Nerve Repair and Grafting in the Upper Extremity

Historical Perspective

Difficulty in achieving successful nerve repair is well-chronicled in the recorded history of medicine. From the time of Galen in the second century AD, nerve regeneration was considered impossible. Although there were merely sporadic reports of successful nerve repair in the Middle Ages, Haighton (1795)^[1] reported survival after bilateral staged vagotomies and immediate repair in dogs as a historic milestone in confirming the efficacy of neurorrhaphy. Since simultaneous vagotomy is fatal, this exercise demonstrated that a delay of 6 weeks between vagotomies (a time adequate for regeneration) resulted in survival and provided indirect evidence that nerve regeneration was possible. Subsequently, Muller^[2] identified regenerating axons distal to the site of repair in the rabbit sciatic nerve and confirmed Haighton's conclusions.

Once the concept of nerve repair was established, a variety of surgical techniques was examined; suturing of epineural flaps,^[3] tangential sectioning of nerves prior to suture,^[4] side-to-side repair,^[5] and intussusception^[3] have all been reported.

Though early reports lack specific outcome information, Sherren^[6] in 1906 achieved a "successful" nerve graft with improvement in outcome after use of a xenograft. In 1917, Mayo-Robson^[7] reported that a nerve allograft could successfully bridge a 2.5-cm defect in the median nerve. A lack of any consistent success with either repair or grafting kept enthusiasm for nerve repair low throughout the 19th century.

Silas Weir Mitchell^[8] reported on his experiences with nerve injury during the Civil War in his book, Injuries of Nerves. During World War I, Tinel^[9] described the "tingling" of nerve regeneration that is elicited by gentle percussion along the course of an injured nerve. During World War II, Sir Herbert Seddon^[10] and Barnes Woodhall, in a classic contribution, tabulated the results and variability of primary nerve repair, secondary nerve repair, and nerve grafting.

The development of improved suture material, specialized instrumentation, and operative magnification improved surgical capability. Sir Sydney Sunderland^[11] detailed descriptions of the internal architecture of various peripheral nerves, allowing clinicians to perform more accurate nerve repairs. These advances permitted the present concepts used in epineural and group fascicular repair.

The present focus of basic nerve research is directed toward a better understanding of the biology of nerve regeneration. The ability to manipulate nerve recovery at the cellular or gene level will provide the next significant improvement in nerve recovery.

Cite this: Nerve Repair and Grafting in the Upper Extremity - Medscape - Nov 01, 2001.

Table 1. Nerve Injury Classification ^[23]
Seddon	Sunderland	Pathophysiologic Basis
Neuropraxia	I	Local myelin damage. Axons preserved. No degeneration.
Axonotmesis	II	Endoneural tube preserved. Axon degeneration.
	III	Loss of endoneural tube continuity. Perineurium intact. Axon degeneration.
	IV	Endoneural tube and perineurium disrupted. Epineurium intact. Axon degeneration.
Neurotmesis	V	Complete loss of neural continuity.

Table 2. Selected Muscle Evaluation for Diagnosis of Motor Nerve Injury ^[35]
I.	Median nerve: intrinsic
	A. Thumb-palmar abduction (abductor pollicis brevis)
II.	Median nerve: extrinsic
	A. All flexor digitorum sublimi
	B. Flexor profundus digitorum to index
	C. Flexor pollicis longus
	D. Flexor carpi radialis
III.	Ulnar nerve: intrinsic
	A. First dorsal interosseous muscle
	B. Muscles of the hypothenar eminence
IV.	Ulnar nerve: extrinsic
	A. Flexor digitorum profundus, small finger
	B. Flexor carpi ulnaris
V.	Radial nerve: extrinsic
	A. Wrist extension (extensor carpi radialis brevis and longus, extensor carpi ulnaris)
	B. Extension of fingers at metacarpophalangeal joint (extensor digitorum communis, extensor indicis proprius, extensor digiti minimi)

Table 3. Sensory Evaluation for Specific Peripheral Nerve Injury ^[35]
I.	Median nerve -- Pulp of thumb and index finger
II.	Palmar cutaneous branch of median nerve -- Proximal palm over thenar eminence
III.	Ulnar nerve -- Pulp of small finger
IV.	Dorsal cutaneous branch of ulnar nerve -- Dorsal ulnar surface of hand
V.	Radial nerve -- Dorsal radial hand over first web space
VI.	Digital nerve -- Area of the distal phalangeal joint flexion crease

Table 4. Evaluation of Motor Recovery After Peripheral Nerve Injury
M0	No contraction
M1	Return of contraction in the proximal muscles
M2	Return of contraction in both proximal and distal muscles
M3	Return of function in both proximal and distal muscles of such a degree that all important muscles are sufficiently powerful to act against gravity
M4	Return of function as in M3; in addition, all synergistic and independent movements are possible
M5	Complete recovery

Table 5. Evaluation of Sensory Recovery After Peripheral Nerve Injury ^[40,54]
S0	Absence of sensibility in the autonomous area
S1	Recovery of deep cutaneous pain sensibility within the autonomous area of the nerve
S2	Return of some degree of superficial cutaneous pain and tactile sensibility within the autonomous area of the nerve
S3	Return of superficial cutaneous pain and tactile sensibility throughout the autonomous area, with disappearance of any previous overresponse
S3+	Return of sensibility as in S3; in addition, there is some recovery of 2-point discrimination within the autonomous area (7-15 mm)
S4	Complete recovery (2-point discrimination, 2-6 mm)

Table 6. Vascularized Nerve Grafts: Donor Nerves and Associated Vessels
Nerve	Vascular Supply
Superficial radial	Radial artery
Ulnar	Superior ulnar collateral artery
Sural	Superficial sural artery
Anterior tibial	Anterior tibial artery
Superficial peroneal	Superficial peroneal artery
Saphenous	Saphenous artery

Adapted from Breidenbach and Terzis. ^[70]

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Historical Perspective

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