~
,. ti~:
SÃO PAULO
.~...~.DICAL
Lauro Barros de Abreu
Upper extrem ity nerve lesions
(diagnosis, indications, surgi cal techniques)
Ulliversity of São Paulo Medicai School - São Paulo, Brazil
O b je ctive : R e visio n a n d q u e stio n in g o f o rth o d o x p rin cip ie s re g a rd in g th e co n d u ctio n o f n e rve im p u lse . D e sig n : R e tro sp e ctive stu d y w ith clin ica i a n a lysis o f re su lts. S ite : H o sp ita l d a s C lin ica s (H C F M S P ), p u b lic u n ive rsity in stitu tio n w ith re se a rch p ro g ra m s a n d te rtia ry a tte n tio n to h e a lth . G ro u p m e m b e rs: A u th o r a n d a te a m o f re sid e n ts a n d tra in e e s. O p e ra tio n : D ire ct su tu re o f n e rvo u s stu m p s u tilizin g a u xilia ry te ch n ica l p ro ce d u re s:- jo in t-fle xio n , n e rve tra n sp o sitio n , te n d o n tra n sp la n ts, b o n e sh o rte n in g . M e a su re m e n t: C lin ica i e va lu a tio n a n d o b je ctive te sts fo r ta ctile a n d ste re o g n o stic fu n ctio n re co ve ry (W e b e rT e st). R e su lts: V a ria b le , d e p e n d in g o n p re o p e ra tive co n d itio n s: - typ e o f le sio n , tim e e la p se d sin ce in ju ry. C o n clu sio n s: N e u ro rrh a p h y sh o u ld b e th e p ro ce d u re o f ch o ice e ve n fo r lo n g te rm le sio n s, a lth o u g h th e e xp e cte d re su lts m a y b e le ss fa vo u ra b le . P e rio d ica l e va lu a tio n fro m 2 4 h s. p o sto p e ra tive , ch e ckin g fo r e a rly u n d e fin e d sig n a ls o f n e rvo u s fu n ctio n re co ve ry. A sso cia tio n o f sp e cific d ru g s fo r ch e m ica l b io p h ysics o f th e n e rve .
U N IT E R M S : P e rip h e ra l n e rve s. A ccid e n ts. In ju rie s. C o m p re ssio n syn d ro m e s. H a n d su rg e ry.
IN T R O D U C T IO N
U
E pidem iologicalpper extrem ity studies of these accidents,nerves are often injured.their effects on m anual labor and the inherent socio-econom ical and psychological aspects, are very im portante1T he m echanization of m odern life both in the cities and in rural areas, the use of m achinery and tools at hom e, in the factories and in the fields, the sophistication of m odern transport and the invasion of hom es by electrieal and electronic appliances have contributed in"a great scale to the increase in the accident rate.
A high price is being paid for this i~provem ent in the standard of li ving
Address for correspondence:
Lauro Barros de Abreu
Alameda Lorena,
9 6 5 -"Apto 131São Paulo/SP - Brasil
- CEP 01424-001
Preventive m easures and cam paigns, especially at w ork, have slightly im proved the situation, although the "Z ero accident" slogan still rem ains utopic.
T he only alternative, therefore, is the im provem ent of treatm ent procedures in order to elim inate or at least m inim ize long term effects.
Peripheral nerve surgery has been practiced for nearly a century but only during the last fifty years has there been a m ajor developm ent in this branch of surgery.
Paradoxically, the great contributors to this developm ent have been the w ars.
Soon after the end of W orld W ar 11, the return to the U SA of "avalanches of injured and crippled soldiers", in the crude but justified w ords of B unnell, forced G eneral N orm an T . K irk., at the tim e C hief of the H ealth C are Services of the A rm ed Forces, to request em ergency m easures to tackle the problem .
N ine special centres w ere set up to handle these cases. In 1946, specialized surgeons located in these centres, under the leadership of B unnell, founded the A m erican Society for H and Surgery. Sim ilar organizations w ere quickly
1496
fo u n d e d in o th e r c o u n trie s a n d H a n d S u rg e ry b e e a m e a
s p e c ia liz e d b ra n c h o f m e d ic in e th ro u g h o u t th e w o rld .
T h e B ra z ilia n S o c ie ty fo r H a n d S u rg e ry w a s fo u n d e d
o n J u n e 1 7 th , 1 9 5 9 .
H IS T O L O G Y
2 ,3!h e n e rv e is fo rm e d b y n e u ro n s a n d its " a x o n s (a x o
-c y lin d e rs , n e u ro fib rile s o r n e rv e fib e rs ) (F ig . 1 , 2 ).
S o m e n e rv e fib e rs a re c o v e re d b y a w h itis h fa tty
s h e a th , th e m y e lin (m y e lin ic o r m e d u lla ry fib e rs ). O th e rs
a re d e v o id o f th is s h e a th (u n m y e lin a te d fib e rs ).
T h e m y e lin s h e a th h a s m in u te g a p s in its d ia m e te r
-th e n o d e s o f R a n v ie r (F ig . 1 , 2 ).
T h e m y e lin s h e a th is c o v e re d b y a n o th e r s h e a th (th e
n e u rile m a o r S c h w a n n s h e a th ) w ith its n u c le i (F ig . 1 , 2 ).
N e u ro fib rile s fo rm n e rv o u s b u n d le s (fu n ic u li), b o u n d
in s i d e th e c o n n e c tiv e tis s u e (e n d o n e u riu m ), s e p a ra te d fro m
e a c h o th e r b y th e p e rin e u riu m . T h e w h o le n e rv e is
s u rro u n d e d b y a fib ro u s s h e a th , th e e p in e u riu m (F ig . 2 ).
A N A T O M Y A N D P H Y S IO P A T H O L O G Y
F ig u r e 2 - N e r v e - C o u r te s y G o ffi, F :S . 1 5 N e rv e s a re c y lin d ric a l w h itis h s tru c tu re s , v a ria b le in
s iz e a n d le n g th , th ro u g h w h ic h n e rv o u s im p u ls e s flo w to
th e m u s c u la r, g la n d u la r a n d o th e r n e rv o u s c e lls .
In th e u p p e r e x tre m itie s th e n e rv e s c o n n e c t th e c e n tra l
n e rv o u s s y s te m to th e d is ta I p a rts (h a n d s ), th ro u g h a ffe re n t
1 .e p in e r v e ( e p in e u r u m ) 2 . e n d o n e r v e ( e n d o n e u r u m ) 3 . p e r in e r v e ( p e r in e u r u m )
4 .a x o n
5 .m y e lin s h e a th 6 . S c h w a n n s h e a th 7 . S c h w a n n n u c le i
8 . R a n v ie r ' n o d e
F ig u r e 1 - N e u r o n - C o u r te s y G o ffi, F :S .1 5
1 .n e r v o u s c e l! 2 . a x o n
3 . m y e lin s h e a th 4 . S c h w a n 'n s h e a th
5 .S c h w a n n n u c le i 6 . R a n v ie r 's n o d e 7 . d e n tr its
1 4 9 7
a n d e f f e r e n t s tim u la tio n , f r o m th e s e n s o r y o r g a n s to th e
c o r te x . F o r th is p u r p o s e th e s e n e r v e s a r e m ix e d , w ith m o to r
a n d s e n s itiv e f ib e r s ' in v a r ia b le p r o p o r tio n s , a n d a ls o w ith
a v a r y in g to p o g r a p h y a lo n g its c o u r s e . 4 ,5
T r a u m a tic le s io n s to th e n e r v e s o f th e w r is t a r e
v e r y f r e q u e n t a n d a r e u s u a lly a s s o c ia te d w ith v a s c u la r
le s io n s .6 ,7
T h e tr a u m a m a y b e s lo w a n d p r o g r e s s iv e , c o n s ta n t
o r in te r m itte n t, c a u s in g tr a u m a tic n e u r itis .8 - 1 O T h e m o s t
f r e q u e n t a r e th e c a r p a l tu n n e l s y n d r o m e ( m e d ia n n e r v e ) ,1 1 - 1 4
th e u ln a r n e u r itis in th e e p itr o c h le o - o le c r a n e a n g r o o v e
g e n e r a lly in th e v a lg u s e lb o w l5 a n d o th e r s ite s .
