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Chapter X CASE STUDY OF THE BEST AND POOREST RESULTS FOLLOWING PERIPHERAL NERVE SUTURE Barnes Woodhall A. INTRODUCTION Although the statistical analysis of the factors influencing the regenera- tion of peripheral nerve injuries may show trends of indisputable signifi- cance, it cannot illustrate the ideal case where all factors are so blended that they produce the maximum return of function of which each nerve may be capable. This method may readily portray those factors that mitigate against good regeneration; the obverse can then only be surmised by the absence of such adverse factors. Whether this is a valid assumption or not, it is a fact that the experienced observer can peruse a succession of individual case reports and form substantial opinions concerning the probable cause of adequate or poor neural regeneration. This approach has been taken with a moderately large group of case histories in which regeneration was recorded as developing to a point that might be termed maximal, and with a similar group in which little or no regeneration was noted after a period of many years. Ten examples of maximal regeneration and a like number with virtually no evidence of regeneration were selected from each of the 7 nerve groups (median, ulnar, radial, tibial, peroneal, sciatic-tibial, and sciatic-peroneal), a total of 140 cases. They were chosen primarily on the basis of the two modified British summaries, one of motor recovery and the other sensory. The specific criteria, of course, varied by nerve, and as shown in table 228. Use of these motor and sensory criteria produced more than 10 examples in each group. Autonomic recovery and overall functional evaluation, therefore, were used to make the final selection of 10 cases from among those eligible under the motor and sensory criteria for each group. Thus, an example of very poor recovery in the median nerve might have: (1) a complete absence of sensibility; (2) an elevated skin resistance in the total area of nerve supply; (3) an overall functional evaluation of 30 percent or less; and (4) either no motor recovery or at most just perceptible contrac- tion in proximal muscles. An example of very good recovery would include: (1) perception of superficial pain and touch throughout the autonomous sensory zone plus some two-point discrimination; (2) normal skin resist- 403930— 57 28 «>9

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ance; (3) an overall functional evaluation of 80 percent or more; and (4) contraction against resistance on the part of all important muscles, both proximal and distal, plus capacity for some synergic and isolated movements. Table 228.—Motor and Sensory Criteria Employed in Choosing Examples of Good and Poor Recovery Following Complete Suture, by Nerve Nerve British motor British sensory Good recovery Median, ulnar, and radial Peroneal. Tibial... Sciatic-peroneal .. Sciatic-tibial. At least all important proxi- mal and distal muscles act- ing against resistance plus capacity for some synergic and isolated movements. At least all important proxi- mal and distal muscles act- ing against resistance. Same as peroneal At least proximal muscles act- ing against gravity, percep- tible contraction in intrinsics. Same as sciatic-peroneal At least return of superficial pain and touch, plus some 2-pt. dis- crimination in autonomous At least return of superficial pain and touch throughout autono- mous zone. At least return of some superficial pain and touch in autonomous zone. At least return of superficial pain and touch throughout autono- mous zone, with overreaction and inability to localize. At least return of some superficial pain and touch in autonomous zone. Poor recovery Median. Ulnar. Radial. Peroneal Tibial Sciatic-peroneal Sciatic-tibial. . . At most perceptible contrac- tion, proximal muscles only. No contraction at all Same as median Same as ulnar. . Same as median. Same as ulnar. . Same as median. At most deep cutaneous pain sensibility in autonomous zone. Same as median At most return of some superficial pain and touch, autonomous zone. Same as median. Same as median. No sensibility in autonomous zone. Same as sciatic-peroneal. The extent of neural regeneration has been charted against the major variables that are assumed to influence regeneration, in particular those that are capable of assessment, that is, location of wound in the extremity, time of definitive treatment after injury, extent of the neural defect, exist- ing neural pathology, and presence of complicating factors such as infec- 410

