UPPER-EXTREMITY PERIPHERAL NERVE INJURIES

Neurosurgery ◽  
2009 ◽  
Vol 65 (suppl_4) ◽  
pp. A11-A17 ◽  
Author(s):  
Judith A. Murovic
Keyword(s):  
Upper Extremity ◽  
Ulnar Nerve ◽  
Action Potentials ◽  
Radial Nerve ◽  
Suture Repair ◽  
State University ◽  
Nerve Injuries ◽  
Louisiana State University ◽  
Nerve Action ◽  
Better Than

Abstract OBJECTIVE Data from three Louisiana State University Health Sciences Center (LSUHSC) publications were summarized for median, radial, and ulnar nerve injuries. METHODS Lesion types, repair techniques, and outcomes were compared for 1837 upper-extremity nerve lesions. RESULTS Sharp laceration injury repair outcomes at various levels for median and radial nerves were equally good (91% each) and better than those for the ulnar nerve (73%). Secondary suture and graft repair outcomes were better for the median nerve (78% and 68%, respectively) than for the radial nerve (69% and 67%, respectively) and ulnar nerve (69% and 56%, respectively). In-continuity lesions with positive nerve action potentials during intraoperative testing underwent neurolysis with good results for the median (97%), radial (98%), and ulnar nerves (94%). For radial, median, and ulnar nerve in-continuity lesions with negative intraoperative nerve action potentials, good results occurred after suture repair in 88%, 86%, and 75% and after graft repair in 86%, 75% and 56%, respectively. CONCLUSION Good outcomes after median and radial nerve repairs are attributable to the following factors: the median nerve's innervation of proximal, large finger, and thumb flexors; and the radial nerve's similar innervation of proximal muscles that do not perform delicate movements. This is contrary to the ulnar nerve's major nerve supply to the distal fine intrinsic hand muscles, which require more extensive innervation. The radial nerve also has a motor fiber predominance, reducing cross-motor/sensory reinnervation, and radial nerve-innervated muscles perform similar functions, decreasing the chance of innervation of muscles with opposite functions.

IATROGENIC SCIATIC NERVE INJURIES AT BUTTOCK AND THIGH LEVELS

Neurosurgery ◽  
2009 ◽  
Vol 65 (suppl_4) ◽  
pp. A63-A66 ◽  
Author(s):  
Esmiralda Yeremeyeva ◽  
David G. Kline ◽  
Daniel H. Kim
Keyword(s):  
Sciatic Nerve ◽  
Total Hip Arthroplasty ◽  
Action Potentials ◽  
Health Sciences ◽  
Motor Deficits ◽  
State University ◽  
Nerve Injuries ◽  
Louisiana State University ◽  
Nerve Action ◽  
Iatrogenic Damage

Abstract OBJECTIVE To provide an overview of iatrogenic sciatic nerve injuries at the buttock and thigh levels, and to analyze results of the treatment provided at Louisiana State University Health Sciences Center–New Orleans. METHODS The data from 196 patients were reviewed retrospectively. All patients had iatrogenic sciatic nerve injuries at the buttock and thigh levels and were evaluated and treated at the Louisiana State University Health Sciences Center between the years 1968 and 1999. One hundred sixty-four of these patients had injuries caused by injections at the buttock level, 15 sustained sciatic nerve injuries after a total hip arthroplasty, and 17 had iatrogenic damage at the thigh level. RESULTS Patients with severe motor deficits underwent neurolysis if they had positive nerve action potentials, and end-to-end anastomosis or grafting if the nerve action potentials were negative. Operations were performed on 64 patients with injection injuries at the buttock level, on 15 with iatrogenic damage at the thigh level, and on 15 with deficits after total hip arthroplasty. Results were analyzed by the procedure performed and by the outcome in both the peroneal and tibial divisions. CONCLUSION Patients with mild or no motor deficits and those with pain that was manageable did not undergo surgery and were treated conservatively. For patients with significant motor deficits and those with pain that was not responsive to pharmacological management, physical and occupational therapy required surgical intervention. Patients who had positive nerve action potentials required neurolysis only and had the best recovery, whereas those with negative nerve action potentials required more extensive intervention entailing reanastomosis or grafting and had worse outcome. In general, the outcome was better for the tibial than for the peroneal divisions, regardless of the type of intervention.

