Nerve stitching. Latin language and the basics of medical terminology: Textbook
The innervation of the hand is mainly carried out by three nerves: the median, ulnar and radial, to a lesser extent, the musculocutaneous, providing sensitivity to the skin of the eminence of the thumb.
They are rare - 0.3%. In fact, wounds of the digital nerves located on the metacarpus, especially with extensive and combined injuries, are observed almost constantly, but are not reflected in the diagnosis.
On fig. 125 shows a diagram of the localization of wounds of the hand, most often complicated by nerve damage. Recognition of nerve damage in accidental wounds of the hand is based on a comparison of the localization 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 suffer significantly. Wounds at the base of the palm, facing the thumb, are complicated by damage to the branches of the median nerve, followed by paralysis of the muscles of the elevation of the thumb and I-II worm-like muscles.
Damage to the median and ulnar nerves at the level of the wrist 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, respectively, in 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 apparent. Then, electrodiagnostics and electromyography, the study of biopotentials and other indirect methods contribute to clarifying the diagnosis.
Neurological examination data play an important role in diagnosis, in assessing the course and regeneration of the nerves of the fingers and hand. For a complete and accurate picture of the sensitivity of the hand and fingers, a study of tactile, discriminatory sensitivity, stereognosis and a ninhydrin test is recommended. 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 processing and nerve suture.
Nerve suture
The need for suturing the damaged digital nerve is not subject to discussion, because if the skin sensitivity of the fingers is disturbed, the functional ability of the hand is sharply reduced. In this case, one should be guided by the provision that the suture of the nerve is a non-urgent operation.
During the primary treatment of the wound of the finger, the primary epineural suture is shown in cases where the surgeon finds it possible to perform a reconstructive operation and suture the wound. For contaminated finger wounds or skin defects where there is no provision for a primary suture, a delayed nerve suture is used.
Stitching the nerves in the hand and fingers is not difficult, since the common and proper digital nerves are not as thin as it is supposed to be. The 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 enough to connect (Fig. 125, b). According to Bennel'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, 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 course of the damaged nerve. When isolating the nerve trunk, all manipulations of the surgeon must be atraumatic; capturing the nerve with tweezers, prolonged exposure, pulling, separating, etc. are unacceptable. When both ends of the damaged nerve are found, they are held by the soft tissues or the epineurium.
When suturing, atraumatic needles and a suture through the epineurium are used. Having sutured the damaged nerve from one, more accessible side, the ends of the threads are taken into a clamp and used as “holders” when subsequent sutures are applied to the opposite side of the nerve. In this case, it is very important not to allow rotation of the nerve segments in relation to each other and not to cause bending of the bundles, but to oppose them to each other until they come into contact. Any gap between the bundles is filled with a hematoma and a scar that prevents the germination of newly formed axons. The number of sutures should be sufficient to ensure the tightness of the contact between the bundles and the epineurium. This technique makes it unnecessary to wrap the area of the nerve suture with various tissues and materials that cause the formation of coarser scars.
If, when tying the sutures, tension is felt on the nerve, then the hand is given a position that eliminates it. Of great importance is the correct management of the patient after surgery, in particular bed rest, elevated position of the hand for 5-7 days. The subsequent complex treatment consists in the influence of physical factors (d "Arsonval currents, iontophoresis, UHF, massage, electrical muscle stimulation, therapeutic exercises and immobilization, drugs).
Restoration of the functions of the hand after damage to the median and ulnar nerves in the carpal tunnel occurs not earlier than six months and often not fully. First, touch is restored, then discriminatory sensitivity - the ability to distinguish between touching two points at the same time. To restore the victim's ability to work, the ability to recognize captured objects without visual control is of the greatest importance - "tactile gnosis", which, according to most authors, is not fully restored.
The study of the long-term results of the suture of the nerves of the hand and fingers shows that only 57% of the victims have no pain, a third of the patients experience cold fingers, paresthesia; even more often pronounced trophic disorders are observed in varying degrees.
In modern nerve surgery, microsurgical techniques are becoming increasingly common, which ensure the synchronous work of the surgeon and assistant, the possibility of accurate restoration of individual bundles of the nerve trunk (K. A. Grigorovich, 1975; B. V. Petrovsky, V. S. Krylov, 1976; Tsuge and et 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 necessary - nerve suturing.
