Peripheral Nerve Regeneration A Follow-Up Study of 3,656 World War II Injuries (1957) / Chapter Skim
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Recovery of Motor Function
Recovery of Motor Function
Pages 71-202
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From page 71... ...
In the plan of the chapter there is first a methodological part in which are described the various methods used in the assessment of motor regeneration. There follows an essentially descriptive treatment of the statistical data on motor recovery in representative samples of peripheral nerve injuries treated by suture or by lysis.
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From page 72... ...
In order to assess the regeneration of a particular peripheral nerve it is imperative that the examiner isolate the movements of those muscles which were affected by the injury. The basic motor examination, in turn, consists of evaluating the movements of such individual muscles as act alone, or of groups of cooperating muscles innervated by a single nerve.
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From page 73... ...
Peroneal and Sciaticperoneal. Tibialis Anticus.1 Extensor Digitorum Longug.1 Extensor Hallucis Longus.1 Peroneus Longus.1 1 Muscles chosen for most intensive analysis; the abductor pollicis brevis did not appear in the original standard list and does not figure in either the count of affected muscles now contracting or in the average power of distal muscles.
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From page 74... ...
There are three main factors to be considered in motor recovery following peripheral nerve injury: (1) growth of nerve fibers in both length and diameter; (2)
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From page 75... ...
Only muscles in the fourth category are studied in this chapter. Several methods have been used to combine the observations on individual muscles into various patterns representing, say, all affected muscles on a limb, or all the distal muscles.
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From page 76... ...
The numbers of affected muscles in the standard list capable of contraction, similarly, are: Proximal muscles: 4. Distal muscles: 3.
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From page 77... ...
a very favorable curve would start near the origin, remain fairly close to the abscissa over much of the range of relative power, and increase rapidly only in the region of normal relative power. As plotted in figure 11, each distribution shows the percentage of affected muscles rated at a specified relative strength or less, the strength being indicated by the horizontal axis.
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From page 78... ...
Although the interest here is in the individual muscle, some comparison among muscles is helpful in understanding the variation in results which may be expected following suture. In the median set, for example, the flexor pollicis longus and the flexor digitorum profundus 2 have almost identical distributions, while that for the abductor pollicis brevis is much less favorable.
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From page 79... ...
Figure 10. Strength of Movement of the Abductor Pollicis Brevis Following Complete Suture of Median Nerve, Strength of Movement Against Resistance, as Percentage of Normal PERCENTAGE 20 40 6O 80 STREH8TH OF MOVEMENT ABAIN3T RESISTANCE: PERCENTAGE OF NORMAL - 50 - 40 - 30 - 20 - 10 100 79
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From page 81... ...
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From page 82... ...
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From page 86... ...
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From page 87... ...
e., high lesions are those occurring at or above the elbow or, in the lower extremity, involving the sciatic, and low lesions are those below the elbow or below the bifurcation of the sciatic into peroneal and tibial nerves. Accordingly, systematic high-low comparisons are presented first; these appear in table 51 for complete sutures only.
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From page 88... ...
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From page 89... ...
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From page 90... ...
Table 50. -- Mean Power of Affected Muscles Following Complete Suture Nerve and muscle Number of cases Mean power as percentage of normal All cases Cases with movement against resistance Median Fl.
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From page 93... ...
This is not true of the lower extremity for which, in addition, any fitted curve would follow a different path, since it is primarily the mean relative power for all cases which is depressed in the lower extremity. On the whole the data for complete sutures suggest the following general conclusions: a.
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From page 94... ...
As in table 51, three different indices of motor recovery are employed, although statistical tests were confined to the average power of all tested muscles, whether or not able to contract against resistance. In the median there is no evidence of any uniform gradient associated with site; in the proximal muscles the lowest lesions do best, and in the distal muscle site seems relatively unimportant.
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From page 95... ...
Within the set of complete sutures, and on the basis of the operator's observation of the gross external appearance of the lesion and the appearance of the cross section, a distinction may be made between apparently complete and apparently incomplete lesions.
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From page 99... ...
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From page 100... ...