LOWER-EXTREMITY PERIPHERAL NERVE INJURIES

Neurosurgery ◽  
2009 ◽  
Vol 65 (suppl_4) ◽  
pp. A18-A23 ◽  
Author(s):  
Judith A. Murovic
Keyword(s):  
Sciatic Nerve ◽  
Tibial Nerve ◽  
Common Peroneal Nerve ◽  
Suture Repair ◽  
State University ◽  
Nerve Injuries ◽  
Louisiana State University ◽  
Use Of Data ◽  
Extensor Muscles ◽  
Better Than

Abstract OBJECTIVE With the use of data from 3 Louisiana State University Health Sciences Center (LSUHSC) publications, various parameters for buttock/thigh-level sciatic nerve and tibial and common peroneal divisions/nerve injuries were summarized, and outcomes were compared. METHODS Data from 806 buttock/thigh-level sciatic nerve and tibial and common peroneal division/nerve injury repairs were summarized. Lesion types, repair techniques, and outcomes were compared. RESULTS Acute lacerations undergoing suture repair were best for the thigh-then-buttock-level tibial (93%/73%) and then same-level common peroneal divisions (69%/30%); at the knee level, tibial outcomes (100%) were better than those for the common peroneal nerve (CPN) (84%). Secondary graft repairs for lacerations had good outcomes for the thigh-then-buttock-level tibial (80%/62%), followed by common peroneal divisions at the same levels (45%/24%). The knee/leg-level tibial nerve (94%) did better than the CPN (40%) here. In-continuity lesions with positive intraoperative nerve action potentials underwent neurolysis with better results for the thigh-then-buttock-level tibial division (95%/86%) than for same-level CPN (78%/69%). The knee/leg-level tibial nerve did better than the CPN (95%/93%). CONCLUSION Better recovery of buttock- and thigh-level tibial division/nerve occurs because: 1) the CPN is lateral and thus vulnerable to a more severe injury; 2) the tibial nerve is more elastic at impact owing to its singular-fixation site (the CPN has a dual fixation); 3) the tibial nerve has a better blood supply and regeneration; 4) the tibial nerve has a higher force-absorbing fascicle/connective tissue count than the CPN; and 5) the tibial nerve-innervated gastrocnemius soleus requires less reinnervation for functional contraction than deep peroneal branches, which innervate long, thin extensor muscles at multiple sites and require coordinated nerve input for effective contraction.

Posterior Interosseous Nerve Palsies

Neurosurgery ◽  
1990 ◽  
Vol 27 (3) ◽  
pp. 397-402 ◽  
Author(s):  
George Cravens ◽  
David G. Kline
Keyword(s):  
Action Potentials ◽  
Ganglion Cyst ◽  
Medical Center ◽  
Preoperative Evaluation ◽  
Suture Repair ◽  
Posterior Interosseous Nerve ◽  
Louisiana State University ◽  
Nerve Action ◽  
Grade 3 ◽  
The Right

Abstract One hundred seventy patients with radial nerve disorders were reviewed at the Louisiana State University Medical Center over a 15-year period. Of these, 32 had involvement of the posterior interosseous nerve exclusively. Findings included weak wrist extension with a radial drift, inability to extend the fingers, paralysis of thumb extension, and weak thumb abduction. Causes included entrapment at the arcade of Froshe (14 patients), laceration (6 patients), fracture (6 patients), compression or contusion (3 patients), and loss associated with tumor (3 patients). The ratio of men to women was 2:1, and the right arm was involved twice as often as the left. Preoperative evaluation included physical examination, electrophysiological testing (electromyogram/nerve conduction velocity), and roentgenograms of the elbow and forearm. Of the 30 patients (2 patients had bilateral lesions), 26 underwent operation. In the operative series, all 28 nerves had a function of Grade 3 or more of a possible 5 after 4 years of follow-up. Seventeen had achieved Grade 4/5, and 7 had obtained Grade 5/5. At operation, 23 nerves were found to be in continuity. Fourteen lesions of nerves in continuity were associated with entrapment and. not unexpectedly, transmitted a nerve action potential with slowed conduction and low amplitude across the lesion. Four nerves in continuity that had lesions caused by injury had nerve action potentials and were treated by neurolysis, and another 4 had no nerve action potentials and were treated by graft or suture repair. Five injured nerves were not in continuity. Two could be repaired by end-to-end suture, and 3 required graft repair. A large ganglion cyst involving the posterior interosseous nerve was also resected.

scholarly journals Penetrating injuries due to gunshot wounds involving the brachial plexus

