Peripheral Nerve Regeneration A Follow-Up Study of 3,656 World War II Injuries (1957) / Chapter Skim
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Neuropathological Predictions of Recovery
Neuropathological Predictions of Recovery
Pages 499-568
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From page 499... ...
to which reference may be made for a technical discussion of histologic method; the second objective defines the scope of the present chapter. Many factors are thought to influence peripheral nerve regeneration; the neuropathologist was asked to make an intensive study of one of them, the surfaces joined by the surgeon in his definitive repair, with the assurance that there would be available for correlation studies not only clinical evaluations of eventual recovery but in addition such other details of the injury and its management as might also have an influence upon endresults.
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From page 500... ...
It was anticipated that any independent, predictive information which the neuropathological studies might contribute could easily be combined with similar information provided by other variables so as to make the best predictions possible as well as to determine the relative contributions of the various predictive variables. At the time the sampling plan for the follow-up study was crystallized, it may be recalled from chapter I, a special effort was made to allocate to the follow-up centers an appreciable number of men on whom histologic studies had been made.
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From page 501... ...
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From page 510... ...
Sensory Recovery Pain Threshold in Crams Numerical values -- threshold as measured; only values of 40, 30, 20*
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From page 511... ...
When only one is given it is the opponens. British Summary 0 No contraction 1 Return of perceptible contraction in proximal muscles 2 Proximal muscles acting against gravity, no return of power in intrinsic muscles 3 Proximal muscles acting against gravity, perceptible contraction in intrinsic muscles 4 Return of function in both proximal and distal muscles so that all important muscles can act against resistance 5 Same as category 4-plus synergic and isolated movements 6 Complete recovery V Unknown For a discussion of this code, see chapter III, pp.
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From page 512... ...
To the extent that the choice employed here is arbitrary, others might conceivably prove more fruitful. Both the distal and the proximal surfaces were evaluated, and four separate assessments were made for each in the form of expected percentage losses in recovery.
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From page 513... ...
The 10 and 25 percent estimated losses for the 2 nerve ends were combined into a summary estimate of recovery of 68 percent.27 Table 244. -- .Neuropathological Ratings, Case 1193 Estimated percentage loss, by region evaluated Nerve segment Epineural Intcrfascicular Perineural Intrafascicular Total segment Proximal 2 0 5 0 3 0 15 10 25 Distal 10 Summary Index 68 "The complements of 10 and 25 percent, i. e., 90 and 75 percent, were multiplied to give the summary estimate of 68 percent.
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From page 514... ...
tibial proximal muscles, nil in intrinsic muscles. Complaints: some loss of gross muscle power, easy fatigability, excessive sweating, split sensation.
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From page 515... ...
Time fibrosis within the tubules of such a long distal segment might also help to explain why large fibers subserving touch and skeletal motor functions did not return adequately. One would also expect atrophy of the distal muscles.
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From page 516... ...
Table 245. -- Xeuropathological Ratings, Case 3046 Estimated percentage loss, by reqion evaluated Nerve segment Epineural Interfascicular Perineural Intrafascicular Total segment Proximal 5 5 10 5 0 0 5 5 20 15 Distal Summary index 68 Imperfect matching of sensory fascicles rather than the slight fibrosis seemed the better explanation for pain and touch returns being subnormal. However, as may be seen in plates 5 and 6 the proximal and distal fascicular appositions were probably better than usual.
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From page 517... ...
Reasons for a nerve faring badly in spite of favorable histology in its sutured stumps have been dealt with extensively in other chapters. Some of these are: badly placed sutures or wrappers; a pathologic "bed"; high lesions resulting in postoperative "time" fibrosis in the distal tubules; stretch fibrosis because of the necessity of resecting too extensively; associated bone, vascular, or other nerve lesions; mismatched proximal and distal fascicular patterns such as illustrated in plate 8 in which the inked-in rings represent the distal fascicles in one possible pattern of apposition with the underlying proximal fascicles.
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From page 518... ...
not only because of the neuromatous proximal stump, but because of the shrunken fibrotic distal fascicles (plates 10, 11, 518
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From page 519... ...
Six of the 8 tested proximal muscles showed varying Table 247. -- Xeuropathological Ratings, Case 3197 Estimated percentage loss* by region evaluated Nerve segment Epi- Interneural fascicular Peiincural Intrafascicular Total segment 5 0 15 5 5 10 15 40 65 Distal i 50 21 .
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The large deduction was made from the distal section because of the endoneural fibrosing process that had almost obliterated the neurilemmal tubules. The summary rating was 19 percent.
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Plate 1 3. Case 4472 •f Plate 14.
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From page 522... ...
Pain threshold 10 gm. and touch 16 gm.; autonomic return was equivocal, a mixed skin resistance pattern having been coded; proximal muscles not involved but 2 of the 3 distal muscles tested contracted against resistance, the other against gravity.
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Plate 17. Case 3269 Plate 1 8.
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From page 524... ...
