End-to-side nerve suture--a technique to repair peripheral nerve injury.

End-to-side nerve suture (ETSNS) has until recently been extensively researched in the laboratory animal (rat and baboon). Lateral sprouting from an intact nerve into an attached nerve does occur, and functional recovery (sensory and motor) has been demonstrated. We have demonstrated conclusively that ETSNS in the human is a viable option in treating peripheral nerve injuries, including injuries to the brachial plexus. Among the many advantages of this new technique are: (i) simple and short operation; (ii) shorter recovery time--suture is done closer to the target organs; (iii) nerve grafts to bridge injured gaps are eliminated, reducing the morbidity of nerve surgery to a minimum; (iv) innervation of paralysed muscles, for which there was previously thought to be no hope of recovery, opens up many new treatment options; and (v) certain aspects of nerve function and regeneration, unknown until recently, open new horizons and understanding. ETSNS has given us new dimensions in the management of peripheral nerve injuries.     

End-to-side nerve repair. A review

In recent years, there has been a resurgence of end-to-side peripheral nerve repair. This technique offers a management of a peripheral nerve defect in the absence of a suitable proximal stump. Although numerous animal laboratory investigations demonstrate motor and sensory functional recovery without deleterious effects to the donor nerve, clinical outcomes are yet to be determined.     

多功能生长因子Pleiotrophin与周围神经损伤的研究进展

原癌基因Pleiotrophin于1989年被发现,在肿瘤发生发展和中枢神经系统内起着重要作用.最近的研究表明:Pleiotrophin分子信号很可能参与周围神经损伤后脊髓神经元的保护、促进轴突再生、轴突再生导向、骨骼肌的神经再支配4个环节,并可能在轴突再生导向和骨骼肌的神经再支配中发挥关键作用.随着研究的深入,Pleiotrophin基因有望成为提高周围神经修复效果和重建神经肌连接的基因调控靶点.     

周围神经损伤修复方法的研究进展

【摘要】〓回顾周围神经损伤的修复方法,从传统的断端吻合法、神经移植法、神经导管法、神经延长法,到组织工程法、基因工程法,修复手段日益完善,但周围神经的功能恢复仍然没有突破性的进展。各种修复技术各有优点,也都存在一定的局限性。因此,提高神经再生的速度和质量、完善现有的修复方法和寻找新的修复方法,仍然是一个巨大的挑战。     

Anatomy and physiology of peripheral nerve injury and repair

The management of peripheral nerve injury continues to be a major clinical challenge. Despite advancements in microsurgical technique, results after nerve repair have been unpredictable and dis appointing. The management of these nerve injuries relies on having a thorough understanding of peripheral nerve anatomy. This is the basis of the classification schemes by Seddon and Sunderland, in which the prognosis of nerve injuries varies depending on the degree of injury to their substructures. The most recent advances in the management of peripheral nerve injuries rely on the ability to manipulate the pathophysiologic processes triggered by nerve injuries and regeneration. End-to-end primary repair should be sought whenever a tension-free repair can be attained. If there is a significant nerve gap, use of nerve autograft remains the gold standard. In nerve injuries where a nerve autograft is not possible, the use of nerve allograft, as well as autogenous, biodegradable, and synthetic nerve conduits has shown promising results in experimental studies.     

End-to-side nerve graft repair based on synergistic peripheral terminal motor branches: investigation in a nonhuman primate model

