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VA Medical Monograph l! PERIPHERAL NERVE REGENERATION A Follow-up Study of 3,656 World War II Injuries Editors BARNES WOODHALL, M. D. Professor of Neurosurgery Duke University Medical School Durham, North Carolina and GILBERT W. BEEBE, Ph. D. Statistician, Follow-up Agency Division of Medical Sciences National Research Council Washington, D. C. 26 JUNE 1956 V* VS^'^L KGADEMY LIBRARY JUL231357 RESEARCH The work reported herein is part of the program of studies of the Follow-up Agency of the National Research Council developed by the Committee on Veterans Medical Problems in cooperation with the Veterans Administration, the Army, and the Navy. This investigation was supported by the Veterans Administra- tion upon the specific advice of the Committee on Veterans Medi- cal Problems of the National Research Council and was conducted as a collaborative effort under contracts with the medical schools of Duke University, Columbia University, Northwestern Uni- versity, the University of Pennsylvania, and the University of California, with the Massachusetts General Hospital, and with the National Academy of Sciences.

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1 LIST OF VA MEDICAL MONOGRAPHS In Print A Follow-up Study of World War II Prisoners of War Tuberculosis in the Army of the U. S. in World War II A Follow-up Study of War Neuroses Peripheral Nerve Regeneration: A Follow-up Study of 3,656 World War II Injuries In Preparation Sequelae of Acute Viral Hepatitis Late Effects of Arterial Interruption in Battle Casualties of World War II The After-Effects of Head Injuries Sustained in World War II Late Effects of Cold Injuries (Ground Type) Sustained in World War II For sale by the Superintendent of Documents. D. S. Government Printing Office Washington 25* D. C.

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Foreword To the Series of Monographs on Medical Follow-up Studies It may have been said by the casual reader that this series of monographs arose from war and owed its interest to the aftermath of war, but this would be less than half truth. It is true that those who saw and mended the wounds of combat took immediate steps to learn in peace the medical cost and errors of war. But the studies which these monographs report are not limited to war injury, and by design are applicable to all patients and all medicine, and to the improvement of medical education wherever practiced or needed. They grew from a concept that was then expressed in part as follows: "During the period beginning with the mobilization of the Army in 1940 and continuing to date an enormous amount of material of great clinical value has accumulated in the records kept in * * * medical installa- tions * * * of the Armed Forces. It can fairly be said that no similar amount of material has ever been accumulated, and it is doubtful whether a similar amount will ever again be available." * * * "It is suggested that this accumulation of material should be turned to practical use by the establishment of a clinical research program, including a follow-up system to determine the natural and post-treatment history of such diseases and conditions as might be selected for the study." * * * "At the clinical research level it furnishes an opportunity to provide an investigative program in which the entire medical profession would par- ticipate and from which all would profit." (Memorandum of 5 March 1946 from Dr. Michael E. DeBakey, then Colonel, Director of Surgical Consultants Division, to The Surgeon General of the Army Norman T. Kirk.) Undoubtedly there were other such generous suggestions during World War II, and indeed DeBakey cited the Army experience with several, such as the registry on peripheral nerve injuries, but this one was well placed and pursued with energy. General Kirk transmitted the plan to the National Academy of Sciences— National Research Council (NAS-NRC), and Dr. Lewis H. Weed, Chair- man of its Division of Medical Sciences, invited an ad hoc committee to consider the feasibility of the proposal. This committee, with Dr. Edward D. Churchill as chairman, in the course of three meetings, April to June 1946, in approving the plan, recommended a standing Committee on Veterans Medical Problems to guide the studies and an operating agency to conduct them. With the stout backing of General Paul R. Hawley, Chief Medical Director, Dr. Paul B. Magnuson, Assistant Medical Director for Research and Education, promised the support of the Veterans Admin- istration, and the Surgeons General of the Army, Navy, and the U. S. Public III

