Peripheral Nerve Regeneration A Follow-Up Study of 3,656 World War II Injuries (1957) / Chapter Skim
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Recovery of Sensory Function
Recovery of Sensory Function
Pages 241-310
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From page 241... ...
to utilize differential sensory recovery as an analytic tool for evaluating the effects of characteristics of the nerve injury, of any associated injuries, and of various details in their management. One cannot expect the content of routine clinical records, much less those of war injuries, to be commensurate in their detail and perfection with observations made years after the injury in accordance with a specific research protocol and in comparatively leisurely fashion.
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From page 242... ...
B METHODS OF EVALUATING SENSORY RECOVERY At the initial January 1947 conference it was pointed out that there then existed very little information on the specific level of sensory return, by modality, which could be expected following injuries of known extent, and that both practical and scientific interests would be served by the careful assessment of individual modalities.
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From page 243... ...
response and areas of complete loss. At the Chicago conference in January 1949 it was decided to abstract from the sensory examination only the superficial pain and touch thresholds for the autonomous zones, together with the pain and touch responses to deep pressure, and to summarize sensory regeneration on the basis of the scale developed by workers associated with the British Medical Research Council (68)
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From page 244... ...
Superficial pressure felt with 3 gin./mm' 7. Superficial pressure felt with <3 gm./mm1 The study of center variation in rating touch thresholds was made along the lines already described in connection with the pain threshold, and considerable center variation was found for each of the four nerves sampled (median, ulnar, tibial, and peroneal)
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From page 245... ...
Table 131. -- Correlation Between Pain and Touch Assessments, Median, Ulnar, Peroneal, and Tibial Nerves Pain response Touch response Absent Present Total Abse n t 83 104 10 93 Present 580 684 Total 187 590 777 3. Position Sense The test of position sense consisted of asking the subject to locate the postion of the moved part, screened from his view.
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From page 246... ...
Localization was tested in less than half the cases, and presence of anesthesia played a large role in the examiner's decision whether to perform the test. Unfortunately, when the observations were coded for statistical analysis all cases not tested were lumped together as unknowns, so that the material as coded cannot be used except in conjunction with the results of tests on pain and touch thresholds.
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From page 247... ...
For these reasons the observations on localization possess only very limited usefulness and their presentation in the following section has been limited to the data from a single center, Philadelphia. Table 133. -- Percentage of Cases Tested for Localization in Relation to Results of Pain and Touch Stimulation, Complete Sutures on Median, Ulnar, Tibial, and Sciatic-Tibial Nerves Examined at Philadelphia Follow-up Center Number of lesions studied Localization test performed Pain threshold Touch threshold Number Percent None, or 50 gm.
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From page 248... ...
Table 134. -- Comparison of Follow-up Centers as to Classification of Sensory Recovery on Basis of British Summary, Completely Sutured Nerves With No Associated Nerve Injuries Percentage distribution of cases by British summary Total Center Not more Pain and Pain and number than retouch, with touch, with of nerves turn of overreaction no overTotal superficial and inabilresponse pain (0, ity to local(5, 6, 7)
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From page 249... ...
Two centeis seem to deviate excessively from the rest, Chicago in the direction of reporting lower sensory return and San Francisco in the opposite direction, if the cases examined by the five centers are in fact homogeneous to begin with. Table 135. -- Comparison of Follow-up Centers as to Percentage of Completely Sutured Lesions With Any Evidence of Anatomic Regeneration of Sensory Fibers, Nerves With JVb Associated Nerve Injury on Same Limb Percentage with evidence of regeneration, by nerve Center Median Ulnar Tibial Sciatictibia!
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From page 250... ...
One result is that the effect of characteristics of the nerve injury, of associated injuries, and of variables in the management of the nerve injury, may be analyzed best on the basis of the pain threshold, but the observations on touch and the British classification have also been used. To the extent that variation among the study centers cooperating in the present investigation may be representative of variation among the generality of skilled neurological observers, however, the fact that the group of examiners was as large as five provides some assurance that their examinations will yield an average picture of all possible examinations, rather than one unduly influenced by a particular point of view.
