What is new in peripheral nerve repair?

Abstract

In the last few years, several new techniques have been added in the repair of peripheral nerves. Some of them are convincing and are gaining popularity amongst peripheral nerve surgeons. Magnification has certainly improved the results of nerve repair. Although autografts are the gold standard for repair of peripheral nerves, allografts have been practiced as an alternative, by incorporation of new immunosuppressive agents such as FK- 506. In select patients with a paucity of autografts, allograft nerve transplantation may be of some utility. For small defects (< 3 cm), nerve conduits made of biological materials or autologous vein, have produced promising results. As an alternative to simple suture repair, fibrin glue is being used for nerve coaptation. Narakas found a 30% decrease in operation time with slightly superior functional outcome relative to traditional suture based coaptation. End - to - side neurorraphy may be helpful when the proximal nerve stump is not available.

Keywords

nerve repair - autografts - allografts - nerve conduits - fibrin glue - end - to - side neurorraphy

• References

• 1 Millesi H. Techniques for nerve grafting. Hand Clinics 16 2000; 73-91
• 2 Doi K, Kuwata N, Kawakami F. et al The free vascularized sural nerve graft. Microsurgery 05 1984; 175-184
• 3 Hasegawa T, Nakamura S, Manabe T. et al Vascularized nerve grafts for the treatment of large nerve gap after trauma to an upper extremity. Arch Orthop Trauma Surg 124 2004; 209-213
• 4 Gu YD, Chan DS, Zhang GM. et al Long term functional results of contralateral C7 transfer. J Reconstr Microsurg 14 1998; 57-59
• 5 Waikakul S, Orapin S, Vanadurongwan V. Clinical results of contralateral C7 root neurotization to the medial nerve in brachial plexus injuries with total root avulsions. J Hand Surg [Br] 24 1999; 556-560
• 6 Kobayashi S, Akizuki T, Sakai Y, Ohmori K. Harvest of sural nerve grafts using the endoscope. Ann Plast Surg 35 1995; 249-253
• 7 Capek L, Clarke HM, Zuker RM. Endoscopic sural nerve harvest in the pediatric patient. Plast Reconstr Surg 98 1996; 884-888
• 8 Clarke HM. An update on endoscopic sural nerve harvest. Plast Reconstr Surg 102 1998; 1304
• 9 Hallock GG. Endoscopic retrieval of the sural nerve. J Reconstr Microsurg 11 1995; 347-350
• 10 Eich BS, Second RJ. Fix. New techniques for endoscopic sural nerve harvest. J Reconstr Microsurg 16 2000; 329-331
• 11 Bain JR, Mackinnon SE, Hudson AR, Wade J, Evans P. et al The peripheral nerve allograft in the primate immunosuppresed with cyclosporine A.I. Histologic and electrophysiologic assessment. Plast Reconstr Surg 90 1992; 1036-1046
• 12 Mackinnon SE, Doolabh VB, Novak CB, Trulock EP. Clinical outcome following nerve allograft transplantation. Plast Reconstr Surg 107 2001; 1419-1429
• 13 Jones JW, Gruber SA, Baker JH, Breidenbach WC. Successful hand transplantation. One year follow up. Louisville Hand transplant team. N Engl J Med 343 2000; 468-473
• 14 Atchabahian A, Doolabh VB, Mackinnon SE. et al Indefinite survival of peripheral nerve allografts after temporary cyclosporin A immunosuppression. Restor Neurol Neurosci 13 1998; 129-139
• 15 Ohara K, Billington R, James RW, Dean GA, Nishiyama M, Naguchi H. Toxicologic evaluation of FK-506. Transplant Proc 22 1990; 83-86
• 16 Starzl TE, Todo S, Fung J, Demetris AJ, Venkataraman R, Jain A. FK 506 for liver, kidney and pancreas transplantation. Lancet 02 1989; 1000-1004
• 17 Gold BG, Katoch K, Storm-Dickerson T. The immunosuppressant FK 506 increases the rate of axonal regeneration in rat sciatic nerve. J Neurosci 15 1995; 7505-7516
• 18 Hudson TW, Evans GR, Schmidt CE. Engineering strategies for peripheral nerve repair. Orthop Clin North Am 31 2000; 485-497
• 19 Francel PC, Francel TJ, Mackinnon SE, Hertl C. Enhancing nerve regeneration across a silicone tube conduit by using interposed short segment nerve grafts. J Neurosurg 87 1997; 887-892
• 20 Midha R, Munro CA, Dalton PD, Tator CH, Shoichet MS. Growth factor enhancement of peripheral nerve regeneration through a novel synthetic hydrogel tube. J Neurosurg 99 2003; 555-565
• 21 Ashley WW, Weatherly T, Park TS. Collagen nerve guides for surgical repair of brachial plexus birth injury. J Neurosurg 106 2006; 452-456
• 22 Young IZ, Medawar PB. Fibrin suture of peripheral nerves. Lancet 02 1940; 126
• 23 Narakas A. The use of fibrin glue in repair of peripheral nerves. Orthop Clin North Am 19 1988; 187-198
• 24 Ornelas L, Padilla L, Di Silvio M, Schalch P, Esperantes RL, Infante. Bustamante JC, Avalos P, Varela D, Lopez M. Fibrin glue: an alternative technique for nerve coaptation- Part-II. Nerve regeneration and histomorphometric assessment. J Reconstr Microsurg 22 2006; 123-128
• 25 Bozorg GA, Mosnier I, Julien N, EI Garem H, Bouccara D, Sterkers O. Long term functional outcome in facial nerve graft by fibrin glue in the temporal bone and cerebellopontine angle. Eur Arch Otorhinolaryngol 262 2005; 404-407
• 26 Viterbo F, Trindale JC, Hoshino K, Mazzori Neto A. End to side neurorrhaphy with removal of the epineural sheath: An experimental study in rats. Plast Reconstr Surg 94 1994; 1038-1047
• 27 Tarasidis G, Watanabe O, Mackinnon SE. et al End-to-side neurorrhaphy: a long term study of neural regeneration in a rat model. Otolaryngol Head Neck Surg 119 1998; 337-341
• 28 Noah EM, Williams A, Jorgensen C, Skoulis TG, Terzis JK. End-to-side neurorraphy – a histologic and morphometric study of axonal sprouting into an end-to-side nerve graft. J Reconstr Microsurg 13 1997; 99-106
• 29 Shah MH, Kasabian AK, Karp NS, Kolker AR, Dublin BA, Zhang I. et al Axonal regeneration through an autogenous nerve bypass: An experimental study in the rat. Ann Plast Surg 38 1997; 408-415
• 30 Tham SKJ, Morrison WA. Motor collateral sprouting through an end – to – side nerve repair. J Hand Surg (Am) 23 1998; 844-885