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Surgical interventions on nerve trunks. Latin language and basics of medical terminology: Textbook How nerves are sewn together

The innervation of the hand is mainly carried out by three nerves: median, ulnar and radial, and to a lesser extent musculocutaneous, which provides sensitivity to the skin of the eminence of the thumb.

Rarely encountered - 0.3%. In fact, injuries to the digital nerves located on the metacarpus, especially with extensive and combined injuries, are observed almost constantly, but are not reflected in the diagnosis.

In Fig. 125 shows a diagram of the localization of hand wounds, most often complicated by nerve damage. Recognition of nerve damage in accidental wounds of the hand is based on a comparison of the location of the wound and the topography of the nerves of the hand. Motor and sensory disorders with complete nerve damage occur immediately, but are not recognized due to incomplete examination. Injuries to the nerves at the level of the fingers and the middle of the metacarpus do not cause movement disorders, but sensitivity and trophism are significantly affected. Wounds at the base of the palm, facing the thumb, are complicated by damage to the branch of the median nerve with subsequent paralysis of the muscles of the eminence of the thumb and the I-II lumbrical muscles.

Damage to the median and ulnar nerves at the wrist level causes typical motor, sensory and trophic disorders (sweating, changes in skin color, temperature, etc.).

Rice. 125. Localization of hand wounds most often accompanied by nerve damage (a); diagram of the nerve suture (b).

Injury to the superficial branches of the radial nerve and the dorsal branch of the ulnar nerve in the lower third of the forearm also entails sensory and trophic disorders according to the zone of innervation.

The diagnosis of nerve damage is often made only after weeks and months after the injury (K. A. Grigorovich, 1969), when the irreversibility of motor and sensory disorders becomes obvious. Then, electrodiagnostics and electromyography, the study of biopotentials and other indirect methods help clarify the diagnosis.

Neurological examination data play an important role in diagnosis and in assessing the course and regeneration of nerves of the fingers and hand. For a complete and accurate picture of the sensitivity of the hand and fingers, it is recommended to study tactile, discriminatory sensitivity, stereognosis and a ninhydrin test. Having recognized or suspected nerve damage, it is necessary to splint the hand and send the victim to the surgical department, where there are conditions for primary treatment and suture of the nerve.

Nerve suture

The need to suture a damaged digital nerve is not subject to discussion, because if the skin sensitivity of the fingers is impaired, the functional ability of the hand is sharply reduced. In this case, one should be guided by the provision that suturing a nerve is a non-urgent operation.

During the initial treatment of a finger wound, a primary epineural suture is indicated in cases where the surgeon finds it possible to perform a reconstructive operation and suture the wound. For contaminated wounds of the fingers or the presence of skin defects, when there are no conditions for a primary suture, a delayed nerve suture is used.

Suturing the nerves of the hand and fingers is not difficult, since the common and proper digital nerves are not as thin as expected. Suture of the digital nerve is also technically feasible on the middle phalanx. Its ends usually do not diverge, and one or two epineural sutures are sufficient for connection (Fig. 125, b). According to Bennell's data, the duration of regeneration of the digital nerve sutured at the level of the proximal phalanx is approximately 85 days, at the level of the palm - BUT days.

Nerve suture technique

The operation of the suture of the nerves of the hand is performed in a hospital setting, under anesthesia or intraosseous anesthesia by a surgeon with experience in hand surgery. When treating a wound to find the ends, it is sometimes necessary to expand the wound along the damaged nerve. When isolating the nerve trunk, all surgeon manipulations must be atraumatic; Grasping the nerve with tweezers, prolonged exposure, pulling, separating, etc. are unacceptable. When both ends of the damaged nerve are discovered, they are held by soft tissue or epineurium.

