302
inGreat Britain Injury (1990) 21,302-304 printed
Nerve injury T. R. Fisher Hartshill Orthopaedic
Hospital, Stoke-on-Trent,
UK
Introduction
Clinical
The building of the present Birmingham Accident Hospital, which was once the Queen’s Medical School, has given a roof to many eminent scientists since the last century. One of these past scientists was Waller, who became Professor of Physiology at the Queen’s Medical School in the 1870s following his original research on nerve transection. He first published his findings on the degenerative changes in the distal glossophalangeal nerve (Wailer, 1850), describing the normally cylindrical-shaped nerve fibres breaking up distally with the myelin sheath then becoming beaded and later absorbed. He described further experiments after dividing the dorsal root of the second cervical ganglion and ventral root in kittens, describing that in each case degeneration occurred only in the fibres separated from the cells (Wailer, 1852). From these experiments the principle of Wallerian degeneration was formulated, namely that those parts of the nerve fibres still connected to the cell bodies retained their normal appearance while that part of the nerve fibre separated from the cell degenerated, i.e that part distal to the transection. He also made the comment that there was some trophic influence supplied by the cell bodies and this influenced the nerve fibres, which we would now understand as the axoplasmic transport system in nerve fibres. This short article can only attempt to provide an outline of developments in peripheral nerve surgery over the last 130 years since Waller’s studies. An enormous literature has developed, particularly over the last 20 years.
Although end-to-end nerve suture, and even nerve grafting, had been performed by the end of the 19th century, and indeed an investigation of nerve injuries was undertaken during the American Civil War in 1863, it was not until the Second World War between 1939 and 1945 that a policy of concentration for treatment was adopted in Britain for peripheral nerve injuries. This work was reported in the Medical Research Council’s special report published in 1954. It was also during the Second World War that there was a major collaboration of clinicians and scientists including J. Z. Young, P. B. Medawar, William Holmes, Herbert Seddon and others who began one of the most fruitful periods of the search into peripheral nerve disorders, and from this work a policy for the clinical management of nerve injuries was developed. In 1972, Herbert Seddon published his monograph on Surgical Disorders of fhe Peri@eral Nerves and summarized the debate as to the merits of primary and secondary epineural repair, the debate had continued principally because up to that time there had been no strictly controlled clinical trial. There was acceptance that a clean, incised wound could give satisfactory results which were reported by Bunnell (1964), although Seddon himself and French surgeons Michon and Masse (1964) still preferred secondary suture. In severe nerve injuries where there were large gaps there was still continuing debate about the results of nerve grafts. There had been interesting work carried out by Bunnell (1927) on digital nerve grafting, Balance and Duel (1932) on repair of the facial nerve by Bunnell and Boyes (1939) on repair of major nerves in the limbs. Subsequently, Seddon reported a degree of success with nerve grafting. Nerve grafting, however, carried out in theatres of war and reported by both British and American surgeons, appear to have been unsuccessful, but were thought to be due to the conditions and techniques used rather than to the principle of nerve grafting itself.
