Sutureless repair of a partially transected median nerve using Tisseel glue and Axoguard nerve protector: A case report

Abstract

Peripheral nerve injuries in which the nerve is not completely severed often result in neuromas‐in‐continuity. These can cause sensory and functional deficits and must be resected and reconstructed. In defects greater than 5 mm in length, nerve graft is indicated, and suture neurorrhaphy is typically used to secure the nerve ends. However, sutures may negatively impact nerve regeneration. Fibrin glue has recently been used to mitigate the inflammatory response associated with suture neurorrhaphy. Most of the literature regarding fibrin glue covers animal models and supports its use for nerve reconstruction. Tisseel, a fibrin sealant developed as an adjunct to hemostasis, has recently shown utility in peripheral nerve repair by increasing tensile strength without additional sutures. We present the successful use of Tisseel sealant in a neuroma resection and reconstruction. In this case, a 35‐year‐old female presented with persistent neuropathic pain and neurologic dysfunction related to the median nerve in her hand with a history of distal forearm laceration and prior carpal tunnel release. Upon exploration, a neuroma‐in‐continuity involving 75% of the nerve was identified, resected, and reconstructed using processed human nerve allograft, as well as Tisseel sealant and Axoguard nerve protector to secure the repair and offload tension. At 1‐year follow‐up, pain was resolved, with ≤8 mm static 2‐point discrimination in the median nerve distribution, and excellent improvement in hand strength compared with preoperative conditions. The outcome of this case indicates that fibrin glue may be useful to avoid excess sutures in cases of neuroma‐in‐continuity not involving the entire cross‐section of the nerve.

Outcomes following use of VersaWrap nerve protector in treatment of patients with recurrent compressive neuropathies

“…The use of nerve wraps in peripheral nerve surgery is well-established ( 2 , 4 , 5 ). However, as one animal study by Nicolas et al demonstrated, the potential for over-tightening nerve wraps has detrimental effects ( 16 ).…”

“…In our series, VersaWrap was used for patients with recurrent compressive neuropathies in the upper extremity requiring surgical intervention. The use of nerve wraps in peripheral nerve surgery is wellestablished (2,4,5). However, as one animal study by Nicolas et al demonstrated, the potential for over-tightening nerve wraps has detrimental effects (16).…”

“…To reduce scarring around the nerve, many surgeons use nerve wraps or conduits. The efficacy of nerve protectors for treatment of different nerve pathologies has been demonstrated in both animal and human models (1)(2)(3)(4)(5)(6)(7). Absorbable nerve wraps are favored, with the benefit conferred by these implants likely related to the separation of soft tissue and nerve, allowing gliding and thus preventing tethering, and providing an optimized environment for nerve healing.…”

Sticky and Strain‐Gradient Artificial Epineurium for Sutureless Nerve Repair in Rodents and Nonhuman Primates

“…[6,7] As a viable alternative, gellike sticky materials based on fibrin glue or cyanoacrylate derivatives have been applied to neurorrhaphy. [7][8][9] Recent techniques to replace the conventional approaches include an "artificial nerve conduit," which is directly applied to the bisected epineural surfaces to bridge a gap while securely suturing both ends. [10,11] The nerve conduit is capable of aligning individual nerve bundles without disorganization, leading to efficient recovery of the sensory/motor neurons and their rearrangements.…”