pedicle muscle transfer procedure moves only the muscle but the blood vessels and nerves to the muscles are left attached.

Tendon transfer

Tendon transfer takes a tendon from one part of the body and moves it to another part of the body. Most tendon transfers do not require microsurgery at the microvascular level.

Fusion

Patients whose affected arm has healed in an unnatural position, may benefit from fusion, in which the bones are realigned into a more natural position and pins and other instrumentation are placed to secure the bone during healing.

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