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| NI FEATURE: THE EDITORIAL DEBATE I-- PROS AND CONS |
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| Year : 2019 | Volume
: 67
| Issue : 7 | Page : 20-22 |
Peripheral nerve injuries and their surgical treatment: New perspectives on a changing scenario
Debora Garozzo
Brachial Plexus and Peripheral Nerve Surgery Unit, Neurospinal Hospital, Dubai, United Arab Emirates
| Date of Web Publication | 23-Jan-2019 |
Correspondence Address:
Dr. Debora Garozzo
Brachial Plexus and Peripheral Nerve Surgery Unit, Neurospinal Hospital, Dubai
United Arab Emirates
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0028-3886.250715
How to cite this article:
Garozzo D. Peripheral nerve injuries and their surgical treatment: New perspectives on a changing scenario. Neurol India 2019;67, Suppl S1:20-2 |
Peripheral nerve injuries are usually considered rare, being presently estimated to occur in about 3% of the population who have undergone traumatic injury.[1],[2],[3],[4] Yet the data in the medical literature are likely to be incomplete or incorrect, due to the current dearth of widespread epidemiological research articles. As most of the studies were perfomed in the Western world, they are inadequate to provide an overall view of the real incidence of these injuries and certainly portray a situation that is often disconnected from world-wide reality.
In recent years, a progressively increasing rate of peripheral nerve injuries has been noticed in developing countries, mostly in South-East Asia and the Arab world. During the last decades, countries such as India, Pakistan or Vietnam have seen a tremendous proliferation of motorization. Due to their cheaper cost, hordes of two-wheelers (used to transport both passengers and goods) have invaded cities populated by millions of people, swarming along their streets and offering a metropolitan scenario that leaves western tourists completely dumbfounded. This fast growing, massive motorization is usually associated with complete lack of security measures; the consequent remarkable increase in the incidence of road traffic accidents regularly leads to more and more victims. In the Arab World, the ongoing warfare afflicting countries like Libya, Syria or Yemen has generated a high percentage of gunshot injuries, mostly complex, as they often involve diverse anatomical structures (bone injuries, tendon lacerations and nerve lesions).
The above-described situations mostly involve young individuals, the majority of them being male patients at the beginning or at the peak of their productive (both professionally and personally) years. A peripheral nerve injury may cause a functional impairment (especially when it involves the upper limb), often resulting in a condition of severe disability deeply impacting the patient's life: a wrist drop due to a radial nerve injury, a loss of the hand dexterity due to a median or an ulnar nerve injury and especially a brachial plexus palsy make manual work impossible. It can be easily inferred that peripheral nerve injuries present a remarkable impact on the individuals as well as the community they reside in, especially in developing countries, as these young individuals become an additional burden for their families already weighed down by other social issues.
Some peripheral nerve injuries may spontaneously recover but the damage on the nerve is irreversible in the majority of these cases; for these patients, surgery becomes the only hope to restore function in the affected limb. Moreover, peripheral nerve injuries are often associated with excruciating pain that has a devastating impact on the quality of life; nerve repair often provides its complete resolution or a remarkable subsidence in the intensity of neuropathic pain or dramatically reduces its severity.
Unfortunately, in developing countries where access to healthcare is not guaranteed by the government, the majority of these patients usually do not receive any treatment as they cannot sustain the elevated costs related to surgery and physiotherapy. Another reason that explains why many patients are conservatively managed, even when they have a definite indication for surgery, is the lack of surgeons specialized in nerve micro-reconstruction.
The above described scenario explains well why peripheral nerve surgery is in high demand in many areas of the world and why neurosurgeons in developing countries in particular should have at least a groundwork training in peripheral nerve surgery, enabling them to correctly assess these patients and provide basic treatment.
In order to better understand the present scenario related to peripheral nerve surgery, it must be brought to attention that until the end of the seventies, nerve repair was burdened by unsuccessful outcome in a high percentage of cases and this resulted in therapeutic nihilism in the medical community. In spite of the recent introduction of newer technology and innovative surgical techniques that have changed the dismal scenario of peripheral nerve surgery that many physicians had perceived in the past, pockets of surgeons still unfortunately remain in the medical community who distrust the surgical procedures and still believe in a dismal outcome related to this sugical field. This is often related to a lack of knowledge of the remarkable progress achieved in the last years in this field.
