What is the role of nerve repair in the treatment of spinal accessory nerve (SAN) injury?

Updated: Feb 09, 2018
  • Author: Rohan R Walvekar, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
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Answer

If the SAN is in continuity and without electrically demonstrable transmission upon direct nerve stimulation, a resection of the nerve with the associated scar or neuroma is performed. This is followed by a primary end-to-end anastomosis. Nerve grafting is performed if the primary anastomosis produces unacceptable tension.

The basic surgical principles of both primary nerve anastomosis and nerve grafting are one and the same, as elegantly outlined in Dvali and Mackinnon in 2003, as follows: [49]

  • Preoperative quantification of motor and sensory function

  • Use of microsurgical technique, including magnification, instrumentation, and microsutures

  • Emphasis on tension-free repair [50]

  • Use of interpositional grafting when tension-free primary anastomosis is not possible

  • Primary repair (anastomosis) when possible

  • Delay in repair for approximately 3 weeks in cases in which primary repair is not optimal (eg, severe crush injury, stretch, or loss of nerve tissue) (This allows the surgeon to identify the true extent of the injured area, which is not always evident in the period immediately subsequent to injury.)

  • Promoting early protected range of motion to facilitate nerve gliding and to prevent contracture formation.

Surgical loupes (with a minimum 4X magnification) and/or operating microscopes should be used for nerve repair. Usually, 9-0 or 10-0 nylon sutures are recommended for nerve anastomosis. [49]


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