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tion, concomitant vascular, bone, and extensive soft tissue injury, and surgical error. Much use has been made of illustrative case material and indeed it is from this that the reader may form his own opinions. The author has chosen to retain these case reports in their original form, and in consequence, tense, style, etc., are not uniform. A summary case report was not required by the protocol, and in most centers was not routine. In the Philadelphia center, however, Dr. Lewey early insisted upon their preparation and for this reason it is largely from the Philadelphia cases that the illustrative material has been drawn. Finally, an effort has been made to draw together and summarize the pertinent data of this case study. B. UPPER EXTREMITY 1. Median Nerve The salient features of 10 examples of median nerve recovery at its best are abstracted in table 229, and the details of several then follow. Asso- ciated nerve lesions are shown only if suture was required; incomplete, lysed lesions are omitted. Case Report 4452 HISTORY OF INJURY This soldier was wounded in action in Italy on April 8, 1944, by a shell explosion, receiving multiple perforating wounds of his left forearm in its lower third and also of his left face. He showed some impairment of his left median nerve with loss of flexion of the 1st, 2d, and 3d fingers, and anesthesia of the palm of the hand and superior half of the 1st, 2d, and 3d fingers. On October 2, 1944, neurorrhaphy was done on the left median nerve at Wakeman General Hospital. In the middle third of the forearm the median nerve showed a lateral neuroma adherent to the adjacent muscle tissue; after an attempt to enucleate this tumor mass without damage to the nerve, only a few shreds of nerve were left, and it showed no response to electrical stimulation. It was therefore resected to a gap of 3 cm. and sutured with silk. Seven months postoperatively the patient had 75 percent function in all median muscles, except the opponens which had 50 percent and the flexor pollicis brevis which had none. At 9 months all median muscles showed 75 percent function. This was the patient's status at discharge on August 16, 1945. INTERVAL HISTORY The patient has had no treatment since discharge, but he has noted the return of ability to adduct his index finger. There has been increased sensation in the palmar surface of the 1st, 2d, and 3d fingers, and all hand motions are stronger. His chief complaint is diminished sensation in the first three fingers, difficulty in picking up small objects, and a drawing up of his forearm in cold weather. He has pain with use and rapid fatigue 411

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only with heavy work. Before the war he was a pipefitter's helper. He changed his occupation because he was afraid of damaging his hand. He is now a trucker for the railway express and is slightly handicapped by the inability to do heavy lifting and he also takes time off sometimes because of his arm. His compensation is 30 percent, and he is satisfied with this. CENTER EXAMINATION March 3, 7950 The patient is left handed. Distance of the injury is 9% inches M and there is a "hot spot" present. The injured hand shows some atrophy of the thenar eminence and the middle phalanx of the index and middle fingers is smaller than normal. The forearm is diminished % inch in circumference. The injured hand is slightly cooler than normal but pulses are equal and full. There is no limitation of motion at the wrist or elbow but there appears to be some flexion contracture of all fingers. The patient is able to pick up a pail of water and to button his shirt, but he is unable to pick up a pin with his eyes closed and he now uses his right hand for most manipulations. In a typical median distribution the patient is able to feel 30 gm. pain and 16 gm. touch; because of calluses, the threshold for the normal part of the hand is 20 gm. pain and 3-5 gm. touch. There is no split sensation and there is good localization, but on the thumb two-point discrimination is 2.5 cm. and on the index finger 7 cm., compared with 2 cm. on other fingers. Position sense is slightly impaired in the median distribution. Deep pressure is almost absent on the index finger and impaired on the thumb and middle fingers. Skin resistance is about normal in the median area of the hand and normal to slightly increased in the ulnar area. Quantitative muscle evaluation is as follows: Flexor carpi radialis, palmar is longus, and flexor carpi ulnaris 100 percent; flexor pollicis longus 100 per- cent; flexor pollicis brevis 100 percent; flexor digitorum profundus to all fingers 100 percent; flexor digitorum sublimis to the index finger 100 percent, to the little finger 100 percent; opponens 14 percent; abductor pollicis brevis not tested. Flexor digitorum sublimis to the middle finger had a rheobase of 35, a chronaxie of 0.36; the opponens had a rheobase of 110, a chronaxie of 0.12. Functional evaluation. This patient has good practical function in his hand and arm; by testing, all muscles show almost 100 percent function, and his sensation is not greatly diminished. If it is true that this patient was left handed and therefore if it was his dominant hand that was injured, he may be slightly handicapped by loss of very fine and skilled movements and also by some lack of sensitivity. Because this was a low median nerve injury, only two muscles (abductor pollicis brevis and opponens) should have been affected, and these as well as sensory function in the hand show a fair degree of return of strength and practically a good degree of function. » Measured from the carpal crease in all cases of upper extremity injury. 414