In such contest, “ Recent advances in nerve repair” by Sudheeesh Ramachandran and Rajiv Midha,[5] certainly represents a vital source of informative reading on the topic as it offers a comprehensive and exhaustive illustration of the state-of-the-art issues related to peripheral nerve surgery; it describes not only the wide spectrum of technical options that are nowadays available but also succeeds in providing a historical overview of the evolution and development of surgery for nerve repair. The article offers a very accurate insight on the diverse surgical strategies applied in nerve repair but especially focuses on nerve transfers, illustrating in details, the indications and surgical techniques; thus, it endorses the central role that these procedures now occupy in peripheral nerve surgery.
Algimantas Narakas and Hanno Millesi deserve the credit to be the pioneers of peripheral nerve surgery in the 70's, reviving the interest for a surgical subspecialty that had been condemned to oblivion, it is unquestionable that the revolution in peripheral nerve surgery was inititated in the early 90's thanks to the French Orthopedic surgeon, Christophe Oberlin. Nerve transfers had already been introduced and applied in brachial plexus surgery (e.g., spinal accessory to suprascapular transfer, intercostal to musculocutaneous nerve transfer, etc.) since long, yet his technique to reinnervate the biceps in C5-C6 avulsion injuries introduced a completely innovative approach. It encompassed the possibility of harvesting only a few selected fascicles from the donor nerve, thus avoiding the need to sacrifice it in order to regain a function that is considered to be of higher priority.[6] Oberlin's nerve transfer thus ushered in a new era in brachial plexus surgery, characterized by the continuous flourishing of newer surgical techniques.[7],[8],[9],[10],[11],[12],[13] Distal neurotizations have offered not only the opportunity to restore function in cases associated with avulsions, but also to obtain better functional results in a shorter time and in a higher percentage of cases in comparison with nerve graft repair. These procedures have also offered the possibility of restoring a good function even when the surgery was delayed, whereas it is very well known that graft repair usually presents unfavorable outcome after more than one year has elapsed following the trauma. Nowadays, in brachial plexus surgery, nerve transfers have largely replaced graft microreconstruction and have become the techniques of first choice, even when the conditions to perfom the latter are present. Some surgeons have also started to successfully apply them in single nerve injuries distal to the brachial plexus.[14],[15],[16],[17] It is well known that graft repair of high upper extremity nerve injuries (e.g., proximal lesions of the ulnar or the median nerve) usually results in a poor functional outcome and nerve transfers have proven to be viable options to restore a valid hand function and critical sensations in such cases.
In more recent years, the newer frontier for nerve transfers has been initiated mainly in the quadriplegic patients.[18],[19],[20],[21] Spinal cord injuries are devastating and are also associated with remarkable financial impact on the community. The application of nerve transfers to spinal cord injuries is still largely in the experimental stage; nevertheless, attempts to restore hand function in tetraplegic patients seem promising as they succeed in restoring some autonomy for the patients. This has resulted in a remarkable improvement in the quality of life of these patients, previously condemned to be completely dependent on their caregivers.
However, the wave of enthusiasm ushered in by the favorable outcome obtained as a result of the nerve transfer procedures should not make us forget that these techniques are not completely flawless.[22] Although statistically low, the possibility that the procedure might be unsuccessful must be considered; the occasional occurrence of complications in the territory of the donor nerve must also be considered. For instance, Oberlin's double transfer[23] does entail the risk of a functional deficit in the hand, a potential complication that should not downplayed. After the successful carrying out of the nerve transfers, the resulting function is not completely independent from the one controlled by the donor nerve; after the ulnar-to-musculocutaneous nerve bypass, the recovery of the biceps muscle is often associated with a tendency to flex the finger in order to bring about elbow flexion, and not all patients learn to separate the two movements. Another potential issue that needs to be taken into consideration with nerve transfers is the degree of pre-existing injury to the donor nerve. A valid functional outcome cannot be guaranteed if the donor nerve had been previoulsy damaged and this usually explains the variations in the surgical results.
The importance of such issues should not be downplayed especially while considering such procedures in quadriplegic patients. The expandable nerve for a nerve transfer is often responsible of the innervation of a muscle that can be a potential donor in a tendon/muscle transfer; the latter are known to have been successfully tested in such cases for a long time and present the advantage of restoring some hand function in these patients without risking any failure and in a much shorter time in comparison with nerve transfers.[23],[24],[25],[26],[27]
The above mentioned considerations clearly highlight that, although characterized by an extremely favorable outcome, nerve transfers are associated with potential risks that should be carefully weighed in each individual case; thus, a wide spectrum of individualized options must be always kept in mind in order to provide the most appropriate surgical treatment for each patient.
Finally, we should consider that peripheral nerve surgery is currently in a golden age in comparison with the conditions in the past. Nowadays, we focus not only on mere survival but also on the quality of life of our patients; we strive to provide them the opportunity to not only overcome their traumatic event but also fully regain their previous lifestyle.
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