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Health Service expressed their approval. Thus the Committee on Veterans Medical Problems came into being in August 1946 under the chairmanship of Dr. O. H. Perry Pepper, and the Follow-up Agency was constituted under Dr. Gilbert W. Beebe. In the intervening 10 years natural changes have occurred in committee and staff personnel with one exception, and it is to this exception that we owe the continuity, the excellence of experimental design and analysis, the high quality, and even the actual production of the reports of these studies. That exception is the stability of the senior group in the Follow-up Agency: Dr. Gilbert W. Beebe, Dr. Bernard M. Cohen, and Mr. Seymour Jablon. This group foresaw and its successors found a panorama of opportunities largely neglected after previous wars: a reservoir of pathological material (now in the Armed Forces Institute of Pathology) common to the military and the succeeding veteran; a punchcard index of episodes of illness in a large segment of our population; a verteran population more easily located and more readily motivated to participate in specific studies than any other large population group; and an integrated system of medical care with emphasis upon war-connected illness or injury administered by 173 hospitals and 69 regional offices, so located that some experience all extremes of cli- mate and altitude that exist in our nation, supplemented by the hospitals' close association with medical faculties through the Deans Committees of 73 medical schools with a like geographic distribution. In all these resources there is a continuing record of stress, trauma, and disease in which illness or injury, from induction in the Armed Forces to death of the veteran, gen- erates a permanent record available for study. To take full advantage of these obvious opportunities the Committee on Veterans Medical Problems was charged with the broad responsibility for initiating and fostering a general program of medical follow-up studies based on experience with the military and veteran population. Under this committee was organized the Follow-up Agency of the National Research Council to carry out the staff functions associated with the planning and organization of research projects, arranging access to medical records, and providing statistical analysis. The program is a general one, its unity arising out of the availability of a research tool of broad applicability in clinical medicine, especially in the area of the natural history of disease. Some studies have been based entirely on existing records (military, clinical, pathological, mortality, dis- ability) while in others the recorded information has been supplemented by intensive current laboratory and clinical observations. Much of the product of the program will be found in medical periodicals appropriate to the subjects of investigation. However, some of the studies are of such magnitude as to require reporting at greater length than would be possible even in a series of journal articles. The Veterans Administra- tion, therefore, has inaugurated this series of monographs as the most effec- tive means of presenting the results of these larger studies.

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The Veterans Administration has provided the direct financial support for the majority of the studies in this program and the Armed Forces have provided strategic support in the form of access to necessary records and ancillary services. Many Federal, State, and private agencies have also given generous assistance to the work as required. Field installations of the Veterans Administration—hospitals, regional offices, and record repositories—have joined with the Central Office in extending needed assistance to the NRC and the investigators responsible for the direction of these studies. While the commitments were made by the Chief Medical Director, most of the VA resources essential to the success of such a program lie under the administrative control of groups other than the Department of Medicine and Surgery, and yet the necessary aid always has been promptly, efficiently, and cheerfully given. We of the present staff of the Veterans Administration are much indebted to the initial group of planners and to their successors on the Committee on Veterans Medical Problems, to many officers and civilians on duty in the offices of the Surgeons General of the Armed Forces and in the record repositories of the Armed Forces, to our own predecessors in the Veterans Administration, to the editors and contributors of each volume, and to the officers, staff, and members of National Academy—Research Council, but most particularly to the continuing staff of the statistical Follow-up Agency. We wish also to emphasize here the peculiar distinction of the National Research Council in bringing together in one effort the research talents of our Nation—those of universities, professional societies, various govern- mental agencies, and private physicians. The Veterans Administration is proud of its privilege in presenting this series of monographs in the belief that each volume is a contribution to all medicine, but most particularly in the conviction that its conception in cooperation is a peculiar contribution of and by a free American Medicine. JOHN B. BARNWELL, M. D. Assistant Chief Medical Director for Research and Education.

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PARTICIPANTS IN VETERAN FOLLOW-UP PROGRAM AT THE LEVEL OF THE NAS-NRC Chairman, Division of Medical Sciences Dr. Lewis H. Weed, 1939-49 Dr. Milton C. Winternitz, 1949-53 Dr. R. Keith Cannan, 1953- Members and Staff, Committee on Veterans Medical Problems Members: Dr. H. Glenn Bell, 1950 Dr. David A. Boyd, Jr., 1956- Dr. Francis J. Braceland, 1946-48 Dr. W. Edward Chamberlain, 1956- Dr. Edward D. Churchill, 1946- 1948 Dr. Winchell McK. Craig, 1946- 1949 Dr. Wilburt C. Davison, chair- man, 1950-55; member, 1956- Dr. Michael E. DeBakey, 1946- Dr. Louis I. Dublin, 1946-47 Dr. Jacob E. Finesinger, 1952- Dr. Morris Fishbein, 1946-51 Dr. A. McGehee Harvey, 1953- Dr. A. LeRoy Johnson, 1951-53 Dr. Chester Scott Keefer, 1949- 1950 Dr. Esmond R. Long, chairman, 1956-; member 1952-55 Dr. Perrin H. Long, 1946-53 Staff-: Dr. John C. Ransmeier, 1946-48 Dr. Thomas Bradley, 1953-56 Dr. Currier McEwen, 1956- Dr. Donald Mainland, 1953 and 1956- Dr. Herbert H. Marks, 1948-53 Dr. William C. Menninger, 1946- 1948 Dr. H. Houston Merritt, 1952-53 Dr. J. Roscoe Miller, 1946-53 Dr. Hugh J. Morgan, 1946^8 Dr. O. H. Perry Pepper, chair- man, 1946-49; member 1950 Dr. I. S. Ravdin, 1949-50 Dr. C. P. Rhoads, 1946 Dr. William S. Stone, 1956- Dr. Roy H. Turner, 1951 Dr. John C. Whitehorn, 1949-50 Dr. Milton C. Winternitz, 1946- 1949 Dr. Stewart G. Wolf, 1951 Dr. Harold G. Wolff, 1949-50 Dr. Barnes Woodhall, 1951 Dr. Theodore S. Moise, 1948-53 Dr. Gilbert W. Beebe, 1946-