2004 ◽  
Vol 16 (5) ◽  
pp. 1-6 ◽  
Author(s):  
Daniel H. Kim ◽  
Judith A. Murovic ◽  
Robert L. Tiel ◽  
David G. Kline
Keyword(s):  
Brachial Plexus ◽  
Action Potentials ◽  
Gunshot Wounds ◽  
Complete Loss ◽  
Sensory Function ◽  
Suture Repair ◽  
State University ◽  
Penetrating Injuries ◽  
Louisiana State University ◽  
Grade 3

The authors review 118 operative brachial plexus gunshot wounds (GSWs), causing 293 element injuries that were managed over a 30-year period at Louisiana State University Health Sciences Center (LSUHSC). Retrospective chart reviews were performed. Using the LSUHSC grading system for motor sensory function, each element's grades were combined and averaged. Most of the 293 injured elements were found to have gross continuity at operation and of 202 elements with complete neurological loss, only 16 (8%) exhibited total disruption. Of 293 injuries, 128 elements with complete or incomplete loss were not only in continuity when explored but also had positive intraoperative nerve action potentials (NAPs). After neurolysis, 120 of 128 elements in continuity (94%) improved to greater than or equal to Grade 3 function. Elements not regenerating early usually required repair. One hundred fifty-six of 202 completely or incompletely injured elements (77%) required resection and suture or graft repair based on intraoperative NAPs. Neurolysis achieved greater than or equal to Grade 3 results in 42 (91%) of 46 elements with complete loss. Suture repair resulted in good outcomes in 14 (67%) of 21 and in 73 (54%) of 135 undergoing graft repairs (1 to 3.5 cm length) and presenting with complete loss. Of 91 incomplete elements, intraoperative NAPs were positive in 82 (90%) and 78 of 82 had good results. Nine had negative NAPs and six elements required suture repair. Three required grafts with results of greater than or equal to Grade 3 in five (83%) of six and two (67%) of three, respectively. Based on 118 patient results with 293 injured elements, guidelines for the management of GSWs were established as described in this paper.

Surgical Management and Results of 135 Tibial Nerve Lesions at the Louisiana State University Health Sciences Center

Neurosurgery ◽  
2003 ◽  
Vol 53 (5) ◽  
pp. 1114-1125 ◽  
Author(s):  
Daniel H. Kim ◽  
Yong-Jun Cho ◽  
Stephen Ryu ◽  
Robert L. Tiel ◽  
David G. Kline
Keyword(s):  
Action Potentials ◽  
Tibial Nerve ◽  
Suture Repair ◽  
Tarsal Tunnel ◽  
State University ◽  
Nerve Lesions ◽  
Louisiana State University ◽  
Nerve Sheath ◽  
Tunnel Syndrome ◽  
Grade 3

Abstract OBJECTIVE This retrospective study presents 33 years of clinical and surgical experience with 135 tibial nerve lesions to review operative techniques and their results and to provide management guidelines for the proper selection of surgical candidates. METHODS Between 1967 and 1999, 135 patients with tibial nerve lesions at the knee level or below were managed surgically at the Louisiana State University Health Sciences Center. We reviewed these cases. RESULTS Of the 135 cases, traumatic injury accounted for 71, tarsal tunnel syndrome for 46, and nerve sheath tumor for 18. Of 22 lesions not in continuity, functional recovery of Grade 3 or better was achieved in 4 (67%) of 6 patients who required end-to-end suture repair and 11 (69%) of 16 patients who required graft repair. One hundred thirteen tibial nerve lesions in continuity underwent primarily external or internal neurolysis or resection of the lesions. A few received end-to-end suture or graft repair. Direct intraoperative recording of nerve action potentials guided case management decisions. Among the 113 patients with lesions in continuity, 76 (81%) of 94 patients receiving neurolysis, 5 (83%) of 6 receiving suture repair, and 11 (85%) of 13 receiving graft repair recovered function to Grade 3 or better. Repair results were best in patients with recordable nerve action potentials treated by external neurolysis. Results were poor in a few patients with very lengthy lesions in continuity and in reoperated patients with tarsal tunnel syndrome. CONCLUSION Surgical exploration and repair of tibial nerve lesions, including nerve sheath tumors and tarsal tunnel syndromes, achieved excellent outcomes.