Only in 3 out of 36 tests was a significant discrepancy noted, and the differences between pairs of means do not seem especially one-sided in their distribution. Table 54. -- Mean Power of Affected Muscles Following Complete Suture, by Type of Lesion Complete lesions Incomplete lesions ' Statistical tests' Nerve and muscle Number of cases Mean power all cases Number of cases Mean power all cases Median Fl car rad 98 73 107 131 85 56.28 31.99 31.78 20.69 12.47 30 22 54.67 36.59 26.43 31.59 14.44 NS NS NS FI.
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From page 101... ...
Lysed and completely sutured cases are compared in table 55; separate comparisons are made in table 55 for high lesions and for low lesions in the case of muscles in which there are important high-low differences, since sutured and lysed cases are not always homogeneous as to the proportions classified as high and low. Although the only probabilities shown in table 55 are based on tests of means for all cases, including as 0 those not contracting against resistance, parallel tests were also done on 101
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From page 105... ...
For sutured lesions of the upper extremity the average percentage with at least minimal contraction is, on the average, about 94 percent of that observed for parallel lysed cases, but for the lower extremity no simple average will describe the relationship, and no curve fits the data well. The average power of muscles capable of movement against resistance following suture is about 74 percent of parallel values for lysed lesions, but the scatter is too great for any single average, or any fitted curve, to have much meaning.
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From page 106... ...
Most lysed cases were described by surgeons as "normal nerve compressed by scar," but a significant number were called neuromas in continuity and a few partial divisions, and it is of interest to explore the prognostic significance of these descriptions by the operator. In the statistical tests, which are summarized in table 57, it was assumed that cases classified as "normal nerve compressed by scar" must be at least as good as those called neuromas or partial lesions; that is, one-tailed tests n were done.
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From page 107... ...
Table 56. -- Mean Power of Affected Muscles Following Definitive Operation, by Type of Operation Type of operation Nerve and muscle Complete suture Partial suture Neurolysis Number of cases Mean power, all cases Number of cases Mean power, all cases Number of cases Mean power, all cases Median Fl.
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From page 108... ...
long Inteross * 1 Tests were one-tailed, attributing to chance any apparent advantage of neuromas and partial lesions except that tests on median muscles were done on three means corresponding to normal nerve, neuroma, and partial division, and without regard to the pattern of variation among them.
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From page 109... ...
Two features of table 58 are worthy of some discussion. One is the fact that the percentage of ulnar and radial lesions in which all affected proximal muscles contract does not vary much by the number of proximal muscles affected, while for proximal plus distal muscles such is not the case.
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From page 110... ...
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From page 112... ...
Table 61 contains a summary of all the data on the proximal muscles affected by complete sutures, and shows the average power of the affected proximal muscles on a given limb to be a highly variable quantity. There is little difference among the three major nerves in the upper extremity, but of course their distributions are much more tavorable than those for nerves of the lower extremity.
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From page 113... ...
3 106 317 105 49 34 132 137 170 75.5 89.0 81.0 79.6 52.9 23.5 47.4 31.8 49 72 8 10 16 48 21. 35 89.8 97.2 100.0 100.0 93.8 64.6 71.4 80.0 Ulnar 2 4 5 4 4 4 4 Radial Tibial Sciatic- tibial Peroneal Sciatic-peroneal Table 61. -- Percentage Distribution of Completely Sutured Lesions by Mean Relative Power of Affected Proximal Muscles Mean power Nerve M U R P T SP ST 0-9 11.2 12 5 18 0 51 2 21 6 80 1 31 5 10-19 13.0 8.6 7.9 16 3 27 5 9 3 23 8 20-29 9.9 9.6 9.0 11.4 11.
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From page 114... ...
The tibial lesions appear to recover better than the peroneal, in these comparisons, and the sciatic-tibial better than the sciatic-peroneal. Table 62. -- Comparison of Lysed and Completely Sutured Lesions as to Percentage With Stated Average Power of All Affected Proximal Muscles Range of relative Lysed PerSutured PerNerve power compared Number centage Number centage of with of with lesions stated lesions stated average average power power Median .
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From page 115... ...
3. Proximal muscles acting against gravity, perceptible contraction in intrinsic muscles.
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From page 116... ...
Table 64. -- Comparison of United States and British Ratings of Motor Recovery, Complete Sutures on Median Nerve Code symbols Percentage distributions United States modification British, 1954 United States cross section British, 5-year results 0 0 3.4 0 1 1 7.3 3.8 2 1 + 14.2 32.8 3 2 24.0 30.7 4 3 29.6 14.1 5+6 4+5 21.5 18.6 Total 100.0 100.0 Number of lesions.