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From page 251... ...
1. Pain For all the complete sutures in the representative sample, without regard to site of injury, extent of injury, presence of associated nerve injury, etc., table 136 provides a summary of findings by nerve.
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From page 252... ...
Table 136. -- Deep-Pressure Pain Response and Superficial Pain Threshold for Completely Sutured Lesions, by Nerve, Autonomous %pne Only Threshold ' Median Ulnar Radial Tibial Peroneal SciaticSciaticperoneal tibial Percent Percent Percent Percent Percent Percent Percent No sensation of pain 8.5 11.9 5.8 19.0 15. 5 22.7 23.3 Deep-pressure pain only .
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From page 253... ...
At the high end of the touch scale the pain and touch thresholds look moderately similar. Table 137. -- Deep-Pressure Touch Response and Superficial Touch Response for Completely Sutured Lesions, by Nerve, Autonomous %pne Only Threshold ' M U R P T SP ST No sensation, or threshold >-50 em.
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From page 254... ...
For both median and ulnar combined, split localization was reported in 46 percent of the cases with absent or deep pain threshold only (but with touch <50 gm.) , and in 42 percent of the cases with a superficial pain response and touch threshold <50 gm.
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From page 255... ...
It will be noted from the detail of the classification scheme that the underlying observations extend well beyond the tests of individual modalities already summarized. The frequencies of table 139 support the same general conclusions already noted and in addition enable one to see just how rarely complete sensory recovery occurred.
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From page 256... ...
On the other hand, it would be an unusual selection which increased the sampling ratio at both the good and the bad ends of the scale, and it therefore seems likely that other factors are at work as well. Table 139. -- British Summary of Sensory Regeneration for Completely Sutured Lesions, by Nerve Summary ' M U R P T SP ST Percent 11 1 Percent 12.
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From page 257... ...
S and British Data on Sensory Regeneration, Complete Sutures on Ulnar, Median, and Tibial Nerves British code ' Median Ulnar Tibial U.S.
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From page 258... ...
Superficial pain and touch, no overreaction (code 5,6,7) At most deep-pressure pain 0 8 1 9 Superficial pain, 20-40 gm 0 45 29 74 Superficial pain, <20 gm 0 30 67 97 Total 0 83 97 ISO Since agreement with British results is so poor, and the summary scale employed here is largely compounded of more specific tests of pain and touch responses, the United States data on the ulnar were subdivided by pain and touch as a further exploration of the basis of the summary classi251
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From page 259... ...
The cases studied here, it may be noted, are not confined to the representative sample, but extend to all examined cases in which the pain and touch thresholds were actually measured. From table 141 it may be seen that the summary rubric "absence of sensibility" follows very closely, as it must, the results of the specific tests of pain and touch; although the detail of table 141 is not sufficient to show it, 56 cases were explicitly coded as having neither pain nor touch response, 59 no pain response, and 61 no touch response, in the group of 64 cases.
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From page 260... ...
168 70.8 Sciatic-tibial 134 74.6 D DESCRIPTION OF SENSORY RECOVERY FOLLOWING NEUROLYSIS In view of the multiplicity of the sensory tests and the generally superior sensory recovery following neurolysis, this separate section is devoted to an exposition of the results obtained with neurolyses and to their comparison with sutures.
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From page 261... ...
However, it is also plain that if surgeons had chosen, instead of neurolysis, resection and suture of the lesions studied here -- neurolyses, the ultimate sensory recovery would probably have been less favorable than it actually was. As was noted in connection with table 143, however, one might argue that 10 to 25 percent of the lysed lesions might have done better if resected and sutured.
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From page 262... ...
