Some questions of the treatment of injuries of extremities peripheral nerves

Abstract

Trauma of extremities peripheral nerves is on the one of first places on disability and results in stable invalidism in 28–75 % of cases. Mistakes in nerves surgery lead not only to unsatisfactory results and repeated operations but also cause the numerous complications. Indications and contraindications to surgery and conservative treatment, surgical tactics and methods of operations on peripheral nerves depend on trauma prescription, injury character and previous surgical interventions, tissue scarring degree and also level of injury. Aim of research: to carry out an analysis of nerve trunk injuries at traumas of upper and lower extremities, to ground the differentiated approach to treatment depending on traumatization degree and time elapsed since the moment of trauma. Materials and methods: Author carried out retrospective analysis of medical histories of 70 patients with injury of extremities peripheral nerves and the choice of treating tactics and methods. Research was carried out on the base of traumatology department of Dnepropetrovsk clinical hospital № 16 from 2010 to 2013 year. Injuries were divided on cause in primary (65,7 %) and secondary (iatrogenic) (34,3 %), and also on the degree of conductivity disorder in: neurotmesis (60,0 %), axonotmesis (27,1 %) and neuropraxia (12,9 %). Diagnosis of the nerve trunks trauma in clinic was set on the base of clinically-neurological examination using paraclinical methods of research: electroneuromyography, thermal tomography, intramuscular electromyography, bones and joints radiography. Results: According to the results of clinically-neurological and paraclinical methods of research the choice of surgical or conservative treatment depends on dynamics of nerve trunk conductivity disorders: the loss of motor function, sensory impairments and vegetative-trophic impairments in innervation area. The most often were injuries of radial nerve on the level of the shoulder middle one-third – 29 cases (41,4 %), and in area of radial bone head resection. In the forearm lower one-third were often injured ulnar and median nerves – 7 cases (10,0 %), on the lower extremities – peroneal nerve – 9 cases (12,9 %). According to our analysis from 70 patients 52 (74,3 %) were operated, 18 (25,7 %) underwent conservative treatment. Special attention must be paid to the choice of surgical technique especially concerning nerves of combined structure. To detect injuries of fascicles within trunk it is recommended to use electro-optic equipment on surgical table. According to the author the most favorable period for surgical treatment is 3 month from the moment of trauma or during 2–3 weeks from the wound healing. The method of so-called “legitimate expectations” of operation on the nerve trunks in 4-6 month was not proved its value. Author did not notice the significant improvement of the nerve motor function over time. Conclusion: an analysis allows us to offer differentiated approach to treatment of injuries of extremities peripheral nerves and make the next conclusions: 1. Patients with EPN (extremities peripheral nerves) trauma must be sent in specialized department or clinic when the neurosurgical intervention on nerves is more reasonable. The main requirement to surgical access is a possibility of sufficient vision of nerve at the injury level in proximal and distal directions. It gives a possibility to manipulate on the nerve trunk, to assess the character and size of injury and to carry out an intervention sufficient by volume. 2. At squeeze of the nerve trunk it is necessary to use neurolysis and in its anatomical pause – neurography with application of epineural and epiperineural stitch and in several cases to use fascicular stitch. At impossibility to match the ends of injured nerve at its mobilization to carry out autoplasty taking into account the fascicular nerve structure with monothread 7/0, best of all with synthetic one 0/00. 3. All patients underwent the course of conservative care and rehabilitation in both preoperative and postoperative periods, its volume and duration depended on degree of an injured nerve dysfunctions and concomitant injuries. The detailed neurological examination after operation in patients with nerve trauma is necessary minimum one time per 4 weeks