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From page 117... ...
In general the variability seen among centers in the classification of motor recovery in this fashion greatly exceeds that observed in determinations on the relative power of individual muscles. Table 65. -- Comparison of United Stales and British Ratings of Motor Recovery, Complete Sutures on Ulnar Nerve Code symbols Percentage distributions United States modification British, 1954 United States cross section British, 5-year results 0 0 3.5 0 1 1 5.3 0 2 1 + 7.4 5.3 3 2,2+ 36.3 75.5 4 3 34.6 14.3 5+6 4+5 12.9 4.9 Total 100.0 100.0 Number of lesions ....
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From page 118... ...
The influence of type of lesion was also explored by means of the modified British classification, with the same conclusion as that already reached on the basis of individual muscles, namely, that severed nerves and lesions in continuity, both sutured, are indistinguishable at follow-up. Incomplete lesions treated by lysis, however, were found to differ quite significantly from those treated by complete suture.
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From page 119... ...
If the expected distribution of these 28 cases is calculated from the data of table 63, one finds the overall discrepancy exhibited in table 71. Table 68. -- Modified British Classification of Motor Recovery Following Neurolyris, by Nerve Percentage distribution on British classification ' Nerve and gross site Total cases 0 1 2 3 4 5,6 Total Median: High 0 6.7 1.3 4.7 0 3.8 12.5 6.7 11.4 14.1 20.0 15.2 29.7 0 24.1 39.1 66.7 44.3 100.1 100.1 100.1 64 15 79 Low Total Ulnar: High 1.4 0 1.0 6.1 8.0 0 7.9 0 1.4 0 1.0 6.1 8.0 8.3 10.5 14.0 2.8 6.1 3.8 6.1 12.0 16.7 15.8 24.0 19.7 24.2 21.2 18.2 20.0 16.7 15.8 34.0 31.0 27.3 29.8 33.3 36.0 29.2 31.6 16.0 43.7 42.4 43.3 30.3 16.0 29.2 18.4 12.0 100.0 100.0 100.1 100.1 100.0 100.1 100.0 100.0 71 33 104 33 25 24 38 50 Low Total Radial Peroneal Tibial Sciatic -peroneal Sciatic-tibial 1 See table 63 for the rubrics of classification.
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From page 120... ...
1 See table 63 for rubrics of classification. For describing the average recovery of lesions upon the major nerves use has also been made of the arithmetic averages of several performance characteristics of the individual muscles chosen as most representative for each nerve.
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From page 121... ...
. 1 8 12 3 1 2 2 Table 71. -- Effect of Multiple Lesions Per Nerve on Motor Recovery, Lesions With at Least One Complete Suture, All Major Nerves Combined British motor classification Number of injured nerves Observed Expected At best perceptible contraction in proximal muscles 14 4.80 Proximal against gravity, no more than perceptible contraction in distal 7 11.15 Both proximal and distal against resistance ...
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From page 122... ...
3. Summary All the motor indices employed here in describing motor recovery yield consistent results, but the observations made on individual muscles affected by representative lesions treated by suture or neurolysis have been most extensively studied.
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From page 123... ...
In addition, site of lesion is observed to exert a profound influence upon motor recovery following complete suture, distal lesions doing far better than proximal, especially from the standpoint of the more proximal muscles. Gross site of lesion has no apparent influence on motor recovery following neurolysis, however.
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From page 124... ...
. Table 73. -- Percentage of Affected Muscles Contracting and Mean Power Following Complete Suture of High Median Lesions, by Presence of Associated Ulnar Lesion Also Completely Sutured Present Complete ulnar suture Absent Median muscle Statistical tests1 Percentage contracting against resistance Percentage contracting Number of cases Mean power, all cases Number of cases against resistance Mean power, all cases A B 49 34 49 41 33 89 84 65 45 26 57.4 41.0 25.4 11.1 8.0 40 28 39 35 26 90 64 63 63 67 60.4 25.9 16.9 23.6 21.0 NS NS Fl poll.
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From page 125... ...
Neither aspect of motor recovery appears to have been influenced, in any general way, by the presence of such injuries or by the character of their healing. Table 75 summarizes the available data on presence of bone injury.
