Vinnitsa National Medical University

Course of Neurosurgery

Methodological recommendations on the theme:

Reconstractive neurosurgery. Traumatic affections of the peripheral nervous system. General symptomatology. And diagnostics of injuries of the main nerves. Indications to surgery and kinds of operative interventions.

Approved at a methodological meeting of the courseof Neurosurgery

The minute № 1

Head of the departmentMoskovko S.P.

Head of the course Olkhov V.M.

Theme: " Reconstractive neurosurgery.Traumaic affections of the peripheral nervous system. General symptomatology and diagnostics of injuries of the main nerves. Indications to surgery and kinds of operative interventions''

Duration of the class: 2,7 hours.

1 Importance of the theme: Traumatic affections of the peripheral nerves are one of the major problems of neurosurgery.

Injuries of the peripheral nerves occur mainly in persons of young and middle age.

The timely diagnostics, the qualified medical aid at different stages, including surgery are very important.

2. The educational aims:

To know:

Classification of traumatic affections of the peripheral nerves.
Manifestation of injuries of the main nerves.
Indications to surgery and kinds of operative interventions.
Peculiarities of carrying out primary surgical treatment of the wound with affection of the peripheral nerves

To be able:

To examine the patient with the supposed injury of the peripheral nerve.

3. Materials for preparations of the students.

3.1. The basic knowledge, skill, which are necessary for independent studying and mastering the theme and which are based on interdisciplinary connections:

№№ / Discipline / To know / To be able
1. / Anatomy / Anatomy of the
Peripheral nerves
2 / Neurology / Neurologic symptoms
Traumatic affection of the peripheral nerves

3.2. The contents of the theme: variant №4

3.3. The recommended literature:

-The main:

3.4. A map for independent preparation of the student by using literature on the theme - Traumatic affections of the peripheral nervous system. General symptomathology and diagnostics injuries of the main nerves. Indications to surgical treatment.

The primary aim / Instructions / Answers
1 / 2 / 3
Kinds of injury of the peripheral nervous system
Symptomatology
In partial injuries of the nerves manifestation
Complete rupture of the nerve.
The acute period
Disturbance
Sensitivity
Disturbance
Treatment. / Traumas of the peripheral nerves are divided into open and closed. The open are: stab, cut, chipped, fragmental, injured, crushed wounds; the closed are concussion, injury, compression, strain, rupture and dislocation. From the morphological point of view, there are distinguished a complete and partial anatomic rupture of the peripheral nerve.
Damage of the nerve is manifested by the complete or partial block of conductivity which results in a different degree of disorder of motor, sensitive and vegetative function of the nerve.
In partial damages of nerves there are symptoms of irritation in the sphere of sensitivity and vegetative reactions (hyperpathy, causalgia, hyperkeratosis). Neuropraxia (praxis–work, apraxia– inability, inactivity is a temporary loss of physiological function – conductivity of the nerve after mild injury. Motor disorders are mainly clinically observed. On the part of sensitivity first of all paresthesias are marked. Vegetative disorders are absent or are not expressed. Restoration occurs within several days. This form corresponds to concussion
Axonotmesis is a more complex form of damage due to compression or strain. Anatomic integrity of the nerve is saved, but morphologicall there is wallerian degeneration is more distal to the site of damage.
Neuropraxia and axonotmesis are treated conservatively.
Neurotmesis is a complete rupture of the nerve or severe injury with a rupture of its separate nervous trunks, due to what regeneration is impossible without surgical intervention.
Process of decomposition of the nervous fibres, described in 1850 by the French scientist Waller, now is termed –Wallerian degeneration. Reverse process – regeneration of the nerve occurs under condition of exact set of fascicles– sensitive and motor accordingly) both pieces of the nerve, it proceeds rather slowly (at a speed of approximately 1 mm day).
The clinical and electrophysiological picture in damages of the peripheral nerves depends essentially on the time interval which has passed since the moment of the trauma.
The acute period of the trauma is the period in which all factors of a trauma on the whole in are manifested a clinical picture rather than damage of the nerves: shock respance to pain, blood loss, presence of a secondary infection, mental trauma etc. The Acute period lasts 15-20 days.
The remote period of the trauma characterized by formation of the main pathomorfologic changes in the fibres of the nerve called wallerian degeneration, begins on the thirds - the fourth week after the trauma.
In the acute period of the trauma the most informative sign of injury of the nerve is: disturbance of sensitivity in the zone of innervation.
The best results of treatment are achieved in carrying out adequate surgery on the day of trauma. Operation is possible in observance of conditions: presence of the experts, necessary equipment, suture a material and the magnifying optics, appropriate anaesthesiological maintenance, absence of complications of the wound.
Disturbance of movement in complete damages of the main nerves of extremities is manifested by a picture of the peripheral paralysis of muscles (atony, areflexia, atrophy).
Study of sensitivity is often in decisive diagnostics of affection of the nerve.
Trophic disarders in damages of the nerves are manifested by perspiration disturbances, immediately after traumas hyperthermia in the zone of innervationy with the subsequent reduction of temperature, thinning of the skin, disappearance of its folds.
Tenderness on palpation and percussion along the peripheral piece of the injured nerve is a characteristic sign of regeneration of the nerve after its sewing together (symptom of Tinnel). The kind and degree of damage of the nerve promotes further tactics of treatment: conservative or surgical.
The basic method of treatment of traumatic affections of peripheral nerves is – surgical.
Surgical treatment consists of neurolysis
– Internal neurolysis, or endoneurolysis –is a removal of fascicles from the nervous trunk.
Uturing the nerve together... The fascicles are set and suturation is carried out exclusively under a microscope. Operation finishes with immobilization of the extremity with the help of a plaster bandage. Immobilization for two – three weeks.

