From Big Medical Encyclopedia

NERVOUS SEAM (neurorraphia) — connection by a seam of the ends of the broken-off or cut nerve. The problem of operation consists in exact comparison of cross sections of the central and peripheral ends of the crossed nervous trunk.

Distinguish seams epinevralny and perineural. Epinevralny stitches are put on an epineurium — the strongest cover of a nerve which is reliably holding seams. Perineural interfastsikulyarny seams — seams between separate bunches of nerves — became possible with development of the microsurgical equipment (see. Microsurgery ). More often they are applied at plastics of nerves when in defect between the ends of the injured nerve sew free transplants from pieces of a nerve of the patient, usually from sural. The term «endoneural seam» is essentially wrong; it is applied sometimes to designation of wrong operation, at a cut thread is carried out through all thickness of a nervous trunk. Thread in such cases passes not through endonev-ry, and through interfascicular cellulose of a nerve, damaging bunches and not increasing durability of a seam.

Indications to a neurorrhaphy and a run time of this operation considerably are defined by a type of an injury. At tidy chipped and cut wounds with injury of a nerve it is often shown primary to N. Highway, imposed at primary surgical treatment of a wound. Operation H. of highway is not urgent. It can be delayed till the moment when all conditions for its performance are optimum. Sometimes it is difficult to correct the mistakes made at urgent nerve operations. Therefore to impose primary N. Highway the surgeon having experience in the field after preliminary diagnosis of injury of a nerve, in the presence of the corresponding equipment, tools and an assistention shall. At the fragmentary, hurt and contaminated wounds recovery nerve operation is postponed for 2 — 3 weeks or for bigger term, being conformed with a current of a wound process.

At gunshot wounds primary to N. Highway it is not shown since in the first days it is difficult to define borders of a necessary resection it is irreversible the damaged sites of a nerve. Besides, in the first days after a gunshot wound disturbance of conductivity of a nerve can be caused by its concussion; later conductivity can spontaneously be recovered. Therefore at gunshot wounds has advantages early delayed by N. Highway after specification of the diagnosis of damage.

At fractures of bones disturbance of conductivity of nerves approximately in 80% of cases comes to an end with spontaneous recovery. Nerve operation at fractures of bones is usually shown after the so-called period of justified waiting within 3 — 4 months when the delay of spontaneous recovery comes to light.

At the closed damages of traction type H. of highway it is shown seldom and, as a rule, in late terms, several months later if on the central end of the interrupted nerve the neuroma testimonial of the remained opportunities of regeneration is defined. Generally at traction damages vnu-tristvolovy disturbances on length of nerves are observed at the different levels and on a big extent that does a resection is irreversible the changed sites and N. Highway impracticable.

At a prelum of nerves from the outside, napr, at hemorrhage in intermuscular intervals or at an ischemic contracture like folkmannovsky, operation can be insistently necessary for a decompression of nervous trunks, but the question of irreversibility of changes of nerves and indications to a resection of the changed sites and N. Highway finally is solved after the research during operation.

At a preparation for surgery carry out nevrol, a research of the patient using electrodiagnosis, photography or a sketch of zones of disturbance of sensitivity and sweating. At late operations carry out the treatment directed to elimination contractures (see) and recovery of normal volume of passive movements in joints. Sometimes plastic surgery for substitution of defect of skin shall precede recovery nerve operation.

From special equipment are necessary the equipment for electrodiagnosis during operation, the additional sources of lighting increasing optical devices (an operative microscope, a frontal telescopic magnifying glass, etc.), mosquito clips; for a perineural seam — a set of microsurgical instruments, monofit amentny thread 10—0(10 of zero) with an atraumatic needle 0,6 — 0,7 mm thick. Apply a thin, but strong suture material with an atraumatic needle to an epinevralny seam. For refreshing of the ends or a resection of the changed site of a nerve use faultlessly fine shaving edge in a clip.