. Lysed and sutured lesions differ as to touch response about as they do as to pain, as may be seen from table 146.
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From page 263... ...
In the great majority of cases there was some return of superficial pain and touch, and complete absence of sensibility was relatively uncommon. Table 147 provides the basic data on all the neurolysed lesions classified as to the modified British scale for sensory recovery.
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From page 264... ...
S -- L -- i S is used for suture, L for lysis. Table 147. -- British Summary of Sensory Regeneration for Lysed Lesions, by Nerve Summary M U R P T SP ST Percent 5.2 Percent 5.2 Percent Percent 12 0 Percent 7 4 Percent 13 2 Percent 14 3 Sensibility absent o Deep pain only 3.9 6.2 3 3 16 0 7 4 10 5 6 3 Superficial pain 0 1 0 10 0 4 0 o 10 5 6 3 Some superficial pain and touch 10 4 19 6 10 0 12 0 7 4 7 9 14 3 Superficial pain and touch, overreaction and poor localization 20.
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From page 265... ...
In the median and ulnar comparisons it will be noted that the lysed have not only fewer poor results but also many more good results, but in the sciatic comparisons the advantage is chiefly one of fewer poor results; even the lysed lesions do not often exhibit superior sensory recovery in the sciatic. Table 148. -- Comparison of Completely Sutured and Lysed Nerve Lesions as to British Summary of Sensory Regeneration, by Nerve Percentage distribution as to sensory regeneration Superficial pain and touch, with overresponse (2*
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From page 266... ...
E INFLUENCE OF CHARACTERISTICS OF NERVE INJURY UPON SENSORY RECOVERY The preceding comparisons of lysed and completely sutured lesions pertain to the most important characteristic of the nerve lesion, namely, its precise anatomic nature and extent, but such comparisons are at best quite imperfect, for one can never know these facts for the lysed lesion as one can for the completely sutured.
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From page 267... ...
but is intuitively unreasonable in its direction; one would almost be willing to require that any discrepancy favor the neuromas in continuity. Despite these two aberrant tests, therefore, the only possible conclusion from these data is Table 150. -- Pain Threshold and Anatomic Completeness of Lesion Prior to Complete Suture, by Nerve Percentage distribution of lesions as to pain threshold J Number of lesions Nerve and completeness of lesion ' None or deeppressure only Median: Complete 20-40 gm.
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From page 268... ...
Table 151. -- Touch Threshold and Anatomic Completeness of Lesion Prior to Complete Suture, by Nerve Percentage distribution of lesions as to touch threshold 2 Number of lesions Nerve and completeness of lesion ' None or 35 gm. or more 16-25 gm.
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From page 269... ...
Table 152 provides the data on the pain threshold for median, ulnar, peroneal, and tibial nerves. In none of these comparisons does the discrepancy approach statistical significance, and despite some suggestion that lower lesions generally do a little better a combined probability on the discrepancies presented by all four nerves Table 152. -- Comparison of High and Low Lesions as to Pain Threshold, Complete Sutures, by Nerve Percentage distribution as to pain threshold ' Number of lesions Superficial pain threshold Nerve and site At most deeppressure Total Median: High 20-40 gm.
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From page 270... ...
Table 153. -- Comparison of High and Low Lesions as to Touch Threshold, Complete Sutures, by Nerve Percentage distribution as to touch threshold ' Number of lesions Nerve and site None or 35 gm or more 5 gm or or less 16-25gm Total Median: High 22.2 25.5 29.1 48.7 48.2 100.0 100.1 117 110 Low 26.4 Ulnar: High 32.6 28.0 36.2 33.2 31.2 100.0 100.1 221 193 Low 38.9 Peroneal: High .
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From page 271... ...