Surgical management and outcome in patients with radial nerve lesions

2001 ◽  
Vol 95 (4) ◽  
pp. 573-583 ◽  
Author(s):  
Daniel H. Kim ◽  
Andrew C. Kam ◽  
Padmavathi Chandika ◽  
Robert L. Tiel ◽  
David G. Kline
Keyword(s):  
Surgical Management ◽  
Radial Nerve ◽  
Gunshot Wounds ◽  
Suture Repair ◽  
Content Type ◽  
Louisiana State University ◽  
Internal Neurolysis ◽  
End To End ◽  
Grade 3 ◽  
Fine Print

Object. The goal of this paper was to review surgical management and outcomes in patients treated for radial nerve (RN) lesions at Louisiana State University Health Sciences over a period of 30 years. Methods. Two hundred sixty patients with RN injuries were evaluated. The most common mechanisms of injuries involving the RN included fracture of the humerus, laceration, blunt contusions, and gunshot wounds. One hundred and eighty patients (69%) underwent surgery. Lesions not in continuity required primary or secondary end-to-end suture repairs or graft repairs. With the use of direct intraoperative nerve action potential recording, RN injuries in which the lesion was in continuity required external or internal neurolysis or resection of the lesion followed by end-to-end suture or graft repair. A minimum of 1.5 years follow-up review was available in 90% of the patients who underwent surgery. Motor function recovery to Grade 3 or better was observed in 10 (91%) of 11 patients who underwent primary suture repair, 25 (83%) of 30 who underwent secondary suture repair, 43 (80%) of 54 who received graft repair, and 63 (98%) of 64 in whom neurolysis was performed. Sixteen (71%) of 21 patients with superficial sensory RN injury achieved satisfactory pain relief after complete resection of a neuroma or neurolysis. Conclusions. This study clearly demonstrates that excellent functional recovery can be achieved with proper surgical management of RN injuries.

Emergence of Radial Nerve Dominance in Median Nerve Cortex After Median Nerve Transection in an Adult Squirrel Monkey

1997 ◽  
Vol 77 (1) ◽  
pp. 522-526 ◽  
Author(s):  
C. E. Schroeder ◽  
S. Seto ◽  
P. E. Garraghty
Keyword(s):  
Median Nerve ◽  
Squirrel Monkey ◽  
Ulnar Nerve ◽  
Action Potentials ◽  
Radial Nerve ◽  
Current Source ◽  
Short Latency ◽  
Nerve Transection ◽  
A Site ◽  
Stimulation Of

Schroeder, C. E., S. Seto, and P. E. Garraghty. Emergence of radial nerve dominance in median nerve cortex after median nerve transection in an adult squirrel monkey. J. Neurophysiol. 77: 522–526, 1997. Throughout the glabrous representation in Area 3b, electrical stimulation of the dominant (median or ulnar) input produces robust, short-latency excitation, evident as a net extracellular “sink” in the Lamina 4 current source density (CSD) accompanied by action potentials. Stimulation of the collocated nondominant (radial nerve) input produces a subtle short-latency response in the Lamina 4 CSD unaccompanied by action potentials and followed by a clear excitatory response 12–15 ms later. Laminar response profiles for both inputs have a “feedforward” pattern, with initial activation in Lamina 4, followed by extragranular laminae. Such corepresentation of nondominant radial nerve inputs with the dominant (median or ulnar nerve) inputs in the glabrous hand surface representation provides a likely mechanism for reorganization after median nerve section in adult primates. To investigate this, we conducted repeated recordings using an implanted linear multi-electrode array straddling the cortical laminae at a site in “median nerve cortex” (i.e., at a site with a cutaneous receptive field on the volar surface of D2 and thus with its dominant afferent input conveyed by the median nerve) in an adult squirrel monkey. We characterized the baseline responses to median, radial, and ulnar nerve stimulation. We then cut the median nerve and semi-chronically monitored radial nerve, ulnar nerve and median nerve (proximal stump) evoked responses. The radial nerve response in median nerve cortex changed progressively during the weeks after median nerve transection, ultimately assuming the characteristics of the dominant nerve profile. During this time, median, and ulnar nerve profiles displayed little or no change.

