Neurorraphy

Factors influencing regeneration after Neurorraphy

1.Age - higher chances of failing in elderly. Higher rate of success in children.

2.Gap between nerves - managed by nerve mobilization, transposition , joint flexion , grafting and

    bone shortening .

3. Delay in repair - upto 12 months - satisfactory results.

4. Level of injury - proximal muscles - good recovery.

                               proximal injury - incomplete motor and sensory recovery.

5. Conduction of nerve ends - for this expose fascicular bundles

6. Time of surgery -

                   primary repair - best done within 6-8 hours

                   delayed repair - best done in 7- 18 days.

Instruments required for neurorraphy

    Pneumatic tourniquet

     suction apparratus

      electrocautery

       Gelfoam and thrombin at nerve ends to control bleeding

       sutures ; 8-0 , 9-0 , 10-0 monofilament

        Epineural repairs ; 8-0 , 9-0

        Epiperineural repairs ; 9-0 , 10-0

Anesthesiae - regional , general or LA - Upper extremity

                        Spinal , general , LA - Lower extremity

Techniques

Exposure - Proximal and  distal ends

Endoneurolysis (Internal Neurolysis )

      if most fasciculi intact and separated and traced - nothing further done.

    If stimulation fails to illicit response , resect neuroma and neurorraphy done.

Partial Neurroraphy

     for large nerves e.g. Sciatic , Trunks, Cords of brachial blxus for partial severence

     suture - end to end ,

             if epineurium inadequate at injury site, epineural

Neurorraphy and Nerve grafting

       with gaps - median and ulnar nerve near wrist and elblow - nerve mobilization can be done.

         2-3 cm - Brachial plexus , Radial ,Sciatic ,Peroneal and Median nerves at midforearm level -

          they require nerve grafting.

Closing Gaps

           options

                        mobilization of nerve,  positioning of extremity, nerve transposition, bone resection ,

                        nerve grafting , neurotization

                        According to Zachory , median and ulnar nerves with gaps

                                                 upto 7-9 cm can be  fullfilled by   nerve mobilization

                                                   Anterior transposition helps closing gap as much as 13 cm .

                        According  to Spinner - not to stripe nerves more than 2-5 cm either side.