Peripheral Nerve Surgery - View through Multidiciplinary Approch Window

Abstract

Modern surgical treatment of peripheral nerves begins with introduction of operative microscope in 1964. Pathology of peripheral nerves is a broad field of neurosurgery and includes injuries, tumors and compressive neuropathies. Indications for operative treatment of peripheral nerve injuries are open injuries with undoubtable nerve injury and neurological deficit, closed injuries that show no sign of recovery even three months after injury, pain that is resistant to therapy. Good preoperative evaluation, detailed examination, electrophysiological studies, neuroradiography and multidisciplinary approach is an imperative. In our Clinic many different procedures are done: neurolysis, direct suture, nerve transplantation, nerve transfer. Treatment of choice is different for every patient and it is individually selected. After surgery, of utmost importance for neurological recovery is physical rehabilitation. Poorer results are when mixed nerves are involved, traction injuries and higher lesions. Timing of the surgical treatment is of the utmost importance. Surgery of brachial plexus injuries is utterly demanding field of surgery. Treatment should be conservative in patients that show spontaneous recovery within the first few weeks after the trauma. Surgical treatment is indicated for patients who have an associated vascular lesion and sharp wounds, where lesion on neural elements is evident. Immediate repair, when possible, is a better therapeutic approach than delayed repair. A closed injury without evidence of root avulsion should be treated surgically, if there is no sign of recovery within 6 months. The selective combination of neurotizations gives a moderate shoulder and elbow control. Compressive neuropathies are a group of disorders of the peripheral nerves that are characterized by pain and/or loss of function (motor and/or sensory) of the nerves as a result of chronic compression. Nerve conduction studies confirm the diagnosis. Some compression neuropathies can be treated surgically -carpal tunnel and cubital tunnel syndrome are two most common examples. Surgery is recommended for patients with symptoms refractory to non-operative measures and/or those with severe and long-standing symptoms or weakness. Tumors of peripheral nerves are rare lesions. They are more frequent in phakomatoses. Patients present for evaluation of peripheral nerve tumors because of a soft tissue mass, pain, or focal neurologic findings. The duration and progression of symptoms or signs is important as most benign tumors have a longer duration and a slow rate of progression, while malignant tumors tend to progress rapidly in size, amount of pain, and neurologic deficit. A careful family history is important in the assessment of an underlying neurogenetic disorder. Treatment of choice is total surgical resection. In certain types of tumors, that affect majority of nerve fascicles (e.g., neurofibroma), resection of nerve must be done to obtain total surgical resection. In this case nerve defect should be repaired using nerve grafting or nerve transfer. In malignant tumors, nerve reparation is not advisable.