Application of free temporoparietal fascial flap for recurrent neural adhesion of superficial radial nerve—A case report

Because of its anatomical location, the superficial radial nerve is vulnerable to trauma as well as injury during various surgical procedures. Once the nerve adheres to surrounding scar tissue, radiating pain often occurs due to nerve traction caused by loss of smooth gliding. Since it has been reported that the success rate with neurolysis only is lower, additional preventive procedures for recurrent neural readhesion are recommended. In the current report, we describe our experience performing neurolysis followed by nerve coverage using a free temporoparietal fascial flap for recurrent neural adhesion of the superficial radial nerve. A 45‐year‐old male complained of motion pain of the left wrist and thumb joints caused by recurrent neural adhesion of the superficial radial nerve after a chain saw trauma and following multiple reconstructive procedures. The radiating pain completely disappeared after neurolysis performed by a previous surgeon; however, it recurred 4 weeks later. Four months after the previous neurolysis the patient underwent external neurolysis and covering of the nerve with a free temporoparietal fascial flap to prevent neural readhesion because local soft tissue could not be used due to the massive scar tissues on the forearm. One year after the secondary neurolysis, the symptoms of radiating pain during wrist and thumb motion were drastically improved. A free adipofascial flap such as a temporoparietal flap may be an option for prevention of neural readhesion after neurolysis of the superficial radial nerve in cases where a local flap cannot be used on the forearm. © 2015 Wiley Periodicals, Inc. Microsurgery 35:489–493, 2015.     

桡神经深支损伤的诊断与治疗分析

目的：分析桡神经深支损伤的临床特点和治疗效果，以提高对桡神经深支损伤的早期诊断和治疗水平。方法：对前臂在多发性损伤的情况下，拇指中立位伸指功能障碍，手和前臂感觉功能正常的11例患者，做出桡神经深支损伤的早期诊断，积极地进行手术治疗并对其疗效进行分析。结果：术中证实诊断正确率100％；随访时间3～13个月，平均6．6个月。急性损伤急诊手术7例，术后功能完全恢复；陈旧性损伤4例，择期手术后功能完全恢复2例，部分恢复2例。结论：根据手和前臂的感觉功能及拇指在中立位伸指功能的障碍，可对前臂多发性损伤时的桡神经深支损伤做出早期诊断。早期手术疗效满意。     

桡神经损伤的治疗效果

目的 观察桡神经损伤后行神经松解，缝合和移植术的疗效。方法 46例桡神经损伤根据损伤类型。采用神经内，外松解术，直接缝合，神经移植治疗。结果 术后随访1年至10年，21例桡神经松解术中，17例的伸腕，伸拇，伸指肌力为M3-M5，虎口区感觉为S4。19例神经直接缝合者14例。伸腕、伸拇，伸指肌力为M3-M5；16例虎口区感觉为S4。6例神经移植者5例伸腕、伸拇，伸指肌力为M3-M5。虎口区感觉达S4。结论 桡神经损伤早期根据其损伤类型进行合适的手术方法均能取得满意的疗效。     

桡神经损伤25例手术效果分析

目的观察桡神经损伤后行神经松解、缝合和移植术的手术效果。方法根据损伤类型，对25例桡神经损伤患者采用神经内外松解术、直接缝合、神经移植术。结果术后随访1～10年，12例桡神经松解术，11例伸腕、伸拇、伸指肌力M3～M4，虎口区刺痛觉S3～S4；10例神经直接缝合者，8例伸腕、伸拇、伸指肌力为M3～M4，虎口区刺痛觉S3～S4；3例神经移植术中，2例伸腕、伸拇、伸指肌力为M3～M4，虎口区刺痛觉S3～S4。结论桡神经损伤早期，根据损伤类型进行合适的手术，均能取得满意疗效。     

The square pronator: an "aspirin" strip in antalgic surgery for painful neuromas of the wrist