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From page 126... ...
dig. long Fl hall long 130 8.4 1 Symbols used in headings are defined as follows: N=Number of injured nerves %= Percentage contracting against resistance X = Mcan relative power, all cases.
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From page 127... ...
If these be averaged one finds that in lesions complicated by infection muscles contract against resistance only about two-thirds as often as muscles not so complicated. Table 76. -- Percentage of Affected Muscles Contracting and Mean Power Following Complete Suture, by Type of Healing of Associated Bone and Joint Injury Nerve Muscle Normal ' Healing Other i Statistical tests ' N % X N % X A B Median Ulnar (high)
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From page 129... ...
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From page 130... ...
The calculated values of table 78 are based on linear regression lines for power and day of operation, which for the radial seem technically satisfactory, and provide estimates of power for sutures done at day 386, which is the average for lesions with infection. Table 78. -- Observed Average Power of Representative Radial Muscles Following Complete Suture, by Presence of Infection at Site of Lesion, and Calculated Power for Sutures Delayed to Same Extent as Lesions With Infection Observed mean power, by presence of infection Calculated mean power, suture done at 386 days Radial muscle Absent Present Ext car.
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From page 133... ...
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From page 134... ...
This may also be done from table 79, which parallels table 53 presented earlier in the discussion of the effect of specific site upon motor recovery. Very litde change is introduced by this refinement; muscles for which motor recovery varies by site in table 53 look about the same in table 79, largely because of the superior performance of low lesions.
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From page 135... ...
Following high median suture recovery of distal muscles (opponens and abductor pollicis brevis) was definitely poorer in men who also had ulnar sutures on the same limb.
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From page 138... ...
Not more than half of the definitive sutures with more than one operation had more than one suture; for each nerve usually half or more had a lysis before or after suture, or a so-called significant cuff removal. Since one would expect 138
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From page 139... ...
There were 10 lesions with 4 operations each, and table 83 provides a summary of the sequence of operations in each instance and of such followup information as became available. Although few in number, these cases constitute strong evidence, if any were needed, that repeated suture need not be self-defeating; most of these had 3 complete sutures and some recovery was noted in 8 of the 9 with follow-up data.
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From page 140... ...
long 1 Results of statistical tests are abbreviated as follows: NS=Not significant.
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From page 141... ...
British motor summarv *
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From page 143... ...
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From page 144... ...
Plainly the effect of time extends to both the likelihood of perceptible contraction and the likelihood of movement against resistance, but again, as in the observations on relative power, the effect is not seen either in all nerves or in all muscles, and tends to be especially marked in muscles innervated by the radial and the peroneal. Also, the effect often seems greatest in the most distal muscles.
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From page 147... ...
Table 85. -- Correlation Ratios Between Relative Power and Days From Injury to Definitive Suture, by Nerve and by Muscle Nerve, site* and muscle Correlation ratio ' Nerve, site, and muscle Correlation ratio ' Median, high Fl.
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From page 148... ...
The echelon of repair was one of these, since all overseas sutures were of necessity done early. Three representative muscles were studied in this connection: extensor carpi radialis, abductor pollicis brevis, and peroneus longus (for peroneal lesions only, i.
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From page 150... ...
Table 90 presents the relation between motor recovery and time to first suture, in terms of capacity to contract against resistance as well as mean power of all muscles, whether contracting against resistance or not. Since, as will be shown later, both the interval from injury to suture and the surgical gap are quite reliably associated with ultimate muscle power, both factors were explored simultaneously on the basis of the extensor carpi radialis and the extensor digitorum, with attention to the site of injury.
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From page 151... ...
long 86.2 53.6 Table 90. -- Percentage of Affected Muscles Contracting and Mean Power Following Complete Suture, by Time From Injury to First Complete Suture Days from injury to suture Number of cases Percentage contracting against resistance Mean relative power* all cases Nerve Site Muscle Median High.
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From page 152... ...
Table 90. -- Percentage of Affected Muscles Contracting and Mean Power Following Complete Suture, by Time From Injury to First Complete Suture -- Continued Days from injury to suture Number of cases Percentage contracting against resistance Mean relative power* all cases Nerve Site Muscle Ulnar High.
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From page 153... ...
