Peripheral Nerve Regeneration A Follow-Up Study of 3,656 World War II Injuries (1957) / Chapter Skim
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Neurosurgical Implications
Neurosurgical Implications
Pages 569-638
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From page 569... ...
men with peripheral nerve injuries can be rehabilitated adequately only through the means of specialized neurosurgical treatment. In the absence of some fundamental contribution to the control of the reaction of connective tissue to injury, which constitutes the essential barrier to peripheral nerve regeneration, the following analysis of management of war injuries to peripheral nerves can be considered as valid as can be fashioned from the observed facts.
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From page 570... ...
If the nerve injury is visible without further nerve dissection at the time of wound debridement, its appearance should be described as accurately as possible in terms of complete nerve division, of partial nerve division with an estimate of the cross section involved or of continuity of nerve segments. Even if the examinations noted have indicated the presence of a major nerve segment injury, undue exploration for the lesion at the time of debridement is contraindicated and it is likewise not indicated at the time of secondary wound closure.
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From page 571... ...
Ischemic paralysis of the median nerve with a tight cast, for instance, and peroneal nerve palsy from local cast pressure are common sequelae of poorly designed or unwatched continuous casting. The corollary to the proper early splinting of nerve injuries is the continuous effort directed toward mobilization of joints by physiotherapy, whether by the physiotherapist or, of greater importance, by the patient himself.
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From page 572... ...
" and "One of the most curious inconsistencies in the whole story of the surgery of peripheral nerve injuries is that it has been generally accepted that primary suture is the ideal form of nerve repair. It has, at the same time, been widely held that in dealing with nerve injuries due to war wounds repair of the nerve is not a matter of urgency, and that in a good proportion of cases an expectant attitude may properly be adopted.
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From page 573... ...
Strange as it may seem, definitive information on the incidence of peripheral nerve injury in World War II is lacking. Men are injured in myriad ways, and injuries to specific structures are also extremely variable.
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From page 574... ...
The nerve casualty may now be considered placed at a more permanent installation than the MASH unit or any other forward resuscitation facility. This is the time for recording certain simple and basic data having to do with the date and time of injury and causative agent, the location of the wound, the immediate subjective responses of the patient to trauma, the operative procedures and observations of the forward surgeon, and the subsequent course of the patient prior to this first formal review of the alleged nerve injury.
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From page 575... ...
quinti First dorsal interosseous Median Nerve Flexor carpi radial is Flexor digitorum profundus (index finger) Flexor pollicis longus Abductor pollicis brevis Opponens pollicis Radial Nerve Triceps Brachioradialis Extensor carpi radialis Extensor digitorum Extensor carpi ulnaris Abductor pollicis longus Extensor pollicis longus ct brevis Sciatic Nerve Proximal -- Biceps fcmoris, scmimembranosus, scmitcndinosus Distal Tibial Nerve Gastrocnemius-soleus Tibialis posticus Flexor digitorum longus Flexor hallucis longus Intrinsic foot muscle (cupping of sole of foot)
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From page 576... ...
If this lesion will not permit satisfactory regeneration, it is evident, from reference to the correlation between time of suture and end result, that this suture should be undertaken as early as possible. There would seem to be no arbitrary time limit -- a suture at 1 month after injury does better than one at 2 months, and far better than one at 6 months where an average reduction of 30 percent in overall motor recovery may be expected.
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From page 577... ...
Such early recovery, either motor or sensory, is especially favorable for, if the nerve trunk contains some axons that did not even degenerate, a major proportion of the degenerated fibers are probably capable of spontaneous regeneration. The kind of disruption that presents a permanent block to axonal regeneration cannot exist in a nerve segment with intact axons.
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From page 578... ...
The rules which are presented for the interpretation of evidence for regeneration cannot be derived from a study of end results but must be based upon serial data obtained from early cases in the interval when decisions regarding surgical management are made. The unavailability of such pertinent data from late follow-up material was realized and a study of 300 patients with early nerve injuries at Valley Forge Army Hospital was therefore undertaken by the Philadelphia Study Center under Army contract in the interval from 1951 to 1954.
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From page 579... ...
Voluntary motor function. When there is movement against resistance which can only be the result of the voluntary contraction of the first muscle receiving its nerve supply through the nerve lesion, satisfactory regeneration is present.