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Case Report 4366 HISTORY OF INJURY This soldier was accidentally shot by a guard in Luxembourg on October 18,1944. The rifle bullet penetrated his left upper arm in the lower third of the medial aspect, severing the brachial artery and the median nerve. There was also a fracture of the proximal phalanx of the right index finger. At debridement the same day the median nerve was seen to be severed 2% inches above the elbow, while the ulnar and medial antebrachial cutaneous nerves were intact. The brachial artery was ligated and the median nerve approximated; penicillin was placed in the wound. Six weeks later the patient had osteotomy performed on the right index finger. On March 3, 1945, neurorrhaphy was performed on the left median nerve at Kennedy General Hospital. At the site of approximation there was a 2-cm. neuroma and there was no electrical response in the nerve. The median nerve was resected 5.5 cm. to good fibrils, sutured with tantalum and wrapped in a tantalum foil. Five months postoperatively there was good function in the pronator teres, flexor carpi raclinlis, palmaris longus, and flexor pollicis longus. At discharge on December 17, 1945, the pronator teres showed 75 percent function, the flexor carpi radialis 75 percent, the flexor digitorum sublimis and flexor pollicis longus 25 percent, the flexor indicis proprius and the opponens 0; there was some sensory return with spread. INTERVAL HISTORY The patient has had no treatment since discharge but his wrist and finger movements have increased in strength. He complains primarily of inade- quate sensation and also of limitation in fine hand movements. Before the war the patient was a steam-shovel operator and he has returned to the same job since the war. He is limited because of fatigue in his injured arm to 50 percent of his previous earnings. The patient's compensation is 50 percent and he is not satisfied. CENTER EXAMINATION November 9, 1949 The patient is right handed. Distance of the injury is 14 inches. There is no marked atrophy, but the forearm is diminished 1 inch in circumference. Pulses are full and strong, and the hands equally warm and moist. Wrist extension is limited to 115 degrees, and there is a slight impairment in flexion of the 2d and 3d fingers. The patient is able to pick up a pin between his thumb and index finger, but is unable to do so with his eyes closed. He is able to pick up approximately 40 pounds weight. Throughout the entire hand the patient is able to feel 6 gm. pain and 5 gm. touch. Deep pressure and position sense are unimpaired. Skin resistance is not noticeably different from that in the normal hand. There is no split sensation. Quantitative muscle evaluation is as follows: Flexor carpi ulnaris, flexor carpi radialis, and palmaris longus 100 percent; pronator teres 100 percent; flexor pollicis longus 100 percent; flexor pollicis brevis 70 percent; flexor 415

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digitorum profundus to the index finger 15 percent, to the middle finger 95 percent, to the ring and little fingers 100 percent; flexor digitorum sublimis to the index finger 60 percent, to all other fingers 100 percent; opponens 80 percent. The opponens shows a rheobase of 85, a chronaxie of 0.28. Functional evaluation. This patient has excellent motor function in his arm, and our testing shows the sensory function to be quite good. How- ever, he complains that he is unable to perform fine movements with his hand and that he is limited by his lack of sensation. We might, therefore, list him as possessing many skilled but awkward movements with some limitation through lack of sensation. Case Report 4266 HISTORY OF INJURY On September 16, 1944, this soldier was wounded in action in Germany, receiving a rifle bullet in the upper third of his left forearm with fracture of the left ulna and anterior dislocation of the left radius. There was no return of function below the pronator teres, and on February 1, 1945, neurorrhaphy was performed on the left median nerve. There was a 2-cm. neuroma in continuity 3 inches below the elbow, and there was no electrical response on stimulation. The nerve was resected 3 cm. to good tubules, sutured with tantalum, and a tantalum foil placed about the site of suture. At discharge on December 12, 1945, there was good function in the forearm muscles, no function in the median intrinsics, but some