When applying a suture, atraumatic needles and a suture through the epineurium are used. Having placed a suture on the damaged nerve on one, more accessible side, the ends of the threads are taken into a clamp and used as “holders” when applying subsequent sutures on the opposite side of the nerve. In this case, it is very important not to allow the nerve segments to rotate relative to each other and not to cause bending of the bundles, but to oppose them to each other until they touch. Any gap between the bundles is filled with a hematoma and scar, which prevents the germination of newly formed axons. The number of sutures should be sufficient to ensure tight contact between the fascicles and epineuria. This technique makes it unnecessary to wrap the nerve suture area with various tissues and materials, which cause the formation of rougher scars.

If tension on the nerve is felt when tying the sutures, the hand is placed in a position that eliminates it. Proper management of the patient after surgery is of great importance, in particular bed rest, elevated position of the arm for 5-7 days. Subsequent complex treatment consists of exposure to physical factors (D'Arsonval currents, iontophoresis, UHF, massage, electrical muscle stimulation, therapeutic exercises and immobilization, medications).

Restoration of hand functions after damage to the median and ulnar nerves in the carpal tunnel occurs no earlier than six months and is often not complete. First, the sense of touch is restored, then discriminative sensitivity - the ability to distinguish between touching two points at the same time. To restore the victim’s ability to work, the most important thing is the ability to recognize captured objects without vision control - “tactile gnosis”, which, according to most authors, is not fully restored.

A study of the long-term results of suture of the nerves of the hand and fingers shows that only 57% of victims have no pain, a third of patients experience coldness of the fingers and paresthesia; Even more often, pronounced trophic disorders are observed to varying degrees.

In modern nerve surgery, microsurgical technique is becoming increasingly widespread, ensuring synchronous work of the surgeon and assistant, the possibility of precise restoration of individual bundles of the nerve trunk (K. A. Grigorovich, 1975; B. V. Petrovsky, V. S. Krylov, 1976; Tsuge and al., 1975).

E.V.Usoltseva, K.I.Mashkara
Surgery for diseases and injuries of the hand

NEUROLYSIS, neurolysis (from the Greek neuron-■ nerve and lysis-release), release of the nerve from the scar tissue compressing it. Entered into surgery. practice almost simultaneously with nerve resection and suture. In the present time, N.'s time represents one of the important khir. activities on the peripheral nervous system. There are external N. (exoneurolysis) and internal (endoneurolysis). N a r u z n y N. - liberation of the nerve from the scars enveloping it from the outside. The surgical technique for cases where the adhesions involve only the epineurium is very simple. Scar tissue is easily removed with a scalpel along with the outer sheath of the nerve (avoid exposing the nerve with a blunt probe, gauze ball, etc.). In the presence of extensive scar masses firmly fused to the nerve trunk, its release presents significant difficulties. In these cases, special care must be taken when isolating muscle (motor) branches to avoid damaging them. The nerve trunk should be carefully examined after isolation is completed.

Figure 1. Releasing the nerve. The dotted line indicates the site of resection.

by palpation to determine intra-trunk injuries (ruptures, neuromas, scars). In the absence of endoneurial changes, the operation of external N. ends with this. Sometimes N. is complicated by the presence of a callus that compresses the nerve. In these cases, to free the nerve trunk, it is necessary to resort to help

Figure 2. Nerve suturing after partial resection.