C o m p r e s s io n m a y b e in s id e th e n e r v e ( in te r s titia l
n e u r itis ) , a s in th e H a n s e n d is e a s e 1 6 ,in th e D é jé r in e - S o tta s
d is e a s e l7 a n d m a n y o th e r s .
T h e b r a c h ia l p le x u s , lo c a te d in th e la te r a l s id e o f th e
n e c k a n d s u p r a - c la v ic u la r r e g io n , is f o r m e d b y r o o ts f r o m
th e c e r v ix ( C 5 ) to th e f ir s t d o r s a l ( T I ) .4 ,9
T r u n k s a n d n e r v e s o f th e b r a c h ia l p le x u s o n its w a y
d o w n a n d o u tw a r d s to th e d is ta I p a r t'o f th e lim b f o r m a
n e t w ith a n X - lik e f ig u r e , w ith its c e n te r u n d e r th e
c la v ic le , in th e s o - c a lle d c o s to - c la v ic u la r o r
c e r v ic o a x illia r y c a n a l, th e is th m u s o f th e b r a c h ia l p le x u s .
I n a d d itio n to th e n e r v e s , th e s u b c la v e a n a r te r y a n d v e in
, r u n th r o u g h th is c a n a l.
T h is n a r r o w p a s s a g e is p a r t o f th e m o b ile o s te o
-a r tic u l-a r c o m p o u n d o f th e s h o u ld e r b la d e a n d f ir s t r ib .
U n d e r c e r ta in c ir c u m s ta n c e s , w ith a lte r a tlo n s o f th e
p o s itio n o f c e r ta in c o m p o n e n ts , th is p a s s a g e b e c o m e s e v e n
n a r r o w e r u n d e r s tr a in c r e a tin g a c r itic a I s itu a tio n in its
in n e r s tr u c tu r e .
A b n o r m a l s tr u c tu r e s ( c e r v ic a l r ib s ) 1 8 a r e s o m e tim e s
p r e s e n t in th is r e g io n , m e g a - a p o p h y s is , lig a m e n ts , m u s c le s ,
f ib r o u s b a n d s a n d /o r s p o n d y lo s is ,1 9 d is k 'le s io n s a n d o th e r s
w h ic h m a y c o m p r e s s th e b r a c h ia l p le x u s c a u s in g c e r v ic o
-b r a c h ia lg ie s a n d /o r v a s c u la r p r o b le m s .
B r a c h ia l p le x u s m a y b e p u s h e d d o w n w a r d s b y
e x te r n a I tr a c tio n , s u c h a s a b a d p o s tu r e a n d /o r th e c a r r y in g
o f h e a v y lo a d s .
A g e , d u e to th e w e a k e n in g o f th e b o d y s tr u c tu r e s ,
m a y c a u s e th e s h o u ld e r to f a lI . I n a s im ila r m a n n e r ,
th e f la c c id ity o f th e c h e s t a n d a b d o m in a l m u s c le s ,
o b e s ity o r th e - in c r e a s e in th e w e ig h t o f th e a b d o m in a l
a n d p e lv ic tu m o r s a n d .p r e g n a n c y a r e f r e q u e n t in te r n a I
f a c to r s .
I n s o m e c a s e s th e p le x u s le s io n m a y b e ia tr o g e n ic ,
d u e to a w k w a r d o b s te tr ic a l m a n o e u v r e s w h e n th e h e a d o f
th e f o e tu s is p u lle d d o w n w a r d s d u r in g c h ild b ir th
( o b s te tr ic a l p a r a ly s is ) .2 0
G u n s h o t o r s ta b w o u n d s o f th e p le x u s p r e s e n t n o
m a jo r p r o b le m , e x c e p t if e x te n s iv e a n d in a s ite o f d if f ic u lt
a ç c e s s .
H o w e v e r , le s io n s d u e to .v io le n t tr a c tio n , s u c h a s
th o s e c a u s e d b y f a lls o n th e h e a d w ith tr u n k r o ta tio n
( m o to r c y c le a c c id e n ts ) , m a y te p r e s e n t a s e r io u s p r o b le m .
T h e tr a c tio n , s tr a in , te a r in g a n d a v u ls io n o f th e r o o ts
r e q u ir e v e r y c o m p le x p r o c e d u r e s .2 1
D E G E N E R A T IO N
- R E G E N E R A T IO N
F o llo w in g in ju r y , th e p r o c e s s o f d e g e n e r a tio n in
th e d is ta I s tu m p ( w a lle r ia n d e g e n e r a tio n ) a n d r e g e n e r a tio n
in th e p r o x im a l s tu m p b e g in s .2
B e tw e e n th e n e r v e s tu m p s s c a r tis s u e s a r e f o r m e d w h ic h
m a k e r e p a ir in c o m p le te a n d d is o r g a n iz e d . I n th e p r o x im a l
s tu m p a n in tu m e s c e n c e is f o r m e d , a n e u r o m a . I n th e d is ta i
s tu m p a la r g e r o n e is f o r m e d th e g lio m a o r n e u r o g lio m a .
O c c a s io n a lly b e tw e e n th e tw o s tu m p s s o m e a x o n s
a r e a b le to g e t th r o u g h th e s c a r tis s u e b a r r ie r a n d a p a r tia l
r e p a ir o f th e n e r v e o c c u r s .
A x o n s r e g e n e r a tio n ta k e s p la c e d is ta lw a r d s , q u ic k e r
in th e f ir s t th r e e w e e k s ( 3 to 5 m illim e tr e s /d a y ) s lo w in g
d o w n la te r to 1m illim e tr e /d a y , g iv in g a n a v e r a g e r e p a ir
r a te o f 1to 2 m illim e tr e s /d a y .
C L A S S IF IC A T IO N
O F L E S IO N S
I n te r r u p tio n , p h y s io lo g ic b lo c k , c o n c u s s io n ,
c o n tu s io n , c o m p r e s s io n a n d o th e r d e n o m in a tio n s w e r e
u s e d to d e s c r ib e le s io n s to th e n e r v e s , c r e a tin g c o n f u s io n
a n d c o m p lic a tin g tr e a tm e n t p r o c e d u r e s .2 2 '
A s th e n e r v e s a r e c o m p r is e d o f m a n y e le m e n ts , e a c h
w ith its o w n s p e c if ic f u n c tio n , a c la s s if ic a tio n b e c a m e
n e c e s s a r y to o r g a n iz e th e le s io n s a c c o r d in g to th e ir e f f e c ts
o n th e m a in s tr u c tu r e s .
T h e c la s s if ic a tio n p r o p o s e d b y S e d d o n w ith th e o b je c tiv e
G r e e k te r m in o lo g y s u g g e s te d b y C o h e n is th e f o llo w in g :
• N e u r o tm e s is
• A x o n o tm e s is
• A p r a x ia .
S o m e a u th o r s in c lu d e N e u r o s te n o s is w h e n th e r e is
in te r n a I a x o n c o m p r e s s io n . ( F ig . 3 ) 1 5 ,2 3 .
N e u r o tm e s is m e a n s c o m p le te d iv is io n ( n e r v e
tr a n s s e c tio n ) .
A x o n o tm e s is m e a n s d iv is io n ó f th e a x o n s , w ith n o
d a m a g e to th e S c h w a n n s h e a th .
A p r a x ia ( n e u r a p r a x ia ) is ju s t a f u n c tio n a lle s io n .
1498
Á~praxia
8~Neurostenosis
G-Axonotnesis
d-Neurotmesis
A
F ig u r e 3 - C la s s ific a tio n o f le s io n s - C o u r te s y G o ffi, F .S .1 5
D IA G N O S IS
D ia g n o s is m u s t b e th e re s u lt o f a lo n g a n d th o ro u g h
c lin ic a I e x a m in a tio n .2 3 L a b o ra to ry a n d o th e r te s ts , s u c h a s
X -ra y , e le c tro m y o g ra p h y , e le c tro -n e u ro m y o g ra p h y ,
c o m p u ta riz e d to m o g ra p h y , m a g n e tic re s o n a n c e a n d o th e rs
m a y b e re q u e s te d la te r, if n e c e s s a ry .