From June 96 to January 2001, 25 patients have been operated on for painful neuromas localised at the wrist. They were between 10 and 52 years of age. These neuromas were located in at the median nerve 17 cases, at the ulnar nerve in seven cases and at the radial nerve in one case. In all cases the pain was not spontaneous but triggered off by external stimulus. All these neuromas were in continuity except 1 case at the median nerve where a total severing was present. After external neurolysis, the quadratus pronatus muscle is wrapped around the neuromas in 24 cases and around epineurial suture in one case. No internal neurolysis was done. This flap was vascularized by the anterior interosseous artery in 23 cases and by the posterior interosseous artery in two cases of distal ulnar nerve neuroma. All patients have been improved by using this method. In 21 cases (84%) (17 median, 4 ulnar nerves) the pain has completely disappeared and in four cases (3 ulnar, 1 radial), the pain has considerably decreased but without total disappearance. In the cases of median nerve neuromas the dysaesthesia has greatly decreased. No complications and no sequelae on the donor site are reported.     

高频超声在肱骨骨折合并桡神经损伤诊断中的应用

目的 评价高频超声对肱骨骨折合并桡神经损伤的诊断价值.方法 对36例肱骨骨折术后并发桡神经完全损伤的患者,于神经损伤后1～3个月行神经电生理检查及高频超声诊断检查,28例患者进行了桡神经松解或桡神经修复手术治疗,8例保守治疗.结果 按照神经巢状结构、神经瘤以及外部组织压迫神经等三方面,将桡神经损伤分成4型:Ⅰ型4例,Ⅱ型9例,Ⅲa型12例,Ⅲb型7例,Ⅳ型4例.31例患者经神经手术或非手术治疗功能恢复良好;5例(Ⅲb型3例,Ⅳ型2例)患者接受二期功能重建手术,功能恢复良好.结论 肱骨骨折术后出现桡神经损伤,超声诊断可以提供早期、直观以及正确的辅助诊断方法,同时根据超声诊断的分型选择合适的治疗方法,对桡神经预后有一定的参考意义.     

Cheiralgia paresthetica — entrapment of the superficial branch of the radial nerve: a report of 15 cases

Attention is drawn to the relatively rare and poorly appreciated clinical featues of entrapment of the superficial sensory branch of the radial nerve (SBR) in the forearm. In a series of 15 patients with cheiralgia paresthetica, alleviation of pain and discomfort was achieved in 66.6% of the conservatively-treated patients and in 80% of the five non-responsive patients who required neurolysis of the nerve. Job-related symptoms were exhibited by 33.3% of the patients, which subsided upon job modification or less hand-intensive work and conservative treatment. We suggest that modalities of treatment should be appropriate for the pathophysioloy of the SBR injury, while early recognition of the syndrome reduces the necessity for surgery.     

Radial nerve lesions associated with fractures of the humeral shaft

Radial nerve palsy associated with a fracture of the shaft of the humerus is a relatively common injury. Out of 91 radial nerve injuries, operated upon in the Neurosurgical University Clinic in Belgrade from 1979 to 1988, 37 were associated with fractures of the humeral shaft or their surgical treatment. These fractures were previously treated in other medical units. In all cases a microsurgical reconstruction of the radial nerve was done: an interfascicular neurolysis in 24 cases and interfascicular grafting in 13 cases. A useful functional recovery was obtained in 91.9 per cent of the cases. Timing of nerve exploration and repair, as a main problem, is discussed.     

