MICROSURGICAL N E R V E SUTURES IMPROVE
R E H A B I L I T A T I O N A N D M A Y P R E V E N T
W A L L E R I A N D E G E N E R A T I O N
EROS ABRANTES ERHART * MARCUS CASTRO FERREIRA * * ANTONIO TEDESCO MARCHESE * * * PEDRO PUECH-LEÃO * * * *
"Nerves and Nerve Injuries" by S. Sunderland
1 8and the symposium on
operative nerve injuries and their repair, published by "The Surgical Clinics
of North America", October 1 9 7 2
l v, present the expertise of many authors
on the matter. Concomitantly, Erhart and collaborators
2-
1 4(1958 up to
1974) have reported the following observations: (i) — Human and dog
ner-ves, after having been completely transected for a long time (one or more
years) exhibited normal nerve fibers in the completely separated distal
seg-ments, because they had been maintained practically undisturbed in their
na-tural connective tissue bed. (ii) — The results obtained with nerve sutures
and or neurolysis in long-time post-traumatic nerve injuries are very
en-couraging, (iii) — Experimentaly it has been demonstrated that it is possible
to prevent the total Wallerian degeneration that normally occurs in the
distal segment of a transected nerve, by means of an adequate and properly
timed microsurgical nerve suture.
These above referred observations, literature data and clinical results,
which were obtained by experienced surgeons who had accompanied our
experimental work and made practical use of our conclusions by operating
their patients, were properly considered for developing the following
modi-fication of the nerve suture technique.
In each operation the surgeon must take great care while handling the
nerve and its natural connective tissue bed, chiefly the nerve vascular supply.
This is true for neurolysis and for nerve sutures.
S T E P 1 — I d e n t i f y t h e p r o x i m a l a n d t h e d i s t a l n e r v e s e g m e n t s b y r e m o v i n g a l l d a m a g e o r s e a r t i s s u e f r o m t h e s i t e o f i n j u r y , b u t s t r i c t l y m a i n t a i n t h e s t u m p s , a s m u c h a s p o s s i b l e , i n t h e i r n a t u r a l c o n e c t i v e t i s s u e b e d s . W h e n t h e r e is a n e u r o m a t o b e e x c i s e d a l o n g t h e n e r v e , c u t i t p e r p e n d i c u l a r t o t h e n e r v e a x i s i n t w o h a l v e s , s o a s t o h a v e a p r o x i m a l n e u r o m a a n d a n e u r o m a l i k e s t r u c t u r e i n t h e d i s t a l s t u m p e x t r e m i t y , a s i t w a s d e s c r i b e d b y E r h a r t a n d R e z z e • ", 1965.
S T K P 2 — U s i n g d e l i c a t e f o r c e p s , g r i p t h e n e u r o m a o f t h e p r o x i m a l s t u m p a n d t h a n t h e n e u r o m a l i k e s t r u c t u r e o f t h e d i s t a l s t u m p e x t r e m i t y a n d p u l l e a c h n e r v e s e g m e n t c a r e f u l l y , i n o r d e r t o f r e e t h e m f r o m t h e s u r r o u n d i n g s c a r t i s s u e . W i t h t h e s e m a n o u v e r s i t m a y b e j u d g e d h o w m u c h o f n e r v e c a n b e s t r e t c h e d a n d t h e r e f o r e e x c i s e d , w i t h n o d a n g e r f o r t h e f u t u r e n e r v e s u t u r e . I f w h i l e p u l l i n g , t h e n e r v e s e g m e n t s d o n o t m o v e o n t h e i r b e d s , a v e r y c a r e f u l l d i s s e c t i o n , j u s t o f t h e s c a r a r e a s h o u l d b e d o n e , b u t l e a v e t h e n e r v e a s m u c h a s p o s s i b l e i n i t s n a t u r a l c o n n e c t i v e b e d . B e w a r e o f t h e v a s a n e r v o r u m . T h e y a r e f u n d a m e n t a l l y i m p o r t a n t f o r t h e f u r t h e r n e r v e r e g e n e r a t i o n ( E r h a r t & R e z z e " , L u n d b o r g1 6
a n d A l m g r e nJ
) .