perception of light touch and deep pain. INTERVAL HISTORY The patient has had no treatment since discharge other than a brief period of physiotherapy. He has noted return of function in the long flexor of his thumb, increased strength of grip, and improved sensation in his fingers. His chief complaint is in diminished maneuverability of his hand, but he can perform all functions with the hand. He has no complaint of pain. He works as a clerk for the Government and does not feel handicapped by his injury. His compensation is 50 percent, of which 40 percent is for his hand injury. CENTER EXAMINA TION August 5, 1949 The patient is right handed. There is slight diminution in substance of the forearm but no gross deformities. There are trophic changes over the median area of the palm and in the nails of the thumb and index finger, and there is loss of pulp in these fingers. The distance of the in- jury is 10K inches from the carpal fold, and at this site the tantalum cuff is palpable. There is no "hot spot." The left ulna is % inch shorter than the right. There is no joint limitation. He has a very strong grip and is able to lift a chair with ease although this strength fades out after several minutes. He can pick up a pencil with his eyes shut, or a pin with his eyes open; he is able to pick the correct coin out of his pocket. 416

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In a typical median distribution he perceives 2 gm. pain and 3 gm. touch, with a very minimal amount of hypersensitivity. There is no split sensation on the palm, and less than 1 cm. on the backs of the fingers. Deep pressure is felt with mild discomfort and referred each time to an- other digit. Two-point discrimination on the thumb is 4 mm. compared with a normal of 2, on the index finger 12 mm. compared with a normal of less than 2. Skin resistance is very slightly increased over the median distribution. Photographs were made of the hand showing opposition and also the trick movement of short abduction. Quantitative muscle evaluation gave the following results: Flexor carpi radialis, palmaris longus 100 percent; pronator teres 75 percent; flexor digitorum profundus to the second finger 35 percent, to the third finger 100 percent; flexor digitorum sublimis to the second finger 80 percent, to the third finger 100 percent; flexor pollicis longus 15 percent; flexor poll iris brevis 100 percent; opponens 35 percent, with substitution; ab- ductor pollicis brevis 28 percent, with substitution. Percutaneous stimula- tion of the median nerve at the elbow gave good response in all median muscles. The flexor pollicis longus had a rheobase of 185, a corrected chronaxie of 4.0; the opponens had a rheobase of 85, a chronaxie of 2.4. Electromyography was done on the opponens; on supermaximal stimula- tion this muscle gave spikes of 2.4 inches compared with a normal of 4.0 inches. Functional evaluation. This patient has excellent functional return, both motor and sensory. He is practically not handicapped. This is a high grade of motor and sensory return. The intrinsic actions of opposition and short abduction are present, but assisted by trick movements. The ten examples of poor recovery are summarized briefly in table 230. The cases chosen for detailed presentation follow. Case Report 4004 HISTORY OF INJURY On October 29, 1944, this patient suffered multiple shell-fragment wounds resulting in bilateral wrist drop and left ulnar and median paralysis from shoulder injuries. By December 27, 1944, the right wrist drop had cleared and only median motor and sensory paralysis persisted on the left. On June 6, 1945, the left brachial plexus was explored and the median nerve was found to be severed 3 cm. distal to the site of its formation from the lateral and medial head. In addition, there was an accessory lateral head which came from the anterolateral trunk to join the median nerve in the upper one-third of the arm; this also was severed. After resection of neuromata there was a gap of 6 cm. (accessory head not stated), the proximal end of which looked good but the distal end contained gelatinous material. The nerves were sutured with black cotton. The other nerves responded well to electrical stimulation. He was given a disability dis- charge on October 8, 1945, at which time he had not yet shown evidence of return of function in the median distribution. 417