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From page 580... ...
The finding of sensory without motor function more than a month after injury calls for more careful examination: either motor recovery actually is present or sensory function is not. Nerve stimulation will produce muscle contraction which the patient has not learned to initiate himself or the sensation perceived is not mediated through the nerve in question.
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From page 581... ...
This simple electrical test so frequently calls for a revision of the estimate of nerve function deduced from clinical examination that it should be a part of the examination of every case where the adequacy of regeneration is at all in doubt. The type of current utilized to stimulate the nerve trunk is unimportant so long as it is of adequate intensity to cause maximal nerve stimulation and is still easily tolerated by the patient.
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From page 582... ...
Accordingly, the same certain evidence for satisfactory regeneration is afforded by muscle contraction on nerve stimulation as is afforded by voluntary muscle testing but at an earlier date and in a way which rules out the possibility that the observed movement is not supplied by the nerve being tested. During the stage of progressive regeneration only a visible contraction in the most proximal muscle is reason to await the development of voluntary contraction against resistance so long as the magnitude of contraction increases with successive examination.
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From page 583... ...
When a Tinel sign is present at all in the distal nerve trunk it will invariably progress distally at a fairly rapid rate to indicate that the sensory axons responsible for this phenomenon are traveling at a rate of 3 or 4 millimeters per day or 3 or 4 inches per month. This behavior of the Tinel sign affords clear evidence that some regeneration is going on but it unfortunately does not give proof that this will be satisfactory regeneration as this has been defined.
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From page 584... ...
Median nerve injuries offered a special problem in that voluntary motor units were frequently seen in attempting to record the opponens pollicis only to find nothing on median nerve stimulation and to realize that potentials on voluntary effort must be viewed with skepticism in areas of shared innervation. In no case could voluntary motor units be recorded from within the substance of a large muscle without the demonstration of potentials on nerve stimulation.
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From page 585... ...
If the method were used in conjunction with nerve stimulation it would afford, in an occasional case, the sole evidence for recovery that would delay the performance of an unnecessary exploration. Clearly evidence for innervation by this sensitive test alone is insufficient for the prediction of satisfactory regeneration and should call for only 2 or 3 weeks' postponement of surgery if more valid signs of regeneration do not appear.
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From page 586... ...
If such is the operative finding, and if either percussion or electrical stimulation of the distal nerve trunk causes paresthesias that establish the presence of axons in continuity through the lesion, resection of the neuroma in continuity is not indicated until sufficient time has passed to clarify from physiologic evidence the potentials for regeneration of this lesion. The problem of the neuroma in continuity whose status cannot be determined by visualization at operation is a frequent one and it is therefore necessary to go to some pains to define certain evidence for unsatisfactory regeneration when this cannot be settled by the gross appearance of the lesion.
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From page 587... ...
In most conservative terms, regeneration will not occur unless a growth rate of at least 1 inch per month is exhibited. In other words, if the first satisfactory test muscle to be innervated below a nerve lesion is x inches from the lesion and does not respond on nerve stimulation after x months, one has certain evidence for unsatisfactory regeneration.
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From page 588... ...
It would seem that nerve lesions requiring resection and suture seldom failed to receive such treatment, but that apparently favorable appearing lesions frequently caused a long delay before reexploration and definitive suture were undertaken. At the same 30 This section is based on the Valley Forge scries studied by Dr.
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From page 589... ...
Nerve stimulation of the sciatic nerve with needle electrodes caused neither visible motor response nor action potentials on recording from the gastrocnemius and the peroneus longus. With the long distance to grow from this high sciatic lesion, this negative physiologic evidence did not necessarily classify the lesion as an unfavorable one but exploration was undertaken on the possibility that a major disruption would be discovered.
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From page 590... ...
This case example points out that when the gross appearance suggests that reasonable regeneration is conceivably possible, there being no obvious discontinuity, a decision for resection should be delayed until physiologic evidence can clarify the picture. One would here have waited 12 months with 12 inches to grow to the most proximal muscle, the gastrocnemius.
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From page 591... ...
. Electrical stimulation of the distal nerve trunk produced ulnar paresthesias and excellent motor response in the flexors of the fourth and fifth fingers and the flexor carpi ulnaris.
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From page 592... ...