Histopathology The work of Ramon Y. Cajal was published in a book Degeneration and Regeneration of the Nervous System in 1928, although the work for this book was prepared in 1905 and for which he won the Nobel Prize. This work based on light microscopy and silver staining techniques clarified the discussions on degeneration and regeneration of nerve fibres and finally established that regeneration occurred as a result of growth of fibres from the single fibre connected with the cell body. In the early 1970s, this work provided a platform for further studies using the electron microscope, and from his ideas and theories further investigation into nerve growth hormones and other factors influencing axoplasmic transport and nerve regeneration was carried out by Morris et al. (1972). 0 1990 Butterworth-Heinemann 0020-1383/90/050302-3
Ltd
Microsurgery In the 1960s the debate on methods of nerve repair was given greater sophistication with the use of the operating microscope in microvascular surgery and its application to peripheral nerve surgery in papers by Smith (1964) and Bora (1967). They demonstrated in animal experiments that it
Fisher: Nerve injury
was possible to resect part of the epineurium from the nerve stump ends to expose the fasciculi with their ensheathing perineurium. The perineurium was a laminated cellular layer which they found had the tensile strength to hold a microsuture in conditions of low tension. It was evident that nerve axons could regenerate across the fascicular suture line. There then followed a number of research studies comparing primary epineural versus primary fascicular suture in rabbits, cats and monkeys in the sciatic, median and the ulnar nerves. These studies used clinical, neurophysiological and biochemical methods of assessment. In a useful paper, Orgel and Terzis (1977) made a comparative study using the divided sciatic nerve in rabbits as a model to evaluate recovery after epineural and perineural repair. On a histological and neurophysiological basis, with a combined light and electron microscopy assessment, the authors were unable to detect any significant difference in the patterns of axonal regrowth in the nerves sutured by either technique. Daniel and Terzis (1977) restored the epineural method of repair as being the method of choice in most situations.
Nerve graft The technique of nerve grafting was further developed by Millesi in the 1960s using the autogenous sural nerve as donor graft and developing a microsurgical group fascicular repair. His published results (Millesi et al., 1976) show that there was a very acceptable level of recovery from this technique. He introduced it as a technique to bridge small gaps where an end-to-end suture would lead to unsatisfactory tension on the suture line. This was a more controversial concept in that it was difficult to define ‘too much tension’ and for how small a gap was it justified to use nerve grafts. The nerve graft of choice was the sural nerve, and removal of this nerve inevitably left some sensory disturbance along the lateral border of the foot. This debate was continued by Mackinnon and Lee Dellon (1988) where they highlight the harmful effect of tension but are conscious of the need to avoid using autogenous nerve grafts. They, with other workers, have experimented with the use of preformed tubes and more recently those made of polyglycolic acid.
Sensory re-education With the increased interest in peripheral nerve surgery and peripheral nerve recovery after repair of a nerve injury there began a closer evaluation of methods of shortening the rehabilitation period. In the 1960s Parry was the first to use the principle of ‘sensory re-education’ for patients with nerve repair in his rehabilitation unit. The evaluation of sensation has always been a source of controversy, although Moberg had rationalized methods of sensory testing for clinicians. However, the important topic of sensation and sensory retraining techniques was brought into prominence in an excellent monograph by Lee Dellon in 1981. The surgeon was now able to work with a concept of nerve recovery that had to include not only the technique of nerve repair, the condition of the distal nerve and peripheral receptors, but also the varying individual capacities for cerebral reorganization, i.e. learning.
Nomenclature The increasing sophistication of surgical techniques, the method of suture and the description by individual surgeons
303
of their methods of repair, inevitably led to a need for a clear nomenclature in peripheral nerve surgery. There was a need for a clear terminology in order to be able to describe the structures and layers within the peripheral nerve, and from this to be able to establish a clear description which had general agreement as to the particular method of nerve surgery that had been carried out in the different clinical situations. This difficult area has been thoroughly and excellently discussed and described by Terzis (1987).
Bra&al
plexus injury
In the late 1970s and the 1980s there began to be published large series of bra&al plexus palsies treated surgically. The improvement in the results were due to a combination of the use of microsurgery and peripheral nerve grafting and a more sophisticated evaluation of the brachial plexus lesion by neurophysiology. The general opinion expressed by these papers indicated that microsurgery did not cause a deterioration in the patient’s condition and that the majority (about 80 per cent) obtained useful recovery. The combination of improved results from nerve reconstmction and the general improvement of preoperative pain, combined with the added benefit of additional surgical reconstruction techniques such as tendon transfer and joint arthrodesis, has led to a greater interest and optimism in treating these of devastating injuries. The more recent development vascularized nerve grafts has so far not led to the improvement that was hoped for initially, and remains at the present time as an experimental procedure. Two recent books can be recommended, the first, Surgey of the Peripfd Nerve by Mackinnon and Lee Dellon (1988) is a comprehensive, well illustrated, knowledgeable and absorbing book based on the personal experiences of these two authors on all matters related to peripheral nerve injuries and compressive lesions of peripheral nerves. An A&s of Surgical Exposures of the Upper Fxfremify by Tubiana, McCullough and Masquelet published in 1990 is a beautifully illustrated book with black and white toned and coloured drawings of surgical exposures of structures in the upper limbs, with descriptive exposures for specific surgical techniques. The first book provides the principles and aims of the surgery and the second provides a means to achieve those aims.