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well. Debridement was carried out and cast applied. Injury to the nerves was not noticed at this time. On July 6, 1945, at McCloskey General Hospital, the sciatic nerve was sutured. The gap was 5 cm. and no cuff was applied. A cast was applied with the knee flexed to 90 degrees. On February 8, 1946, the patient was discharged and a notation was made that there was some return of sensation and muscle function. CENTER EXAMINATION December 6, 1948 The suture line is 11^ in. from the medial malleolus. The suture-line is palpable with a fusiform swelling but no radiating pain can be released on pressure. The circumference of the leg, 6 in. below the tibial tubercle, is 9 in. on the left and 12 in. on the right. It is of interest that the left leg is 1 in. shorter than the right, and that there is severe atrophy of the calf. The left foot is definitely cooler although there are no gross ulcerations or trophic changes present in the skin. The pulses are somewhat diminished on the left side but still quite full. The knee joint is perfectly free and mobile as are the toes. The ankle, however, is somewhat stiff and can be only dorsiflexed to 105 degrees as compared to 90 degrees on the normal side. This is simply a function of the minimal work that the patient has put into limbering this joint. On performance tests, he claims that he can walk with or without his brace for about the same distance, a mile. However, without his brace he is very fatigued and complains of a great deal of pain in the foot at the end of this distance. He is unable to walk barefooted because of pain. At the present time his brace is broken and he is making an attempt to get it fixed. Pressure sensation is present in all the toes but is not normal pressure sense, but is rather a painful tingling which shoots backward up the leg. Position sense is about 50 percent of normal in all the toes. Clinical examination of muscle function shows an excellent biceps femoris; the peroneus longus can just be made out, tibialis anticus is 2-plus, the extensor digitorum longus and the extensor hallucis longus show a trace. The gastrocnemius is strong, the tibialis posticus and the flexor digitorum profundus show only a trace, as does the flexor hallucis longus. The intrinsic foot muscles are definitely present, but weak. Chronaxie examination of the tibialis anticus shows a rheobase of 120 and a chronaxie of 1.2 msec., which is excellent. The extensor digitorum longus shows 75 rheobase and a 4.8 msec. chronaxie. The intrinsic foot muscles show a 90 rheobase and a 12 msec. chronaxie. This more or less confirms the clinical impression of the amount of regeneration present in these muscles. Stimulation of the nerve was said not to be necessary be- cause of the patient's good clinical result. Sensory examination showed a good return of sensation over the entire foot. There was some slight hypersensitivity of the sole to nocuous stimuli.

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Functionally, we felt that this patient, despite the shortening of the leg and the marked atrophy of the calf, had an unusually good result, con- sidering that this was a complete sciatic suture. He has good dorsiflexion at the ankle, and provided he loosens up the joint, will have even better function. He should wear a thick sponge rubber insert sole and a some- what larger shoe. However, the patient did not seem interested in our sending a letter to him to that effect, and possibly he will go over to the VA to see whether or not they can arrange for the new shoes. Ten cases illustrating poor recovery in the sciatic-peroneal are summarized in table 242. Detailed case reports follow. Case Report 4042 HISTORY OF INJURY This soldier was wounded in the buttocks September 16, 1944, suffering a complete right sciatic nerve paralysis. Neurorrhaphy was performed December 13,1944. The nerve was found to be involved in a large neuroma just below the sciatic notch; after resection there was a 12 cm. defect. It was necessary to sacrifice some of the branches to the hamstrings. End- to-end suture with tantalum wire was performed without undue tension and the ends wrapped in tantalum foil. Before discharge in May 1946, he was noted to have feeble plantar flexion, no return of sensation, and a Tinel's sign in peroneal nerve to within 3 inches of ankle. INTERVAL HISTORY This patient worked in a distillery prior to his service, and is presently employed as a file clerk at lower salary. His compensation is 70 percent. He complains of spontaneous pain in the ankle and toes, paresthesias, complete sensory loss in the affected area, painful response to extreme cold, severe ulcerations on the sole of the foot, pain with use, and marked fatigability at end of day's work. He wears a brace and can walk 1 mile before he is required to rest. Despite these complaints he is apparently not markedly handicapped in his present position. CENTER EXAMINATION May 14, 1948 On the sensory side, there was a complete analgesia and anesthesia throughout the peroneal and tibial distributions. Skin resistance was sharply increased over this same area. Position sense seemed normal for both the ankle and large toe, absent in the other toes. On voluntary motor examination, only the gastrocnemius functioned (70 percent). There was stiffness in the ankle and toe joints. Percutaneous stimulation of the peroneal nerve at the knee gave only perceptible contractions in tibial anticus, peronei and toe extensors. There was no response to posterior tibial stimulation at the knee and ankle. Neither chronaxie nor tetanus ratio could be determined because of the high rheobase of all musculature. Functionally, the patient walks without a limp with his brace. He shows a complete foot-drop when he attempts to walk without the brace. 4*1