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Follow-Up Agency Professional Staff Senior Statisticians: Dr. Gilbert W. Beebe, 1946- Dr. Bernard M. Cohen, 1948- Mr. Seymour Jablon, 1948- Operations: Miss Regina Loewenstein, 1948- Miss Nona-Murray Lucke, 1947- 1954 1951 Mr. A. Hiram Simon, 1949- Mr. Sidney Wald, 1951-54 vll

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PERSONNEL OF DEPARTMENT OF MEDICINE AND SURGERY, VETERANS ADMINISTRATION, RESPON- SIBLE FOR INITIATION AND CONTINUED SUPPORT OF PROGRAM OF VETERAN FOLLOW-UP STUDIES Chief Medical Director Dr. Paul R. Hawley, 1946-47 Dr. Joel T. Boone, 1951-55 Dr. Paul B. Magnuson, 1948-51 Dr. William S. Middleton, 1955- Assistant Chief Medical Director for Research and Education Dr. Paul B. Magnuson, 1946-47 Dr. George M. Lyon, 1952-56 Dr. E. H. Cushing, 1948-52 Dr. John B. Barnwell, 1956- Direclor, Research Service Dr. E. H. Cushing, 1946-47 Dr. John C. Nunemaker, 1952 Dr. Louis Welt, 1947-48 Dr. Arthur F. Abt, 1952-53 Dr. Alfred H. Lawton, 1948-51 Dr. Martin M. Cummings, 1953- Chief, Contractual Division, Research Service Dr. Marjorie Price Wilson, 1952-53 Dr. Theodore S. Moise, 1953- Special Assistant to Assistant Chief Medical Director for Research and Education Mr. Robert A. Kevan, 1946-48 Mr. Ralph T. Casteel, 1948-55 viii

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COLLABORATORS IN THE FOLLOW-UP STUDY OF PERIPHERAL NERVE INJURIES The present study constitutes a large collaborative effort on the part of many investigators representing several disciplines and eight institutions. In addition to the contributors of the individual chapters, many others have shared in the planning and organization of the work, including development of the standard protocol for the examination, and in the examinations of patients. Membership in the study group is listed below; composition of the teams at the respective centers is indicated in the footnotes. Barnes Woodhall, M. D., Chairman Professor of Neurosurgery Duke University School of Medicine Durham, N. C. GUbert W. Beebe, Ph. D. Statistician* Division of Medical Sciences National Research Council Washington, D. C. Loyal Davis, M. D.' Professor of Surgery Northwestern University Medical School Chicago, 111. Thomas L. DeLorme, M. D.J Instructor in Orthopedics Massachusetts General Hospital Boston, Mass. S. Malvern Dorinson, M. D.2 Director* Physical Medicine Maimonides Hospital San Francisco, Calif. Harry Grundfest, Ph. D.1 Associate Professor of Neurology Columbia University College of Physicians and Surgeons New York, N. Y. Ernst Herz, M. D.1 Assistant Professor of Clinical Neurology Columbia University College of Physicians and Surgeons New York, N. Y. Frederic H. Lewey, M. D. (deceased)« Associate Professor of Neuropath- ology University of Pennsylvania School of Medicine Philadelphia, Pa. William R. Lyons, Ph. D., M. D. Professor of Anatomy University of California Medical School Berkeley, Calif. Joseph Moldaver, M. D.3 Associate in Neurology Columbia University College of Physicians and Surgeons New York, N. Y. Howard C. Naffziger, M. D.5 Professor of Surgery University of California School of Medicine San Francisco, Calif. Frank E. Nulsen, M. D.« Professor of Neurosurgery Western Reserve University School of Medicine Cleveland, Ohio Y. T. Oester, M. D.1 Associate Professor of Pharmacology Stritch School of Medicine Loyola University Chicago, 111. See footnotes on page x. Ix