bone instruments. Measures to prevent new development of scars around the nerve after N. are the same as after nerve suture(cm.). Internal N. - liberation of individual nerve bundles from scar tissue that has developed in the thickness of the nerve trunk. The surgical technique was developed by Ch. arr. Shtoffel (Stoffel). The separation of the bundles begins within the healthy area, then each bundle is sequentially isolated from the scar tissue. The operation is applicable only in cases where intra-trunk scars occupy a limited extent. In the presence of extensive scar masses, endoneurolysis turns out to be technically impossible. In these cases, the affected area of the nerve is resected and its ends are sutured (Fig. 1 and 2). The French method used can be considered as a modification of endo-neurolysis. by the authors, nerve combing (hersage) is a longitudinal splitting of the nerve into bundles using thin needles or a series of silks. The length used in some cases has a similar meaning - 41# N.'s results according to some authors (wartime damage). Number of Success Neu - cases (in %) dacha (in %) 88.9 11.1 84.2 15.8 84.0 16.0 69.2 30.8 nerve ruptures in the presence of transverse scar bridges.- N.'s results are usually quite good. After 2-3 days, symptoms of irritation disappear, and after 2-3 weeks, nerve function is restored. Lit.: P y s s e p L., Fundamentals of surgical neuropathology, part 1-Peripheral nervous system, P., 1917; Guide to Practical Surgery, ed. S. Girgolava, A. Martynova, S. Fedorova, vol. II, dep. 2, M.-L., 1929; Lehmann W., Die Chirur-gie der peripheren Nervenverletzungen, B.-Wien, 1921 (lit.); Neugebauer, Zur Neurorhaphie u. Neurolysis, Bruns Beitrage z. klin. Cbir., B. XV, 1896; Stiles H.a. Forrest e r-B g o w n M., Treatment of injuries of the peripheral spinal nerves, Oxford, 1922. A. Vishnevsky.

Surgical treatment is aimed at creating favorable conditions for the penetration of regenerating nerve fibers from the central end of the damaged nerve to the peripheral one. This is achieved:

a) isolation of the nerve trunk from scar tissue;
b) separation of epineural and perineural adhesions;
c) restoration of the anatomical continuity of the nerve trunk by suturing its ends or homo- and autoplasty;
d) elimination of compression of the nerve trunk by bone fragments, growing hematoma, incorrectly applied plaster cast or progressive swelling of soft tissues.

represents the isolation of the nerve trunk from the surrounding scars or callus (Fig. 106). When the nerve trunk is superficially located, in order to prevent involvement of the nerve trunk in the musculocutaneous scar, it is advisable to use non-projection skin incisions, in which the incision line does not coincide with the projection of the nerve.

Nerve suture- the most important therapeutic measure in case of damage. The main indication for suturing a nerve is a complete or approaching irreversible degree of disruption of its conductivity. In this case, they distinguish:

A) primary nerve suture, when the suture is applied simultaneously with the primary surgical treatment of the wound;
b) delayed suture, which is performed after primary surgical treatment of the wound.

Rice. 106. Neurolysis.

With a complete anatomical break of the nerve, after mobilizing its ends and removing tension, the torn edges of the nerve are refreshed to such an extent that on its transverse sections bundles of viable axons surrounded by perineurium are clearly visible. Non-viable areas of the nerve are excised with a razor blade strictly perpendicular to the length of the nerve trunk. The objective of the operation is the most accurate comparison of the cross sections of the nerve, refreshed with a razor, bringing them together almost closely, but without bending the bundles, and holding them in the achieved position for the period necessary for strong fusion of the epineurium. Very thin sutures with an atraumatic needle are applied only to the epineurium in an amount sufficient to ensure the tightness of the suture line (Fig. 107). At the end of the operation, the limb should be fixed with a plaster splint in the position that was given to it at the time the suture was applied to the nerve, taking into account the removal of tension on the nerve.

Rice. 107. Technique for suturing nerves. a - isolation of the nerve from scars and removal of neuroma; b - comparison of the ends of the nerve and application of sub-epineural sutures; c - diagram of subepineural sutures

In case of closed nerve injuries, the operation of exposing it should not be delayed for more than 4-6 weeks.

Surgery on the nerve late after injury begins with neurolysis. It is extremely important to excise the neuroma but preserve the parts of the nerve that can regenerate. If the nerve trunk is not completely interrupted, separate the affected part from the healthy part, excise the neuroma of the affected part and apply a suture to this part of the nerve. The best results of nerve suturing are obtained using microsurgical techniques.