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POINTS OF SPECIAL INTEREST (1) Unsatisfactory recovery from a high sciatic lesion. The nerve was sutured in the region of the sciatic notch after overcoming a gap of 12 cm. This procedure was carried out 3 months after injury under apparently ideal situations. (2) The patchy nature of the recovery. Although the gastrocnemius has received a good innervation, all of the remaining posterior tibial muscles are without innervation. The peroneal muscles have regained slight inner- vation but this is insufficient to be of any practical use to the patient. A complete anesthesia with trophic disturbances persists. (3) From the standpoint of treatment, only an ankle fusion would be feasible and this is not desirable as it would result in the loss of the stepping off function which is provided by the well-functioning gastrocnemius. Case Report 4027 HISTORY OF INJURY This soldier suffered a penetrating wound from a shell fragment in the upper third of the right thigh on April 23, 1943, in Tunisia. By the next day, it was apparent that there was a severe cellulitis present in the wounded area; this healed fairly well in 2 weeks. He was noted to have paralysis of the sciatic nerve, right, common peroneal portion, with inability to dorsi- flex foot and anesthesia over the dorsum of foot. On August 26, 1943, the nerve was explored. There were dense adhesions, but the "peroneal" (actually the tibial—Ed.) nerve was found to be in fairly good continuity with a small injury to the nerve itself. A neuroma in continuity was removed along with a small amount of scar tissue in the nerve. Neurorrhaphy was deemed unnecessary because of the limited involvement; therefore, internal neurolysis was performed, the nerve was wrapped in tantalum foil and the wound closed. Postoperatively an advancing Tinel's was noted down to the ankle, but despite this the only return was a slight amount of sensation. Accordingly, he was reoperated upon February 8,1945. Electrical stimula- tion showed hamstrings and tibial nerves functioning normally but no peroneal function. It was discovered that the tibial nerve had been lysed and cuffed in the previous operation. The peroneal segment was bound in dense scar tissue; it was sectioned to good tubules proximally, but the distal end appeared degenerated even after a defect of 8^ cm. was fashioned. The nerve was sutured with tantalum; no cuff used. At discharge on January 25, 1946, there were "fairly definite peroneal muscle contractions" and patient could evert his foot. There was no tibialis anticus function or toe extensor function. CENTER EXAMINATION April 19, 1948 The patient complains chiefly of numbness in the peroneal area and adverse reaction to cold. He must wear a foot-drop brace continuously, but he is able to walk over a mile and can be on his feet from 1 to 2 hours, before pain forces him to rest. He has had some trouble with his braces, 494

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having broken several. He is a gardener as he was prewar; evidently he handles the job without too much difficulty or handicap. He has abso- lutely no function ascertainable sensory-wise or motor-wise. His peroneal muscles show chronaxies distinctly above the normal range. Tetanus ratio was not possible to determine. There is little to be offered this man in the way of treatment other than a satisfactory brace. He does have a painful callus on the lateral surface of the sole—padding should help. Possibly tendon work would help him if he were interested. POINTS OF INTEREST The case is very interesting from several standpoints. First of all, there has been no return of function, doubtless because of the long interval before suture—when sutured, the distal segment of the nerve appeared quite degenerated. Secondly, the original operation in August 1943 was unsuccessful, due to the fact that electrical stimulation was not performed. Because it was not, the chance for definitive repair of the peroneal segment was missed. The tibial component was lysed with the thought that it was the peroneal. Thirdly, following lysis of the tibial component, the peroneal component was repeatedly observed to have an advancing Tinel's sign. Either Tinel's didn't mean much here or the observers were overenthusiastic. Case Report 4243 HISTORY OF INJURY This soldier was wounded in action in France on January 3, 1945, by a shell explosion, one fragment of which penetrated the medial third of his left thigh, resulting in a paralysis of his left sciatic nerve. He showed