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Lewis J. Pollock, M. D.1 Professor of Neurology Northwestern University Medical School Chicago, 111. Robert S. Schwab, M. D.' Assistant Clinical Professor of Neurology Harvard University Medical School Boston, Mass. Bertram Selverstone, M. D.1 Professor of Neurosurgery Tufts College Medical School Boston, Mass. Eugene B. Spitz, M. D.« Assistant Professor of Neurosurgery University of Pennsylvania School of Medicine Philadelphia, Pa. Arthur L. Watkins, M. D.' Assistant Clinical Professor of Medicine Harvard University Medical School Boston, Mass. Eugene M. Webb, M. D.« Assistant Clinical Professor of Neurosurgery University of California School of Medicine San Francisco, Calif. James C. White, M. D.J Professor of Surgery Harvard University Medical School Boston, Mass. Melvin D. Yahr, M. D.' Assistant Professor of Clinical Neurology Columbia University College of Physicians and Surgeons New York, N. Y. Korea intervened before the work of the original study group could be completed and provided an opportunity for the further study of early peripheral nerve injuries. Dr. Frank E. Nulsen organized a team of in- vestigators which included William J. Erdman, II, M. D., Instructor, Physical Medicine and Rehabilitation, University of Pennsylvania Medical School, and Harry W. Slade, M. D., Instructor in Neurosurgery, Western Reserve University School of Medicine. This work was done on Army patients at Valley Forge General Hospital, under a contract between the Army and the University of Pennsylvania. 1 Member of the Chicago team, headed by Dr. Davis. 2 Member of the Boston team, headed by Dr. White. 3 Member of the New York team, headed by Dr. Grundfest. 4 Member of the Philadelphia team, headed by Dr. Lewey. 6 Member of the San Francisco team, headed by Dr. Naffziger.

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Foreword The publication of this study of peripheral nerve regeneration after battle-incurred injury marks the end of a huge clinical research program that began in 1943, in the course of World War II. The program was participated in by more than a hundred of the neurosurgeons who served in the Medical Corps, as well as by many neurologists, neuroanatomists, neurophysiologists, neuropathologists, physical therapists, statisticians, and representatives of the administrative personnel of every echelon of command in the Army Medical Corps. Later the program was also participated in by representatives of the Veterans Administration and the National Re- search Council. A clinical research program of such magnitude has probably never before been attempted by Federal agencies concerned with the care and rehabilita- tion of military personnel. That enthusiasm for its completion should have extended over the 11 postwar years is in itself a remarkable fact. It is also a lasting tribute to the foresight and tenacity of the man who conceived this project and brought it to fruition, Dr. Barnes Woodhall, now Professor of Neurosurgery at the Duke University School of Medicine and formerly Lieutenant Colonel, Medical Corps, A.U.S. This investigation does not, of course, provide all the answers to all the unsolved problems of peripheral nerve surgery. For one thing, it was not possible, as is true in all clinical research programs, to set up ideal control conditions for all phases of the study. In wartime the pressure of routine work in the operating room and out of it left surgeons with little time, strength, or enthusiasm to keep accurate records of all the details essential in a research investigation. Furthermore, as the editors point out, when this study was conceived, the investigators themselves did not know exactly what information regarding the early care of patients with peripheral nerve injuries would prove to be of the greatest importance. In spite of these deficiencies, many basic problems have been answered by this investigation, and to the satisfaction, it seems certain, of the most critical observer. We now know, for instance, the optimum time for nerve suture and the value of physical therapy during the period of regeneiation. We can accept the validity of the concept that one must be radical in the exploration of every case of nerve injury with total loss of function but ex- tremely conservative before one substitutes end-to-end suture for neurolysis when continuity of the nerve has not been interrupted. We also know now that the degree of functional recovery can be prophesied with reasonable precision by estimating the distance of the lesion from the area of principal innervation. These examples are only a few of the basic concepts estab- lished, with irrefutable evidence, by this study. The answers to certain

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Chapter III. Recovery of Motor Function—Continued Page E. Influence of Technical Aspects of Management—Continued 6. Transposition or Extensive Mobilization as Special Operative Fea- tures 159 7. Bone Resection 166 8. Bulb Suture 166 9. Character of Nerve Ends at Definitive Suture 167 10. Tension Upon Suture Line 170 11. Suture Material 174 12. Use of Cuff 180 13. Use of Stay Suture 185 14. Technique of the Definitive Lysis 190 15. Training of Surgeon 191 16. Summary 191 F. Combined Influence of Adverse Factors Upon Motor Recovery Follow- ing Suture 198 Chapter IV. Electrical Evidence of Regeneration—Harry Grundfest, T. T. Oester, and Gilbert W. Beebe 203 A. Introduction 203 B. Methodology 204 1. Stimulation of Nerve 204 2. Chronaxiemetry 207 3. Galvanic Tetanus Ratio 211 4. Electromyography 214 5. General Remarks on the Evaluation of the Results and Usefulness of Electrodiagnostic Tests 219 C. Analysis of Electrodiagnostic Data 220 1. Orientation and Methodology 220 2. Estimated Influence of Factors Preventing Voluntary Contraction . 235 Chapter V. Recovery of Sensory Function—T. T. Oester and Loyal Davis 241 A. Introduction 241 B. Methods of Evaluating Sensory Recovery 242 1. Pain 243 2. Touch 244 3. Position Sense 245 4. Localization 245 5. Modified British Summary of Sensory Regeneration 247 6. Sensory Evidence of Anatomic Regeneration 248 7. Sources of Error 250 C. Description of Sensory Recovery Following Complete Nerve Suture.. .. 251 1. Pain 251 2. Touch 252 3. Localization 254 4. British Summary of Sensory Regeneration 254 5. Sensory Evidence of Anatomic Regeneration 259 D. Description of Sensory Recovery Following Neurolysis 260 1. Pain 260 2. Touch 262 3. British Summary of Sensory Regeneration 263 4. Sensory Evidence of Anatomic Regeneration 265 E. Influence of Characteristics of Nerve Injury Upon Sensory Recovery... 266 1. Anatomic Completeness of Traumatic Lesion Preceding Complete Suture 266 2. Site of Lesion 268 3. Multiple Lesions 276 xlv

