Radial nerve repair using an autologous denatured muscle graft: comparison with outcomes of nerve graft repair.

BACKGROUND: The efficiency of denatured muscle grafting in nerve repair has been confirmed in experimental models and animals. The first clinical trials to repair digital nerves and mixed sensory-motor nerves were encouraging regarding sensory recovery but motor recovery was poor, probably because of delayed repair. We present the functional outcome of repair of motor nerves using denatured muscle graft and compare the results with those using standard nerve graft techniques. METHODS: This prospective study included 9 radial nerve defects repaired with denatured muscle grafts and 23 radial nerve defects repaired using nerve grafts. Missile induced nerve injury, mid-arm level of lesion, a nerve gap smaller than 6 cm, and a preoperative interval of less than 5 months were characteristics shared by all patients. None of the patients had concomitant vascular injury, severe scarring, or significant soft tissue damage in the region of nerve repair. Motor recovery was estimated with 0-5 points, at least 4.7 years after surgery, according to the BMRC scale. RESULTS: A successful outcome (>or=M3) was achieved in 7 out of the 9 patients treated using a muscle graft and in 21 out of the 23 patients treated using nerve grafts (P > 0.05). Excellent recovery and the clinically significant re-establishment of thumb extension (M5 grade) were never achieved in the patients treated using muscle grafts. The average motor score was significantly better in patients treated with nerve grafts than in those who received muscle grafts (3.8 +/- 0.9 and 3.2 +/- 0.8; P = 0.035). With the patients who received muscle grafts, an inverse correlation existed between motor recovery and the length of the nerve gap (P = 0.017). CONCLUSIONS: Denatured muscle grafts can be useful for bridging short radial nerve defects, but the quality of recovery is significantly worse than after nerve graft repair. Even if relatively short nerve defects are bridged with denatured muscle grafts, the outcomes correlate inversely with the length of the gap.

Missile severances of the radial nerve. Results of 131 repairs.

BACKGROUND: Reports on missile-caused radial nerve injuries are relatively rare in current literature. We present the outcome after repair of such injuries as well as the factors influencing the result of treatment. METHODS: Prospective study included 131 complete missile-caused radial nerve severances repaired with nerve graft or direct suture. Final outcome was defined 4 years postoperatively at least, on the basis of motor recovery (M), EMNG recovery (E) and patient's judgement on the quality of outcome (P). Recovery was estimated with 0-5 points and final outcome was defined according to the total sum (0-15 points) as: poor, insufficient, good or excellent. Both the good and the excellent outcomes were considered as successful, and both the poor and the insufficient outcome as unsuccessful. RESULTS: Excellent outcome was noted in 38.2% and good outcome in 47.3% of all patients. Average point score was 9.9 +/- 3.3 points for the whole series (domain of good outcome) and 6.6 +/- 3.0, 10.1 +/- 3.2 and 10.9 +/- 2.2 points for high, intermediate and low repairs, respectively (p<0.01). Useful motor recovery (>or =M3), good EMNG recovery (> or =E3) and affirmative patient's judgement on the outcome (> or =P3) had similar frequencies for intermediate (83.2-89.7%) and low repairs (85.7-92.8%), but for high repairs, good EMNG recovery was more frequent (70%) than were useful motor recovery and affirmative patient's judgement (40%). Successful outcome was noted in 89.3% of direct sutures and in 82.7% of nerve grafts (p>0.05). Patients with a successful outcome had a significantly shorter nerve defect (p<0.001), shorter preoperative interval (p<0.001) and younger age (p<0.05) than patients with an unsuccessful outcome. Significant deterioration of results began with defects longer than 8 cm, preoperative interval longer than 6 months and age above 40 years. CONCLUSIONS: The outcome is significantly worse after high radial nerve repairs than after intermediate and low repairs. The length of nerve defect, duration of preoperative interval and age of the patient also influence the repair outcome. Correlation of motor recovery with EMNG recovery and with patient's judgement on the outcome is relatively good, but depends on the level of the repair.

[Risk factors for the onset of vasospasm and rebleeding after spontaneous subarachnoid hemorrhage]. / Faktori rizika za nastanak vazospazma i rekrvarenja nakon spontane subarahnoidne hemoragije.