The pathologist recorded the presence of about 10 shrunken distal fascicles among fibrotic surroundings, and also noted that amyelinated axons had grown into some of them following the bulb suture. In order to qualify the record of this unexpected functional recovery, some of the adverse phenomena coded under complaints (see above)
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From page 525... ...
Table 250. -.\europathological Ratings, Case 5357 Estimated percentage loss, by region evaluated Nerve segment Epincural Interfascicular Perineural Intrafascicular Total segment 0 3 5 10 2 5 0 70 7 88 Distal .
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There was good practical function with an overall rating of 80 percent. Dynamometry on the 2 distal muscles showed 80 percent of normal.
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From page 527... ...
Table 251. -- Neuropathological Ratings, Case 1214 Estimated percentage loss, by region evaluated Nerve segment Epineural Interfascicular Perineural Intrafascicular Total segment 0 5 3 2 5 0 10 5 25 Distal 5 71 Case 3250. A neuroma in continuity of the ulnar nerve, and a complete severance of the radial nerve at the elbow.
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Estimated percentage loss, by region evaluated Nerve segment Epincural Interfascicular Perineural Intrafascicular Total segment Proximal 10 40 5 o 55 Distal 0 0 5 10 Summarv index 41 Plate 25.
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Case 3250 Radial. Pain threshold 40 gm.; touch nil; autonomic was normal; motor was good, all of the 6 tested proximal and distal muscles contracting against gravity and 2 against further resistance.
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From page 530... ...
Case 3250 Eight cases, illustrated in plates 30-37, have been chosen to exhibit variation in distal tubular diameters and to suggest their relation to the interval from injury to suture. All plates are cross sections of a representative distal fascicle stained with protargol-analine blue, enlarged 600 times.
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Plate 28.
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Recovery: pain threshold 6 gm.; touch 16 gm.; autonomic was poor in total area; 4 of 4 muscles tested showed good contraction.
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From page 533... ...
The summary rating was 88 percent, the second highest in the entire series. Plate 31.
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From page 534... ...
Recovery: pain felt on deep pressure only; touch nil; autonomic was poor in total area; of 7 muscles tested, 1 showed good contraction, 4 were weak, and 2 remained paralyzed. Table 256. -- Neuropathological Ratings, Case 3420 Estimated percentage loss, by region evaluated Nerve segment Epineural Interfascicular Perineural Intrafascicular Total segment Proximal 5 10 3 0 18 Distal 5 5 5 25 40 Summary index ....
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A deduction of 20 percent was made because of tubular shrinkage and beginning endoneural collagenization; other deductions are as shown in 535
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From page 536... ...
lower-third of leg; 5 months after injury. Most of the tubules in all of the distal fascicles appeared shrunken, although the endoneural fibrosLs was Table 258. -- .\europathological Ratings, Case 3405 Nerve segment Estimated percentage loss, by region evaluated Epineural Interfascicular Perineural Intrafascicular Total segment Proximal 5 5 10 0 20 Distal 10 10 5 20 45 44 Plate 35.
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From page 537... ...
Recovery: pain felt on deep pressure only; touch threshold 50 gm.; autonomic was normal; the one muscle tested showed good contraction. Table 259. -- .\europathological Ratings, Case 3342 Estimated percentage loss, by region evaluated Nerve segment Epineural Interfascicular Perineural Intrafascicular Total segment Proximal 5 5 C 5 5 30 20 45 Distal 5 Summary index 44 Case 3268 (Plate 36)
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From page 538... ...
4 months after injury, with resection to fascicles already fibrotic and supposedly destined to become even more so, should show even the indicated degree of functional recovery. It would seem that axons need not be thick and well-myelinated to transmit tactile impulses and to activate skeletal muscles, or that such axons did indeed maturate fully in spite of the spacial limitations detected in the distal sections.
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From page 539... ...
Number of distal muscles contracting voluntarily. Overall functional evaluation.
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From page 540... ...
Length of surgical defect. Although correlation studies were done on the basis of individual nerves as much as possible, because the cases were so few it was necessary at many points to combine two or more nerves, especially in the lower extremity.
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From page 541... ...
tibial >.051 The differences are in line with any expectation based on functional recovery: they are less extensive than might be anticipated from observed variation in motor recovery. One would expect war wounds affecting peripheral nerves to be quite variable from lesion to lesion, but not, in the aggregate, from nerve to nerve, and it is of some interest that the pathological assessments serve to distinguish the individual nerves at all.
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Since the neuropathologist read fibrosis as he saw it, without reference to the time interval, it is instructive to study his assessments in relation to time, as may be done from table 262, which represents the overall pattern of variation for all nerves combined. The fact of association between time and pathological rating is quite reliable in the statistical sense, but in degree unimpressive.
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From page 545... ...
If preoperative time is of significance in influencing distal tubular fibrosis, equal consideration should be given to the postoperative period in which tubules are empty and presumably shrinking. It might be expected that preoperative changes would be reflected in the neuropathologist's assessments, but the only measure of postoperative change is provided by the height of the lesion or, more precisely, the distance from lesion to end-organ.
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From page 546... ...