Again, therefore, the evidence is far from satisfactory but suggestive of some effect favoring lower sites. Table 154. -- Comparison of High and Low Lesions as to British Summary of Sensory Regeneration, Complete Sutures, by Nerve Percentage distribution as to British summary of regeneration Number of lesions Nerve and site Not more than return of superficial pain Pain and touch with overreaction and inability to localize Pain and touch with with no no overresponse Total Median: High 24.4 26.5 48.0 37.6 27.6 35.9 100.0 100.0 127 117 Low Ulnar: High 34.2 30.9 33.8 38.7 32.1 100.1 100.0 237 204 Low 30.4 Peroneal: High 42.7 32.1 33.3 28.6 23.9 39.3 99.9 117 28 Low 100.0 Tibial: High 48.3 45.6 44.8 39.7 6.9 14.7 100.0 100.0 29 Low 68 Site was studied in full detail for all sutures in the entire sample, not merely those in the representative sample and, for the pain threshold, table 155 gives a distribution of results for each site, by nerve.
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From page 272... ...
Table 155. -- Specific Site of Lesion and Pain Threshold at Follow-up, Complete Sutures, by Nerve Percentage distribution as to pain threshold ' Number of lesions ' Specific site Superficial pain threshold At most deeppressure Total 20-40 gm.
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From page 273... ...
Table 155. -- Specific Site of Lesion and Pain Threshold at Follow-up, Complete Sutures, by Nerve -- Continued Percentage distribution as to pain threshold ' Number of lesions 2 Specific tite Superficial pain threshold At most deeppressure Total 20-40 gin.
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From page 274... ...
Even the differences noted for the median and sciatic-tibial are not very Table 156. -- Specific Site of Lesion and Touch Threshold at Follow-up, Complete Sutures on the Median and Sciatic- Tibial Nerves Percentage distribution as to touch threshold ' Specific site Number of lesions3 50 gm. or more including no sensation 16-35 gm.
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From page 275... ...
In general, it would appear that the lower lesions do better than the higher, and that the very highest tend to do least well. Table 157 provides a partial summary of the relationship, with emphasis upon the likelihood of no sensory response whatsoever in the autonomous zone, based on the modified British classification.
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From page 276... ...
Multiple Lesions The foregoing analysis is concerned almost exclusively with single lesions to a nerve trunk, but there were a handful of cases, here termed "multiple lesions," in which a single nerve sustained more than one injury. These cases are too few for refined statistical study, but those in which at least one of the lesions on the nerve was completely sutured are listed in table 158 as to pain and touch thresholds, and British sensory recovery.
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From page 277... ...
Table 158. -- Pain and Touch Thresholds and British Sensory Recovery Following Multiple Lesions to Single Nerves, and With One Lesion Completely Sutured Case number Nerve Pain threshold gm.' Touch threshold gm.1 British summary 3 1074 Median 20 16 reaction. Unknown.
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From page 278... ...
F INFLUENCE OF ASSOCIATED LESIONS Although the decision to limit the statistical study of pain and touch response to the observations on the autonomous zone should obviate most of the influence of an associated nerve lesion upon the examiner's evaluation of the sensory recovery of another, it was considered wise to examine the data on the median and ulnar from this point of view.
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From page 279... ...
Table 160. -- Presence of Associated Nerve Injury and Pain Response in Autonomous %pne at Follow-up, Complete Sutures on the Median and Ulnar Nerves Percentage distribution as to pain threshold * Number of cases Associated nerve injury At most deep pain 30-40 gm.
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From page 280... ...
Table 162 presents the observations on the median as a sample of the available material. The British summary of sensory regeneration was also employed as a sensory index in an effort to test the relationship between bone and joint Table 161. -- Presence and Character of Any Associated Bone or Joint Injury, and Pain Threshold in Autonomous %one at Follow-up, Complete Sutures on Median Nerve Percentage distribution as to pain threshold ' Presence and character of associated bone or joint injury Superficial pain felt Number of lesions At most deeppressure pain With 20-40 gm.
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From page 281... ...