O b v io u s le s io n s c o n s titu te n o p ro b le m . B u t th e
a s s o c ia tio n fo r in s ta n c e , o f c o n g e n ita l a n o m a lie s in h a n d s 4
o r fo re a rm s w ith c e rv ic a lle s io n s 1 8m a y p re c lu d e d ia g n o s is .1 9
F u n c tio n a l a n d s tru c tu ra l h ig h c o m p re s s io n s ,
p e rm a n e n t o r in te rm itte n t, m a y m im ic le s io n s to th e e lb o w ,
fo re a rm a n d o h a n d ; w h e re a s d is ta lle s io n s s u c h a s c a rp a l
tu n n e l o r G u y o n c a n a l s y n d ro m e s m a y c a u s e d a m a g e to
th e e lb o w ,' a rm a n d s h o u ld e r.2 4
In o rd e r to a v o id m is ta k e s a n d c o n s e q u e n tly w ro n g
tre a tm e n t in d ic a tio n s , th e d ia g n o s is s h o u ld b e a s p re c is e
a s p o s s ib le .2 5 , 2 6
A p ro p e rly d ire c te d a n a m n e s is a n d a c a re fu l
a s s e s s m e n t o fth e p a tie n t's g e n e ra l c o n d itio n a n d c o m p la in ts ,
is v e ry im p o rta n te . W e s h o u ld n o t fo rg e t .lh e p a tie n t's
p s y c h o lo g ic a l p ro file , th e ,b a s is o f a ll h u m a n b e h a v io u r.
T R E A T M E N T
IN D IC A T IO N S
In th e tre a m e n t o f n e rv e le s io n s v a rio u s te c h n iq u e s a n d
p ro c e d u re s , e ith e r a lo n e o r c o m b in e d , m u s t b e c o n s id e re d .2 7 ,2 8
T h e g e n e ra l tre a tm e n t p la n w ill d e p e n d o n th e d ia g n o s is ,
w h ic h , a s a lre a d y m e n tio n e d , is n o t a lw a y s e a s y ~
A x o n o tm e s is a n d n e u ra p ra x ia d o n o t re q u ire s u rg ic a l
tre a tm e n t a s th e re is ~ o d a m a g e t,o th e S c h w a n n s h e a th .
H o w e v e r, n e u ro tm e s is , w ith d a m a g e d s tiu c tu re s ,
re q u ire s s u rg ic a l tre a tm e n t.
A c o n s e rv a tiv e tre a tm e n t , u tiliz in g p h y s ic a l m e a n s
a n d te c h n ic a l s u p p o rt m a y p re c e d e , c o m p le m e n t o r e v e n
s u b s titu te s u rg ic a l tre a tm e n t..
A n e x a m p le o f th is ty p e o f c o n d u c t is o b s te tric p a ls y ,
c a u s e d b y tra c tio n o f th e ro o ts w ith v a ry in g d e g re e s o f
in te n s ity d e p e n d in g o n th e e x te n t o f th e tra u m a . T h e b e s t
in itia l a p p ro a c h s h o u ld b e th e c o n s e rv a tiv e o n e , w ith
a d e q u a te p o s itio n in g (e le v a te d h a n d , a ~ d u c tio n o f th e
s h o u ld e r a n d e x te rn a I ro ta tio n o f th e a rm ). In th e m a jo rity
o f c a s e s th e re is a s p o n ta n e o u s re c o v e ry ; o n ly w h e n th is
d o e s n o t o c c u r s h o u ld o th e r tre a tm e n t m e th o d s b e
c o n s id e re d .2 9 ,3 0
T h e c o m p re s s io n o f a lim b w ith a n o n -p n e u m a tic
to u m iq u e t c a n p ro v o k e p a ra ly s is , i.e . a n a p ra x ia (te m p o ra ry
le s io n ).3 1
W h e n e v e r th e re is a v io le n t lo c a liz e d c o m p re s s io n
a n a x o n o tm e s is le s io n m a y o c c u r. R e c o v e ry , in th e s e
c a s e s , is s lo w .
S U R G IC A L T IM IN G
P rim a ry re p a ir o f th e n e rv e is th e id e a l
tre a tm e n t,3 2 -3 4 b u t c e rta in c o n d itio n s m u s t b e m e t; it
m u s t b e d o n e im m e d ia te ly .
In th e p ro m p t tre a tm e n t o f p a tie n ts w ith o p e n n e rv e
le s io n s w e m u s t c o n s id e ~ th e a s p e c ts o f e a c h c a s e ,
e s p e c ia lly w ith re fe re n c e to th e tim e w h ic h h a s e la p s e d
s in c e th e in ju ry o c c u re d .
P rim a ry re p a ir is th a t d o n e s o o n a fte r th e a c c id e n t,
w ith in th e firs t fe w h o u rs .. A ty p ic a l e x a m p le is a n
'1 4 9 9
\
ia tr o g e n ic le s io n c a u s e d b y th e s u r g e o n d u r in g a n
o p e r a tio n , w h e r e th e c o n d itio n s a r e id e a l.
A s a s a f e ty m e a s u r e w e s h o u ld c o n s id e r th a t a
p r im a r y r e p a ir is p e r m is s ib le w h e n :
1 . th e w o u n d is f r e s h , c le a n a n d r e g u la r ;
2 . th e s u r g e o n is w e ll a c q u a in te d w ith th e a n a to m y
o f th e r e g io n , is w e ll tr a in e d a n d in g o o d p h y s ic a l
a n d p s y c h o lo g ic a l c o n d itio n s to p e r f o r m a p o s s ib ly
lo n g a n d tir in g o p e r a tio n ;
3 . a d e q u a te in s tr u m e n ts a n d a ll n e c e s s a r y e q u ip m e n t
a r e a v a ila b le ;
4 . th e o p e r a tin g th e a tr e is a d e q u a te , w e ll e q u ip p e d
a n d q u a lif ie d s u r g ic a l, g e n e r a l a n a e s th e s ü l a n d
n u r s in g te a m s a r e a v a ila b le ;
5 . th e p a tie n t is p r e p a r e d f o r a lo n g s u r g e r y u n d e r .
g e n e r a l a n a e s th e s ia ;
6 . p r im a r y r e p a ir is o b v io u s ly o b lig a to r y w h e n th e
n e r v e is c u t a c c id e n ta lly b y th e s u r g e o n d u r in g a n
o p e r a tio n . A ll c o n d itio n s a r e p r e s e n t a n d th e e r r o r
h a s to b e c o r r e c te d a t o n c e .
T h e s e a r e th e m a in r e q u ir e m e n ts to a v o id u n f o r tu n a te
m is ta k e s , n o t u n c o m m o n e v e n in w e ll d e v e lo p e d c o u n tr ie s .
T h e w e ll k n o w n " c la s s ic a l s u tu r e " 3 2 o r th e " m id n ig h t
s u tu r e " is o n e o f th e s e m is ta k e s 3 3 ( F ig . 4 ) . T h e s e s e r io u s
m is ta k e s u s u a lly o c c u r a t th e e n d o f a d u ty s tr e tc h , c a u s e d
b y tir e d a n d u n s k ille d s u r g e o n s .
P r im a r y d e la y e d s u tu r e ( th e " U r g e n c e d e f e r r é e " o f
th e F r e n c h ) is th e r e p a ir p e r f o r m e d a f te r th e tim e lim it ( 6
h o u r s ) , o w in g to u s u a l d if f ic u ltie s , s u c h a s : u n a v a ila b le
f u ll s ta f f , ill- p r e p a r e d p a tie n t, p a tie n ts w ith m u ltip le in ju r ie s
a n d o th e r s . T h is d e la y e d tr e a tm e n t is ju s tif ie d in a s m u c h
a s it a llo w s th e c o r r e c tio n o f c e r ta in c o n d itio n s th u s
g u a r a n te e in g th e s a f e ty o f th e p a tie n t.