Vein conduit with microsurgical suture repair of superficial branch of the radial nerve injuries at the wrist

2018 ◽  
Vol 37 (4) ◽  
pp. 238-242 ◽  
Author(s):  
R. Pinet ◽  
G. Raimbeau ◽  
Y. Saint-Cast ◽  
P.-A. Fouque ◽  
F. Rabarin
Keyword(s):  
Radial Nerve ◽  
Suture Repair ◽  
Nerve Injuries ◽  
Superficial Branch

Management and Outcomes of 42 Surgical Suprascapular Nerve Injuries and Entrapments

Neurosurgery ◽  
2005 ◽  
Vol 57 (1) ◽  
pp. 120-127 ◽  
Author(s):  
Daniel H. Kim ◽  
Judith A. Murovic ◽  
Robert L. Tiel ◽  
David G. Kline
Keyword(s):  
Shoulder Pain ◽  
Suprascapular Nerve ◽  
State University ◽  
Suprascapular Notch ◽  
Presenting Symptoms ◽  
Louisiana State University ◽  
Ganglion Cysts ◽  
Good Improvement ◽  
Grade 3 ◽  
Better Than

Abstract OBJECTIVE: Retrospective chart reviews of 42 patients with surgical suprascapular nerve (SSN) injury/entrapment were performed. Presenting symptoms, findings, operative approach, and results are documented. METHODS: Forty-two patients with SSN injuries/entrapments underwent operations between 1970 and 2002. Charts were retrospectively reviewed for the presence of shoulder pain; spinati muscle function was evaluated with the Louisiana State University Health Sciences Center grading system. Side of lesion and sex were equally represented; mean follow-up was 18 months (range, 12–48 mo). SSN injuries/entrapments were associated with occupational overuse (19), sports-related injury (16), direct trauma (4) and ganglion cysts (3). Thirty-one (79%) of 39 patients with suprascapular notch SSN injuries/entrapments, excluding ganglion cysts, presented with mild to moderate shoulder pain and spinati weakness. RESULTS: Motor function for these 31 patients was graded on a scale of 0 to 5. Preoperatively, patients had supraspinatus function Grades 0 to 2 and infraspinatus function Grades 0 to 2. Supraspinatus function improved postoperatively to Grade 4 or better in 28 patients (90%) and to Grades 2 to 3 in 3 patients (10%). Infraspinatus function improved to better than Grade 3 in 10 patients (32%), to Grades 2 to 3 in 14 patients (45%), and to Grade 1 in 7 patients (23%). Preoperatively, eight (21%) of 39 patients presenting with persistent severe pain had Grade 3 spinati strength. Of these eight patients, seven (88%) had an improvement in pain postoperatively. Strength in this group remained the same or improved to Grade 4. Postoperatively, three patients with ganglion cysts had good improvement in spinati function. CONCLUSION: Although SSN injury/entrapment is rare, 42 patients are presented who responded well to SSN release. Supraspinatus muscle improvement was as good as or better than that achieved in the infraspinatus.

scholarly journals Infraclavicular brachial plexus stretch injury

2004 ◽  
Vol 16 (5) ◽  
pp. 1-6 ◽  
Author(s):  
Daniel H. Kim ◽  
Judith A. Murovic ◽  
Robert L. Tiel ◽  
David G. Kline
Keyword(s):  
Brachial Plexus ◽  
Median Nerve ◽  
Ulnar Nerve ◽  
Axillary Artery ◽  
Vascular Injuries ◽  
State University ◽  
Associated Injuries ◽  
Stretch Injury ◽  
Louisiana State University ◽  
Acceptable Outcome

Object The authors report the surgery-related results obtained in 143 patients with stretch-induced infraclavicular brachial plexus injuries (BPIs). The entire series comprised 1019 operative BPIs managed at the Louisiana State University Health Sciences Center between 1968 and 1998. Methods Infraclavicular lesions represented 143 (28%) of the total of 509 stretch injuries involving both the infra-and supraclavicular brachial plexus, of which 366 (72%) were supraclavicular lesions. The operative approach is thoroughly outlined, and common patterns and combinations of involvement of nerves peculiar to the infraclavicular area are presented. Overall, the results of suture and graft repair were favorable for the lateral and posterior cord and their outflows. Repair of medial cord–median nerve also yielded acceptable results. The results of medial cord and medial cord–ulnar nerve, however, were poor. The incidence of associated injuries in the infraclavicular as opposed to the supraclavicular area, including shoulder dislocation and fracture and humeral fractures as well as vascular injuries including axillary artery injury was higher. Results of a literature search supported the finding that vascular injuries were increased due to the juxtaposition of vessels among the brachial plexus elements. Conclusions Thus, although less common than their supraclavicular counterpart, infraclavicular stretch injury lesions when they occur are technically more difficult to treat and are associated with a higher incidence of vascular and dislocation/fraction injuries. Favorable results were obtained for lateral and posterior cord lesions and their outflows, with acceptable outcome after medial cord–median nerve stretch injury repair. The results of medial cord and medial cord to ulnar nerve, however, were poor.

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