References BaIlance C. and Duel A. B. (1932) Operative treatment of facial palsy by the introduction of nerve grafts into fallopian canal and by other intratemporal methods. Arch. Ofokmyrzgol.Head Neck Surg. 15, I.
Bora F. W. (1967) Peripheral nerve repair in cats: The fascicular stitch. J. Bone]oinf. Surg. 49A, 659. Bunnell S. (1927) Surgery of nerves of the hand. Surg. Gpecol. Obsfef. 44, 145. Bunnell S. (1964) Surgety offhe Hand 4th Ed. Revised by Boyes J. H. Montreal: Pitman Medical; Philadelphia: Lippincott. Bunnell S. and Boyes J. H. (1939) Nerve grafts. Am. J Stlrg. 44,64. Daniel R. K. and Terzis J. K. (1977) Recmfrucfive Microsurgery. Boston: Little, Brown. Lee Dellon A. (1981) Evaluation of !Snddily and Re-education of Sensafim in the Hand. Baltimore/London: Williams and Wilkins. Mackinnon S. E. and Lee Dellon A. (1988) Surgw of the Peripheral nerve. Stuttgart, New York: G. Thieme Verlag.
304
Injury: the BritishJournalof Accident Surgery (1990) Vol. 21/No. 5
Michon J. and Masse P. (1964) Le moment optimum de la suture nerveuse dans les plaies du membre superieur. Rev. Chir. G-hop. 50,205. Millesi H., Meissl G. and Berger A. (1976) Further experience with interfascicular grafting on the median, ulna and radial nerves. 1. Bone Joint Surg. 58A, 209. Morns J. H., Hudson A. R. and Weddell G. (1972) A study of degeneration and regeneration in the divided rat sciatic nerve based on electronmicroscopy. Z. zellforsch. 124, 76. Orgell M. and Terzis J. K. (1977) Epineurial vs perineurial repair. An ultrastructural and electrophysiological study of nerve regeneration.]. Pk&. Reconstr. Sug. 60, 80. Ramon Y. Cajal (1928) In: May R. M. (ed) Degeneration and Regeneration of the Nervous System (1959) Vol. 1 New York: Hafner. Seddon H. (1972) Surgical Disorders of the PeriipheralNerves 2nd Ed. Edinburgh: Churchill Livingstone.
Smith J. W. (1964) Microsurgery of peripheral nerves. J. F&t. Reconstr. Surg. 33,317. Terzis J. K. (1987) Microreconsfntction of Nerve Injuries. Philadelphia: W. B. Saunders. Tubiana R., McCullough C. J. and Masguelet A. C. (1990) An Afhs of Surgical Exposure of the Upper Ertremify. Martin Dunitz. Wailer A. V. (1850) Experiments on the glosso-pharangeal and hypglossal nerves of the frog and observations produced thereby in the structure of their primitive fibres. Philos. Trans. Roy Sot. Land. 140,423. Wailer A. V. (1852) Nouvelles recherches sur le regeneration des fibres verleux. C. R. Acad. Sci. Paris 34. 675.