桡神经浅支卡压的解剖与临床

目的:了解桡神经浅支卡压的依据并讨论了该征的诊断及治疗原则。方法:解剖观测了20具40侧成人上肢标本桡神经浅支穿出处的局部解剖特点及其距桡骨茎突的距离,随访了12例患者,9例采用局部封闭治疗,3例采用手术神经松解治疗。结果:桡神经浅支穿出部位为腱性组织所包绕。该处筋膜将肱桡肌腱挤在一起,从而易于受压。临床随访6个月至2年,保守及手术治疗患者症状均完全消失无复发。结论:解剖:桡神经浅支在前臂中下段易发生卡压有其解剖学基础。临床上病程短症状轻患者保守治疗往往能有较好疗效,病程长症状重或存在其它病理性压迫患者往往需要手术治疗。     

Sensory sequelae of injuries to the median nerve]

Median nerve wounds are frequent because of the superficial course of this nerve, especially in the wrist. The sensory sequellae of such lesions, either complete or dissociated, represent a major handicap which may be associated to a motor impairment of the external thenar muscles. The curative procedures such as neurolysis and, above all, sutures or grafts, must be very widely used, even some time after the initial injury and in spite of motor reinnervation. The role of palliative surgery is therefore limited, although it is sometimes useful. There are many procedures, which may be summed up by two techniques: use of sensitive neurovascular skin flaps, the most frequent grafts, neurotization of the median nerve with a transfer of sensory rami from the radial nerve, a less-known technique. The treatment of the sensory sequellae of median nerve lesions is primarily based on a good initial management of the nerve lesions by a good-quality emergent microsurgical suture.     

Early surgical exploration of radial nerve injury associated with fracture shaft humerus

The series included 36 patients, predominantly male, mean age 30.3 years. The most common cause of injury was motor car accident in 20 patients. Postreduction radial nerve injury occurred in nine cases. Open fracture humerus with radial nerve injury in seven cases. The fractures were situated in the middle or distal third of the humeral shaft. Most were transverse fractures. Twelve patients had surgery on the day of injury and the other 24 at a mean of 8 days later (3-14). Narrow dynamic compression plate was generally used for fixation. Exploration of the radial nerve demonstrated compression at the lateral intermuscular septum in 19 cases, entrapment in the fracture site in nine cases, and loss of its continuity in eight cases. Neurolysis was required in 20 cases, epineurorrhaphy in nine cases, interfascicular nerve grafts in five, and first-intention tendon transfer in two. Results of nerve surgery were assessed with the MRC (Medical Research Council) at a mean follow-up of 8.2 years. Outcome was rated good to excellent in 28 patients, fair in 1, and poor (failure) in 3. First-intention tendon transfers were performed in 2 patients and 2 patients were lost to follow-up. Mean delay to recovery was 7 months after neurolysis and nerve repair and 15 months after nerve grafts. The fracture was united in all cases. The mean time of union was 5 months.     

Surgical treatment modalities for lower-extremity iatrogenic nerve lesions

Thirty-six patients with lower-extremity iatrogenic nerve injury were treated with neurolysis (23), direct nerve coaption (1), and nerve grafting (12) depending on the nature, duration, and degree of nerve injury. Seventeen (74%) of 23 patients presenting with motor nerve injury achieved motor function against resistance. In 24 (80%) of 30 patients with sensory nerve involvement, at least some superficial sensory function was restored. Surgeons should be familiar with clinical and electroneurophysiological tests for early diagnosis of iatrogenic nerve injuries to allow early intervention for maximum nerve recovery.     

Minimally invasive peripheral nerve surgery: peroneal nerve neurolysis

Background: Both patients and surgeons recognize the value of procedures that minimize scarring and tissue dissection. No previous reports have described a minimally invasive technique for peroneal nerve neurolysis, or evaluated its safety. Methods: The senior author's technique for a minimally invasive approach to neurolysis of the common, superficial, and deep peroneal nerves is presented. Safety of the technique was determined by review of records of all patients undergoing this procedure from 2003–2011, looking for major complications. Results: Using the minimally invasive approach to peroneal nerve neurolysis, average skin incision size is 3.5 cm for the common peroneal nerve, 4 cm for the superficial peroneal nerve, and 2.5 cm for the deep peroneal nerve. In 400 patients undergoing 679 total procedures, there were no nerve injuries, postoperative neuromas, or adjacent structures harmed. Conclusions: Peroneal nerve neurolysis can be accomplished safely and effectively via a minimal skin incision, improving aesthetic results and decreasing possible scar‐related complications. © 2011 Wiley Periodicals, Inc. Microsurgery, 2012.     