Table 162. -- Presence and Character of Any Associated Bone or Joint Injury and Touch Threshold in Autonomous %pne at Follow-up, Complete Sutures on Median Nerve Presence and character of bone or joint injury Percentage distribution as to touch threshold ' Number of lesions None or 50 gm. or more 16-35 gm.
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From page 282... ...
The point of view adopted here is that any effect must be general, and that the observed variation provides no basis for believing that chronic infection exerts any influence upon the ultimate regeneration of pain fibers. Table 163. -- Presence of Chronic Infection Delaying Nerve Repair and Recovery of Pain Response, Complete Sutures, by Nerve Infection present Infection absent Statistical tests2 Nerve Percentage with threshold of 10 gm.
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From page 283... ...
One must conclude, therefore, that the presence of chronic infection sufficient to delay repair, or the fact of such delay, or other factors associated with such infection, probably do tend to impair recovery of the touch threshold. Table 164. -- Presence of Chronic Infection Delaying Nerve Repair and Recovery of Touch Response, Complete Sutures, by Nerve Infection present Infection absent Percentage with superficial touch threshold of 5 gm.
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From page 284... ...
Table 165. -- Presence of Chronic Infection Delaying Nerve Repair and British Overall Assessment of Sensory Recovery, Complete Sutures, by Nerve Infection present Infection absent Statistical tests > Nerve Number of cases Percentage classified as superior ' Number of cases Percentage classified as superior ' Median .
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From page 285... ...
The observed variation is unusually small even as an example of chance variation. Table 166. -- Presence of Associated Arterial Injury and Recovery of Pain Response in Autonomous Zpne, Complete Sutures and Neurolyses in the Upper Extremity, by Nerve Arterial injury absent Arterial injury present Statistical tests' Nerve and definitive operation Percentage with threshold of 10 gin.
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From page 286... ...
G INFLUENCE OF TECHNICAL ASPECTS OF MANAGEMENT It is extremely difficult to assess the value of therapeutic procedures in the absence of experimental safeguards on the selection of clinical material, but in view of the great practical interest which inheres in the results of various choices which the surgeon may make as to therapeutic procedures, the analysis of sensory recovery has been extended to such details of management as seemed obtainable from the original military records.
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From page 287... ...
Table 168. -- Number of Operations and British Summary of Sensory Recovery, Complete Sutures on Pure Nerve Lesions, by Nerve Nerve One operation Two or more operations Statistical tests2 Number of cases Percentage classified as superior ' Number of cases Percentage classified as superior ' Median. 138 291 100 86 31.2 34.0 28.0 15.1 41 94 45 6 22.0 21.3 17.8 16.7 NS Ulnar *
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From page 288... ...
Interval From Injury to Definitive Suture The pitfalls of any analysis of the possible effect of time have been discussed at length in chapter III and need not be repeated here. At the outset the analysis of sensory recovery was confined to pure lesions on the median, ulnar, peroneal, and tibial, but no more than suggestive evidence of an effect was obtained.
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From page 290... ...
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From page 291... ...
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From page 293... ...
Sciatic-tibial Total 32 28 19 79 1 As denned in tables 170 and 171. Table 173. -- Sensory Recovery Following Complete Sutures at Intervals Greater Than 700 Days After Injury Case Pain threshold ' in gm.
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From page 294... ...
Touch threshold s in gm. British summary' Median .
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From page 295... ...
Table 174. -- Echelon of Definitive Suture and Recovery of Pain Response in Autonomous Zone at Follow-up, Pure Lesions on Median, Ulnar, Peroneal, and Tibial Ov erseas Ifl Statistical Nerve Percentage with pain threshold of 10 gm. or less ' Percentage with pain threshold of 10 gm.
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From page 296... ...
abbreviated as follows: NS -- Not significant. and touch thresholds and the British summary of sensory recovery were all utilized in this analysis, which was not confined to pure lesions and extended to all seven major nerves, but the resulting variation appears to lie well within the power of chance to produce.