Requesfs for reprints should be aa%essed to: Mr T. R. Fisher, Hartshill Orthopaedic Hospital, Hartshill, Stoke-on-Trent, Staffordshire ST4 7NZ, UK.
inGreat Britain Injury (1990) 21,302-304 printed
Nerve injury T. R. Fisher Hartshill Orthopaedic
Hospital, Stoke-on-Trent,
UK
Introduction
Clinical
The building of the present Birmingham Accident Hospital, which was once the Queen’s Medical School, has given a roof to many eminent scientists since the last century. One of these past scientists was Waller, who became Professor of Physiology at the Queen’s Medical School in the 1870s following his original research on nerve transection. He first published his findings on the degenerative changes in the distal glossophalangeal nerve (Wailer, 1850), describing the normally cylindrical-shaped nerve fibres breaking up distally with the myelin sheath then becoming beaded and later absorbed. He described further experiments after dividing the dorsal root of the second cervical ganglion and ventral root in kittens, describing that in each case degeneration occurred only in the fibres separated from the cells (Wailer, 1852). From these experiments the principle of Wallerian degeneration was formulated, namely that those parts of the nerve fibres still connected to the cell bodies retained their normal appearance while that part of the nerve fibre separated from the cell degenerated, i.e that part distal to the transection. He also made the comment that there was some trophic influence supplied by the cell bodies and this influenced the nerve fibres, which we would now understand as the axoplasmic transport system in nerve fibres. This short article can only attempt to provide an outline of developments in peripheral nerve surgery over the last 130 years since Waller’s studies. An enormous literature has developed, particularly over the last 20 years.
Although end-to-end nerve suture, and even nerve grafting, had been performed by the end of the 19th century, and indeed an investigation of nerve injuries was undertaken during the American Civil War in 1863, it was not until the Second World War between 1939 and 1945 that a policy of concentration for treatment was adopted in Britain for peripheral nerve injuries. This work was reported in the Medical Research Council’s special report published in 1954. It was also during the Second World War that there was a major collaboration of clinicians and scientists including J. Z. Young, P. B. Medawar, William Holmes, Herbert Seddon and others who began one of the most fruitful periods of the search into peripheral nerve disorders, and from this work a policy for the clinical management of nerve injuries was developed. In 1972, Herbert Seddon published his monograph on Surgical Disorders of fhe Peri@eral Nerves and summarized the debate as to the merits of primary and secondary epineural repair, the debate had continued principally because up to that time there had been no strictly controlled clinical trial. There was acceptance that a clean, incised wound could give satisfactory results which were reported by Bunnell (1964), although Seddon himself and French surgeons Michon and Masse (1964) still preferred secondary suture. In severe nerve injuries where there were large gaps there was still continuing debate about the results of nerve grafts. There had been interesting work carried out by Bunnell (1927) on digital nerve grafting, Balance and Duel (1932) on repair of the facial nerve by Bunnell and Boyes (1939) on repair of major nerves in the limbs. Subsequently, Seddon reported a degree of success with nerve grafting. Nerve grafting, however, carried out in theatres of war and reported by both British and American surgeons, appear to have been unsuccessful, but were thought to be due to the conditions and techniques used rather than to the principle of nerve grafting itself.