Surgical management and outcome in patients with radial nerve lesions

OBJECT: The goal of this paper was to review surgical management and outcomes in patients treated for radial nerve (RN) lesions at Louisiana State University Health Sciences over a period of 30 years. METHODS: Two hundred sixty patients with RN injuries were evaluated. The most common mechanisms of injuries involving the RN included fracture of the humerus, laceration, blunt contusions, and gunshot wounds. One hundred and eighty patients (69%) underwent surgery. Lesions not in continuity required primary or secondary end-to-end suture repairs or graft repairs. With the use of direct intraoperative nerve action potential recording, RN injuries in which the lesion was in continuity required external or internal neurolysis or resection of the lesion followed by end-to-end suture or graft repair. A minimum of 1.5 years follow-up review was available in 90% of the patients who underwent surgery. Motor function recovery to Grade 3 or better was observed in 10 (91%) of 11 patients who underwent primary suture repair, 25 (83%) of 30 who underwent secondary suture repair, 43 (80%) of 54 who received graft repair, and 63 (98%) of 64 in whom neurolysis was performed. Sixteen (71%) of 21 patients with superficial sensory RN injury achieved satisfactory pain relief after complete resection of a neuroma or neurolysis. CONCLUSIONS: This study clearly demonstrates that excellent functional recovery can be achieved with proper surgical management of RN injuries.     

Evaluation of iatrogenic lesions in 722 surgically treated cases of peripheral nerve trauma.

OBJECT: The purpose of this study was to discover the number and types of iatrogenic nerve injuries that were surgically treated during a 9-year period at a relatively busy nerve center. The specific nerves involved, their sites of injury, and the mechanisms of injury were also documented. METHODS: The authors retrospectively evaluated the surgically treated iatrogenic lesions by reviewing case histories, operative reports, and follow-up notes in 722 cases of trauma. These cases were treated between January 1990 and December 1998 because of pain, dysesthesias, and sensory and/or motor deficits. latrogenic injury was a much larger category of trauma than predicted. One hundred twenty-six (17.4%) of the 722 surgically treated cases were iatrogenic in origin. Most of these injuries occurred during a previous operation. To a major extent, nerves of the extremities were affected, and a relatively large number of injuries occurred in the neck and groin. Incidence was highest in the spinal accessory nerve (14 cases), the common peroneal nerve (11 cases), the superficial radial nerve (10 cases), the genitofemoral nerve branches (10 cases), and the median nerve (nine cases). At least two thirds of the patients did not undergo surgery for the iatrogenic injury within an optimal time interval due to delayed referral. Follow-up data were available in 97 of the 126 patients. Surgical outcomes demonstrated improvement in 70% of patients. Operative results were especially favorable in patients suffering from iatrogenic injuries to the accessory and superficial sensory radial nerves. CONCLUSIONS: latrogenic injuries should be corrected in a timely fashion just like any other traumatic injury to nerve.     

肱骨干骨折术后桡神经损伤的诊治分析

目的 探讨肱骨干骨折钢板内固定术后发生桡神经损伤的病因特点及治疗分析。方法 对我科自1997～2003年间收治的15例肱骨干骨折钢板内固定术后发生桡神经损伤病例的致病原因、临床表现、诊治方法及预后转归进行回顾性分析。结果 所有病例随访6～18个月。所有病例自觉症状消失，伸腕、伸指肌力恢复至V级，肌电图复查神经传导速度和潜伏期恢复正常范围。结论 过度牵拉、粗暴操作和钢板卡压是医源性桡神经损伤的三大主要原因。早期诊断和早期手术松解可使神经功能完全恢复。     