Anesthesia at the majority of operations on nerves local since at it the contact with the patient is possible during electrodiagnosis. In more difficult situations make the choice between a potentialized anesthesia and an endotracheal anesthesia.

Technology of operation

Fig. 1. The diagrammatic representation of cross sections of an upper extremity at roundabout accesses (are specified by shooters) to nerves: and — to a median nerve in an average third of a shoulder (1 — a median nerve, 2 — a humeral artery, 3 — humeral veins, 4 — an elbow nerve, 5 — a beam nerve, 6 — a tricipital muscle, 7 — a humeral bone, 8 — a humeral muscle, 9 — a lateral saphena of a hand, 10 — a myshech-but-cutaneous nerve, 11 — a biceps, 12 — hooks dilators); — to median, elbow and a superficial branch of a beam nerve in an upper third of a forearm (1 — the round pronator, 2 — a beam sgibatel of a wrist, 3 — a superficial sgibatel of fingers, 4 — a median nerve, 5 — an elbow nerve, 6 — a deep sgibatel of fingers, 7 — an ulna, 8 — the long muscle which is taking away a thumb of a brush, 9 — the general razgibatel of fingers, 10 — an instep support, 11 — a deep branch of a beam nerve, 12 — above and below branch beam razgibatel of a wrist, 13 — a beam bone, 14 — a superficial branch of a beam nerve, 15 — a humeroradial muscle, 16 — hooks dilators).
Fig. 2. The diagrammatic representation of the cuts which are not crossing skin folds and providing access to nerves: 1 — on an upper extremity; 2 — on the lower extremity; 3 — for an exposure of vessels and nerves of axillary area without injury of a big pectoral muscle; 4 — for an exposure of a brachial plexus in a side triangle of a neck; 5 — for an exposure of a brachial plexus in axillary area.

Imposing of an epinevralny seam. Primary N. Highway can be sometimes imposed through the available wound, but more often it is expanded, turning into typical quick access. At the delayed operations roundabout accesses (fig. 1) quite often have advantage. In all cases the cuts which are not crossing across flexion folds over joints and not leaving behind the pulling together hems (fig. 2) are preferable.

Allocation of a nerve at primary operations comes easy if it is good to know topographical ratios. At the delayed operations the nervous trunk is allocated in the acute way at first in not changed fabrics above and below the place of damage, and then from hems.

The research of the allocated nerve is the responsible moment of intervention. At a full break of a nervous trunk define borders of necessary refreshing of the ends. At the hurt and gunshot wounds the intra trunk hematoma and crush of bunches, and later hems can extend on a big extent in a nervous trunk. At an insufficient resection the subsequent scarring prevents regeneration. Too extensive resection leads to a tension of the ends of a nerve. At an external continuity of a nerve there are diagnostic difficulties in definition of weight of intra trunk changes, especially at primary operations. In such cases resort to survey of a nerve (sometimes in a transmitted light), palpations and it is obligatory to electrodiagnosis, irritating sites of a nerve places of damage are lower and higher.

After the decision to put a stitch is made, the nerve will be mobilized up and from top to bottom from the level of damage for the purpose of elimination of a tension. Prepare a bed by excision of the damaged fabrics and hems. Moving of a nerve to a new bed is undertaken by hl. obr. concerning an elbow nerve.

The resection of the changed ends of a nerve is an obligatory stage of operation even after pure cut wounds. Such refreshing of the ends is made strictly cross. On cuts the bunches which are cross cut in one plane, not changed intra trunk cellulose and vessels shall be visible. Bleeding is stopped applying of a wet gauze ball. At an external continuity of a nerve it is more convenient to make a resection of the changed site on the brought finger.

Fig. 3. Diagrammatic representation of imposing of an epinevralny seam: 1 — threads handles are carried out through an epineurium by means of an atraumatic needle on lateral and medial sides of a nerve; 2 — stitches on an epineurium are put.