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Chapter V. Recovery of Sensory Function—Continued Page F. Influence of Associated Lesions 278 1. Associated Nerve Injury 278 2. Associated Bone or Joint Injury 279 3. Chronic Infection Delaying Repair 281 4. Associated Arterial Injury 284 5. Major Plastic Procedure at Site of Nerve Injury 285 G. Influence of Technical Aspects of Management 286 1. Number of Operations 286 2. Interval From Injury to Definitive Suture 288 3. Echelon of Definitive Repair 295 4. Length of Surgical Gap 295 5. Transposition or Extensive Mobilization as Special Operative Fea- tures 297 6. Bulb Suture 299 7. Character of Nerve Ends at Definitive Suture 300 8. Tension Upon Suture Line 301 9. Suture Material 301 10. Use of Cuff 303 11. Use of Stay Suture 306 12. Training of Surgeon 308 13. Summary 308 Chapter VI. Pain and Related Phenomena, Including Causalgia—James C. White and Bertram Selverstone 311 A. Introduction 311 B. Causalgia 311 1. Description of Causalgia Syndrome 311 2. Historical Considerations 314 3. Treatment 315 4. Statistics From Present Study 317 5. Typical Case Histories 328 6. Summary 334 C. Other Painful Phenomena 335 1. Definitions 335 2. Relation to Characteristics of Injury 337 3. Relation to Treatment of Injury 338 4. Relation to Other Follow-up Characteristics 339 Chapter VII. Autonomic Recovery—Bertram Selverstone and James C. White 341 A. Introduction 341 B. Descriptive Data on Autonomic Recovery 342 C. Influence of Characteristics of Injury 344 D. Influence of Technical Aspects of Management 345 E. Autonomic Recovery and Other Evidence of Regeneration 346 F. Relation Between Subjective and Objective Evidence of Autonomic Recovery 346 Chapter VIII. Functional Recovery and Occupational Adjustment—Gilbert W* Beebe 349 A. Introduction 349 B. Methods of Evaluating Functional Recovery and Occupational Adjust- ment 350 C. Variation in Functional Regeneration 354 D. Overall Functional Evaluation in Relation to Motor and Sensory Re- covery 368 E. Relation Between Functional Recovery and Compensation Ratings by Veterans Administration 375

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Chapter VIII. Functional Recovery and Occupational Adjustment—Con. Page F. Occupational Changes 377 G. Occupational Handicaps 382 H. Functional Capacity of Men Who Remained in Service 383 Chapter IX. Recovery Following Injury to the Brachial Plexus—Frank E. Nulsen and Harry W. Slade 389 A. Introduction 389 B. Regeneration 390 C. Discussion 399 1. Spontaneous Recovery 399 2. Surgery to Determine Prognosis 400 3. Surgery of the Plexus as a Therapeutic Measure 401 4. The Use of Tendon Transfers 404 5. Other Rehabilitative Measures 405 D. Conclusions 407 Chapter X. Case Study of the Best and Poorest Results Following Peripheral Nerve Suture— Barnes Woodhall 409 A. Introduction 409 B. Upper Extremity 411 1. Median Nerve 411 2. Ulnar Nerve 424 3. Radial Nerve 436 4. Summary 446 C. Lower Extremity 447 1. Peroneal Nerve 447 2. Tibial Nerve 460 3. Sciatic-Tibial Nerve 473 4. Sciatic-Peroneal Nerve 487 5. Summary 496 D. Conclusion 498 Chapter XI. Neuropathological Predictions of Recovery—William R. Lyons and Barnes Woodhall 499 A. Introduction 499 B. Methodology 512 C. Gross Variation in Pathological Predictions of Regeneration 541 D. Correlation Between Neuropathological Forecasts of Regeneration and Clinical Assessments of Eventual Recovery 547 1. Pain Threshold 548 2. Touch Threshold 548 3. Skin Resistance (SR) 552 4. Motor Recovery 559 5. Overall Functional Evaluation 563 6. Composite Index of Nerve Regeneration 563 E. Summary 565 Chapter XII. Neurosurgical Implications—Barnes Woodhall* Frank E. Nulsen, James C. White, and Loyal Davis 569 A. Introduction 569 B. Management in Forward Areas 569 1. Recognition of Peripheral Nerve Involvement 569 2. Immediate or Emergency Treatment of Peripheral Nerve Wounds . 570 3. Early Splinting of Paralyzed Muscles 571 xvl

