Surgery for nerve injury: current and future perspectives

Abstract

In this review article, the authors offer their perspective on nerve surgery for nerve injury, with a focus on recent evolution of management and the current surgical management. The authors provide a brief historical perspective to lay the foundations of the modern understanding of clinical nerve injury and its evolving management, especially over the last century. The shift from evaluation of the nerve injury using macroscopic techniques of exploration and external neurolysis to microscopic interrogation, interfascicular dissection, and internal neurolysis along with the use of intraoperative electrophysiology were important advances of the past 50 years. By the late 20th century, the advent and popularization of interfascicular nerve grafting techniques heralded a major advance in nerve reconstruction and allowed good outcomes to be achieved in a large percentage of nerve injury repair cases. In the past 2 decades, there has been a paradigm shift in surgical nerve repair, wherein surgeons are not only directing the repair at the injury zone, but also are deliberately performing distal-targeted nerve transfers as a preferred alternative in an attempt to restore function. The peripheral rewiring approach allows the surgeon to convert a very proximal injury with long regeneration distances and (often) uncertain outcomes to a distal injury and repair with a greater potential of regenerative success and functional recovery. Nerve transfers, originally performed as a salvage procedure for severe brachial plexus avulsion injuries, are now routinely done for various less severe brachial plexus injuries and many other proximal nerve injuries, with reliably good to even excellent results. The outcomes from nerve transfers for select clinical nerve injury are emphasized in this review. Extension of the rewiring paradigm with nerve transfers for CNS lesions such as spinal cord injury and stroke are showing great potential and promise. Cortical reeducation is required for success, and an emerging field of rehabilitation and restorative neurosciences is evident, which couples a nerve transfer procedure to robotically controlled limbs and mind-machine interfacing. The future for peripheral nerve repair has never been more exciting.

Acute Flaccid Myelitis: A Clinical Review

“…Nerve or tendon transfer surgery has been used to promote functional recovery in patients with lower motor neuron injury secondary to a range of diseases. 52,53 While the utility of these methods has not been studied extensively in AFM, there are reports suggesting success in individual cases. 54…”

Peripheral Nerve Regeneration and Muscle Reinnervation

“…There is also a long history of surgical repair via autologous nerve bridges and via a wide variety of conduits that include acellular allografts [61][62][63][64]. Other important surgical procedures in practice are (1) the nerve transfer of either a redundant proximal nerve stump or dissected fascicles of a functioning nerve to a denervated distal stump to restore function [65][66][67][68][69] and (2) the transfer of tendons to assist lost movements [70]. The use of stem cells such as mesenchymal stem cells as substitutes for SCs is also being explored in animal models [71,72].…”

Establishment of a Sheep Model for Hind limb Peripheral Nerve Injury: Common Peroneal Nerve

“…The main objective of the surgical approach is to overcome the limitations associated with nerve regeneration and create the conditions for its full occurrence (19). In cases where tension-free conditions are observed, direct anastomosis between the nerve tops is still the gold-standard technique (20).…”