Survey of cross sections and imposing of epinevralny seams, especially on thin nerves, carry out under control of the increasing optics and at the strengthened illumination of a surgery field. At first impose two seams handles from lateral and medial side of a nerve so that not to cause twisting of its pieces around a longitudinal axis, and then intermediate noose sutures in the quantity providing tightness of contact of cuts of an epineurium! both ends (fig. 3). Seams tighten before contact of the connected cuts so that not to cause a bend of bunches. It excludes a possibility of growing of neogenic fibers into surrounding fabrics. Any wrapping of a suture line outside is not recommended by any fabrics and materials (tubazh nerves) since it breaks blood supply of a nerve at the expense of vessels of surrounding fabrics and leads to a sclerosis of the site of a nerve.

The Egshnevralny stitch is put in that position of an extremity, at Krom the injured nerve tests the smallest tension. In this situation the extremity is held a plaster splint for 3 weeks after operation.

Fig. 4. The diagrammatic representation of operation at partial damage of a nervous trunk with formation of a side neuroma: 1 — borders of excision of a side neuroma are specified by a dotted line; 2 — the side neuroma is excised, on edges of defect of a nerve put stitches; the remained part of a nerve is bent by an arch (in the subsequent it is usually involved in hems); 3 — option of plastics — after excision defect is replaced with an autograft from a cutaneous nerve.

At partial damages of a nervous trunk with formation of a side neuroma sometimes excise a neuroma and put a partial stitch (fig. 4). At the same time the remained part of a nerve deprived on the one hand of an epineurium is bent by an arch and involved in hems. Results of this operation, as a rule, unsatisfactory. Therefore better or to leave a side neuroma on site, or to replace defect with a free transplant from a cutaneous nerve, especially if it was also damaged, or to excise a neuroma together with the subject site of a nerve and then to sew a nerve the end in the end.

Imposing of an interfastsikulyarny seam. After approach to a nerve it is cut proksimalno and distally from the damaged site with excision of an epinev-ralny cover at this level. For the purpose of allocation separate fastsikul and fascicular groups preparation is carried out on interfascicular spaces. The cross section fastsikul is made at that level where their normal look is lost. In the course of operation on paper sketch an intra neural structure of the central and peripheral end of the crossed nerve with identification motive and sensitive fastsikul. For the last use motive, touch and Electrophysiologic effects of electrostimulation separate fastsikul. Further atraumatic needles with a suture material in 8 — 0 — 10 — 0 put a stitch on the separate fastsikula corresponding each other. It should be noted that success of this operation depends on lack of a tension between kontsakhm of a nerve.

In the postoperative period prolonged treatment by physical methods is necessary. Thermal procedures (paraffin, ozokerite, dirt, etc.) are especially useful repeated courses for a year and longer, LFK, massage, electrostimulation of the paralyzed muscles.

The result of operation depends on a type of an injury, size of defect, level of damage, existence of the accompanying damages of vessels, bones, sinews, age of the patient, term of operation, full value of refreshing and rapprochement of the ends of a nerve, qualification of the surgeon, etc. In the next months after N. Highway only initial signs of regeneration of a nerve come to light. Regeneration of nerves after heavy damages can continue many years (10 — 15 years and more).

Bibliography: Grigorovich K. A. Surgery of nerves (elected heads), JI., 1969, bibliogr.; it, About assessment of results of surgical treatment of injuries of nerves, Vestn, hir., t. 119, No. 10, page 131, 1977; Milies i H., M e i s s 1 G. a. Berger A. The interfascicular nerve-grafting of the median and ulnar nerves, J. Bone Jt Surg., v. 54-A, p. 727, 1972, bibliogr.; Seddon H. J * Surgical disorders of the peripheral nerves, Edinburgh — L., 1972; Sunderland S. Nerves and nerve injuries, Edinburgh — L., 1972.

K. A. Grigorovich; And. H. Shevelyov (neyrokhir.).