Primary treatment is not carried out if there are other extensive injuries that do not allow for additional surgical intervention, or severe contamination (infection) of the wound. A microscope and other technical innovations are used to stitch too small nerves. If it is impossible to carry out the primary surgical treatment, the ends of the nerve trunks are isolated and freely compared to prevent contraction and dysfunction. This facilitates secondary processing.
Pain relief for nerve entrapment
General or conduction anesthesia, depending on the duration and location.
Preparing for Nerve Stitching
The wound is covered with sterile napkins, the skin around is shaved and carefully prepared. Then the wound is opened and abundantly irrigated with warm saline. They are covered with sheets and a tourniquet is applied to the shoulder. First, the limb is raised, then an elastic bandage is applied from the fingertips above. Normally, in an adult, the pressure rises to 250 mm Hg. Art. After that, 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 it can be applied again for the next 1.5 hours.
Nerve suturing technique
For a more complete surgical treatment and examination of nerve segments, the boundaries of the incision must be increased to the entire depth of the wound. should not be afraid to do this, you just need to make sure that the cut lines do not cross the flexor lines. The skin flaps are pulled to the sides and sections of the nerve are highlighted above and below the rupture site. The incision is made along the axis of the nerve carefully so as not to damage the small nerve branches and adjacent structures. To excise a scar or neuroma, the incision is made arbitrarily 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 removed using gauze loops moistened with saline.
After selecting the ends of the nerve using an atraumatic needle, guiding sutures are placed on the epineurium of the proximal and distal ends to align the sections of the nerve. Using a small expander covered with a damp gauze pad, the nerve is supported before cutting off the damaged areas. The ends of the nerve are released and with a sharp scalpel the damaged areas are cut off perpendicular to the axis of the nerve until normal nerve fibers are visible.
A neuroma or a combination of a proximal neuroma and a distal glioma is resected in the same way. It is useful 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, sufficient relaxation must be achieved to prevent tension on the anastomosis. Additional lengthening can be achieved by careful mobilization of the nerve trunks a few centimeters from the incision site. To achieve greater relaxation, the proximal portion of the nerve is shortened by grafting (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 compared, the nerve fibers are carefully fastened to ensure the 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, the epineurium is sutured across the defect at a distance of 1 mm from each end. The second seam is applied 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 with interrupted sutures laid around the anastomotic line. It is more accurate to capture only the epineurium. The sutures should be sufficient for a fixed alignment of the ends of the nerve trunk.
The tourniquet is removed, the bleeding vessels are ligated. The wound must be completely dry. Then it is irrigated with warm saline. solution to remove blood clots and organic matter. Remove guide sutures.
The wound after stitching the nerve is sutured in layers with intermittent sutures, covered with a gauze napkin, a layer of cotton wool, an elastic bandage is applied. Immobilization in a state of slight flexion is achieved with a splint.
Care After Nerve Stitching Surgery
During this period, the risk of ischemia or hematoma. After 4 weeks, the splint can be slightly loosened and left for another 3 weeks. However, if motor paralysis and accompanying deformity occurs, for example, of the hand, all this can be corrected by proper splinting until full recovery of motor activity. The tire should not remain for a long time, so that stiffness of the joint (joint) does not occur. To maintain muscle tone and prevent ankylosis of the joint - physiotherapy. To exclude atrophy after suturing the nerve - electrical stimulation of the denervated muscle.
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Nerve suture (neurorrhaphy). The task of the operation is to accurately match the transverse sections of the central and peripheral ends of the transected nerve trunk.
There are epineural and perineural sutures. Epineural sutures are placed on the epineurium, the strongest sheath of the nerve, which 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.
A distinction is made between the primary suture of the nerve, which is applied at the time of the primary surgical treatment, and delayed sutures, which can be early if they are produced in the first weeks after injury, and late if they are produced later than 3 months. since the day of injury. The main conditions for suturing are a clean wound, an injury site without crush foci, a highly qualified team of surgeons equipped with modern microsurgical equipment. In the absence of these conditions early after injury, delayed suture should be considered the method of choice.
Indications for a nerve suture are signs of a complete anatomical interruption of it or a violation 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, concomitant injuries, accurate identification and comparison of intraneural structures.