Retrospective study comprised 120 patients with spontaneous subarachnoid hemorrhage (SAH) and risk factors for vasospasm and rebleeding were analyzed. Rebleeding and vasospasm had the same incidence (26.7%). Vasospasm prolonged preoperative and postoperative hospital period (p > or = 0.05) and deteriorated the final treatment outcome (incidence of favorable outcome was decreased from 56.9% to 41.7%). Total rebleeding mortality rate was 62.5% and depended on the clinical state before rebleeding (p < 0.05). Risk factors for vasospasm were: poor clinical condition of a patient after the initial SAH, the period of 5-13 days after hemorrhage (p < 0.01) and aneurysm located on the anterior communicant artery (p < 0.01). Risk factors for rebleeding were: poor clinical condition of the patient after the initial SAH, the first 36 hours and the period of 8-11 days after the initial SAH, advanced age of the patient, severe arterial hypertension, vasospasm and aneurysm on the internal carotid artery.

[Diagnosis of subarachnoid hemorrhage]. / Dijagnostikovanje subarahnoidnog krvarenja.

OBJECTIVES AND METHODS: A total of 115 patients with subarachnoid hemorrhage were retrospectively analyzed with the aim to evaluate the timing and reliability of the applied diagnostic procedures. In the group of 63 patients the reliability of CT as the diagnostic procedure was investigated, and CT scan was correlated with the clinical status of the respective patient. In the group of 79 patients with operatively treated cerebral aneurysm the angiographic and intraoperative findings were mutually compared and discrepancies were analyzed. RESULTS: During the first 48 hours after the hemorrhage, only 35.2% of all the angiographies were performed, so the final diagnosis was late in 64.8% of patients. Hemorrhage was diagnosed by CT in 87.3% of the cases and pronounced correlation existed between CT and the clinical status of the patient. Discrepancies between angiographic and operative findings existed in 16.4% of patients. CONCLUSION: CT should be the initial procedure for the diagnosis of subarachnoid hemorrhage. In nonmoribund patients the early angiography should also be performed. The main reason for delaying in diagnosis is the overdue transfer of the patients to the referral hospitals.

[Primary neurosurgical treatment of craniocerebral war injuries]. / Primarno neurohirursko lecenje ratnih kraniocerebrumskih povreda.

From September 1991 to December 1992, 41 patients with nonpenetrating and 84 patients with penetrating craniocerebral injuries were neurosurgically treated at the Military Medical Academy. The severity of injuries was estimated according to GCS and the outcome according to GOS. In 17 out of 27 patients with moderate nonpenetrating CCI, the outcome was favorable, and 5 patients out of 7 with severe CCI died (p < 0.01). Out of 33 patients with moderate penetrating CCI, favorable outcome or moderate disability were observed in 21 patients, and out of 26 patients with severe CCI, 19 died (p < 0.01). The majority of unilobar CCI resulted in favorable outcome or moderate disability, while 10 out of 26 patients with multilobar CCI, as well as 9 out of 16 patients with bichemispheric CCI died (p < 0.01). Mortality rate in patients with penetrating CCI was 25%. No significant differences were observed in the outcome of penetrating CCI in relation to the missile type (p > 0.05). Nonpenetrating CCI had a better outcome than the penetrating ones (p < 0.05). The outcome of war nonpenetrating CCI depended on the severity of injury and of penetrating CCI on the severity injury, of the extent of cerebral lesion and the form of penetration, respectively.

Factors influencing the outcome of nerve repair.

The dependence of the nerve repair outcome on the following 7 factors was analyzed: regenerative potential of the interrupted nerve, local vascular and scar state, level of nerve lesion, applied surgical technique, length of nerve defect, preoperative interval and patient's age. Prospective study included 490 ruptures of peripheral nerves, operated in two years period and the final outcome was established 24-30 months after reparation. The influence of the each of mentioned factors on the treatment outcome was tested in experimental groups, in which total homogenization existed, according to all other factors which could cause the differences in the repair outcome. The obtained results point out that local vascular and scar state, applied surgical technique and the age of patients between 16 and 50 did not influence significantly the final results of treatment. According to the intensity of regenerative potentials, three groups of nerves could be recognized: with excellent (radial, musculocutaneus and femoral nerves), with moderate (median, ulnar and tibial nerves) and with poor regenerative potential (peroneal nerve). The level of repair significantly affected the final outcome only for nerves with moderate regenerative potential (median, ulnar and tibial nerves), while for nerves with excellent (radial nerve) and poor recovery potential (peroneal nerve), differences in outcome after high, intermediate and low level repairs were not significant. The length of the defect did not influence significantly the repair outcome for nerves with excellent regenerative potential (radial nerve), while for other nerves significant linear correlation existed between length of the defect and the repair results. Linear correlation also existed between the repair outcome and the preoperative interval. Border values of the length of the defect and for preoperative interval were calculated, which gave minimal and maximal possibilities for the successful recovery after the repair.

