Treatment of peripheral nerve injuries: Surgeons' perspective

Abstract

P erip heral nerve repair has been a source of considerable controversy almost since the beginning of recorded history. In approximately 1300 AD, Galen postulated that there was no benefit in repairing peripheral nerves. For this reason and because of the significant incidence of gangrene following surgery, peripheral nerve repair was not widely practiced. Subsequently, Guy de Chaulic proposed that both tendons and nerves were amenable to suture. In the 1800s, Muller reported that nerve axons could regenerate across a site of nerve transection. Using silver stain, Cajal showed the presence of regenerating axons across the site of nerve repair. Also in the 1800s, Vulpius reported the first basic science studies of nerve grafts and their outcomes. The clinical foundations for peripheral nerve surgery have been traced to the observations of Silas Weir Mitchell during his work as a Civil-Warera physician. In his treatise Injuries of Nerves and Their Consequences, Mitchell describes causalgia as a syndrome characterized by burning pain and trophic limb changes often caused by ballistic nerve injury. During World War II, Barnes Woodall and Sir Herbert Seddon performed pioneering work in the care of casualties with peripheral nerve injury. They critically examined the methods of primary nerve repair, secondary nerve repair, and nerve grafting. In the 1960s Jacobsen and others developed the operating microscope which, combined with new methods of producing ultrafine suture and precision needles, allowed surgeons to more precisely coapt transected nerves. Sunderland and colleagues performed extensive anatomic work on the internal architecture of peripheral nerves, providing surgeons with an accurate road map for repair. Ten years ago clinicians caring for peripheral nerve injuries had access to sophisticated internal road maps of peripheral nerves and high-quality