3.5. Materials for self-control.

3.5.1. Questions.

1. What is the open and closed traumatic injuries of the peripheral nerves?

2. Name symptoms of traumatic affection of the main nerves.

3. On the basis of what inspections are diagnoses of traumatic affections of the peripheral nervous system made?

4. What kinds of operative intervention do you know?

3.5.2. Test tasks for self-control.

The patient of 20 years old has come with complaints of absence of movements in the left humeral and ulnar joints, with preservation of movements in the fingers and hand, reduction of sensitivity on the external surface of the shoulder, forearm, hand. One month ago he had a fracture of transversal processes С5-С6. What is preliminary diagnosis?

+А. Posttraumatic upper humeral left-hand plexiris

B. A posttraumatic neuritis of the left median nerve.

C. A posttraumatic neuritis of the left radial nerve

D. A posttraumatic neuritis of the left ulnar nerve

E. A posttraumatic neuritis of the left median and radial nerves

The patient has come with complaints of restriction of bending of the hand, absence of bending of the terminal phalanxes of the 4th and 5th fingers, impossibility of opposition of the 5th and 1st fingers. On examinationi the hand is claw-like: a hypesthesia in the zone of the 4th, 5th fingers and hand on the palmar and back surfaces, cicatrixon the upper third of the medial surface of the left forearm. The preliminary diagnosis?

A. Posttraumatic inferior humeral left-hand plexitis

B. A posttraumatic neuritis of the left median nerve

C. A posttraumatic neuritis of the left radial nerve

+D. A posttraumatic neuritis of the left ulnar nerve

E. A posttraumatic neuritis of the left median and radial nerves

The patient has come with complaints of restriction of bending of the 1-th and the 2-nd fingers, impossibility of clenching a fist. On examination the hand was edematous with impossibility of pronation the forearm and with hypesthesia of the palm and the back surfaces of the 1-st,2-nd,3 –rd fingers, with vasomotor trophic changes and rough cicatrux at the inferior of the one/ third of right shoulder.

What is the preliminary diagnosis?

A. Posttraumatic inferior humeral left-hand plexitis.

B. Posttraumatic neuritis of the left median nerve.

C. Posttraumatic neuritis of the left radial nerve.

D. Posttraumatic neuritis of the left ulnar nerve.

E. Posttraumatic neuritis of the left median and radial nerves

3.6. Subjects of the Research Themes:" Reconstractive neurosurgery.Traumatic affections of the peripheral nervous system. General symptomatology and diagnostics of damages of the main nerves. Indications to surgery.”