T h e th ir d w e e k , w ith th e s k in in g o o d c o n d itio n s , w h e n
a x o n r e g e n e r a tio n r a te is h ig h , is th e a p p r o p r ia te tim e f o r
r e p a r a to r y s u r g e r y . T h is is th e e a r ly s e c o n d a r y r e p a ir .9 . 2 4 .3 2 - 3 4
L o n g d e la y e d r e p a ir o f n e r v e le s io n s , s o m e tim e s m o n th s
o r y e a r s la te r , s h o u ld n o t b e c o n d e m n e d .9 . 3 5 - 3 8
A lth o u g h e x p e c te d r e s u lts , d e p e n d in g o n th e tim e
e la p s e d , m a y b e p o o r , th e im p r o v e m e n t o f lo c a l tr o p h ic .
c o n d itio n s , w ith h e a lin g o f u lc e r s , r e d u c tio n o f e d e m a a n d
th e e s ta b lis h m e n t o f s lig h t p r o te c ti v e s e n s a tio n s , ju s tif ie s
th is p r o c e d u r e w h ic h is g r e a tly b e n e f ic ia I to th e p a tie n t
( F ig . 5 , 6 , 7 , 8 , 9 , 1 0 ) .
S U R G I C A L N E R V E R E P A I R T E C H N I Q U E S
N e u r o ly s is is th e f r e e in g o f th e n e r v e . I t c a n b e
e x te r n a I , a s in th e c a s e o f s c a r c o m p r e s s io n o r b Q n e c a llo u s .
T h e c o m p r e s s io n f a c to r m a y b e in ~ id e th e n e r v e , a s
in in te r s tic ia l n e u r itis o r le s io n s in c o n tin u ity . in th e s e c a s e s
in te r n a I n e u r o ly s is is o b ta in e d b y " c o m b in g " th e n e r v e
f a s c ic u li o r b y e x c is in g f ib r o u s tis s u e th r o u g h p a r tia l
e p in e u r iu m r e s e c tio n ( F ig .ll) .
F ig u r e 4 - M e d ia n n e r v e " c r o s s - s u t u r e " t o F le x o r C a r p i R a d ia lis .
in t e n s iv e f ib r o s is , a d h e r e n c e t o f in g e r f le x o r t e n d o n s . S M K
F ig u r e 5 - S c a r s a n d o b v io u s c o n v e x it y o n t h e in s id e o f t h e w r is t ( t e n d e r n e u r o m a ) , t h e n a r a m y o t r o p h y , a n e s t h e s ia in t h e m e d ia m n e r v e a r e a . I n ju r e d in 1 9 4 4 , e x a m in e d o n J u n e , 8 , 1 9 5 9 ( 1 5 y e a r s
a n d 4 m o n t h s la t e r ) .
1 5 0 0
F ig u re 6 - A c tiv e fle x io n o f th u m b a n d fin g e rs
F ig u re 7 - L a rg e n e u ro m a , a b o u t 5 c e n tim e n te rs in le n g th .
F ig u re 8 - E x c is io n o f n e u ro m a , d is p la c e m e n t o f th e n e rv o u s s tu m p s a n d c o n v e n tio n a l e p in e u ra l s u tu re , a fte r e lb o w a n d w ris t fle x io n o f 9 0Q
• O p e ra te d o n J u n e 2 7 , 1 9 5 9 , (1 5 y e a rs a n d 4 m o n th s a fte r in ju ry ).
I n th e n e r v e tr a n s s e c tio n , th e s u tu r e
( n e u r o r r h a p h y ) u s in g th e c o n v e n tio n a l a p p r o a c h , c o n s is ts
o f th e lo o s e n in g o f th e ' s tu m p s a n d s u tu r e o f th e
e p in e u r iu m3 9• T h e n o r m a l to p o g r a p h y o f th e n e r v e s h o u ld
b e m a in ta in e d a s f a r a s p o s s ib le .4
,2 2 A n o n - te n s io n s u tu r e s h o u ld b e d o n e in th e e p in e u r iu m , w ith s e p a r a te s titc h e s ,
F ig u re 9 - P ro te c tiv e ta c tile s e n s a tio n in m e d ia n n e rv e a re a , w ith s lig h t a m y o tro p h y o f s h o rt th u m b a b d u c to r. E x a m in e d o n J u ly 7 , 1 9 6 7 , a p p ro x im a te ly 1 0 y e a rs a fte r n e rv e s u tu re .
F ig u re 1 0 - S tro n g fle x io n o f th u m b .
E x a m in e d o n J u ly 7 , 1 9 6 9 , m o re th a n 1 0 y e a rs a fte r o p e ra tio n .
F ig u re 1 1 - N e u ro ly s is te c h n iq u e s - C o u rte s y G o ffi,
~s.
1 5 A - L a te ra l e x c is io n o f in tra n e u ra l n e u ro m a .B - E x c is io n o f d e e p d iffu s e n e u ro m a
1 5 0 1
th u s a v o id in g fib ro s is b e tw e e n th e n e rv e s tu m p s (s o m e
a u th o rs d o n o t a g re e w ith th is p ro c e d u re ).4 0
T h e o b je c tiv e is to a llo w a w ra p p in g w h ic h m a y s e rv e
a s a g u id e to th e p ro g re s s io n o f th e a x o n s d u rin g
re g e n e ra tio n .
B e fo re p ro c e e d in g w ith th e n e u ro rrp h a p h y , th e s tu m p s
a re s e c tio n e d to a llo w s u tu re in h e a lth y tis s u e , th e a s p e c t
is s im ila r to a te le g ra p h ic c a b le , w lth m in im u m a lte ra tio n s '
in th e in te rn a I to p o g ra p h y o f th e n e rv e (F ig . 1 2 ).
/ ;"
/ / / I / .
Il;;:
F igure 12 - C hecking the extension of the neurom a - C ourtesy G offi, F .S .15
1 and 2 - fibrous tissue, few nervous fibers. 3 - "telegraphic cable" appearance, healthy nerve.
In th e c a s e o f n e u ro m a fu s ifo rm o r in tra n e u ra l, th e
re s e c tio n o f th e n e u ro m a is a ls o p e rfo rm e d , try in g to
m a in ta in a s m u c h a s p o s s ib le o f th e h e a lth y p a rt o f th e n e rv e .
T h e re s e c tio n o f la te ra l n e u ro m a m a y b e d o n e a p a rt
fro m th e n e u ro m a w ith s u tu re o n ly o f th e a re a o f th e le s io n .
T h e s u tu re th re a d s m a y b e o f v a rio u s ty p e s , b u t
s h o u ld b e in n o c u o u s , v e ry fin e , m o n o fila m e n ts a n d
m o u n te d o n c y lin d ric a l a tra u m a tic n e e d le s . T h e g ly c o lic
a c id th re a d s , 4 1 ,4 2n u m b e r 8 to 1 0 /0 , h a v e n o w s u b s titu te d
th e o ~ d m a te ria Is (s ilk , n y lo n , s te e l, ta n ta lu m a n d e v e n
h u m a n h a ir)5 (F ig . 1 3 ,1 4 ).
P o s s ib ly , in s te a d o f th e s u tu re o f th e e p in e u riu m , flX a tio n
o f th e s tu m p s m a y b e d o n e w ith a d h e s iv e s .4 3 -4 7
D e lic a te in s tru m e n ts a n d g e n tle m a n ip u la tio n o f th e
n e rv e s tu m p s a re o f g re a t im p o rta n c e . A tra u m a tic
te c h n iq u e , re fra in in g fro m n ip p in g th e n e rv e w ith fo rc e p s ,
is o n ly p e rm itte d o n n e u ro m a s to b e e x c is e d . T h e n e rv e
m a y , u n d e r c e rta in c irc u m s ta n c e s , b e g e n tly m a n ip u la te d
b y th e s u rg e o n 's fin g e rs (F ig . 1 5 ).
In O c to b e r 1 9 5 2 , a s s is tin g P u lv e rta ft in a n o p e ra tio n ,
w e d id fo r th e firs t tim e th a t w h ic h w e n o w d o o n a ro u tin e
b a s is : a d e lic a te m a s s a g e o n ~ s u tu re lin e o f th e n e rv e ,
w ith th e th u m b a n d in d e x fin g e rs , s im ila r to ro llin g a
c ig a re tte b e tw e e n th e fin g e rs . H e a p p ro v e d th e te c h n iq u e
a n d n a m e d it " A b re u 's m a n o e u v re " (F ig . 1 5 a , 1 5 b ).