an inability to dorsiflex or plantar flex his left foot, although the extensors and flexors of the knee were functioning, and he had a complete sensory loss in the peroneal area with dimished sensation in the tibial area as well. However, the ankle jerk was active, and the knee jerk hyperactive. On March 29,1945, at Lawson General Hospital, neurorrhaphy was performed on the peroneal component of the left sciatic nerve, and neurolysis on the tibial component. While there was scarring over a distance of 10 to 12 inches in the middle of the thigh, the tibial component was found to be grossly continuous and neurolysis was considered sufficient; there was a 5-cm. gap in the peroneal component, which was resected and sutured with tantalum; sulfanilamide was dusted freely throughout the wound. At discharge on June 20, 1946, there was weakness but no atrophy of the muslces of the lower leg. Two bands of hypesthesia were present, one on the posterior aspect of the thigh, the other on the posterior aspect of the leg. There was some return of function in the tibial component, but none in the peroneal. INTERVAL HISTORY In June 1948 the patient was at a VA hospital for physiotherapy for his leg, but he has received no other treatment and has noted no improvement in the leg except some return of sensation to the sole of the foot. He has 495

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no complaint of pain in the leg under any circumstances, nor of rapid fatigue; his only complaint is the inability to dorsiflex his foot. Before the war he installed oil burners; now he is a farm laborer, receiving room and board. His compensation is 90 percent for his leg and an additional 10 percent for his shoulder, which he considers fair. CENTER EXAMINATION June 16, 1949 Distance of the injury is 30 inches. Circumference of the left calf is diminished K inch. Dorsiflexion of the ankle is limited to 10 degrees passively. Pulses are equal and full bilaterally, and there is equal warmth and moisture. There is some atrophy of the intrinsic foot muscles and of the peroneal muscles of the leg. The patient does not use the foot-drop brace, and he walks well on flat surfaces as long as he wears his shoes; he is able to walk a mile without difficulty, and has no trouble climbing stairs unless he is carrying weight. In both the peroneal and tibial distributions the patient is unable to feel 40 gm. pain even as pressure, or 35 gm. touch. Skin resistance is decreased in the peroneal area, with a line of demarcation following the anterior border of the tibia. Deep pressure of the toes is referred to the peroneal cutaneous area of the calf as an ache; there is about 25 percent position sense. Quantitative muscle evaluation is as follows. Gastrocnemius 75 percent of normal; tibialis posticus 25 percent; flexors of all the toes, intrinsic foot muscles, tibialis anticus, peroneus longus, and extensors of all toes, 0. The gastrocnemius had a rheobase of 165, chronaxie 16.0 (at 280 volts), fast; the intrinsic foot muscles had a rheobase of 175, chronaxie 16.0 (280 volts), slow; tibialis anticus had a rheobase of 150, chronaxie of 16.0 (280 volts), slow; the peroneus longus showed only a flicker at 280 volts. Electromyography was done on the tibialis anticus. Functional evaluation. Despite the fact that this patient has function only in the gastrocnemius and tibialis posticus, he is able to do without a foot- drop brace and is able to walk at least a mile, and otherwise shows very little handicap as a result of his injury. POINTS OF SPECIAL INTEREST This was a fairly high sciatic nerve injury (30 inches); however, the main injury was only to the peroneal component, with some scarring of the tibial component. Ten weeks after injury, neurorrhaphy was performed on the peroneal nerve and neurolysis on the tibial nerve; despite this there was return of function only in the gastrocnemius and tibialis posticus, and no sensory return in either component. In the face of this meager return, the patient has made a very satisfactory adjustment, and suffers very little handicap. 5. Summary The normal functions of the lower extremity have to do with the main- tenance of an erect station and adequate ambulation aided by the appro- 496