Moving the nerve to a new bed along a shorter path is used mainly for extensive damage to the ulnar nerve on the shoulder and forearm and makes it possible to bring together the far diverged ends of the transected nerve without tension (sometimes for 8-10 cm). In cases where significant diastasis does not allow the ends of the nerve to be brought together without tension, plastic surgery is used:

a) replacement of a nerve defect with an autograft (for example, a cutaneous nerve);
b) plastic surgery of the nerve with its branch, which does not have much functional significance;
c) flap plastic surgery of the nerve, which consists of partial incision in the transverse direction of the peripheral end over an extent slightly greater than the existing defect. Then a longitudinal split is made, the flap is folded up and sutured to the central end;
d) replacement of the nerve defect with fresh or preserved nerve grafts.

Traumatology and orthopedics. Yumashev G.S., 1983

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Nerve suture (neurorrhaphy). The task of the operation is to accurately compare the cross sections of the central and peripheral ends of the transected nerve trunk.

There are epineural and perineural sutures. Epineurial sutures are placed on the epineurium - the strongest nerve sheath that securely holds the sutures. Perineural interfascicular sutures - sutures between individual bundles of nerves - became possible with the development of microsurgical techniques. The latter are most often used in nerve plasty, when free autografts are sewn into the defect between the ends of the damaged nerve - interfascicular autotransplantation.

There are primary nerve sutures, applied at the time of initial surgical treatment, and delayed sutures, which can be early, if they are made in the first weeks after injury, and late, if they are made later than 3 months. from the day of injury. The main conditions for suturing are a clean wound, a site of injury without crush areas, and a highly qualified team of surgeons equipped with modern microsurgical equipment. In the absence of these conditions in the early stages after damage, delayed suture should be considered the method of choice.

Indications for a nerve suture are signs of a complete anatomical break or disruption of nerve conduction without external signs of a break in the nerve trunk with an irreversible nature of the process, established by extra- and intraoperative electrophysiological diagnostic methods.

The outcome of operations depends on the type of injury, the size of the defect, the level of damage, the age of the patient, the duration of the operation, associated injuries, accurate identification and comparison of intraneural structures.

The operation is performed under anesthesia. The damaged nerve is isolated from scar tissue in the same sequence as during neurolysis. Predominantly non-projection surgical access is used. In cases of significant development of scar tissue in the area of nerve damage, the scars are excised layer by layer in a single ellipsoidal block. Subsequently, the isolation of the proximal and distal segments of the nerve begins from the level of healthy tissue and gradually reaches the area of traumatic neuroma. This technique reduces the risk of damage to large blood vessels lying near the nerve, then the scar tissue around the nerve is excised and the neuroma is isolated. If the ends of the nerve are not connected to each other by a scar bridge, then, grasping each of these ends with tweezers, cross them with a sharp scalpel or razor blade within healthy tissue. If there is external continuity of the nerve in the area of the neuroma, the excitability of the peripheral segment is checked with a faradic current. If there is no response to the current, the proximal and distal segments of the nerve are captured with rubber or gauze strips and crossed above and below the neuroma within healthy areas. The unchanged nerve on the cross section has a granular appearance, the vessels of the epineurium and perineurium bleed - this indicates complete removal of the neuroma.

Next, they begin to mobilize the nerve segments to ensure tension-free suturing. The assistant grabs the central and peripheral segments of the nerve with his fingers and brings them together until they are aligned, and the surgeon places two guide sutures made of thin silk or nylon on the sides of the joined ends, capturing only the epineurium. For final suturing, depending on the thickness of the nerve, 2-3 intermediate epineural sutures are added (4-5 sutures are required for suturing the sciatic nerve). During the operation, the wound is moistened with napkins moistened with a warm isotonic solution. In order to prevent possible nerve entrapment due to postoperative growth of scar tissue, the isolated nerve and the suture area are wrapped in a thin fibrin film. The wound is sutured tightly.

When mobilizing nerve segments, avoid exposing the nerve trunk over a large area and excessive tension on the nerve segments for suturing. All this leads to disruption of the blood supply to the nerve trunk and worsens the conditions for axon regeneration.