Table 90. -- Percentage of Affected Muscles Contracting and Mean Power Following Complete Suture, by Time From Injury to First Complete Suture -- Continued Days from injury to suture Number of cases Percentage contracting against resistance Mean relative power* all cases Nerve Site Muscle Peroneal All Peron.
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From page 154... ...
digitorum Upper third, arm ... -.30 -.38 -.28 -.15 -.35 -.30 VfirMlf third, arm Lower third, arm Estimation of the average magnitude of the effect of delayed repair will depend in part upon whether one believes the effect to be the same for all nerves and which index of motor recovery is employed.
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From page 155... ...
These equations are, where Y denotes relative power and X number of days from injury to suture: Figure 13. Average Relative Muscle Power in Relation to Time From Injury to First Suture, by Nerve PERCENT OF NORMAL POWER HIGH MEDIAN 150 .t fc;„.;.„ :.i i t .
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From page 156... ...
Table 92. -- Average Motor Recovery and Time From Injury to First Suture, for Two Indices of Motor Recovery, All Nerves Combined Relative motor recovery Days from injury to first suture Average strength of all muscles Average percentage contracting against resistance 1-99 100 84 74 51 43 100 94 76 73 34 100-179 180-279 280-399 400 or more A surgical qualification is needed to balance the foregoing statistical analysis which ignores the important fact, established in chapter II, that about half of the very early or emergency sutures required resuture. Also, the emergency sutures per se were not isolated for separate study and presentation in the foregoing analyses, but grouped with other early sutures.
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From page 157... ...
That is, although on the average the very long gaps are associated with markedly less motor recovery, there is so much inherent variation that knowledge of gap is of no great prognostic value in the individual case. Figures 14 and 15 depict the average relationship observed for each nerve, the first on the basis of mean relative power of all muscles and the second on the basis of the percentage of muscles contracting against resistance.
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From page 158... ...
Table 94. -- Comparison of Overseas and £/I Definitive Sutures Matched as to Time From Injury to Repair, as to Number of Affected Muscles Moving Against Resistance Overseas sutures Z/I sutures Nerve and muscle Number moving against resistance Number moving against resistance Number of cases Number of cases Median: Abd. p Radial: Ext.
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From page 159... ...
It does seem well established, then, that these two special operative features have no demonstrably adverse influence upon motor recovery.
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From page 160... ...
Figure 14. Average Relative Muscle Power in Relation to Length of Surgical Gap at Definitive Suture, by Nerve POWER pa (El MEDIAN 1.6 1.2 .8 ULJA8 1-6.
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From page 161... ...
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From page 162... ...
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From page 163... ...
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From page 165... ...
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From page 166... ...
and averaging 6.4 cm. Follow-up examinations were performed on 5 of the men and for 7 sutured nerve lesions motor recovery was classified according to the modified British code as follows: Modified British classification Number of lesions 0 No contraction at all None 1 Return of perceptible contraction, proximal muscles only None 2 Proximal muscles acting against gravity, no return of power in in- None trinsics.
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From page 167... ...
Table 97. -- Definitive Sutures With and Without Prior Bulb Suture, and Average Percentage of Affected Muscles Contracting Against Resistance, by Nerve Average percentage of affected muscles contracting against resistance Nerve sutured Bulb suture No bulb suture High median 59 37 46 0 8 22 40 35 45 15 5 25 Radial Peroneal Sciatic-peroneal Sciatic-tibial 167
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From page 169... ...
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From page 170... ...
10. Tension Upon Suture Line The operator reported his impression of the tension on the suture line even less often than he described the nerve ends; 46 percent of the definitive sutures could not be coded adequately for this characteristic.
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From page 173... ...
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From page 174... ...
in the Z/I, and despite the fact, already described, that it represented consecutive, unselected cases seen at that hospital. The comparison of tantalum and plasma glue sutures was made on the basis of the following characteristics, separately by nerve and, for median and ulnar lesions, by gross site: Associated nerve injury.
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From page 175... ...
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From page 178... ...
. Table 102. -- Percentage of Definitive Sutures With More Than One Operation, by Type of Suture Material, and by Nerve and Gross Site Percentage than one with more operation Nerve and gross site Tantalum Plasma glue Low median 16 45 Low ulnar 20 29 Radial 17 19 Sciatic .
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From page 179... ...