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Chapter XII. Neurosurgical Implications—Continued Page C. Evaluation and Definitive Management 571 1. Introduction 571 2. Evaluation of Evidence For or Against Nerve Regeneration as an Indication for Resection and Suture 576 a. Certain Evidence of Regeneration 579 (1) Voluntary Motor Function 579 (2) Preservation or Recovery of Sensation 580 (3) The Preservation of Sweating 581 (4) Motor Response on Nerve Stimulation 581 b. Uncertain Evidence for Regeneration 583 (1) Tinel's sign 583 (2) Shrinkage of the Area of Sensory Loss 583 (3) Improvement in the Usefulness of the Extremity 583 (4) Electromyography 584 (5) Chronaxie 585 (6) Galvanic Tetanus Ratio 585 c. Certain Evidence for Unsatisfactory Regeneration 586 D. The Problem of the Neuroma in Continuity 588 1. Introduction 588 2. Illustrative Cases 589 3. Discussion 622 E. Administration 623 1. Personnel 624 2. Equipment 625 3. Time and the Wound Policy Factor 625 4. Influence of Associated Injuries 626 a. Bone 626 b. Arterial 627 c. Soft Tissue 629 d. Chronic Infection 629 F. Influence of Technical Factors of Surgical Management Upon Anatomi- cal Regeneration 629 G. Disposition to Duty 630 H. End Results of Repair, Summary by Individual Nerve 630 1. Lower Extremity Injuries 631 2. Upper Extremity Injuries 634 I. Final Note 638 Bibliography 639 Index to Names 643 Index to Subjects 646 403930—57

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Introduction Barnes Woodhall More than 10 years have elapsed since the first casualties of the African invasion arrived at the Walter Reed General Hospital for continuing treat- ment of their war wounds. In this initial convoy of 94 casualties, the harbinger of many others, were 10 peripheral nerve injuries. They were the first of 25,000 peripheral nerve injuries that were subsequently dis- tributed among 19 neurosurgical centers established by the Army Medical Corps. Many of these patients had already received definitive peripheral nerve surgery in specialized neurosurgical facilities in general hospitals in England and in the North African theater. The responsibility for their treatment rested upon a small group of young neurosurgeons who had been largely recruited under the leadership of Colonel R. Glen Spurling of Louisville, Ky., and upon others who were in turn stimulated to initiate a similar program among injured personnel of the Navy and Marine Corps. To this nidus of neurosurgically trained individuals was added a larger group, both here and overseas, of general surgeons who had been trained under civilian, Army, and Navy auspices in the specific demands of military neurosurgery. In this respect, particular mention should be made of schools established at Columbia University and at the University of Penn- sylvania under, respectively, Tracy Putnam and Francis Grant, where general surgeons were indoctrinated in neuroanatomy and neurophysiology. These were experimental ventures at the time but they proved exceedingly worthwhile. The tradition of peripheral nerve surgery of war had been in large part dimmed by the passage of time since World War I, not only in this country but in the whole world. The 3,500 nerve casualties of that conflict had been absorbed in the veteran population, and the care of similar injuries, incurred in the growing industrial life of the United States, was spread widely among any and all surgeons. Only in our medical schools could the student of surgery encounter this tradition and this contact was but a casual one. The Friday morning surgical clinics of Professor Dean Lewis at the Hopkins were too rarely highlighted by the laborious progress of a fourth-year medical student around the circular highway of the anatomical structures of the wrist, with particular attention being directed to the nerve supply of the intrinsic hand muscles. Such grueling episodes might have been repeated with Loyal Davis in Chicago, the late Claude C. Coleman in Richmond, the late Charles Elsberg in Philadelphia, or with Byron Stookey in New York City. Lewis Pollock, with Loyal Davis and also Byron Stookey, xlx