N e rv e g ra fts a re u s e d to fillla rg e g a p s ,4 8 -5 0a llo w in g
a " n o n -te n s io n s u tu re " .
T h e s u tu re te c h n iq u e is th e s a m e a s th a t fo r
n e u ro rrh a p h y (F ig . 1 6 ).
W h e n n e rv e a n d g ra ft h a v e d iffe re n t d ia m e te rs , g ra fts
a re jo in e d in b u n d le s w ith s titc h e s - " c a b le g ra ft" . 9 ,4 9
In th e s e c a s e s , in s te a d o f s u tu " re w ith th re a d s ,
e s p e c ia lly in b ra c h ia l p le x u s le s io n s a n a d h e s iv e ' (fib rin e
o . ~'::::','':" ....::;:~
F igure 13 - E pineural conventional suture - C ourtesy G offi,F :S .1 5
A - support stitches C - rotation of the
nerve
B - positioning of the stum ps O - back suture
F igure 14 - C ourtesy G offi, F .S .1 5
A - lateral neurom a B - neurom a excision . C - partial suture of the nerve
1 5 0 2
S i m u l t a n e o u s m u s c l e o r m u s c u l o t e n d i n o u s t r a n s p l a n t s a r e s o u n d p r o c e d u r e s t o r e p l a c e o r
A L T E R N A T IV E
T E C H N IQ U E S
T h e t e c h n i q u e i s . v e r y d e l i c a t e , r e q u i r i n g t h e u s e
o f m a g n i f y i n g l e n s e s ( 2 ,6 x ) o r m i c r o s c o p e s ( 1 2 , 1 5 x ,
o r l e s s ) ( F i g .1 7 ) ..
S o m e t i m e s , p e d i c l e n e r v e g r a f t 5 7 ,5 8 m a y b e u s e d i n
t h e f o r e a r m , i n e s p e c i a l l y d i f f i c u l t c a s e s o f d o u b l e i n j u r y (
t o m e d i a n a n d u l n a r n e r v e .
N e u r o t o m y a n d n e u r e c t o m y a r e n o t n e r v e r e p a i r
t e c h n i q u e s . T h e y c o n s i s t o f t h e s e c t i o n i n g o f a n e r v e
w i t h t h e p u r p o s e o f m i n i m i z i n g o r i n t e r r u p t i n g
c o m p l e t e l y i t s f u n c t i o n5 9 ,6 0
N e u r o t o m y i s a s i m p l e n e r v e d i v i s i o n ; n e u r e c t o m y
i s a d o u b l e d i v i s i o n , w i t h e x c i s i o n o f t h e m i d d l e p a r t , t o
a v o i d r e g e n e r a t i v e b r i d g i n g .
I t m a y b e u s e d t o c o n t r o l m u s c l e s p a s m a s a p a l l i a t i v e
t r e a t m e n t i n p a i n f u l s y n d r o m e s a n d i n c e r e b r a l p a l s y .
N e u r e c t o m y i s u s e d f r e q u e n t l y i n l a r g e a n d p a i n f u l
n e u r o m a t a i n a m p u t a t i o n s t u m p s .
N e u r o t i z a t i o n i s a n o l d t e c h n i q u e u s e d t o s t i m u l a t e p a r a l y s e d m u s c l e s , b y i m p l a n t i n g n e r v e s i n t o t h e m u s c u l a r ~ y
i n s e v e r e l e s i o n s , m a i n l y i n t h e b r a c h i a l p l e x u s .61 , 62
F igure 16 -"C able graft" - C ourtesy G offi, ~ S .15
A - nerve B - grafts
C - cables link D - positioning of the cables
E - suture of the graft
F igure 15A -N M S , 1 1 years old, transsection of m edian and ulnar nerves of the right w rist (January, 1957). E xam ined in July 1965, approxim ately 8 years after operation, by P rofessor E rik M oberg: good m otor recuperation of interossei and lum bricals, active thum b-index finger pinch grip, slight c1aw ing on ring and little fingers. G ood
tactile sensation on m edian and ulnar areas. W eber test -2,5m ilim eters.
g l u e o r h u m a n p l a s m a ) i s u s e d . T h i s t y p e o f a d h e s i v e w a s
n o t u s e d d u r i n g m a n y y e a r s .
T h e g r a f t d o n o r s o u r c e i s u s u a l l y a s e g m e n t o f t h e
s e n s i t i v e n e r v e , e i t h e r t h e s u r a l n e r v e s , t h e m e d i a I
c u t a n e o u s n e r v e o f t h e a r m o r f o r e a r m .
S o m e a u t h o r s r e c o m m e n d t h e u s e o f h o m o g r a f t s . 4 5 ,5 1
I n t e r f a s c i c u l a r o r i n t e r f u n i c u l a r g r a f t s , p r o p o s e d b y
H a s h i m o t o ( 1 9 1 7 ) , L a n g l e y ( 1 9 1 8 ) a n d S u n d e r l a n d ( 1 9 4 3 )
c a r n e b a c k i n t o u s e .5 2 -5 6
F a s c i c u l i a r e h e l d t o g e t h e r b y o n l y o n e s t i t c h , w i t h
e p i n e u r u m e x c i s i o n . T h e v a l u e D f t h i s p r o c e d u r e i s s t i l l
u n d e r d i s c u s s i o n ..
F igure 158 -A ctive first dorsal interosseous, good abduction of . fingers, good m otor recuperation of thenar and hypothenar
m uscles, w ith slight claw ing of ring and little fingers (exam ined on July, 7, 1965)
1 5 0 3
Figure 18 - 10 centimeters gap in the ulnar ner~e.
Bone excision of 3,5 centimeters on fracture callus of humerus, anterior ulnar nerve transposition and 90º flexion of elbow allowed epineural direct non-tension suture.
Figure 17 - Interfascicular or interfunicular suture - Courtesy Goffi,
F .S .1 5
A - excision of epinerve. B - suture (one stitch)
C - suture of epinerve (optional)
r e in f o r c e m u s c u la r f u n c tio n . N e r v e f u n c tio n r e c o v e r y
is n e v e r c o m p le te .6 3 - 6 6
N e r v e tr a n s s e c tio n w ith 2 o r m o r e c e n tim e tr e s g a p
is a c h a lle n g e to th e s u r g e o n , w h o m u s t f a c e a d ile m m a :
g r a f t o r b o n e s h o r te n in g a n d d ir e c t s u tu r e .6 7 - 7 8
B o th a p p r o a c h e s h a v e a d v a n ta g e s a n d d is a d v a n ta g e s .
T h e g r a f t a llo w s a n o n - te n s io n n e r v e s u tu r e b u t
c r e a te s tw o b a r r ie r s to a x o n p r o g r e s s io n , a n d th e d e f e c t in
,d o n o r a r e a m u s t b e c o n s id e r e d .
B o n e r e s e c tio n a llo w s d ir e c t n o n - te n s io n s u tu r e o f th e
n e r v e . A le s s im p o r ta n t tis s u e ( b o n e ) is s a c r if ic e d o n b e h a lf
o f a m o r e im p o r ta n t o n e ( th e n e r v e ) . A f e w c e n tim e tr e s
s h o r te n in g o f a n u p p e r lim b r e p r e s é n ts n o p r o b le m .
F o r m e d ia n a n d r a d ia l c a s e s th e r e s e c tio n is d o n e a t th e
d ia p h y s is o f th e h u m e r u s , w ith im m e d ia te o s te o s s y n th e s is
in th e c a s e s o f th e r a d ia l, m e d ia n a n d u ln a r n e r v e s ( F ig .1 8 ) .
F o r u ln a r c a s e s , a n e a s ie r te c h n iq u e is u s e d :
-tr a n s p o s itio n o f th e n e r v e f r o m th e e p itr o c h le o - o le c r a n e a n
.g r o o v e , s h o r te n s th e c o u r s e o f th e n e r v e . T h is te c h n iq u e
c a n e a s ily c o m p e n s a te f o r th e lo s s o f a tw o o r m o r e
c e n tim e te r s .8
I n s e v e r e a n d e x te n s iv e le s io n s to th e f o r e a r m ,
a r th r o d e s e o f th e w r is t w ith b o n e r e s e c tio n o r r e s e c tio n
o f th e f ir s t r o w o f c a r p a l b o n e s a r e in d ic a te d .
