Evaluation and management of peripheral nerve injury

Abstract

Common etiologies of acute traumatic peripheral nerve injury (TPNI) include penetrating injury, crush, stretch, and ischemia. Management of TPNI requires familiarity with the relevant anatomy, pathology, pathophysiology, and the surgical principles, approaches and concerns. Surgical repair of TPNI is done at varying time intervals after the injury, and there are a number of considerations in deciding whether and when to operate. In neurapraxia, the compound muscle and nerve action potentials on stimulating distal to the lesion are maintained indefinitely; stimulation above the lesion reveals partial or complete conduction block. The picture in axonotmesis and neurotmesis depends on the time since injury. The optimal timing for an electrodiagnostic study depends upon the clinical question being asked. Although conventional teaching usually holds that an electrodiagnostic study should not be done until about 3 weeks after the injury, in fact a great deal of important information can be obtained by studies done in the first week. Proximal nerve injuries are problematic because the long distance makes it difficult to reinnervate distal muscles before irreversible changes occur. Decision making regarding exploration must occur more quickly, and exploration using intraoperative nerve action potential recording to guide the choice of surgical procedure is often useful.

Ethical considerations in elective amputation after traumatic peripheral nerve injuries

“…3-10 Evaluation for traumatic PNI constitutes up to 3.7% of referrals for electrodiagnostic evaluation, 11 a percentage that is likely to increase as advances in battlefield medicine and body armor improve survival of combat trauma. 5,12 …”

“…[3][4][5][6][7][8][9][10] Evaluation for traumatic PNI constitutes up to 3.7% of referrals for electrodiagnostic evaluation, 11 a percentage that is likely to increase as advances in battlefield medicine and body armor improve survival of combat trauma. 5,12 PNI, particularly from military combat, are often associated with extensive coexisting skeletal, vascular, and soft tissue injuries that may require amputation. However, since the Korean War, rapid access to increasingly sophisticated surgical techniques has dramatically improved the percentage of salvageable extremities, 6,13 in which varying degrees of residual neurologic dysfunction may remain.…”

Closed Median Nerve Rupture from Elbow Trauma

“…It is established that primary repair as early as the extent of the lesion can be determined provides the best likelihood of recovery-motor function is lost without neurotization at 18 months after disruption of peripheral nerves, though sensory function can be restored up to years later [1]. Decision for surgical intervention in closed peripheral nerve injury is made based upon assessment of severity of injury and determination of potential for recovery.…”

“…Initially, regardless of the type of injury, since Wallerian degeneration has not yet occurred, studies like compound muscle action potentials (CMAP) can only be used to localize the lesion [10]. However, electrodiagnonstic studies as early as the first 1-2 weeks can be used to distinguish neurapraxia, in which the nerve distal to the lesion continues to conduct upon stimulation, from axonotmesis/neurotmesis in which the distal stump does not [1]. Current management of peripheral nerve injuries involves electrodiagnostic testing 3-4 months after injury to allow resolution of neurapraxia and spontaneous regeneration after more severe injuries [10].…”

Cervical and Upper Limb Peripheral Nerve Injuries in Adults: Electrodiagnostic Studies and Symptoms

“…It may be accompanied by neurological deficits. These injuries may lead to irreversible disabilities in patients, such as sensory loss, deficient motor function, pain problems in terms of cold intolerance and hyperesthesia that can ultimately impair hand function, and affect quality of life at work and in society (4)(5)(6).…”