Functional Recovery following Repair of Long Nerve Gaps in Senior Patient 2.6 Years Posttrauma

Abstract

Summary: Sensory nerve grafts are the clinical “gold standard” for repairing peripheral nerve gaps. However, reliable good-to-excellent recovery develops only for gaps less than 3–5 cm, repairs performed less than 3–5 months posttrauma, and patients aged less than 20–25 years. As the value of any variable increases, the extent of recovery decreases precipitously, and if the values of any two or all increase, there is little to no recovery. One 9-cm-long and two 11-cm-long nerve gaps in a 56-year-old patient were repaired 2.6 years posttrauma. They were bridged with two sensory nerve grafts within an autologous platelet-rich plasma-filled collagen tube. Both were connected to the proximal ulnar nerve stump, with one graft end to the distal motor and the other to the sensory nerve branches. Although presurgery the patient suffered chronic level 10 excruciating neuropathic pain, it was reduced to 6 within 2 months, and did not increase for more than 2 years. Motor axons regenerated across the 9-cm gap and innervated the appropriate two measured muscles, with limited muscle fiber recruitment. Sensory axons regenerated across both 11-cm gaps and restored normal topographically correct sensitivity to stimuli of all sensory modalities, including static two-point discrimination of 5 mm, and pressure of 2.83 g to all regions innervated by both sensory nerves. This novel technique induced a significant long-term reduction in chronic excruciating neuropathic pain while promoting muscle reinnervation and complete sensory recovery, despite the values of all three variables that reduce or prevent axon regeneration and recovery being simultaneously large.

Inducing Ulnar Nerve Function while Eliminating Claw Hand and Reducing Chronic Neuropathic Pain

“…3,8 Autografts may increase or slightly reduce chronic neuropathic pain but may not eliminate it. 4,9 While the autografts and the subject's relatively young age may have facilitated the recoveries and pain reduction, alternatively, the results are consistent with two recent case studies, 6,7 suggesting that PRP may underlie these changes, which can be tested by examining the efficacy of PRP alone.…”

“…The subject’s recovery is consistent with two recent case studies using this technique. 6 , 7 Because autografts do not reliably induce good recovery of long gaps 2 or eliminate ulnar nerve injury-induced claw hand, 1 these results suggest that platelet-released factors induce recovery and eliminate finger clawing, effects that are limited by other techniques, especially across long nerve gaps.…”

“…Animal model 5 and clinical 6 , 7 studies show that applying PRP to nerves enhances axon regeneration and reduces pain. To test whether PRP within the gaps induced more extensive recoveries than autografts alone and eliminate hand clawing, three 10-cm-long ulnar nerve gaps were bridged with two autografts within a PRP-filled collagen tube.…”

“…1 Another challenge is that nerve traumas cause 50%-79% of individuals to develop chronic neuropathic pain, 3 and autografts do not induce pain reduction or elimination. 4 Animal model 5 and clinical 6,7 studies show that applying PRP to nerves enhances axon regeneration and reduces pain. To test whether PRP within the gaps induced more extensive recoveries than autografts alone and eliminate hand clawing, three 10-cm-long ulnar nerve gaps were bridged with two autografts within a PRP-filled collagen tube.…”

A Novel Technique Restores Function while Eliminating Intractable Neuropathic Pain in a 71-Year-Old Diabetic Patient under Challenging Injury Conditions

“…Because such recoveries are not induced by sensory nerve grafts alone, these results indicate that platelet-released factors induced the recoveries. This hypothesis is consistent with the data showing that the application of PRP to injured nerves promotes axon regeneration in animal models [34][35][36][37] and clinical studies [38][39][40] and reduces/eliminates chronic neuropathic pain in animal models [34][35][36][37] and clinically. 38,39,41,42 These recoveries indicate that this novel technique induced axon regeneration in this diabetic patient similar to that seen in healthy patients.…”