The operation is performed under anesthesia. The damaged nerve is isolated from the scar tissue in the same sequence as in neurolysis. Predominantly non-projective operative access is used. In cases of significant development of scar tissue in the area of nerve damage, the scars are excised in layers in a single block of an elliptical shape. In the future, the allocation of the proximal and distal segments of the nerve starts from the level of healthy tissues and gradually reaches the area of the traumatic neuroma. This technique reduces the risk of damage to the large blood vessels lying near the nerve, then the scar tissue in the circumference of the nerve is excised and the neuroma is isolated. If the ends of the nerve are not connected by a cicatricial bridge, then, having captured each of these ends with tweezers, they are crossed with a sharp scalpel or razor blade within healthy tissues. If there is external continuity of the nerve in the region 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 in the cross section has a granular appearance, the vessels of the epineurium and perineurium bleed - this indicates the complete removal of the neuroma.
Next, proceed to the mobilization of the segments of the nerve, to ensure this stitching without tension. The assistant grabs the central and peripheral segments of the nerve with his fingers and brings them together up to comparison, and the surgeon puts two guiding sutures made of fine silk or capron on the sides of the reduced 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 sciatic nerve suturing). During the operation, the wound is moistened with napkins moistened with a warm isotonic solution. In order to prevent possible infringement of the nerve by postoperative growth of scar tissue, the isolated nerve and the suture area are wrapped in a thin fibrin film. The wound is sewn up tightly.
When mobilizing the nerve segments, avoid exposure of the nerve trunk over a large extent and excessive tension of the nerve segments for suturing. All this leads to disruption of the blood supply to the nerve trunk and worsens the conditions for regeneration of axons.
Therefore, with large defects in the nerve trunk after removal of the neuroma, it is better to bring the nerve segments together by bending the limb in 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, in the presence of a large diastasis between 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 ulnar fossa. To prevent rupture of the sutures and reduce pain, the operated limb is applied for 3-4 weeks. plaster splint.
The prognosis is favorable in many cases, although with nerve defects greater than 5 cm, the percentage of positive results is markedly reduced.
Nerve damage caused by trauma can be partial or complete. If in the first case the nerve will recover itself, then in the second case it will have to be sutured.
If the nerve is left torn, over time, a thickening forms at the site of damage - a neuroma, which makes it difficult to transmit impulses, and the innervated tissues undergo atrophy and degeneration. Therefore, damaged nerves are sutured. If the patient applied late and a neuroma formed at the site of the rupture, it is removed during the operation.
How nerves are sutured
Nerve stapling operations are:
- primary, when the nerves are sutured together with the 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.
Belated operations are accompanied by neurolysis - the 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 sheath surrounding the nerve. To do this, the neurosurgeon brings the edges of the gap as close as possible to each other.
If a large gap has formed as a result of damage, plastic surgery is performed using a transplant from a nerve taken from another part of the body. However, the delayed results of plasty are always worse than direct stitching. Most often, the use of grafts is resorted to with a significant amount of damage.
After this operation, axons - processes of cells of the nervous system - will grow into the neighboring area, connecting the two stitched parts of the nerve.
Stitching of nerves in the Open Clinic
The thickness of the nerve is 0.8–8 mm; therefore, its suturing requires high precision, achieved by the use of microsurgery, modern operating microscopes, and the thinnest 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 the nerves to be sutured with minimal risk of complications.
Therefore, in case of nerve damage, you need to contact the Open Clinic, where you will be provided with timely, highly qualified neurosurgical care. The sooner you apply, the easier, faster and more successful the treatment will be.
Price
nerve stapling
| Service | Time, min. | Cost, rub. | Primary neurosurgeon appointment | 30 | 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:
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180 | 70 000 | Treatment in a two-bed day hospital from 6 hours to 1 day with meals | - | 5 000 |
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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 breaks up into small grains, and its myelin sheath, which forms absorbable fat droplets. Only the desolated Schwann's sheath 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 the injury and end by the end of the 1st month, when the complete picture of nerve degeneration is already visible.
In the central segment of the nerve, rather complex processes of a multi-vector orientation occur. On the one hand, it undergoes periaxonal degeneration, which is expressed by the breakdown of the myelin sheath, on the other hand, the process of centrogenous regeneration of the nerve occurs simultaneously. 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, a dense scar, etc. create insurmountable obstacles to the germination of axons. At the central end of the nerve, a hyperplastic thickening is formed - a neuroma that disrupts the conduction 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 having a normal structure. At the same time, axons growing from the central end of the nerve penetrate into the sheaths of its peripheral end.