Surgical outcomes of 111 spinal accessory nerve injuries

OBJECTIVE: Iatrogenic injury to the spinal accessory nerve is not uncommon during neck surgery involving the posterior cervical triangle, because its superficial course here makes it susceptible. We review injury mechanisms, operative techniques, and surgical outcomes of 111 surgical repairs of the spinal accessory nerve. METHODS: This retrospective study examines clinical and surgical experience with spinal accessory nerve injuries at the Louisiana State University Health Sciences Center during a period of 23 years (1978-2000). Surgery was performed on the basis of anatomic and electrophysiological findings at the time of operation. Patients were followed up for an average of 25.6 months. RESULTS: The most frequent injury mechanism was iatrogenic (103 patients, 93%), and 82 (80%) of these injuries involved lymph node biopsies. Eight injuries were caused by stretch (five patients) and laceration (three patients). The most common procedures were graft repairs in 58 patients. End-to-end repair was used in 26 patients and neurolysis in 19 patients if the nerve was found in continuity with intraoperative electrical evidence of regeneration. Five neurotizations, two burials into muscle, and one removal of ligature material were also performed. More than 95% of patients treated by neurolysis supported by positive nerve action potential recordings improved to Grade 4 or higher. Of 84 patients with lesions repaired by graft or suture, 65 patients (77%) recovered to Grade 3 or higher. The average graft length was 1.5 inches. CONCLUSION: Surgical exploration and repair of spinal accessory nerve injuries is difficult. With perseverance, however, these patients with complete or severe deficits achieved favorable functional outcomes through operative exploration and repair.     

儿童桡神经损伤78例分析

目的讨论儿童桡神经损伤的临床特点和治疗方法。方法对７８例儿童桡神经损伤的临床资料进行总结和分析。伤因：６６例为上肢骨折或脱位时合并神经损伤，其中肱骨下段骨折７例，肱骨髁上骨折３７例，孟氏骨折或单纯桡骨头脱位１８例，尺骨和／或桡骨骨折４例。１２例为单纯神经损伤。采用手法复位、石膏固定或牵引１８例，神经松解术３８例，神经吻合术２０例，肌腱转移功能重建术２例。结果４２例随访２个月～２６年，平均４年２个月。用Ｈｉｇｈｅｔ运动评定法评定，疗效为优者３４例，优良率达８１％。伤后３个月内治疗者优良率占９６．５％，明显优于伤后６个月处理者的５０％。结论儿童上肢骨折脱位易合并桡神经损伤，对开放性骨折合并桡神经损伤者应尽快手术治疗。闭合性损伤在保守治疗１～３个月后功能无恢复时应考虑手术治疗     

Superficial radial nerve injury during standard K-wire fixation of uncomplicated distal radial fractures

This study determines the incidence of superficial radial nerve injury after Kirchner wire insertion. An experienced orthopedic surgeon inserted the K-wires into the radii of 92 adult cadavers. Subsequent dissection of the area exposed the superficial radial nerve and any observed nerve injury was documented. It is clear from the results that nerve injury may still occur as a result of K-wire insertion; however, the current method of K-wire insertion still proves to be a reliable and safe procedure for fixation of distal radial fractures.     

拇指撕脱离断伤再植术中两侧指固有神经的修复

目的介绍拇指撕脱离断伤再植术中修复拇指两侧指固有神经的方法。方法1999年8月-2009年4月,在12例拇指撕脱离断伤再植术中,采用食指桡侧指固有神经背侧支和桡神经浅支第2指蹼支移位的方法,修复拇指两侧指固有神经。结果12例拇指撕脱离断伤均再植成功,均获随访1～2年,平均16月。拇指两侧感觉均恢复良好,两点分辨觉小于10mm,平均约7mm,按照感觉功能评定标准为S4。结论拇指撕脱离断伤再植术中,应用食指桡侧指固有神经背侧支与桡神经浅支第2指蹼支移位,能恢复拇指指腹两侧良好感觉。