Nerve suturing. Latin language and basics of medical terminology: Textbook

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

After a traumatic nerve rupture, primary or late (secondary) treatment is required - nerve suturing.

Primary treatment is not carried out if there are other extensive injuries that do not allow additional surgical intervention, or severe contamination (infection) of the wound. To stitch together too small nerves, a microscope and other technical innovations are used. If primary surgical treatment is not possible, the ends of the nerve trunks are isolated and freely juxtaposed to prevent contraction and dysfunction. This makes secondary processing easier.

Pain relief during nerve suturing

General or conduction anesthesia depending on duration and location.

Preparation for nerve suturing

The wound is covered with sterile napkins, the skin around it is shaved and carefully prepared. Then the wound is opened and generously irrigated with warm saline solution. Cover with sheets and apply a tourniquet to the shoulder. First, the limb is raised, then an elastic bandage is applied from the fingertips above. Normally, in an adult, blood pressure rises to 250 mmHg. Art. After this, the elastic bandage is removed. The tourniquet can remain on the arm for 1.5 hours. Then it is removed for 15 minutes, and then can be applied again for the next 1.5 hours.

Nerve suturing technique

For more complete surgical treatment and examination of nerve segments, the incision boundaries must be increased to the full depth of the wound. you should not be afraid to do this, you just need to make sure that the cutting lines do not intersect the flexor lines. The skin flaps are pulled to the sides and sections of the nerve above and below the tear site are isolated. The incision is made along the axis of the nerve carefully so as not to damage small nerve branches and adjacent structures. To excise a scar or neuroma, the incision is made randomly in one direction and parallel to the nerve. The dissection is carried out through the muscle layer along the same axis. Before isolating the damaged area of the nerve, its healthy areas are exposed at a distance of 1 cm above and below the defect. If necessary, the nerve trunks are retracted using gauze loops moistened with saline solution.

After isolating the ends of the nerve using an atraumatic needle, guide sutures are placed on the epineurium of the proximal and distal ends to align the sections of the nerve. Using a small retractor covered with damp gauze, the nerve is supported before the damaged areas are cut off. The ends of the nerve are released and the damaged areas are cut off perpendicular to the axis of the nerve with a sharp scalpel until normal nerve fibers are visible.

The neuroma or combination of proximal neuroma and distal glioma is excised in the same way. It is helpful to make a series of incisions, leaving a small bridge of tissue that will facilitate further manipulation of the nerve trunk.

During this procedure, a nerve fiber of 1 cm or more can be removed. In the postoperative period, it is necessary to achieve sufficient relaxation to prevent tension on the anastomosis. Additional lengthening can be achieved by carefully mobilizing the nerve trunks a few centimeters from the incision site. To achieve greater relaxation, the proximal portion of the nerve is shortened using a graft (example with the ulnar nerve). A nerve graft is used where the ends of the nerve trunk cannot be connected without tension. Then the ends of the nerve are aligned and the nerve fibers are carefully secured to ensure normal function of the pathways. The success of the nerve suturing operation largely depends on this moment.

When the ends of the nerve are sufficiently straightened, a suture is placed across the defect on the epineurium at a distance of 1 mm from each end. The second seam is placed and tied at an angle of 120° to the first on the opposite side. These 2 sutures are now used to rotate (rotate) the nerve trunk until the edges of the epineurium are aligned using interrupted sutures placed around the line of anastomosis. It is more careful to capture only the epineurium. Sutures should be sufficient to immobilize the ends of the nerve trunk.

The tourniquet is removed, the bleeding vessels are ligated. The wound should be completely dry. Then it is irrigated with warm saline. solution to remove blood clots and organic matter. The guide seams are removed.

After suturing the nerve, the wound is sutured in layers with interrupted sutures, covered with gauze, a layer of cotton wool, and an elastic bandage is applied. Immobilization in a state of slight flexion is achieved with a splint.

Care after nerve suturing surgery

During this period, there is a risk of ischemia or hematoma. After 4 weeks, the splint can be loosened slightly and left like that for another 3 weeks. However, if motor paralysis occurs and accompanying deformity, for example, of the hand, all this can be corrected with the correct application of a splint until motor activity is fully restored. The splint should not be left on for a long time to prevent stiffness of the joint. To maintain muscle tone and prevent joint ankylosis - physiotherapy. To avoid atrophy after suturing the nerve, electrical stimulation of the denervated muscle is performed.

The article was prepared and edited by: surgeon

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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 nerve segments 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.

Nerve damage caused by trauma can be partial or complete. If in the first case the nerve recovers on its own, then in the second it will have to be sutured.

If the nerve is left torn, over time a thickening will form at the site of damage - a neuroma, which impedes the transmission of impulses, and the innervated tissues will undergo atrophy and degeneration. Therefore, damaged nerves are sutured. If the patient comes late and a neuroma forms at the site of the rupture, it is removed during surgery.

How nerves are sewn together

Nerve suturing operations include:

primary, when the nerves are sutured together with surgical treatment of the wound;
early - the suture is applied within 2-3 weeks after the injury;
delayed – the operation is performed after 3 or more months.

Delayed operations are accompanied by neurolysis - removal of scar areas that compress the nerve.

Before stitching, the doctor cuts off the damaged areas of the break and stitches the epineurium - the membrane surrounding the nerve. To do this, the neurosurgeon brings the edges of the tear as close to each other as possible.

If the injury results in a large gap, repair is performed using a nerve graft taken from another part of the body. However, the delayed results of plastic surgery are always worse than those of direct stitching. Most often, transplants are used when there is a significant amount of damage.

After this operation, axons - processes of cells of the nervous system - will grow into the adjacent area, connecting the two stitched parts of the nerve.

Nerve stitching at the Open Clinic

The thickness of the nerve is 0.8–8 mm, so its suturing requires high precision, achieved by using microsurgery, modern operating microscopes and the finest suture material. Only then can we hope that the nerve will heal safely.

It is on this principle that the operation is carried out in the “Open Clinic”, where experienced doctors who have performed many such interventions work. The clinic uses modern microscopes and special suture material. This allows nerves to be sutured with minimal risk of complications.

Therefore, if your nerves are damaged, you need to contact the Open Clinic, where you will receive timely, highly qualified neurosurgical assistance. The sooner you contact, the easier, faster and more successful the treatment will be.

Price

nerve suturing

Service

Time, min.

Cost, rub.

Primary appointment with a neurosurgeon

1 500

Neurorrhaphy of the peripheral nerves of the upper and lower extremities (median, ulnar, radial, axillary, sciatic, tibial and peroneal) using microsurgical techniques?

The cost of the operation includes:

infiltration anesthesia
operation
compression hosiery (stockings)
hospital stay (1 day)

180

70 000

Treatment in a double day hospital from 6 hours to 1 day with meals

5 000

11218 0

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 primary 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 is 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 nerve suture 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

Rice. 17.4 Fixing the cuff. Suturing a peripheral nerve after treating a neuroma

The stitched nerve must be placed in a muscle sheath to prevent fusion with aponeuroses, fascia and skin.