Summary BACKGROUND: Spinal nerve avulsion frequently occurs in brachial plexus injury, becoming irreparable lesions. Nerve transfer at the very proximal site within a limited time interval after injury leads to satisfactory functional results. Oberlin reported a neurotization technique at a more peripheral location. Hypothetically, there might be useful functional results performing very peripheral end-to-side nerve graft repair using synergistic tiny terminal motor branches. We created one possible application of such a peripheral synergistic terminal end-to-side nerve transfer in a median nerve defect model in nonhuman primates. An end-to-side nerve graft repair bridging from the terminal motor branch of deep branch of the ulnar nerve to the thenar motor branch of median nerve was performed. The purpose of this study was to investigate the efficacy of this hypothesis. METHODS: Seven adult baboons were used in this study. At baseline, we electrophysiologically demonstrated no variation in innervation of median- and ulnar-nerve-innervated thenar muscles. Transection of the median nerve was performed. Subsequently, the abductor pollicis brevis muscle could neither be stimulated by the median nerve nor by the ulnar nerve. Baboons underwent end-to-side coaptation of a nerve graft to the deep branch of the ulnar nerve and end-to-end coaptation to the thenar motor branch of the median nerve. Assessment of functional recovery was performed by electrophysiological evaluation, thenar muscle weight, and video slow-motion analysis. RESULTS: All animals recovered opposition of the thumb 3 months after surgery. The abductor pollicis brevis muscle, preoperatively innervated by the median nerve, did not respond to electrophysiological stimulation of the transected median nerve but to stimulation of the ulnar nerve via the nerve graft. Length of nerve graft (in average 2.3 cm) showed no correlation to muscle weight or electrophysiological parameters. CONCLUSIONS: The results in this series demonstrate the efficacy of end-to-side nerve graft repair at the level of tiny very peripheral terminal motor branches in a nonhuman primate median nerve defect model. Applications of this technique may enhance functional results by avoidance of time-dependent end organ failure.      

周围神经损伤临床修复技术概况

周围神经损伤的修复，过去长期以来都是肉眼下操作，进行简单的神经外膜缝合，因得不到神经束的精确对合，以致神经再生效果很差。近10余年来，我国的周围神经外科事业随着机械化程度的提高和交通事业的发展，周围神经损伤发生率大幅度的上升，以及显微外科技术的应用而有了长足的发展，极大地推动了周围神经外科的基础研究和修复水平，丰富     

End-to-side nerve repair: review of the literature and clinical indications

End-to-side (ETS) nerve repair, in which the distal stump of a transected nerve is coapted to the side of an uninjured donor nerve, has been suggested as a technique for repair of peripheral nerve injuries where the proximal nerve stump is unavailable or a significant nerve gap exists. Full review of the ETS literature suggests that sensory recovery after ETS repair results in some, but not robust, regeneration. Sensory axons will sprout without deliberate injury. However, motor axons only regenerate after deliberate nerve injury. Experimental and clinical experience with ETS neurorrhaphy has rendered mixed results. Continued research into ETS nerve repair is warranted. ETS techniques should not yet replace safer and more reliable techniques of nerve repair except when some, but not good, sensory recovery is appropriate and a deliberate injury to the donor motor nerve is made.     

Presurgical ultrasound-assisted neuro-examination in the surgical repair of peripheral nerve injury.

In spite of electrodiagnostic examinations, the determination of the precise localization of the injured site along the involved peripheral nerve may remain obscure or uncertain. Before starting the operation, a surgeon should have knowledge about the type of injury, the position of the proximal and distal nerve stumps, and the presence or absence of a neuroma and excessive perilesional scar tissue formation for orientation and planning of the surgical intervention. We hypothesized that real-time ultrasound could be helpful in the determination of the type of injury, the localisation of proximal and distal nerve stumps, as well as for diagnosing a neuroma. Fourteen patients with traumatic peripheral nerve injuries that were verified by neurological examinations and electrodiagnostic tests underwent surgical repair, and were examined by ultrasound before and during the surgical intervention. Visualisation of the injured site, the type of the injury, the position of the nerve stumps and the diagnosis of the neuroma were reliably feasible in all the patients by using ultrasonography. Axonal swelling of a nerve was diagnosed in 4 (29 %) patients, a stump neuroma was diagnosed in 3 (21 %) patients, a total nerve interruption (neurotmesis in the Seddon classification) was diagnosed in 9 (64 %) patients, and surrounding scar tissue was diagnosed in 5 (35 %) patients. Presurgical and intraoperative ultrasound-assisted neuroexamination is a useful diagnostic method in the determination of the precise localisation of the injured site, the type of injury, the position of stumps, and the diagnosis of a neuroma. The use of preoperative and intraoperative ultrasound can enhance the orientation of the surgeon to the surgical field. The application of our method to our patients shows that presurgical ultrasonographic neuroexamination can be used in the surgical repair of peripheral nerve injury.     