S T E P 3 — P r e p a r i n g t o p a s s t h e t h r e a d s . U s e a l w a y s a s u r g i c a l d i s s e c t i n g m i c r o s c o p e , w i t h a t l e a s t 2 0 c m f o c u s , t o f a c i l i t a t e a c c u r a t e e x a m i n a t i o n , h a n d l i n g , t h r e a d i n g a n d a p p o s i t i o n o f t h e f u t u r e f r e s h n e d n e r v e e n d i n g s . U s e f o r a n a t o m i c a l l a n d m a r k s t h e s m a l l e p i n e u r a l l o n g i t u d i n a l v e s s e l s t o a v o i d t o r s i o n s . W i t h t h e h e l p o f t h e f o r c e p s w h i c h s t i l l r e m a i n f i x e d o n t h e n e u r o m a t o u s s t r u c t u r e s a b o u t t o b e e x c i s e d , s t r e t c h g e n t l y t h e n e r v e s t u m p s , f i r s t o n e a n d t h e n t h e o t h e r , i n o r d e r t o c u t o f f t w o s m a l l r i n g s o f t h e e p i n e u r i o n o u t e r m o s t l a y e r : o n e r i n g , p r o x i m a l t o t h e n e u r o m a o f t h e p r o x i m a l s t u m p a n d t h e o t h e r , i m m e d i a t e l y d i s t a d t o t h e n e u r o m a l i k e s t r u c t u r e o f t h e d i s t a l s t u m p , s o t o h a v e e x p o s e d t h e n e r v e f a s c i c l e s , e a c h o n e o f t h e m m a i n t a i n e d b y t h e i r o w n p e r i n e u r i o n a n d b y t h e r e m a i n i n g i n n e r m o s t l a y e r o f t h e e p i n e u r i o n .
S T E P 4 — P a s s t h e t h r e a d s , m o n o n y l o n 8 t o 1 0 z e r o , w i t h a t r a u m a t i c n e e d l e s . T h e f o u r c a r d i n a l p o i n t s — N , S, E a n d W — ( u p p e r , l o w e r , i n n e r a n d o u t e r ) a r e r e c o m m e n d e d . T h e t h r e a d s m u s t b e p l a c e d e p i p e r i n e u r a l l y i n o r d e r n o t t o i n j u r e t h e n e r v e f a s c i c l e s ( F i g . 2 ) . T h e s i t e o f i n s e r t i o n a l o n g t h e n e r v e e p i -n e u r i o -n a -n d p e r i -n e u r i o -n w i l l b e i -n d i c a t e d b y t h e s i z e a -n d t y p e o f t h e -n e u r o m a ( s e e F i g . 1 — " g o o d a n d b a d n e u r o m a s " ) . I t is i m p e r a t i v e t o n o t e t h a t a n y n e u r o m a t o u s t i s s u e l e f t b e h i n d m a y i n t e r f e r e w i t h t h e n e w g r o w i n g r e g e n e r a t i n g n e r v e f i b e r s f r o m t h e p r o x i m a l t o t h e d i s t a l s t u m p .
S T E P 5 — T h e p r o x i m a l a n d d i s t a l n e r v e s t u m p e x t r e m i t i e s a r e c u t s h a r p l y a t t h e l e v e l w h e r e t h e e p i n e u r i o n r i n g s w e r e e x c i s e d . S l i g h t u s e d r a z o r b l a d e s a r e b e s t . T h i s s t a t e m e n t is b a s e d o n o u r o w n e x p e r i m e n t a l o b s e r v a t i o n s . C h e c k t h e f r e s h l y c u t s u r f a c e s o f b o t h n e r v e e x t r e m i t i e s w i t h t h e d i s s e c t i n g m i c r o s c o p e t o s e e t h a t t h e n e r v e p a t t e r n f a s c i c l e s e x h i b i t a n o r m a l a s p e c t . I f n e u r o m a t o u s s c a r t i s s u e b e s t i l l p r e s e n t , r e v e r t t o s t e p 3 a l l o v e r a g a i n . A f t e r a c q u i r i n g s o m e e x p e r i e n c e , e v a l u a t i n g t h e n e u r o m a t o u s d i s p o s i t i o n b y i t s g e n e r a l m o r p h o l o g y ( F i g . 1 — " g o o d a n d b a d n e u r o m a s " ) , a n d k n o w i n g h o w t o e v a l u a t e h o w m u c h o f n e r v e s t u m p c a n b e e x c i s e d , t h e s e i n c o n v e n i e n c e s r a r e l y o c c u r .