B o n e r e s e c tio n is a r o u tin e te c h n iq u e in lim b
r e im p la n ta tio n 7 5
DISCUSSION
I n th e s u r g ic a l r e c o v e r y o f th e n e r v e s o f u p p e r lim b s ,
tw o f a c to r s a s s u m e g r e a t im p o r ta n c e : - m ic r o s u r g e r y 7 6 ,-7 8
a n d n e w m a te r ia I s f o r th e f ix a tio n o f n e r v e s tu m p s .
. T h e u s e o f m ic r o s u r g e r y , w ith th e a id o f m a g n if y in g
g la s s e s a n d m ic r o s c o p e s a llo w s a c le a r v ie w o f th e f in e
s tr u c tu r e s o f th e n e r v e a n d c o n s e q u e n tly a m o r e p r e c is e
r e c o n s titu tio n .
T h e f ix a tio n o f th e n e r v e s tu m p s a ls o im p r o v e d g r e a tly
w ith th e u s e o f n e w s u tu r e th r e a d s ,7 ? m o n o f ila m e n ts ,
d e lic a te , r e s is ta n t a n d in n o c u o u s ( m a n y a r e r e a b s o r b e d b y
th e b o d y ) , a tta c h e d to d e lic a te c y lin d r ic a l n e e d le s .4 1 ,4 2
I n th e p le x u s , in c a s e s o f s e v e r e le s io n s o f d if f ic u lt
a c c e s s , it is o f te n n e c e s s a r y to u s e a d h e s iv e s w h ic h m a k e
th e r e p a r a tio n o f th e n e r v e s tu m p s e a s ie r .4 3 - 4 7 "
CONCLUSIONS
W ith th e f a c ilitie s c r e a te d b y m ic r o s u r g e r y , w e h a v e
s e e n r e m a r k a b le w o r k d o n e b y d e te r m in e d s u r g e o n s
w h o ~ e e n th u s ia s m h a s b e e n b o u n d le s s , a tr u e s a g a
c h a lle n g in g .n a tu r e . 8 0 - 8 8
N e r v e g r a f t is b e in g w id e ly u ,s e d , r e p la c in g th e
c o n v e n tio n a l te c h n iq u e s - n e u r o r r a p h y , p la in s u tu r e .
B u t n e r v e g r a f t, b e s id e s th e p r o b le m s in h e r e n t to th e
d o n o r s ite , h a s a n o th e r m o r e s e r io u s p r o b le m - th e s e c o n d
s u tu r e , a n e w b a r r ie r to b e o v e r c o m e b y th e a x o n in
r e g e n e r a tio n .8 1
1 5 0 4
In te rfa s c ic u la r (o r in te rfu n ic u la r) s u tu re s a n d g ra fts
a re u n re a lis tic .
T h e ta s k o f re p a irin g th e m in u te , s p e c ific a n d p e c u lia r
s tru c tu re s is n o ta b le d u e to its d e ta ils , a re a l C h in e s e a rt.
O p tic a l m a g n ific a tio n o f th o s e d e lic a te s tru c tu re s
w ith th e a id o f le n s e s , m ic ro s c o p e s a n d ' c o m p u te rs h a s
b e c o m e ro u tin e .
H ig h ly s k ille d s u rg e o n s , w e ll tra in e d m e d ic a I a n d
p a ra m e d ic a l s ta ff a t s p e c ia liz e d h o s p ita Is , th e in s tru m e n ts ,
e q u ip m e n ts a n d im p le m e n ts a v a ila b le e n a b le th e c o n d u c t
o f s u rg ic a l o p e ra tio n s u s in g s ta te -o f-th e -a rt te c h n o lo g y ,
re a l h ig h te c h s u rg e ry .
U n fo rtu n a te ly , h o w e v e r, d e s p ite a lI th e m e a n s
a v a ila b le , th e re c o v e ry o fth e n e rv e fu n c tio n h a s b e e n o n ly
p a rtia l, n o t c o m p le te . T h is fa c t is re c o g n iz e d b y m a n y
s p e c ia lis ts a n d re c o rd e d in m e d ic a llite ra tu re . 8 1 ,8 2
M ic ro s u rg e ry , in tro d u c e d in th e s ix tie s , is
in d is p e n s a b le fo r th e re p a ir o f v e s s e ls a n d m ic ro s tru c tu re s
o f o th e r p a rts o f th e b o d y , s u c h a s th e b ra in , s p in a l c o rd ,
e y e s , e a rs a n d o th e rs . It is in v a lu a b le fo r th e re c o n s tru c tio n
o f v e ry fin e n e rv e s o f th e u p p e r lim b s , in th e in tra n e u ra l .
n e u ro ly s is o r in g ra fts lo c a te d in d iffic u lt s ite s s u c h a s in
th e b ra n c h ia l p le x u s . M ic ro s u rg e ry is g re a tly d e p e n d e n t
o n th e s u rg e o n ' s v is u a l a c u ity .
N e v e rth e le s s , m ic ro s u rg e ry s h o u ld n o t b e c o n s id e re d ,
a s h a s b e e n th e c a s e s o fa r, a s a m ira c u lo u s re s o u rc e ,
c a p a b le o f s o lv in g a ll p ro b le m s .
In o u r o p in io n , o n e th a t w e h a v e b e e n e x p re s s in g fo r a
lo n g tim e , th is c u rre n t a p p ro a c h is n o t th e rig h t o n e ; it s e e m s
th e y h a v e c o m e to a " d e a d -e n d tra c k " a w a y fro m th e " m a in
ro a d " .
F o r a lo n g tim e w e h a v e b e e n q u e s tio n in g o u r
p a tie n ts , fro m th e firs t d a y a fte r th e o p e ra tio n .
" I fe e l m y fin g e r (o r h a n d ) b e tte r" , is th e in v a ria b le
re p ly . V a s c u la r, s y m p a th e tic o r n e rv e re a c tio n ?
W e h a v e c o m e to th e c o n c lu s io n th a t, a s w ith s p lit
e le c tric a l c o rd s w h e n p u t to g e th e r, " th e c u rre n t flo w s " . 8 9
W e firrn ly b e lie v e th a t s e c tio n e d n e rv e s s h o u ld b e
re p a ire d , re g a rd le s s o f th e tim e w h ic h h a s e la p s e d s in c e
th e le s io n ,3 7 e v e n if b o n e s h o rte n in g is re q u ire d in s e v e re
c a s e s .3 7 , 3 8 ,6 7 -7 8
W e in s is t in ~ o n v e n tio n a l e p in e u ra l n o n -te n s io n
s u tu re s .
T h e m a in s te p s o f th e o p e ra tio n a re :
D is p la c e m e n t a n d fre e in g o f th e n e rv e s tu m p s , s lig h t
tra c tio n o n th e n e rv e ,9 if n e c e s s a ry , a d e q u a te fle x io n o f
th e n e ig h b o u rin g jo in ts , re ro u tin g o f th e n e rv e to re d u c e
th e g a p a s in th e u ln a r n e rv e in th e e lb o w .2 8
C lin ic a I o b s e rv a tio n h a s le d u s to q u e s tio n th e c u rre n t
n e rv e re g e n e ra tio n d o g m a s . R e s e a rc h in th e b io m e d ic a l
s c ie n c e s a re a a n d th e lik e s h o u ld b e in c re a s e d a n d
c o n ~ u c te d in g re a te r d e p th .
T h u s w e s u g g e s t th e m a in te n a n c e o f th e c o n v e n tio n a l
te c h n iq u e s w ith d ire c t s u tu re o f th e n e rv e , a s s o c ia te d , if
n e c e s s a ry , to a lte rn a tiv e p ro c e d u re s , c o m p le m e n te d w ith
n e w d a ta o rig in a tin g in c u rre n t c lin ic a I s tu d ie s in th e a re a s
o f b a s ic s c ie n c e s (h is to n e u ro p h y s io p a th o lo g y , c h e m ic a l
b io p h y s ic s a n d re la te d d is c ip lin e s . 9 0 -9 2
W ith th is g lo b a l v ie w o f th e p ro b le m , w e m u s t
m e d ita te o n th e d e p th a n d w is d o m o f th e w o rd s w ritte n
m o re th a n o n e h u n d re d y e a rs a g o b u t w h ic h s till a p p ly
to d a y :
" T h e re is d e a d m e d ic a llite ra tu re , a n d th e re is a lio n g
o n e . T h e d e a d is n o t a ll a n c ie n t, a n d th e liv e is n o t a ll
m o d e rn " .