Actually regeneration was far better than average for a suture in this location, yet this patient had a better functioning hand before operation and before spontaneous recovery had reached its peak. The gross appearance of the nerve lesion caused the surgeon to choose the known result of suture to the unknown result of spontaneous regeneration.
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From page 598... ...
EMG recording from the peroneus longus during nerve stimulation and voluntary effort showed no action potentials. Although the interval since injury was short, operation was advised.
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From page 599... ...
Three months later it was seen that the ulnar forearm muscles were functioning well with the presumption that the nerve trunk was damaged at a point below their branches. No type of sensation could be perceived in the ulnar autonomous sensory zone and no motor function was elicited from ulnar intrinsic muscles on voluntary effort or on nerve stimulation.
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From page 600... ...
Nerve stimulation caused slightly stronger contractions than observed on voluntary effort. There was rigid clawing of the fourth and fifth fingers and fixation of joints which could be attributed to the combination of ulnar intrinsic muscle loss, direct soft tissue damage in the forearm to the flexor muscles, and a long period of splinting after resurfacing of the forearm by plastic procedures.
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From page 603... ...
It is also of interest that this extensive crushing type of injury had damaged the proximal nerve beyond the limits of resection of grossly abnormal tissue with the result that the proximal face of the suture gave the appearance of being downstream from an area of considerable damage. By 6 months after suture, with some 5 inches to grow to the abductor digiti quinti, the patient still exhibited no voluntary action in this muscle but showed a definite contraction on ulnar nerve stimulation.
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From page 604... ...
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From page 607... ...
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From page 608... ...
However, at 8 months after injury, with 10 inches to grow to the median forearm muscles, there had developed only 25 percent function in the flexor carpi radialis and a trace of voluntary movement in the flexor indicis proprius. Stimulation of the median nerve resulted in only this same amount of motor response as was observed on voluntary effort with no action in the long flexor to the thumb or the intrinsic muscles of the hand.
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From page 609... ...
Although this man at 8 months after injury seemed destined for an unsatisfactory degree of spontaneous recovery, microscopic study of the resected lesion revealed a level of regeneration which, when seen in distal lesions of long standing, had been consistent with as much function as could be obtained with suture. In other words, with involvement of the median nerve at an unfavorable level high in the axilla, this patient was presumably on the way to better functional recovery than could be offered by suture at this location.
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From page 610... ...
Three months later there was a complete ulnar motor and sensory deficit. However, on EMG recording from the abductor digiti quinti there was a definite action potential in response to ulnar nerve stimulation.
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From page 611... ...
From a motor standpoint he now showed a barely visible flicker of motor activity in the flexor carpi ulnaris on voluntary attempt and on nerve stimulation, while deep flexors to the fourth and fifth fingers were able to move the distal finger tips against % pound resistance, less than 2 percent normal strength. There was no voluntary function in the intrinsic hand muscles but on stimulation there was a visible flicker in the abductor digiti quinti and an action potential in this muscle in response to stimulation which was considered of normal amplitude.
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From page 613... ...
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From page 615... ...
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From page 616... ...
There was no sensory recovery in the ulnar autonomous zone. Stimulation of the ulnar nerve above the elbow failed to cause any visible movement in the forearm muscles but a few action potentials could be seen by EMG.
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From page 619... ...
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From page 620... ...
Eight months following suture there was over 50 percent strength in the ulnar forearm flexors while insufficient time had elapsed for any physiologic evidence of recovery to the intrinsic hand muscles. The earliest signs of sensory recovery were present in the ulnar autonomous zone in that deep pressure to the tip of the fifth finger could be clearly perceived as a spreading painful sensation.
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From page 621... ...
From a pathological standpoint, this is an example of a neuroma in continuity whose gross appearance, both to the surgeon and to the pathologist in the laboratory, suggested a major degree of axonal continuity, quite disproved by histologic study of the lesion and the distal nerve segment. Plate 60.
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From page 622... ...
Yet, when the gross appearance is conceivably consistent with major continuity, no amount of fusiform enlargement or firmness to palpation should of themselves constitute indications for resection and suture If, with possible major continuity, the conscious patient does not experience nerve paresthesias on stimulation of the distal segment, resection is indicated. If, with x inches to the first muscle, more than the same x months have elapsed since injury, a failure in motor response on nerve stimulation is an indication for resection.