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published textbooks devoted to this subject. There undoubtedly were others who endeavored to sustain interest in a subject which often was delegated to the attention of the surgical intern on call in the emergency room. The Medical History of World War I concerned with neurosurgery weighed 8 pounds and, on the back shelves of the medical libraries, ap- peared lost to many observers. It contained the neuropathological research studies of Carl Huber and his associates and a very complete clinical section by K. Winfield Ney, both as valid at the start of World War II as they had been when written. The Neurosurgical Centers of World War I, at Cape May and elsewhere, had registered some 3,000 peripheral nerve injuries, with the hope that some type of follow-up program might be instituted in the postwar years. Registers of 3,129 peripheral nerve injuries were completed. The examina- tions of 400 cases of nerve suture by physicians of the Veterans Administra- tion in the postwar period were only reported in terms of good, mediocre, or negative. An analysis of 470 cases by a single neurosurgical observer yielded 34 percent "good" results, 36 percent "mediocre," and 26 percent "failures." No objective definition of these terms was published. The situation was little better in the other countries that had been engaged in the battles of World War I. In England, Sir Robert Jones had assembled a distinguished group of surgeons, anatomists, and neuro- physiologists with the knowledge and skill to study and treat nerve injuries, and their casualties too were segregated in specialized centers. The members of this group might be termed the opposite numbers of the surgeons, who, for a shorter period, served in a similar capacity in the United States Army. No arrangements were made, however, for the analysis of the vast amount of data assembled by these observers and the report on nerve injuries published by the Medical Research Council in Great Britain was an inconclusive one. Again the only surgeons who evinced interest in this matter in the postwar years were those few who had participated directly in nerve surgery during World War I. No follow-up studies were available from the other major combatant powers, France and Germany, although the infrequently read observations made by Tinel and Foerster in this field were of the highest order. In October 1944, The Surgeon General of the United States Army, Major General Norman T. Kirk, directed the establishment of a Peripheral Nerve Registry for the dual purpose of evaluating the existing program of nerve surgery and laying a foundation for postwar studies. Registry forms were devised, sent to all neurosurgical hospitals, and the completed initial and 3-months' assessment reports were forwarded to the Surgeon General's Office. In consultation with Army representatives, the neuro- surgical services of the naval hospitals at St. Albans (New York) and Oak Knoll (San Francisco) agreed to collect similar data on their nerve injuries in sailors and marines. These reports were coded and filed under the statistical guidance of the Medical Statistics Division of the Surgeon General's Office. By September 1945, a total of 7,050 nerve sutures and

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67 nerve grafts had been registered. As this basic roster was being com- piled, identical efforts on a more circumscribed scale were being initiated by individual observers, the most comprehensive of these being that assembled under the direction of the late Frederic H. Lewey at the Cushing General Hospital. It was clearly manifest during the war period that the data recorded on the individual patient's history varied greatly in detail and accuracy, due presumably to lack of planning in the prewar period. It is a historical fact, however, that such planning proceeded at a rapid pace during the war years and, as the fighting in the Western theater came to its end, postwar study centers were envisaged. The time hiatus between discharge from military hospital and the functioning of these study centers interdicted the study of many longitudinal data. On the other hand, the large rosters which are mandatory in the study of such a many-faceted injury were available, and the essential information upon which a follow-up study of late peripheral nerve regeneration largely depends, was at hand, both in the hospital records and registry forms. These were indisputable advantages which favored any proposed postwar study. The lack of good longitudinal data in the original study project has been alleviated in large part through a meticulous survey of early peripheral nerve injuries in casualties from the Korean campaign hospitalized in the Valley Forge General Hospital. This project, initiated and carried on by Frank E. Nulsen, under an Army contract recommended by the National Research Council, represents an early and very valuable dividend from these basic studies. They represent some foretaste of what this monograph may establish on a firm foundation for the future. The study centers and their organization responsible for this report are described in the early part of this monograph. Their objectives could be visualized but were not to be readily attained. The elaborate patterns of synergistic muscle activity and sensory synthesis that are damaged when a peripheral nerve is divided are not easy to study, either as an initial and relatively static injury or during the course of spontaneous or acquired nerve regeneration. Statistical data may be provided by the measurement of the return of voluntary power in muscle and the return of sensibility in skin and deeper tissues. The physiological changes that occur in dener- vated and reinnervated muscle in electrical excitability and electromyo- graphical activity are also susceptible of statistical analysis. From such data, some of the factors, both biological and technical, that influence peripheral nerve regeneration may be assessed. The average expectation of anatomic regeneration may be plotted with reasonable certainty, and in relation to the varying factors of time interval, height of lesion, specific neuropathology, and a host of others, but in the aggregate such factors as these do not so closely determine the end result as to enable prognoses to be made with confidence about individual cases. The variables having to do with retrograde neuronal reaction, delayed recovery, incomplete recovery and persistent transsynaptic effects are beyond the skill of a surgeon to influence and may largely contribute to the fact that recovery xxl