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From page 297... ...
5. Transposition or Extensive Mobilization as Special Operative Features Bulb sutures associated with transposition or extensive mobilization were omitted from this study, which extended to all major nerves regardless of presence of associated nerve injury, provided the definitive operation was complete suture.
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From page 298... ...
abbreviated as follows: NS- - Mot significant. Table 179. -- Extensive Mobilization and Transposition and Recovery of Touch Response in Autonomous £one at Follow-up, All Complete Sutures, by Nerve Lesions with no Lesions with transspecial features position or extensive mobilization StatisNerve tical Percentage Percentage tests' with touch with touch Number threshold Number threshold of 5 gm.
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From page 299... ...
On the average the surgical gap in such cases was 2 to 3 times that noted in lesions with no operative features, but as already noted there is little or no evidence of an effect of gap upon sensory recovery. The proportion of complete sutures preceded by bulb sutures is not large, but if all 7 major nerves are studied there are about 120 bulb sutures distributed among them.
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From page 300... ...
Pain, touch, and British summary were studied for each nerve, but with generally negative results as illustrated in table 182 for pain. Table 182. -- Surgeon's Description of Nerve Ends at Definitive Suture and Recovery of Pain Response in Autonomous %pne at Follow-up, Pure Lesions on the Median, Ulnar, Peroneal, and Tibial Both distal and proximal ends normal Other Statistical tests1 Nerve Percentage with pain thresholds of 10 gm.
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From page 301... ...
Only pure lesions on the median, ulnar, peroneal, and tibial nerves were studied as to the possible effect of tension upon sensory recovery. Pain, touch, and the British summary of sensory recovery were all included in these studies, but for none of the sensory indices was the variation associated with differences in tension of a magnitude which achieved statistical significance.
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From page 302... ...
Controlled comparisons of this nature were made for median and ulnar nerves, and are summarized in table 185. Since it has already been shown that associated nerve lesions do not affect examiners' evaluations of sensory recovery, 302
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From page 303... ...
Table 185. -- Suture Material at First Operation and Sensory Recovery, All Median and Ulnar Lesions Studied at New York Center Tantalum or silk Plasma glue Statistical tests' Nerve No. of Percent No.
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From page 304... ...
01. The evidence from the British summary of sensory recovery is even more definite.
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From page 305... ...
Unlike motor recovery, sensory recovery is not appreciably affected by these restrictions; a larger sampling variation is introduced by the fact of smaller numbers of cases, but no systematic shift appears in either the group with, or the group without, cuffs. In consequence, lesions with tantalum foil again appear to have recovered more fully than those without, although the margin of advantage is less certain and more variable in this smaller amount of material.
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From page 306... ...
Only the nerves of the upper extremity were studied, and the British summary of sensory recovery was used to provide the criterion. As may be seen in table 190, this limited study provides no evidence of any effect upon sensory return.
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From page 307... ...
Table 190. -- British Summary of Sensory Recovery and Use of Stay Suture at Definitive Suture, Nerves of the Upper Extremity Number of lesions Percentage with superior sensory return l Nerve Stay suture Median None 217 30.4 Any . 49 34.7 Total 266 31.2 Ulnar 360 30.0 77 28.6 Total 437 29.7 Radial None 169 55.0 Anv 52 42.3 Total 221 52.
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From page 308... ...
The analysis of variation in sensory recovery associated with these differentials in neurosurgical training was done on pure lesions managed by complete suture. Pain recovery, touch recovery, and the British summary of sensory recovery were all employed as measures of functional sensory return, but for none of them was any evidence found that neurosurgical training, thus defined, was associated with differentials in sensory recovery.
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From page 309... ...
Level of formal neurosurgical training of operator. In marked contrast to the analysis of motor recovery, it is extremely significant that the analysis here yields no evidence that time from injury to suture influenced sensory recovery in any way.
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