Histopathology The work of Ramon Y. Cajal was published in a book Degeneration and Regeneration of the Nervous System in 1928, although the work for this book was prepared in 1905 and for which he won the Nobel Prize. This work based on light microscopy and silver staining techniques clarified the discussions on degeneration and regeneration of nerve fibres and finally established that regeneration occurred as a result of growth of fibres from the single fibre connected with the cell body. In the early 1970s, this work provided a platform for further studies using the electron microscope, and from his ideas and theories further investigation into nerve growth hormones and other factors influencing axoplasmic transport and nerve regeneration was carried out by Morris et al. (1972). 0 1990 Butterworth-Heinemann 0020-1383/90/050302-3
Ltd
Microsurgery In the 1960s the debate on methods of nerve repair was given greater sophistication with the use of the operating microscope in microvascular surgery and its application to peripheral nerve surgery in papers by Smith (1964) and Bora (1967). They demonstrated in animal experiments that it
Fisher: Nerve injury
was possible to resect part of the epineurium from the nerve stump ends to expose the fasciculi with their ensheathing perineurium. The perineurium was a laminated cellular layer which they found had the tensile strength to hold a microsuture in conditions of low tension. It was evident that nerve axons could regenerate across the fascicular suture line. There then followed a number of research studies comparing primary epineural versus primary fascicular suture in rabbits, cats and monkeys in the sciatic, median and the ulnar nerves. These studies used clinical, neurophysiological and biochemical methods of assessment. In a useful paper, Orgel and Terzis (1977) made a comparative study using the divided sciatic nerve in rabbits as a model to evaluate recovery after epineural and perineural repair. On a histological and neurophysiological basis, with a combined light and electron microscopy assessment, the authors were unable to detect any significant difference in the patterns of axonal regrowth in the nerves sutured by either technique. Daniel and Terzis (1977) restored the epineural method of repair as being the method of choice in most situations.
Nerve graft The technique of nerve grafting was further developed by Millesi in the 1960s using the autogenous sural nerve as donor graft and developing a microsurgical group fascicular repair. His published results (Millesi et al., 1976) show that there was a very acceptable level of recovery from this technique. He introduced it as a technique to bridge small gaps where an end-to-end suture would lead to unsatisfactory tension on the suture line. This was a more controversial concept in that it was difficult to define ‘too much tension’ and for how small a gap was it justified to use nerve grafts. The nerve graft of choice was the sural nerve, and removal of this nerve inevitably left some sensory disturbance along the lateral border of the foot. This debate was continued by Mackinnon and Lee Dellon (1988) where they highlight the harmful effect of tension but are conscious of the need to avoid using autogenous nerve grafts. They, with other workers, have experimented with the use of preformed tubes and more recently those made of polyglycolic acid.
Sensory re-education With the increased interest in peripheral nerve surgery and peripheral nerve recovery after repair of a nerve injury there began a closer evaluation of methods of shortening the rehabilitation period. In the 1960s Parry was the first to use the principle of ‘sensory re-education’ for patients with nerve repair in his rehabilitation unit. The evaluation of sensation has always been a source of controversy, although Moberg had rationalized methods of sensory testing for clinicians. However, the important topic of sensation and sensory retraining techniques was brought into prominence in an excellent monograph by Lee Dellon in 1981. The surgeon was now able to work with a concept of nerve recovery that had to include not only the technique of nerve repair, the condition of the distal nerve and peripheral receptors, but also the varying individual capacities for cerebral reorganization, i.e. learning.
Nomenclature The increasing sophistication of surgical techniques, the method of suture and the description by individual surgeons
303
of their methods of repair, inevitably led to a need for a clear nomenclature in peripheral nerve surgery. There was a need for a clear terminology in order to be able to describe the structures and layers within the peripheral nerve, and from this to be able to establish a clear description which had general agreement as to the particular method of nerve surgery that had been carried out in the different clinical situations. This difficult area has been thoroughly and excellently discussed and described by Terzis (1987).
Bra&al
plexus injury
In the late 1970s and the 1980s there began to be published large series of bra&al plexus palsies treated surgically. The improvement in the results were due to a combination of the use of microsurgery and peripheral nerve grafting and a more sophisticated evaluation of the brachial plexus lesion by neurophysiology. The general opinion expressed by these papers indicated that microsurgery did not cause a deterioration in the patient’s condition and that the majority (about 80 per cent) obtained useful recovery. The combination of improved results from nerve reconstmction and the general improvement of preoperative pain, combined with the added benefit of additional surgical reconstruction techniques such as tendon transfer and joint arthrodesis, has led to a greater interest and optimism in treating these of devastating injuries. The more recent development vascularized nerve grafts has so far not led to the improvement that was hoped for initially, and remains at the present time as an experimental procedure. Two recent books can be recommended, the first, Surgey of the Peripfd Nerve by Mackinnon and Lee Dellon (1988) is a comprehensive, well illustrated, knowledgeable and absorbing book based on the personal experiences of these two authors on all matters related to peripheral nerve injuries and compressive lesions of peripheral nerves. An A&s of Surgical Exposures of the Upper Fxfremify by Tubiana, McCullough and Masquelet published in 1990 is a beautifully illustrated book with black and white toned and coloured drawings of surgical exposures of structures in the upper limbs, with descriptive exposures for specific surgical techniques. The first book provides the principles and aims of the surgery and the second provides a means to achieve those aims.