W h e n t h e i n t e r v a l b e t w e e n t h e t w o s t u m p s i s t o o w i d e , t w o c o n d u c t s m a y b e u s e d : ( a ) u s e o f n e r v e g r a f t s ; ( b ) s h o r t e n i n g o f t h e l i m b o n e o r b o n e s , i n o r d e r n o t t o s t r e t c h t h e n e r v e .
S T E P 6 — P u l l t h e t h r e a d s g e n t l y t o g e t h e r i n o r d e r t o j o i n t h e v i t a l n e r v e t i s s u e o f t h e p r o x i m a l s t u m p t o t h e n e r v e t i s s u e o f t h e d i s t a l s e g m e n t a n d , w i t h p r o p e r t e n s i o n , t i e k n o t s . T h e a d e q u a t e t e n s i o n i s n o t t o o t i g h t , n o r t o o l o o s e ; j u s t t h e r i g h t t e n s i o n . M o r e t h r e a d s s h o u l d b e u s e d , if n e c e s s a r y , t o b e t t e r c o m p l e t e t h e n e r v e s u t u r e .
S T E P 7 — R e c h e c k c a r e f u l l y w i t h t h e m i c r o s c o p e t h e e n d t o e n d s u t u r e l i n e , t h e n e r v e v a s c u l a r i z a t i o n a n d t h e i n t e g r i t y o f t h e n e r v e c o n n e c t i v e t i s s u e b e d .
S T E P 8 — C l o s e t h e w o u n d a n d a d e q u a t e l y i m o b i l i s e t h e p a t i e n t l i m b w i t h p l a s t e r o f P a r i s f o r 3 0 t o 4 0 d a y s .
S T E P 9 — F o l l o w i n g t h i s , g e n t l y p r o g r e s s i v e a n d c l o s e l y s u p e r v i s e d p h y -s i o t h e r a p y i-s r e c o m m e n d e d .
This modification of nerve suture technique is being used now in
cli-nical series. It will most certainly improve the motor and sensory
rehabi-litation of long-term post-traumatic nerve injuries because of the following:
(i) — Distal nerve segments completely separated from the proximal stump,
by complete transection, for a long time (one or more years), present
nor-mal nerve fibers (Erhart et a l .
2-
3»
4.
5.
6.
8.
9.
1 0.
1 2) , (ii) — These fibers may
repopulate long-time denervated and atrophic skeletal muscle (Erhart et al.
9) .
(iii) — Long-time denervated distal bellies of the biventer cervicis muscle
of the chick, when properly reoperated by cross-grafting suture with the
normal contralateral muscle, lost their atrophic appearance and showed to be
successfully recovered in about thirty days (Erhart et a l .
9) . (iiii) —
Mi-crosurgical nerve sutures when properly performed immediately after the
nerve transection, may prevent the total Wallerian degeneration that
nor-mally occurs in the distal nerve segment. This last statement is based on
experimental evidences reported in a previous paper (Erhart et a l .
1 2) from
which two schematic drawings are here reproduced (Figs. 2 and 3).
Finally, the clinical results obtained in primary sutures, performed
follo-wing the main steps of the above described technique, are being very
encouraging. In forthcoming papers these results shall be presented.
R E S U M O
Neurorrafias com técnica microcirúrgica permitem melhor reabilitação
e podem evitar a degeneração walleriana
ocorre no segmento distal ΰ transecção. Os resultados obtidos em pacientes
que estão sendo operados c o m esta técnica são encorajadores; serão assunto
de futuras publicaçυes.