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after nerve division is never complete, even under the most favorable circumstances. A considerable mass of statistical material has been collected and studied. It is valid, difficult to read, and represents the source data from which certain clinical conclusions have been expressed. It must be emphasized that in 92 percent of the cases the follow-up data were secured 3 or more years after suture (or, for lyses, after injury), and that the median length of follow-up is 52 months. They do not, therefore, reflect the different findings that may be seen immediately after nerve injury or suture and in the early period of neural regeneration. From the whole complex functional result must be abstracted, for pur- poses of statistical analysis, those components which somehow seem more important or which are more reliably measured, with the realization that the status of functional regeneration is more than the sum of these com- ponents and reflects in part influences which extend far beyond mere anatomic reinnervation. These factors become increasingly evident years after injury when the results of treatment may be studied in terms of func- tion of the entire extremity rather than its component parts. During this time, the patient has become adjusted to his residual disability both mentally and physically, and the extent of his readjustment may be defined as functional regeneration. The neural basis of skilled movement, involving motor and sensory neurons and central integration, must be reestablished on the basis of either diminished stimuli and effectors or reeducated in terms of new patterns introduced through the medium of tendon transfer. The patient himself has a profound influence upon the extent of his own functional regeneration, both from the point of view of his personal reaction to injury and the demands of his occupational training. An effort has been made to analyze functional regeneration in this report, although any type of truly scientific expression of this faculty is lacking. The primary purpose of this study of postwar nerve regeneration has been that of providing for the surgeon of the future a body of information upon which he may guide repair of injured peripheral nerves and initiate needed orthopedic rehabilitation. In particular, a clear knowledge of the regeneration which can be expected from a given nerve suture in a given location will allow an intelligent choice between the alternatives of such surgical treatment as opposed to preservation of a nerve lesion permitting partial function. The more accurate early anticipation of end results will also delineate more promptly the indicated orthopedic measures. Prolonged hospitalization can be curtailed far short of an end point for nerve regeneration when it is clear that all applicable rehabilitative meas- ures have been utilized. In the closing chapter an attempt has been made to draw from the material, supplemented by extensive clinical experience with the problem, its implications for the management of lesions in the future. Finally, not the least of the aims of this investigation has been that of procuring for the Armed Forces adequate information on the time xxlt

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spent in hospital by men with well-defined peripheral nerve injuries and of securing specific information on residual disabilities. This work is a classical example of cooperative clinical research, subject to the strengths and weaknesses of such an endeavor. The investigators concerned with sifting this huge mass of material were individuals of proved talent, working under certain handicaps characteristic of the veteran population, pioneering in a new field and possessed of strong personal interests in the total area of peripheral nerve injury. They were permitted full freedom of research interest since they were eminently qualified as responsible investigators. The exigencies of the problem of evaluating peripheral nerve regeneration required the use of diverse talents, largely outside the domain of clinical or operative neurosurgery. To these neuro- physiologists, the seeming lack of surgical direction and the apparent failure early to establish questions to be answered or denied, beyond those designated in the initial code design, must have been a continuing source of irritation. In retrospect, their criticisms may be valid. On the other hand, by this technique objective data of great variety and detail, unprej- udiced by previous thinking, have been laboriously collected and this is the major contribution of this inquiry. This monograph is not a textbook of peripheral nerve surgery. During the longtime period encompassed by this study of neural regeneration, a number of clinical contributions have been published that have stemmed from this identical material. These include studies on peripheral nerve diagnosis, the neuropathology of peripheral nerve injuries and critical evaluations of electrodiagnostic techniques. From the data presented in the body of the monograph, certain surgical conclusions have been reached or, when necessary, restated so that the informed surgeon can treat a new peripheral nerve injury with a firm concept of the result that he will attain under the diverse and many factors that influence such an injury. The wide clinical spectrum of peripheral nerve injury has been reviewed in fresh format and meticulous insight in the newly published British periph- eral nerve report in which chapter VIII alone is devoted to the results of peripheral nerve suture. From the technical point of view of defining the source of data, the assem- bling and presentation of data, the discussion of ancillary or specialized topics, and the marshalling of pertinent conclusions, this monograph stands as a study in continuity. No facile or superficial method has been found to substitute for the rather painstaking recording of factual data although considerable effort has been expended to formulate conclusions in a readable form. The casual reader should lay aside this report; the reader who commences his task in the middle of this monograph will make a grave error. To this should be added the observation that the reader who completes the monograph is a brave disciple of our art. Many individuals and agencies have contributed to this effort to salvage from the surgical experience of World War II basic information on the xxlll

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regeneration of peripheral nerves: The surgeons whose experience in the evaluation and treatment of the lesions created the source-records on which the study rests; the Army officials who perceived the value of a registry of peripheral nerve injuries, directed its establishment, and made it available for use here; the Veterans Administration which provided generous financial support for the undertaking and, through its regional offices, furnished access to necessary records and other direct assistance in the follow-up work; the American Red Cross which extended invaluable aid in the actual follow-up work; and, finally, the patients who, often at personal incon- venience, presented themselves for follow-up examination many years after original injury. xxlv