Therefore, in case of large defects of the nerve trunk after removal of the neuroma, it is better to bring the segments of the nerve closer together by bending the limb at the joint. In this way, it is possible to achieve convergence of nerve segments in the presence of a defect of 6-9 cm. Flexion in the joints is allowed within a right angle. In some cases, if there is a large diastasis between the segments of the nerve, they resort to moving the nerve to another bed, for example, the ulnar nerve from the ulnar groove to the medial part of the cubital fossa. To prevent suture rupture and reduce pain, apply to the operated limb for 3-4 weeks. plaster splint.

The prognosis is favorable in many cases, although for nerve defects larger than 5 cm, the percentage of positive results decreases markedly.

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Trauma, accompanied by a violation of the integrity of peripheral nerve fibers, initiates the processes of degeneration and regeneration in them. The phenomena of degeneration develop mainly in the peripheral area of the cut nerve.

They concern both the axial cylinder, which disintegrates into small grains, and its myelin sheath, which forms absorbable fat droplets. Only the desolate Schwann membrane is preserved, which, when growing, covers the transverse section of the nerve with the development of a thickening - schwannoma. The described processes begin in the first 24 hours after damage and end by the end of the 1st month, when the full picture of nerve degeneration is already visible.

Quite complex multi-vector processes occur in the central segment of the nerve. On the one hand, it undergoes periaxonal degeneration, expressed by the disintegration of the myelin sheath, and on the other hand, the process of centrogenic regeneration of the nerve simultaneously occurs. Some time after the injury, the central end of the axial cylinder becomes club-shaped and grows towards the peripheral segment. In the absence of diastasis, the axial cylinders penetrate the Schwann sheaths of the peripheral end of the nerve.

Conduction along the nerve is restored. Otherwise, bone fragments, foreign bodies, dense scar, etc. create insurmountable obstacles to the growth of axons. At the central end of the nerve, a hyperplastic thickening is formed - a neuroma, which disrupts the conductivity of the nerve. Based on this, the essence of the operation of suturing the ends of the damaged nerve is to bring together (correctly compare!) its central and peripheral segments, which have a normal structure. In this case, axons growing from the central end of the nerve penetrate the membranes of its peripheral end.

The radial and musculocutaneous nerves have the best regenerative ability. Low - characteristic of the ulnar, sciatic and common peroneal nerves. The operation to restore the integrity of the peripheral nerve consists of several stages:
- neurolysis;
- excision of neuroma (resection “refreshing” of damaged ends);
- imposing.

Neurolysis is the separation of a nerve from surrounding tissues and scars to create favorable conditions for its regeneration and functioning. Depending on the nature of the injury and the time that has passed since the injury, external, internal neurolysis or a combination of both is performed. The surgical essence of external neurolysis is the mobilization of the nerve, freeing it from extraneural scar resulting from damage to neighboring organs. This procedure removes tension on the nerve and is performed on a healed wound. Internal neurolysis is aimed at relieving axonal compression and comes down to excision of interfascicular fibrous tissue. One of the main conditions for the successful outcome of neurolysis of an injured peripheral nerve is adequate access to it.

It allows you to carefully examine the actual substrate of the operation and perform a high-quality surgical technique - suturing. The length and shape of the incision to access the injured nerve is calculated taking into account the need for maximum exposure of the nerve above and below the site of injury. To expose deep nerves covered by muscles, it is recommended to use a direct approach. To approach the trunks of nerves that occupy a relatively superficial position, it is rational to use a roundabout approach (outside the projection of the nerve onto the skin). In this case, the likelihood of pressure from the postoperative scar on the nerve trunk is reduced. In a fresh wound (without signs of infection), use the access made during the initial surgical treatment.

Having ensured sufficient access, the nerve is isolated to intact tissue and the extent of neurolysis is determined. The ends of the transected nerve are found in a fresh wound. The boundaries of the required nerve resection are determined - the extent of irreversible changes (combustion, hemorrhage, etc.). To clarify the depth of damage, intraoperative electrodiagnostics are used. To do this, the nerve above the injury site is irritated. Contraction of the muscles innervated by this nerve indicates its patency. The extraneural scar is excised with a scalpel. The nerve, compressed by bone fragments, is freed from the callus with a chisel.