R E F E R E N C E S
1 . A L M G R E N , K . G . — R e v a s c u l a r i z a t i o n o f f r e e p e r i p h e r a l n e r v e g r a f t s . A c t a O r t h o p a e d i c a S c a n d i n a v i c a , S u p p l e m e n t u m 1 5 4 , 1 9 7 4 .
2 . E R H A R T , E . A . & E R H A R T , M . B . — N o r m a l a x i s c y l i n d e r s i n t h e d i s t a l s e g m e n t o f n e r v e s c o m p l e t e l y s e p a r a t e d f r o m t h e p r o x i m a l s t u m p f o r u p t o 24 y e a r s . A n a t . R e c . 136 ( A b s t r a c t s ) : 1 8 9 , 1 9 6 0 .
3 . E R H A R T , E . A . — N o r m a l n e r v e f i b e r s in t h e d i s t a l s e g m e n t o f n e r v e s c o m p l e t e l y s e p a r a t e d f r o m t h e p r o x i m a l s t u m p f o r m o r e t h a n s i x m o n t h s . A r q . N e u r o P s i q u i a t . ( S ã o P a u l o ) 2 0 : 2 8 9 , 1 9 6 2 .
4 . E R H A R T , E . A . & R E Z Z E , C . J. — N e r v e f i b e r s in i s o l a t e d s e g m e n t s o f d o g u l n a r n e r v e s a f t e r c o m p l e t e b r a c h i a l p l e x o t o m y a n d p e r i a x i l a r a r t e r y s y m -p a t h e c t o m y . A r q . N e u r o P s i q u i a t . ( S ã o P a u l o ) 2 3 : 8 2 , 1 9 6 5 .
5 . E R H A R T , E . A . & R E Z Z E , C . J. — T h e n e u r o m a l i k e s t r u c t u r e o f l o n g t i m e s e v e r e d a n d i s o l a t e d n e r v e s t u m p s . A r q . N e u r o P s i q u i a t . ( S ã o P a u l o ) 2 3 : 9 1 , 1 9 6 5 .
6 . E R H A R T , E . A . & R E Z Z E , C . J. — E x p e r i m e n t a l d a t a a n d p r a c t i c a l r e s u l t s w h i c h m o d i f y t h e p r e s e n t c o n c e p t s o f p e r i p h e r a l n e r v e f i b e r d e g e n e r a t i o n a n d r e g e n e r a t i o n . P r o c . V I n t e r n a t i o n a l C o n g r e s s o f N e u r o p a t h o l o g y , Z u r i c h , p p . 8 6 4 , 1 9 6 5 . P u b l i s h e d b y E x c e r p t a M e d i c a .
7 . E R H A R T , E . A . & R E Z Z E , C. J. — E f f e c t s o f e x p e r i m e n t a l d e v a s c u l a r i z a t i o n o n p e r i p h e r a l n e r v e s . A r q . N e u r o P s i q u i a t . ( S ã o P a u l o ) 2 4 : 7 , 1 9 6 6 .
8 . E R H A R T , E . A . & R E Z Z E , C. J. — F u r t h e r d i s c u s s i o n o n t h e " n e w g r o w i n g " n e r v e f i b e r s w h i c h r e p o p u l a t e t h e d i s t a l s e g m e n t o f n e r v e s c o m p l e t e l y s e p a r a t e d f r o m t h e p r o x i m a l s t u m p f o r m o r e t h a n s i x m o n t h s . A r q . N e u r o P s i -q u i a t . ( S ã o P a u l o ) 2 4 : 9 1 , 1 9 6 6 .
9 . E R H A R T , E . A . ; R E Z Z E , C . J. & B I A Z O T T O , W . — T h e e c t o p i c n e w l y f o r m e d n e r v e f i b e r s w h i c h r e p o p u l a t e t h e l o n g t i m e d e n e r v a t e d a n d a t r o p h i c c h i c k s k e l e t a l m u s c l e . A r q . N e u r o P s i q u i a t . ( S ã o P a u l o ) 2 6 : 1 8 7 , 1 9 6 8 .