12 Ulnar 19 53 74 29 51.41 Radial 18 53 27 2 52.07 Total 49 55.65 48 53.46 Lower extremity Peroneal and sciatic-peroneal . 32 39.72 11 43.82 Tibial and sciatic-tibial 19 41.05 15 47.53 Total 51 40.22 26 45.96 1 As used in earlier chapters; in the upper extremity high lesions are those on the arm or at the elbow, and in the lower extremity on the thigh or at the knee.
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From page 547... ...
CORRELATION BETWEEN NEUROPATHOLOGICAL FORECASTS OF REGENERATION AND CLINICAL ASSESSMENTS OF EVENTUAL RECOVERY As might be anticipated from the distributions in figures 23 and 24, when preliminary tables were prepared to explore the individual and summary assessments prepared by the neuropathologist, it was found that three assessments gave essentially the same information: intrafascicular region of distal segment, entire distal segment, and both segments combined. However, since the variation associated with the summary forecast seemed slightly greater than with the other two, it was chosen to represent the neuropathologic evaluations in the correlation studies which follow.
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From page 548... ...
e. Median -- without associated arterial injury Ulnar -- below elbow All four lower extremity nerves combined -- cuff used For each of these table 267 shows in somewhat more detail the association between forecast and pain threshold.
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From page 552... ...
However, the decision was made to dichotomize the observations, regardless of the autonomous zone, into elevated SR versus other SR, with the omission of cases with "mixed patterns." As may be seen from table 271, which gives the mean values of the forecasts corresponding to this dichotomy any evidence of association between the summary forecast and SR is confined to the ulnar and peroneal (including sciatic-peroneal) nerves.
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From page 559... ...
Although the most reliable motor observation is the measured strength of individual muscles, the more summary indices were explored first, and only after it became apparent that any relationship between the forecast and motor recovery was probably weak were tabulations extended to a few representative muscles as a final check. Table 274 provides a summary of the relationship between the neuropathologist's forecasts and the British classification.
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From page 561... ...
Table 275. -- Summary Forecast of Regeneration and British Classification1 of Motor Recovery, for Median and Ulnar Lesions With Specified Controls Median, operated upon only once Ulnar at or below elbow Forecast of regeneration A' B' A" BI 0-12 0 1 0 0 0 0 1 0 2 5 3 1 1 0 3 0 3 4 4 0 0 0 0 3 0 2 3 6 0 0 13-22 23-32 33-42 1 43-52 2 53-62 2 4 0 0 63-72 73-82 83-92 Total 10 12 15 14 Moan rating 51.6 66.2 48.5 54.5 1 In every case calculated here proximal muscles were acting against gravity, so that two classes were denned on the basis of the modified British scale: A -- Proximal muscles acting against gravity or against resistance, intrinsic muscles showing at most perceptible contractions. B -- Both proximal and distal muscles contracting against resistance.
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From page 562... ...
Table 277. -- Mean Summary Forecast of Regeneration and Number of Affected Muscles ' Contracting Voluntarily at Follow-up, Peroneal and Tibial Injuries Peroneal and sciatic peroneal Tibial and sciatictibial Number of muscles contracting Number of nerves Mean forecast (percent) Number of nerves Mean forecast (percent)
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From page 563... ...
The material was tabulated separately for the upper and lower extremities and table 278 gives the mean summary forecast for each point on the scale of useful function. For neither upper nor lower extremity lesions is there statistical evidence of association.
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From page 564... ...
Table 278. -- Mean Summary Forecast of Regeneration and Overall Functional Evaluation at Follow-up Upper extremity Lower extremity Scale of function Number of cases Mean forecast Number of cases Mean forecast 0 1 2 3 5 2 14 18 22 23 9 1 5 3 0 0 0 4 7 15 25 21 2 0 28 10 50 37 54 45 59 55 55 48 67 40 20 30.
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From page 565... ...
The mechanics of correlation have been in the hands of the statistician for the follow-up study. Table 279. -- Mean Summary Forecast of Regeneration and Composite Index of Regeneration Number of modalities with regeneration rated favorably Number of lesions Mean rating 0 18 48.33 1 33 51.67 2 37 49.59 3 31 52.90 4 6 53.33 Total 125 50.96 Follow-up status was represented by the pain and touch thresholds, skin resistance, several indices of motor recovery, and overall functional recovery.
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From page 566... ...
There were 30 cases with poor assessment ratings, and in the correlation tables they were equally distributed among good, bad, and indifferent classes of muscle recovery. Since voluntary motor fibers are usually considered to be large in caliber and well myelinated, the good and fair results under adverse histologic circumstances suggest that shrunken neurilemmal tubules may be redistended, or that voluntary contraction of muscle may be accomplished even though the effector fibers may not regain their normal girth or state of myelination.
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From page 567... ...
On an absolute scale, nerve ends range in quality from those produced by the surgeon's scalpel to the blunt, neuromatous bulbs commonly presented to the surgeon exploring war injuries. Only the better part of this absolute range is adequately represented in the material studied here, and the findings, therefore, pertain only to that part of the range.
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