FK 506加速周围神经损伤修复后的功能恢复

目的：探讨FK506对大鼠坐骨神经横断伤修复后肢体功能恢复的影响。方法：45只SD大鼠高位切断坐骨神经后原位缝合，术后实验组（25只）用FK506灌胃，对照组（20只）不给药，于术后第1、2、3、5个月检测术肢比目鱼肌肌湿重恢复率，小腿三头肌肌力恢复率，坐骨神经功能指数及皮层体感诱发电位（SEEP）的潜伏期，结果：实验组肢体功能恢复时间较对照组提前大约2个月。结论：FK506可加速周围神经横断伤修复后肢体功能的恢复。     

甲基泼尼松龙对周围神经修复的影响

目的 探讨甲基泼尼松龙对周围神经再生的促进作用及剂量选择。方法 28只成年SD雌性大，取股外侧切口，钳夹造成双侧坐骨神经损伤。创伤后1h起分别肌注不同剂量的甲基泼尼松龙或对照溶液，并间隔3h维持肌注，持续24h。按肌注剂量的不同随机分为大剂量组（首剂150mg/kg）、中剂量组（首剂30mg/kg）、小剂量组（首剂15mg/kg）和对照组（生理盐水与0．9％苯甲醛1：1混合液）。肌注后观察各组大鼠一般状态，记录术前及术后4周大鼠足印，测定坐骨神经功能指数（SFI0；术后4周显露双侧坐骨神经测定神经传导速度（NCV）；对取得的数据进行统计学分析。同时行神经横切片组织学观察。结果 中、小剂量组SFI均值优于大剂量组和对照组，但差异无显著性意义；中、小剂量组神经诱发电位引出率（100％）明显高于对照组（57．1％）（P＜0．01）；小剂量组NCV值优于其他三组，而且差异具有显著性意义（P＜0．05）；大剂量组大鼠均出现明显神经精神症状，有1只因感染死亡，3只4侧出现局部感染，其他三组未见明显异常。中、小剂量组神经横切片轴索再生情况优于大剂量组及对照组。结论 甲基泼尼松龙的全身应用可有效促进周围神经损伤后再生，但剂量选择不应过大，以减少感染及精神症状等副作用。     

Use of nerve conduits in peripheral nerve repair

Studies on nerve conduits for peripheral nerve regeneration have concentrated on the manipulation of various conduit materials to avoid sacrificing native nerve in the clinical situation. With the proliferation of available nerve growth-stimulating factors, the focus is shifting experimentally toward molecular biologic manipulation, with the addition of these materials as substrates within the conduit. The clinical use of conduits has concentrated on the use of autogenous tissue, with a few examples of polyglactin (PGA) mesh and silicone. Ultimately, as yet, conduit material does not seem to have a profound effect on outcome. Substrate manipulation has not yet had clinical application. An important problem that remains, both experimentally and clinically, is overriding the size of the maximal gap that can be bridged successfully, as well as obtaining good functional sensory and motor recovery, compared with the use of nerve grafts. Advances in molecular biology may reveal further details about the nerve growth phenomenon, the precise sequencing of the substrate materials that are effective in promoting nerve growth, and when they should be applied. Advances in chemical engineering may provide additional biologically stable materials that have the ability to integrate growth-enhancing agents or factors into the lumen of the conduit.     

End-to-side nerve graft for facial nerve reconstruction

Reconstruction of multiple branches of the facial nerve by sural nerve graft using end-to-side nerve suture was performed successfully on a patient with advanced parotid tumor. In this technique, one end of the grafted nerve is sutured with the stump of the facial nerve trunk in an end-to-end manner. Epineural windows are made on the nerve graft, and the distal stumps of the facial nerve branches (temporal, zygomatic, and buccal branches) are sutured with the graft in an end-to-side manner. Functional recovery of all branches and satisfactory facial expression were obtained within 2 years postoperatively. Axonal regeneration through the graft was confirmed by electrodiagnosis. Regeneration through the anastomosis at the stump of the facial nerve trunk using this technique is more efficient than conventional cable grafting, and the length of the nerve required is minimal. This technique may be a useful option for facial nerve reconstruction managing multiple branches.     

Progress of peripheral nerve repair

Study on repair of peripheral nerve injury has been proceeding over a long period of time.With the use of microsurgery technique since 1960s, the quality of nerve repair has been greatly improved.In the past 40 years,with the continuous increase of surgical repair methods,more progress has been made on the basic research of peripheral nerve repair.