Radial and musculocutaneous nerves have the best regenerative capacity. 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 the neuroma (resection "refreshment" of the damaged ends);
- overbearing.
Neurolysis - isolation of the nerve from the surrounding tissues, scars to create favorable conditions for its regeneration and functioning. Depending on the nature of the injury and the time elapsed after the injury, external, internal neurolysis, or a combination of both, is performed. The surgical essence of external neurolysis is the mobilization of the nerve, its release from the extraneural scar resulting from damage to neighboring organs. This procedure eliminates nerve tension and is performed in a healed wound. Internal neurolysis is aimed at relieving axonal compression and is reduced to excision of interfascicular fibrous tissue. One of the main conditions for a 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 to perform a high-quality surgical technique - suturing. The length and shape of the incision for access to the injured nerve is calculated taking into account the need for maximum exposure of the nerve above and below the injury site. To expose deeply located nerves covered by muscles, it is recommended to use direct access. 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 on the skin). In this case, the likelihood of postoperative scar pressure on the nerve trunk is reduced. In a fresh wound (without signs of infection), the access made during the primary surgical treatment is used.
Having provided sufficient access, the nerve is isolated to intact tissues and the extent of neurolysis is determined. The ends of the cut nerve are found in a fresh wound. The boundaries of the necessary resection of the nerve are determined - the extent of irreversible changes (disintegration, hemorrhage, etc.). To clarify the depth of damage using intraoperative electrodiagnostics. To do this, irritate the nerve above the injury site. The 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 under the epineurium are used. 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 the damaged ends is performed with a safety razor blade or scalpel.
At the same time, the neuroma is removed at the central end and the schwannoma at the peripheral end. Applying balls with warm saline, stop 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 sheen. With intraoperative microscopy, individual bundles of axons are visible.
The connections of the ends of the damaged peripheral nerve reach the interrupted epineural sutures (Fig. 17.1).
Rice. 17.1. Epineural suture
The operation consists in exact comparison of transverse 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 prevents misalignment of the intrastem structures. For stitching, an atraumatic needle with synthetic threads (10/0) is used. Both non-absorbable suture material is chosen (explaining this by a lesser reaction of tissues), and absorbable.
Depending on the diameter of the nerve diameter, 2-4 thin sutures are applied. The first sutures are placed symmetrically along the lateral and medial edges of the nerve. The prick and prick 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 the axis by 180° towards the assistant for additional sutures (first posterior, then anterior).
After that, the surgeon and his assistant, while 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 Najotte sutures. However, when they are performed, 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, bent or bent.
The suture is placed in the position of the limb, which creates minimal tension for the nerve. This position is held with a plaster cast for 3-4 weeks after the operation. In the event that during the initial treatment of the wound there were no conditions for applying the primary suture, 3-4 weeks after the injury, an early delayed suture of the nerve is applied. This applies to bruised, 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 parts of the nerve. Conduction disturbances may be due to its concussion. Later, conductivity may spontaneously recover.
The secondary suture of the nerve is used at various times after injury - from 4-6 weeks to several years. The essence of the secondary suture is to excise the scar of the nerve and stitch its "refreshed" ends. In this case, the advantages of a delayed suture on the nerves are used. Firstly, it is usually performed by a doctor with experience in surgery of the peripheral nervous system, and, secondly, the risk of postoperative infectious complications is minimized, since the inflammatory process, as a rule, can 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 tissues. Having fixed the selected parts of the nerve on rubber or gauze holders, neurolysis begins.
Mandatory excision of the neuroma from cicatricial adhesions is performed. For surgical treatment of the central neuroma, the epineurium is first removed, wrapping it up in the form of a cuff (Fig. 17.2).
Rice. 17.2 Wrapping the epineurium in the form of a cuff during the 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 a good contact of 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 shaped sutures passing through the base of the cuff
Rice. 17.4 Fixing the cuff. Suturing a peripheral nerve after treatment of a neuroma
The sutured nerve must be placed in a muscular sheath to prevent fusion with aponeuroses, fascia and skin.