Next comes the stage of internal neurolysis. To detect the localization of the internal scar, injections of 0.25% novocaine solution are used under the epineurium. The solution freely penetrates under the sheath of the intact nerve and stops at the site of the intraneural scar. This is especially clearly seen when using intraoperative microscopy. Resection of damaged ends is performed with a safety razor blade or scalpel.

In this case, the neuroma is removed at the central end and the schwannoma at the peripheral end. Applying beads with warm saline solution stops the inevitable bleeding. The main criteria for the sufficiency of resection (excision) are bleeding of the vessels of the epi- and perineurium, as well as a granular cross-section of the nerve with a peculiar shine. During intraoperative microscopy, individual axon bundles are visible.

The connections between the ends of the damaged peripheral nerve are reached by interrupted epineural sutures (Fig. 17.1).

Rice. 17.1. Epineural suture

The operation consists of accurately comparing cross-sections of the central and peripheral ends of the damaged nerve trunk. Before suturing, the ends of the nerve are placed in their original position without twisting along the axis, which protects against mismatch of intra-trunk structures. For stitching, an atraumatic needle with synthetic threads (10/0) is used. Both non-absorbable suture material is chosen (explaining this by less tissue reaction) and absorbable.

Depending on the diameter of the nerve, 2-4 thin sutures are applied. The first sutures are placed symmetrically along the lateral and medial edges of the nerve. The injection and puncture are carried out epineurally along the nerve at a distance of 2-4 mm from the edge. These sutures temporarily serve as holders, with the help of which the nerve is carefully rotated along its axis by 180° towards the assistant to apply additional sutures (first posterior, then anterior).

After this, the surgeon and his assistant, simultaneously pulling the thread, bring the ends of the nerve together, leaving a distance of 1-2 mm between them. The threads are tied. If the sutures are cut, it is possible to apply not longitudinal, but U-shaped epineural Nageotte sutures. However, when performing them, there is a danger of trapping bundles of nerve fibers in the suture.

When tightening the knots, the connected ends of the nerve should not be compressed, twisted or bent.

The suture is placed in the position of the limb that creates minimal tension on the nerve. This position is maintained with a plaster splint for 3-4 weeks after surgery. If during the initial treatment of the wound there were no conditions for applying a primary suture, an early delayed suture of the nerve is applied 3-4 weeks after the injury. This applies to bruises, contaminated and gunshot wounds. In the first days after a gunshot wound, it is difficult to determine the boundaries of the necessary resection of irreversibly damaged nerve sections. Conduction disturbances may be caused by its concussion. Later, conductivity may spontaneously recover.

Secondary nerve suture is used at various times after injury - from 4-6 weeks to several years. The essence of the secondary suture is to excise the nerve scar and stitch its “refreshed” ends. This takes advantage of the delayed suture on the nerves. Firstly, it is usually performed by a doctor experienced in surgery of the peripheral nervous system, and secondly, the risk of postoperative infectious complications is minimized, since the inflammatory process can usually be stopped by this time.

In a healed wound, the scars are first excised and the nerve trunk is prepared above and below the injury site within healthy tissue. Having fixed the isolated parts of the nerve on rubber or gauze holders, neurolysis begins.

Mandatory excision of the neuroma from scar adhesions is performed. For surgical treatment of the central neuroma, the epineurium is first removed by wrapping it upward in the form of a cuff (Fig. 17.2).

Rice. 17.2 Wrapping the epineurium in the form of a cuff during surgical treatment of a neuroma

After refreshing the peripheral segment of the nerve, three or four U-shaped interrupted sutures are applied, which pass through the base of the cuff (Fig. 17.3). When tying the threads, the peripheral segment of the nerve enters the cuff of the central segment. This creates good contact between the nerve fibers. The edges of the cuff are shifted to the peripheral end of the nerve and sutured with separate interrupted sutures to its epineurium (Fig. 17.4).

Rice. 17.3 Connecting the ends of the nerves with figurative sutures passing through the base of the cuff