O L IV E R W E N D E L L H O L M E S (1 8 0 9 - 1 8 9 4 )9 3
A C K N O W L E D G
E M E N T S
Q u r s in c e re th a n k s to H e lo is a A b re u D ib , w h o s e
d e d ic a tio n a n d p ro fe s s io n a lis m m a d e th is w o rk p o s s ib le .
REFERENCES
1.
Abreu LB. ClinicaI aspects of muscle imbalance in the hand
due to ulnar herve lesions. Anatomia Clínica, Springer
Verlag, 1984, 6: 177-182.
2.
Junqueira LC, Carneiro J. Histologia básica. Ed. Guanabara
Rio de Janeiro, 1990, 131,136.
3.
Schumacher S. Compêndio de histologia humana. Editorial
Labor S.A.,3
aed., Barcelona, M adrid, 1948,73-75.
4.
Foerster
O. Anatomie
und Physiologie
der peripheren
Nerven in Handbuch der Neurologie, Berlin, Julius Springer
Verlag, 1929, 50b.
5.
Seddon HJ. Three types of nerve injury. Brain,1943, 66
(4):237.
.
6.
Abreu LB. Reparação secundária por enxerto tendinoso das
lesões traumáticas dos tendões flexores dos dedos dentro
da bainha osteofibrosa (experiência de 110 cas9s operados).
1959Thesis FM USP, São Paulo.
.
7.
Graner O. Lesões traumáticas dos nervos. In Atualização
Terapêutica, Liv.Luso-Esp. e Brasileira Ltda., São
Prado
J., Ramos 1.,
Vale
JR., 1958:791-793.
8.
Spinner M ., Spencer FS. Nerve compression lesions of the
upper extremity. Clin. Orthop., 1974,104:46.
9.
Bunnell S. Surgery ofthe hand, 2nd.ed., JB Lippincott Co.,
Phil., London, M ontreal, 1948.
10. Leite VM . Sindrome
compressiva
do nervo interosseo
posterior. Diagnostico
e tratamento.1988,
Thesis EPM
-UNIFESP, São Paulo.
11. Eversmann W V.(Jr) Compression entrapment neuropathies
of the upper extremity. Hand Surgery, 1986,8 (5):759~766.
12. Lech O. A dor de braço. Proteção,2:120-123.
13. Abreu LB., Godoy-M oreira R. M edian nerve compression
at the wrist. J Bone J Surg, 1958,40A, 96: 1426-1427.
14. Kojima T, Ide, Y. et aloHemangioma of median nerve causing
tunnel syndrome. The Hand, 1976,8 (1):62-65.
15. Abreu LB. Cirurgia dos nervos periféricos. In Goffi
FS.-Técnica Cirúrgica.Livraria
Atheneu, Rio de Janeiro, São
Paulo, 1978:309-315.
16. Abreu LB. Cirurgia da mão nas lesões nervosas da lepra.
Actas y Trabajos deI III Congresso Argentino de Ortopedia
y Traumatologia, M ar deI Plata, 1961,2: 199.
17. Iacovone M , Julião OF, Abreu, LB. M olestia de
Dejerine-Sottas. III Jornada SBCM , Rio de Janeiro, 1963.
18. W olosker M . Tratamento da costela cervical. 1972, Thesis
FM USP, São Paulo.
19. Carvalho RDD Espondilose cervical; indicações e resultados
no tratamento da mielopatia. 1974, Thesis Fac M ed Santa
Casa de São Paulo.
20. Abreu
LB. Traumatismos
do recém-nascido.
Rev.
M aternidade e Infância, 1953,12:211-224.
21. Azze RJ. Tratamento microcirúrgico das lesões traumáticas
do plexo braquial. 1991, Thesis FM USP,São Paulo.
22. Seddon HJ. A classification of nerve injuries. Brit.M ed.J.,
1942,2:237.
23. Palazzi Colli S, Palazzi Colli C. Diagnóstico. In Cirurgia de
los nervios
perifericos.
III Congresso
Nacional
de la
SECOT, 1972, M adrid.
24. Littler JW . The Hand and W rist in Howarth M B. Text book
of orthopedics. W B Sanders Co., P~il, London, 1952,261.
25. M oberg E.
Akute Handchirurgie-Koln,
Lindenthal,
Joseph Schumpe, Lund-CW K,Gleerup,Bokfortag,1953,p.9.
26. Caetano EB. Contribuição
ao estudo da inervação
dos
musculos
tenares
e da
anastomose
de
Canieu
e
Richet.1982,Thesis- Fac.M ed., PUCSP, Sorocaba.
27. Abreu LB. Cirurgia dos nervos periféricos. In Carvalho
RRD, Neurocirurgia, Sarvier, São Paulo,1979,119-134.
28. Gonçalves DC. Aspectos da cirurgia dos nervos periféricos.
Rev.M ed M unicipal,Rio de Janeiro, 1957,24(4):253-270.
29. Peixinho M .. Tratamento
cirúrgico
das contraturas
em
aduação e em rotação interna do braço nas sequelas da
paralisia obstétrica. 1970, Thesis FM USP,São Paulo.
30. Peixinho M .. Tratamento cirúrgico das sequelas da paralisia
obstétrica. 1971, Thesis FM USP,São Paulo.
31. M oldaver 1. Tourniquet paralysis syndrome.AM A, Archives
Surg., 1954,68: 136-144.
32. Littler JW . M edian and ulnar nerve injuries. In Reconst. Surge
and Traumatology, 1953,1:227-240.
33. Abreu LB. Reparação primária de nervos e tendões na mão.
Rev Hosp Clin, 1959,14(3):160-166.
34. Abreu LB. Pronto-atendimento
de acidentados
de mão.
IM ESP, São Paulo,1993.
35. Davis L. Neurological surgery through the years of W orld
W ar II.ln Abst Surg Gynec Obst, 1949,89(1),1-23.
36. Kirklin JW ,Berkson J. Suture of peripheral nerve. In Abst.
Surge Gynec. Obstet. 1949,88 (6),719-730.
37. Abreu LB, Erhart EA. Considerações sobre neurorrafias em
lesões antigas. Rev. Paulista de M edicina - 1950,52(2):
149-150.
38. W ertheimer P, Auet J. Les paralysies
radiales dans les
fractures fermées de la diaphyse humerale. Sem Hop. Paris.
Ann.Chir. 11:675, 1957. In. Abst Surge Gynec. Obstet.1958,
106(4)390.
39. Azze RJ. Lesões de nervos in Pardini AG. Traumatismo da
mão. M édica e Científica, Rio de Janeiro, 1985,189-197.
40. Clifton EE. Tension at the suture line in peripheral nerve
surgery. Surgery, 1949,26:756.
41. Bratton BR, Kline DG, Hudson AR, Coleman W T. The use
of monofilament polyglycolic acid suture for experimental
peripheral nerve repair. Surg Res. 1981, 31 :482.
42. Sunderland S, Smith GK. The relative merits of various
n1aterials for the repair of severed
nerves.
Austral.
/
N.Zealand 1.Surg., 1950,20:85.
43. M edawar PB, Young JZ. Fibrin suture ofperipheral nerves.
Lancet,1940,126.
44. Seddon HJ, M edawar PB. Fibrin suture of human nerves.
Lancet 1942,143:87-88.
45. Davis L, Rude D. Functional recovery following the use of
homogenous nerve grafts. Surgery, 1950,27: 102.
46. M attar
(Jr) R. Reparação
microcirúrgica
dos nervos
periféricos;estudo
compàrativo
entre sutura epineural e
adesivo de fibrina .. 1989 Thesis FM USP,São Paulo.
47. Freeman BS, Perry J, Brown D. Experimental
study of
adhesive surgical tape for nerve anastomosis. Plast Reconst
Surg, 1969,43: 174.