Table 104. -- Voluntary Contraction of Representative Affected Muscles Following Complete Suture, by Nerve and Type of Suture Material Voluntary contraction Silk and tantalum Number Percent Plasma glue Number Percent Low median None 15 18.8 Perceptible or against gravity, but not against resistance 24 30.0 Against resisrance 41 51.2 Total 80 100.0 Low ulnar None 19 8.8 Perceptible or against gravity, but not against resistance 98 45. 1 Against resistance 100 46.0 Total 217 99.9 Radial None 9 6.3 Perceptible or against gravity, but not against resistance 15 10.5 Against resistance 119 83.2 Total..
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From page 180... ...
On the average, both mean relative power and percentage of muscles contracting against resistance were about 20 to 25 percent higher when tantalum cuff had been used. Surgical experience in the Z/I suggested that the decision not to employ a cuff might often be based on considerations which were unfavorable to regeneration.
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From page 181... ...
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From page 182... ...
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From page 184... ...
Conversely, however, the data by no means disprove the value of the cuff as a therapeutic device; the data simply do not fulfill the requirements of an unbiased treatment comparison. Cuff removal was studied in all cases wrapped in tantalum foil at the definitive suture, but no real evidence was developed to suggest that the practice, which became a very nearly routine procedure in some neurosurgical centers, exerted any effect upon motor recovery.
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From page 185... ...
Table 106. -- Mean Power Following Complete Suture and Percentage of Affected Muscles Contracting Against Resistance, by Use of Tantalum Foil Wrapping at Definitive Suture, Lesions of Comparable Prognosis No cuff used Tantalum cuff Nerve and muscle Mean relative power, all Percentage contracting against resistance Mean relative power, all cases Percentage contracting against resistance Number of cases cases Number of cases High median Fl car rad .
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From page 186... ...
dig. long Comparisons of sutured lesions with and without stay sutures were made on the basis of mean relative power of affected muscles and are summarized in table 108.
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From page 187... ...
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From page 190... ...
, and the opportunity was taken to compare internal with external lyses to the extent permitted by this material, on the frank assumption that the two groups were comparable to begin with. The comparisons are made in table 109 on the basis of mean relative power.
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From page 191... ...
Information about gap is of less prognostic value than information about time, but if time be ignored the effect of gap is a significant one; there is an average loss of about 6 percent per cm. from the optimal motor recovery following sutures on the shortest gaps, until the critical limit is reached when suture becomes impossible.
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From page 197... ...
Moreover, some of the apparent influence of other treatment factors is associated with that of time, so that any overall measure of the extent to which differences in management explain variation in final recovery would not greatly exceed that observed for time alone and would hardly be impressive in any event. In addition to the treatment variables, however, as already shown in the earlier sections of this chapter there are many characteristics of the nerve injury itself, including associated lesions of various kinds, which also have a marked bearing on motor recovery.
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From page 198... ...
The latter technique has been followed here, except that delay in definitive suture has been scaled as either 1 or 2 units of the score, depending on whether the suture was done in the interval 90-269 days after injury or 270 or more. Only the median and ulnar nerves have been studied in the fashion outlined above, with a separation into high and low lesions, and with recovery based on the relative power of the following muscles: Median muscles Ulnar muscles flexor pollicis longus flexor digitorum prof.
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From page 199... ...
to be 12 percent of normal for high lesions and 15 percent for low lesions. Among the high lesions there is one group of 18 cases with moderate delay in repair plus an associated nerve injury, for which the average power is only 5 percent.
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From page 200... ...
Table 112. -- Mean Relative Power of Affected Muscles Following Complete Suture, Median Lesions by Site and Score on Presence of Prejudicial Factors Muscle Score Fl. poll.
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From page 201... ...
inteross. N' Mean N' Mean N' Mean High lesions 1 18 26 22 5 15 10 2 46 28 51 5 41 12 3 98 37 109 10 77 9 4 63 23 71 5 53 6 5-7 28 26 35 4 27 1 Total 253 30 288 7 213 8 Low lesions o 12 48 20 12 16 6 1 24 41 55 14 43 17 2 43 44 98 15 69 15 3 59 7 42 10 3-6 30 27 4-6 24 11 21 5 Total 109 39 256 13 191 12 1 N represents the number of cases upon which the mean is based.
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