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.
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