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priate appreciation of touch, pain, and proprioceptive sensory modalities. In the examples of good regeneration in the lower extremity, sensory return was not complicated by incapacitating painful sensation; in the poor cases, there was usually complete lack of sensory return, a relatively minor handi- cap in the foot as compared to a similar failure of sensory return in the hand. The apparent influence of the factors involved in regeneration in the lower extremity was as follows: Location of injury There were 35 cases of complete sciatic nerve injury among 40 sciatic- peroneal and sciatic-tibial injuries, and in only 7 of the good results was the injury at or above the upper third of the thigh. Thirteen of the poor results, on the other hand, were situated at this level. Case 4406, a com- plete sciatic nerve injury just external to the sciatic notch, showed good and painless sensory return to the foot and motor power return adequate for ambulation, suggesting that high sciatic sutures can be followed by adequate neural regeneration. This analysis only suggests that high lesions do less well than low injuries. Certainly the evidence is not as striking as that found concerning the influence of this factor in the upper extremity. Time after injury In cases exhibiting good regeneration the average nerve suture was performed 121 days after injury; in the poor cases, the average definitive suture was done 241 days postinjury. This latter figure probably represents merely the association of a more complicated leg injury since satisfacory regeneration was found in case 2,166, sutured 290 days after injury, and in cases 2,151 and 4,157, both sutured 240 days after injury. By comparison, very poor neural regeneration was obtained in 20 cases that were defini- tively sutured 30 to 160 days postinjury. Six secondary sutures, performed because an obvious failure was demonstrated after the initial suture, all failed at time intervals from 250 to 810 days postinjury. When suture was done under an 8-month period, no unequivocal influence of delay could be demonstrated in this small series. Nerve defect and tension In general, long nerve defects and suture line tension were more often found in instances of poor nerve regeneration, particularly in the more severe and complicated nerve injuries. Some striking exceptions were seen, as noted in case 2,151, where good tibial nerve regeneration was found in the presence of a 12-cm. defect, and in case 3,455 where good sciatic nerve regeneration was found after repair of an 11-cm. nerve defect. Suture material No positive influence of the type of suture material could be demonstrated except in the X-ray diagnosis of suture line disruption in the tantalum sutures, which represented a common cause for failure. 497

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Complications Except for suture-line separations and neuromas, there was no striking difference between the cases of good and poor nerve regeneration with respect to frequency of complications in the lower extremity. In the good cases, there were 23 instances of a second nerve injury in the same extremity, 14 fractures, 3 major soft tissue injuries, 3 wound infections of significance, and 3 vessel ligations low in the extremity. In the poor cases, by compari- son, there were 21 concomitant nerve injuries, 17 fractures, 6 major soft tissue wounds, 1 arterial ligation, 5 wound infections, and 11 suture line separations or neuromas. The very high incidence of proved suture line separations in nerve operations in the lower extremities suggests a probable cause for the many instances of poor regeneration for which an adequate reason has not been otherwise demonstrated. D. CONCLUSION A careful scrutiny of 140 records of good and bad instances of peripheral nerve regeneration has failed to demonstrate any single factor that favor- ably influences regeneration and reveals only the general impression that simple uncomplicated injuries do better than their counterparts. It is easy, on the other hand, to show that high injuries, particularly in the upper extremity, do less well than low injuries, that combined nerve- artery injuries in the upper extremity do poorly and that in the lower ex- tremity technical errors or excessive suture-line tension, followed by suture line separation, play a very significant role in the failure of regen- eration. Although the average time of suture after injury is appreciably lower in cases of good regeneration than in those of poor regeneration, many injuries sutured at 8 to 9 months after injury showed good sensory and motor return. No really good results were found in sutures performed after the 1-year period and, in particular, late secondary sutures in this series always showed failure of regeneration. The most helpful aspect of this review of records supports a host of personal observations by military neurosurgeons that adequate motor and sensory return can be obtained in uncomplicated or pure nerve lesions, when the necessary surgical experience is applied to the problem at hand, when the effector mechanism has not been destroyed by undue delay of suture after injury and when the same mechanism is kept in order while reinnervation is proceeding. Unfortunately, the realities of war injury permit all these circumstances to combine in few cases. The potential gain of nerve suture must be viewed objectively and equal if not greater emphasis must be placed upon other means of rehabilitation, especially for those nerve injuries in which suture must inevitably fail. 498