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From page 623... ...
E ADMINISTRATION The foregoing material is already sufficient in scope to indicate that the proper study of the peripheral nerve injury of warfare demands an exact organization of resources not only during the conflict but in advance of 633
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From page 624... ...
The corollary to this statement is that the trained neurosurgeon should control the initial or neurosurgical evaluation of peripheral nerve injuries. It has been further shown, in separate centers, that fixed professional personnel not subject to the vagaries of assignment shifts, will reflect their increasing experience in terms of both better peripheral nerve regeneration and limb rehabilitation.
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From page 625... ...
There is ample evidence that the eventual outcome of an extremity wound depends in large part upon the extent of its peripheral nerve injury and the progress of peripheral nerve regeneration. This in turn depends upon definitive disposition of the peripheral nerve wound as soon as feasible following injury.
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From page 626... ...
The limitation of the material studied makes it impossible to delineate more exactly the postinjury interval for each nerve after which motor or sensory recovery is impossible. This appears an academic point since functional motor recovery is exceedingly rare if operation must be postponed as long as 12 months postinjury and available data indicate sensory return should be sought, particularly for the median nerve, at any time period following injury.
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From page 627... ...
The British summary of sensory regeneration was also employed as a sensory index with results entirely consistent with those already given. In spite of the delay in peripheral nerve surgery, these regeneration studies suggest that a commendable approach to the combined bone-nerve injury was present under the conditions of World War II surgery.
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From page 628... ...
Among all of the late sequelae of vascular injuries, the expanding arterial aneurysm is the only vascular lesion that should command precedence over the therapy of peripheral nerve injury. Smaller arterial aneurysms may actually erode peripheral nerve tissue.
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From page 629... ...
Repair of the vascular lesion does not favorably influence the cranial nerve injury, and this particular group of cranial-peripheral nerve involvements should be the responsibility of the vascular surgeon directly.
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From page 630... ...
H END RESULTS OF REPAIR, SUMMARY BY INDIVIDUAL NERVE The decision that the patient will not benefit from further hospitalization requires knowledge of the best that can be expected of his nerve injury and the degree to which his existing disability can be improved by orthopedic techniques.
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From page 631... ...
These studies have shown that no resuture of an original peroneal suture which had been performed adequately showed improved regeneration, and that resuture of a low tibial nerve injury that has been done adequately may increase or precipitate painful sensory reaction over the sole of the foot and increase functional disability. In most instances of uncomplicated lower extremity peripheral nerve injuries, discharge is indicated 3 to 4 months after peripheral nerve suture.
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From page 632... ...
long Sensory recovery Autonomic recovery Practical function Percent Pain threshold, 10 gm. or less .
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From page 633... ...
long 71 42 Sensory recovery Autonomic recovery Practical function Percent Pain threshold, 10 gm. or less 38 Touch threshold, 5 gm.
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From page 634... ...
1 Mean relative power of affected muscles capable of movement against resistance. Even with the best sensory recovery after suture, the patient with a median nerve injury will still have difficulty in the organization of perceived pain and touch sensations that limit the hand's usefulness even though
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From page 635... ...
In a few cases, there may be failure of innervation of the flexor digitorum longus and flexor pollicis longus with high median nerve injuries. The loss of flexion of the terminal phalanges of the index finger and thumb may be readily supplied by tendon transfers.
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From page 636... ...
The tendon transfer technique is commonplace. Combined median-ulnar nerve injuries are extremely disabling since all the fingers become flexed into the hand and the only grasp possible is between the thumb and the side of the index finger.
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From page 637... ...
. 100 92 94 89 93 78 83 79 69 68 49 47 50 37 37 36 Sensory recovery Autonomic recovery Practical function Percent Pain threshold, 10 gm.
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From page 638... ...
The concept of relatively early nerve suture carried out perhaps within 3 months following injury by an experienced team, the importance of peripheral nerve regeneration in total limb rehabilitation, the emphasis upon orthopedic hand surgery, the understanding of pathologic changes in peripheral nerve tissue, and the trend toward exact neurophysiological studies of peripheral nerve injury and regeneration are, however, relatively new. It is hoped that this final report of the peripheral nerve study centers will provide data in support of the surgical principles that have become accepted over the years and have been restated here.
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