References BaIlance C. and Duel A. B. (1932) Operative treatment of facial palsy by the introduction of nerve grafts into fallopian canal and by other intratemporal methods. Arch. Ofokmyrzgol.Head Neck Surg. 15, I.
Bora F. W. (1967) Peripheral nerve repair in cats: The fascicular stitch. J. Bone]oinf. Surg. 49A, 659. Bunnell S. (1927) Surgery of nerves of the hand. Surg. Gpecol. Obsfef. 44, 145. Bunnell S. (1964) Surgety offhe Hand 4th Ed. Revised by Boyes J. H. Montreal: Pitman Medical; Philadelphia: Lippincott. Bunnell S. and Boyes J. H. (1939) Nerve grafts. Am. J Stlrg. 44,64. Daniel R. K. and Terzis J. K. (1977) Recmfrucfive Microsurgery. Boston: Little, Brown. Lee Dellon A. (1981) Evaluation of !Snddily and Re-education of Sensafim in the Hand. Baltimore/London: Williams and Wilkins. Mackinnon S. E. and Lee Dellon A. (1988) Surgw of the Peripheral nerve. Stuttgart, New York: G. Thieme Verlag.
304
Injury: the BritishJournalof Accident Surgery (1990) Vol. 21/No. 5
Michon J. and Masse P. (1964) Le moment optimum de la suture nerveuse dans les plaies du membre superieur. Rev. Chir. G-hop. 50,205. Millesi H., Meissl G. and Berger A. (1976) Further experience with interfascicular grafting on the median, ulna and radial nerves. 1. Bone Joint Surg. 58A, 209. Morns J. H., Hudson A. R. and Weddell G. (1972) A study of degeneration and regeneration in the divided rat sciatic nerve based on electronmicroscopy. Z. zellforsch. 124, 76. Orgell M. and Terzis J. K. (1977) Epineurial vs perineurial repair. An ultrastructural and electrophysiological study of nerve regeneration.]. Pk&. Reconstr. Sug. 60, 80. Ramon Y. Cajal (1928) In: May R. M. (ed) Degeneration and Regeneration of the Nervous System (1959) Vol. 1 New York: Hafner. Seddon H. (1972) Surgical Disorders of the PeriipheralNerves 2nd Ed. Edinburgh: Churchill Livingstone.
Smith J. W. (1964) Microsurgery of peripheral nerves. J. F&t. Reconstr. Surg. 33,317. Terzis J. K. (1987) Microreconsfntction of Nerve Injuries. Philadelphia: W. B. Saunders. Tubiana R., McCullough C. J. and Masguelet A. C. (1990) An Afhs of Surgical Exposure of the Upper Ertremify. Martin Dunitz. Wailer A. V. (1850) Experiments on the glosso-pharangeal and hypglossal nerves of the frog and observations produced thereby in the structure of their primitive fibres. Philos. Trans. Roy Sot. Land. 140,423. Wailer A. V. (1852) Nouvelles recherches sur le regeneration des fibres verleux. C. R. Acad. Sci. Paris 34. 675.
Requesfs for reprints should be aa%essed to: Mr T. R. Fisher, Hartshill Orthopaedic Hospital, Hartshill, Stoke-on-Trent, Staffordshire ST4 7NZ, UK.