1 0 . E R H A R T , E . A . ; B E R A R D I , A . C ; F U R L A N I , J.; B Ι R Z I N , F . & B I A Z O T T O , W . — N e w e x p e r i m e n t a l d a t a o n n e r v e c o n d u c t i o n p a t t e r n s i n v i v o , d e t e r m i n e d e l e c t r o n i c a l l y , f o r a n a l y s i n g t h e p e r i p h e r a l n e r v e s b e h a v i o r d u r i n g d e g e n e r a t i o n a n d r e g e n e r a t i o n . A p r e s e n t a d o n o I X I n t e r n a t i o n a l C o n g r e s s o f A n a -t o m i s -t s , L e n i n g r a d , R u s s i a , 1 9 7 0 . A r q . N e u r o P s i q u i a -t . ( S ã o P a u l o ) 2 8 : 1 1 8 , 1 9 7 0 .
1 1 . E R H A R T , E . A . — M o d i f i e d n e r v e s u t u r e t e c h n i q u e i m p r o v i n g r e h a b i l i t a t i o n o f r e c e n t a n d l o n g t e r m p o s t t r a u m a t i c n e r v e i n j u r i e s . A p r e s e n t a d o n o I I I P a n A m e r i c a n C o n g r e s s o f A n a t o m y , N e w O r l e a n s , U . S . A . , 1 9 7 2 .
1 2 . E R H A R T , E . A . ; F E R R E I R A , M . C ; M A R C H E S E , A . T . ; A Z Z E , R . & P U E C H ¬ L E A O , P . — S u t u r a s d e n e r v o s c o m t é c n i c a m i c r o c i r ٥ r g i c a p o d e m e v i t a r t o t a l d e g e n e r a ç ã o W a l l e r i a n a . R e v . A s s . M é d i c a B r a s i l e i r a . ( A c e i t o p a r a p u -b l i c a ç ã o e m 1 2 d e s e t e m -b r o d e 1 9 7 4 ) .
1 3 . F E R R E I R A , M . C ; E R H A R T , E . A . ; M A R C H E S E , A . T . ; A Z Z E , R . & C O S T A , R . C . — M i c r o c i r u r g i a d e n e r v o s : e s t u d o e x p e r i m e n t a l . A p r e s e n t a d o n o X I I I C o n g r e s s o L a t i n o A m e r i c a n o d e C i r u r g i a P l á s t i c a , C a r a c a s , V e n e z u e l a , 1 9 7 4 . 1 4 . F E R R E I R A , M . C ; E R H A R T , E . A . ; M A R C H E S E , A . T . & A Z Z E , R . —
M i c r o c i r u r g i a d e n e r v o s p e r i f é r i c o s . R e v . P a u l . M e d . 8 4 : 5 2 , 1 9 7 4 .
1 5 . F E R R E I R A , M . C ; A Z Z E , R . & B A R R O S A B R E U , L . — E n x e r t o i n t e r f u n i -c u l a r d e n e r v o s -c o m t é -c n i -c a m i -c r o -c i r ٥ r g i -c a . R e v . P a u l . M e d . ( e m p u b l i -c a ç ã o ) . 1 6 . L U N D B O R G , G . — I s c h e m i c n e r v e i n j u r y . S c a n d i n a v i a n J o u r . P l a s t i c a n d
1 7 . M I L L E S I , H . ; M E I S S L , G . & B E R G E R , U . A . — T h e i n e r f a s c i c u l a r n e r v e g r a f t i n g o f t h e m e d i a n a n d u l n a r n e r v e s . J o u r . B o n e a n d J o i n t S u r g . 5 4 A : 1 2 7 , 1 9 7 2 .
1 8 . S U N D E R L A N D , S. — N e r v e s a n d N e r v e I n j u r i e s . L i v i n g s t o n e L t d . L o n d o n , 1 9 6 8 .
1 9 . S u r g i c a l C l i n i c s o f N o r t h A m e r i c a — S y m p o s i u m o n o p e r a t i v e n e r v e i n j u r i e s a n d t h e i r r e p a i r . 5 2 , n u m b e r 5, O c t o b e r 1 9 7 2 .
Laboratório de Microcirurgia Experimental — Faculdade de Medicina da