1506
48. Seddon HJ. Surgery of nervous system.The use of
autogenous grafts for the repair of large gaps in peripheral
nerves. Bri1. J. Surg., 1947,35:151.
49. Seddon HJ. Peripheral nerve injuries. MedicaI Research
Council, Her Majesty's Stationery Office (special series),
London, 1954,282.
50. Terzis J, Faibisoff B,Williams H. Nerve gap; suture under
tension vs. graf1. Plas1. Recons1. Surg., 1975, 56: 166. 51. Rezende N. Enxerto de cadáver em Cirurgia Humana. BoI
Col Brasileiro de Cirurgiões, 1944,19 (I).
52. Sunderland S. Funicular suture and funicular exclusion in
the repair of severed nerves. Brit J. Surg.,1953, 40:580.
53. Millessi H, Berger A. The interfascicular nerve grafting of
the median and ulnar nerve. 1. Bone J1. Surge i972, 52A:727-750.
54. Fe~reira MC,Azze RJ, Abreu LB. Enxerto funicular de nervo
com técnica microcirurgica. Rev. Paul. Med. 1975,86:
113-116.
55. Millessi H,Meissel G,Berger A. Further experience with
interfascicular graft of median, ulnar and nerve. J. Bone J1.
Surge 1976, 58A,209.
56. Bratton B,Kline DG,Hudson AR. Experimental
interfascicular nerve grafting ..J. Neurosurg, 1979,51 :323.
57. Strange FGStC. An operation for nerve pedicle grafting;
preliminary communication. Bri1. J: Surg.,1947, 34:423.
58. Alpar EK, Brooks DM. Long term results ofulnar to median nerve pedicle graf1. Hand Surg., 1978, 10:61.
59. Fusco EB. Paralisia cerebral; correção do espasmo de flexão dos dedos e do punho pela neurectomia de ramos do mediano
(pesquisa e resultados sobre 45 casos operados). 1964,
Thesis FMUSP, São Paulo.
60. Carroll RE,Craig FS. The surgical treatment of cerebral palsy.
Surge Clin. N. Am.,1951, 31(2):385-395.
61. Nutt JJ. Neurotization of paralised muscle grafting. A
laboratory and clinicaI study. 1. Bone 1. Surg., 1918, XVI
(5), May.
62. N arakas A. Les neurotisations on transferts nerveux dan les
lesions du plexus brachial. Ann. Chir. Main, 1982, 1: 101. 63. Hamlin (Jr) E,Watkins AL. Peripheral Nerves-Regeneration
in the ulnar, median and radial nerve. Surge Clin. N. Am 1947,27:1052.
64. Abreu LB. Neurorrafia e transplantes tendinosos simultaneos nas lesões nervosas do membro superior. Actas y Trabajos
deI III Congresso Argentino de Ortopedia y Traumatologia
Mar deI Plata, 1961, 1: 186-189.
65. Moberg E,McDowell CL,House JH. Third International
Conference on Surgical Rehabilitation of the Upper Limb
in tetraplegia (Quadriplegia). Hand Surg., 1988, 1064-1066.
66. Abreu LB. EarlY restoration of pinch grip after ulnar nerve
repair and tendon transfere Hand Surg., 1989, 14B,3:309-314.
67. Massie WK, Ecker A. InternaI fixation of bone and
neurorhaphy-combined lesions of radial nerves and humerus
fractures. J. Bone J. Surg., 1947,20 (4):977-979.
68. Speed JS, Smith
1-1;.
In Campbell's Operative Orthopedics.CVMosby Co., St Louis, 949, 2nd.ed., vol. 1.
69. Murphy P. Peripheral nerve injuries. In Campbell's Operative
Orthopedics. Speed JS, Smith, H, 2nd. ed, CVMosby Co.,
S1. Louis, vol. 1, chap. XI, 1949, p. 745.
70. Brown JB. Restoration of major defects in the arm by
combination of plastic, orthopedic neurological procedures.
Plas1. Recons1. Surg., 1949,4 (4): 337.
71. Evans EM. The treatment of major injuries in the hand.
Brit.J. of Plas1. Surg., 1949, 2 (3): 150-174.
72. Nichols HM. Shortening the forearm for serious soft tissue
loss about the wris1. 1. Bone J. Surg., 1958, 40A,
(4):958-959. .
73. Goldner JL,Kelley JM. Radial nerve injuries. 1.Bone 1. Surg., 1958, 40A , (4):966-967.
74. Abreu LB. Encurtamento ósseo no tratamento das lesões
, nervosas graves do membro superior. Actas y Trabajos deI
III Congresso Argentino de Ortopedia y Traumatologia. Mar
deI Plata, 1961,1:190-185.
'75. Costa RC. Implante de membros superiores (aspectos
ortopédicos}.1972,Thesis FMUSP, São Paulo p.52.
76. Smith S.W. Microsurgery of peripheral nerves. Plast.
Reconst. Surg., 1964,33:317-329.
77. Watson N, Smith RJ. Methods and concepts in Hand Surgery.
Butterworth & Co. Ltd., 1986, London, Boston, Durban,
Sidney, Toronto, Wellington.
78. Dick PJ,Thomas PR,Griffith L,Poduslo JF,Low PA.
Peripheral neuropathy 3rd. ed., WB Saunders Co., Phil,
London, Toronto, Sydney, Tokyo, 1993, 2: 1678-1689.
79. Naffziger HC. Metho.d to secure suture ofperipheral nerves.
1. Orthopedic Surgery, 1921,3 (7):348-349.
80. Sunderland S. ClinicaI and experimental approaches to nerve
repair, in perspecÍive. In Jewett DL, McCarrol (Jr) HR. Nerve
and repair and regeneration. CVMosby Company, S1. Louis,
Toronto, London, 1980,37:337-355.
81. Milford L. In Bunnell Symposiu~, Jewett DL, McCarrbl
(Jr) HR Nerve repair and regeneration. CVMosby Co., St
Louis, Toronto London, 1980,36:329-336.
82. Edgerton NT. What's new in surgery. Surge Gynec. Obste1., , 1963, 116,: 155-157.
83. Bora TFW. Peripheral nerve repair in cats. J.Bone J. Surg.,
1967, 49 (A), 4:659-666.
84. Michon J, Moberg E. Les lesions traumatiques des nerfs
peripheriques. Exp. Scient. Française, Paris, 1973.
85. Erhart EA, Ferreira,MC, Marchese At et aI. Sutura de
nervos com técnica microcirurgica podem evitar total
degeneração waleriana. Rev. Ass. Med. Brasil 1975, 21
(7):213-217.
86. Hudson AR,Hunter D,Kline D et aI Histological studies of
experimental interfascicular nerve graft repair. J. Neurosurg,
1979,51:333.
87. Sunderland S. Nerves and nerve injuries. Edinburgh,
Churchill, Livingstone, 1980, 2nd. ed.
88. Zumiotti A. Estudo sobre a influência da sutura distaI em
enxertos longos de nervo com emprego. de técnica
microcirurgica. 1988, Rev. Bras. Ortop. 23 (8):231-234.
89. Gonçalves DC. Atualidades em cirurgia dos nervos
periféricos. 1978, Rev. Bras. Ortop.,13 (4):191-192.
90. D a-S ilva C F , M adison R , D ikkes P . et aI. A n in vivo m odel
to quantify m otor and sensory peripheral nerve regeneration
using bioresorbable nerve guide tubes. B rain R
esearch-E Isevier S cience P ublishers, B V , B iom edical D ivision, 1985,
342:307-315.
91. M adison R D ,D a-S ilva C F ,D ikkes P . E ntubulation repair w ith
protein additives increases the m axim um nerve gaps distance
successfully bridged w ith tubular prostheses. B rain
R esearch-E Isevier S cience P ublishers, B V B iom edical
D ivision ,1988, 447:325-334.
92. L ainetti R D , D a-S ilva C F . L ocal addition of
m onosialoganglioside G M 1 structurates peripheral axon
regeneration in vivo. B rasilian M ed. B iol. R es.,1993,
26:841-845.
93. B ick E M . S ource book of orthopedics. T he W illiam s and
W illiam s C o., 2nd.ed., B altim ore, 1948: fronte
