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Injury of peripheral nerve — Clinical Guidelines

Overview

Peripheral nerve injuries involve damage to nerves outside the central nervous system, often affecting motor, sensory, or autonomic functions, with significant socioeconomic impacts 1.

Diagnosis

Clinical Examination: Assess motor function, sensory loss, and reflexes 12.

Electromyography (EMG) and Nerve Conduction Studies (NCS): Evaluate nerve function and damage extent 12.

Grading Systems: Utilize Seddon's classification (Neuropraxia, axonotmesis, neurotmesis) for injury severity 2.

Management

Primary Repair: Early surgical repair without tension for optimal outcomes 20.

Nerve Grafting: For larger nerve gaps, using autologous grafts when necessary 6 10.

Secondary Reconstruction: Techniques include vascularized grafts, tubulization, and distal neuratization for delayed repairs 6.

Regenerative Guidance: Consider molecular guidance strategies to improve axonal alignment 5.

Special Populations

Pediatrics: Individualized repair techniques are crucial due to ongoing growth and development 15.

Elderly: Consider comorbidities and functional goals when planning surgical interventions 12.

Key Recommendations

Perform early surgical repair of peripheral nerve injuries without tension to enhance functional recovery (Evidence: Strong 20).

Utilize nerve grafting for gaps larger than what can be reliably repaired by primary suture techniques (Evidence: Moderate 6).

Implement individualized surgical approaches based on the specific anatomic and functional circumstances of each patient (Evidence: Expert opinion 15).

References

1 Bergmeister KD, Große-Hartlage L, Daeschler SC, Rhodius P, Böcker A, Beyersdorff M et al.. Acute and long-term costs of 268 peripheral nerve injuries in the upper extremity. PloS one 2020. link 2 Kaya Y, Sarikcioglu L. Sir Herbert Seddon (1903-1977) and his classification scheme for peripheral nerve injury. Child's nervous system : ChNS : official journal of the International Society for Pediatric Neurosurgery 2015. link 3 Worm BS, Krag M, Jensen K. Ultrasound-guided nerve blocks--is documentation and education feasible using only text and pictures?. PloS one 2014. link 4 Orebaugh SL, Kentor ML, Williams BA. Adverse outcomes associated with nerve stimulator-guided and ultrasound-guided peripheral nerve blocks by supervised trainees: update of a single-site database. Regional anesthesia and pain medicine 2012. link 5 Lotfi P, Romero-Ortega MI. Control of neural interfacing in peripheral nerves through regenerative molecular guidance. Annual International Conference of the IEEE Engineering in Medicine and Biology Society. IEEE Engineering in Medicine and Biology Society. Annual International Conference 2011. link 6 Wyrick JD, Stern PJ. Secondary nerve reconstruction. Hand clinics 1992. link 7 Raymond SA, Abrams SB, Raemer DB, Philip JH, Strichartz GR. The NerveSeeker: a system for automated nerve localization. Regional anesthesia 1992. link 8 Wong AY, Scott JJ. Functional recovery following direct or graft repair of nerve gaps in the rat. Experimental neurology 1991. link90162-6) 9 Tonkin MA. Posterior interosseous nerve axonotmesis from compression by a ganglion. Journal of hand surgery (Edinburgh, Scotland) 1990. link90100-i) 10 Mackinnon SE. Surgical management of the peripheral nerve gap. Clinics in plastic surgery 1989. link 11 Bowers WH, Carlson EC, Wenner SM, Doyle JR. Nerve suture and grafting. Hand clinics 1989. link 12 Chehrazi B. Peripheral nerve injuries: principles of surgical management and outcome. Journal of neurotrauma 1989. link 13 Omer GE. Timing of tendon transfers in peripheral nerve injury. Hand clinics 1988. link 14 Fernandez E, Pallini R, Talamonti G. Sleep palsy (Saturday-night palsy) of the deep radial nerve. Case report. Journal of neurosurgery 1987. link 15 Smith JW. Peripheral nerve surgery--retrospective and contemporary techniques. Clinics in plastic surgery 1986. link 16 Skottner A, Fryklund L, Hansson HA. Experimental research on IGF-1. Acta paediatrica Scandinavica. Supplement 1986. link 17 Monteleone M, Montorsi A, Luchetti R, Rovesta C. Ischaemic isolated retraction of the abductor digiti minimi. Journal of hand surgery (Edinburgh, Scotland) 1985. link80017-6) 18 de Medinaceli L, Church AC, Wang YN. Posttraumatic autoimmune reaction in peripheral nerve: effect of a single injury. Experimental neurology 1985. link90199-2) 19 Salonen V, Lehto M, Vaheri A, Aro H, Peltonen J. Endoneurial fibrosis following nerve transection. An immunohistological study of collagen types and fibronectin in the rat. Acta neuropathologica 1985. link 20 Usbeck W. Nerve suture without tension, a method for repairing transected peripheral nerves. Acta neurochirurgica 1976. link

Injury of peripheral nerve