[Results of repair of severed nerves in war injuries]. / Rezultati reparacije ratnih neurotmeza.

The results of surgical treatment of 397 wounded with 482 neurotmeses (64 median, 97 ulnar, 100 radial, 7 musculocutaneal, 120 peroneal and 94 tibial nerves) were analyzed. The treatment outcome was determined 12-36 months postoperatively by analyzing the sensorimotor recovery, EMNG status and operated person's attitude to the repair outcome. The change of all the four mentioned parameters was graded from 0 to 5 points, and the outcome was qualified as poor, moderate, good or excellent according to the point sum total. The majority of good and excellent results was obtained after radial (85%) and musculocutaneal (100%) nerve repairs and the less after peroneal nerve repair (13.3%). Based on the obtained results, it was concluded that radial and musculocutaneal neurotmeses should always be repaired, disregarding the height of lesion. Repair of high ulnar and peroneal lesions was unsuccessful. High lesions of tibial and median nerves should be repaired because of the possible recovery of protective sensibility in autonomous nerve zone.

[Craniocerebral injuries at the Vukovar battlefield]. / Kraniocerebralne povrede sa vukovarskog ratista.

In Neurosurgical Clinic of Military Medical Academy 33 wounded persons with craniocerebral injuries (CCI) from Vukovar battlefield were treated from September 16 to December 3. After the follow-up period of average 48 months the outcome of treatment was analyzed compared to the clinical status on admission and to the extent of cerebral lesion. All wounded with minor CCI (GCS = 15) and majority with mild injuries (GCS = 13-14) had the good outcome, and all the wounded with severe injuries (GCS = 3-8) died (p < 0.01). After unilobar penetrating CCI the outcome was mostly good, but after multilobar and transventricular injuries the outcome was worse or lethal (p < 0.01). Total mortality rate was 27.3%. Our conclusion is that bad clinical status on admission and more extensive cerebral lesions correlate with worse outcome of treatment of war CCI.

[Lesions of the peripheral nerves associated with pseudoaneurysms of the major arteries caused by gunshot wounds]. / Lezije perifernih nerava uzrokovane postsklopetarnim pseudoaneurizmama magistralnih arterija.

Ten wounded persons, operated on for gunshot-induced peripheral nerve lesion in which pseudoaneurysm of the main artery was found intraoperatively, were presented. Preoperative clinical course, intraoperative neurovascular topography and pathoanatomy, operative procedures and postoperative results were analyzed. The correlation was established between preoperative neurologic deficit and intraoperative findings on arteries and nerves. It was concluded that such patients have to be operated on as soon as possible, but not later than five days from the beginning of neurologic aggravation, to prevent the development of irreversible neural damage.

[Post-gunshot wound lesions of the peripheral nerves which may be prevented with adequate primary surgical wound care]. / Postsklopetarne lezije perifernih nerava koje se mogu prevenirati adekvatnom primarnom hirurskom obradom rane.

The retrospective study includes 24 wounded persons with iatrogenic peripheral nerve lesion and 94 wounded whose neural damage occurred due to peripheral nerve engagement in scar tissue after main artery reconstruction, missile bone fracture or after soft tissues defects covering by Tiersch transplants. The authors analyzed frequency and localization of these lesions, intraoperative findings, applied operative procedures and clinical findings during preoperative follow-up. It is recommended to create the new bad for exposed peripheral nerve from adjacent muscles as part of primary surgical wound treatment. This procedure eliminates the risk of subsequent epineural scar formation in all situations that have been described (soft tissue defects, artery reconstruction and bone fracture) and makes the later operations on peripheral nerves unnecessary.

[Repair of a severed nerve with denatured muscle graft--preliminary results of a new surgical technic]. / Reparacija neurotmeza denaturisanim misicnim graftom--preliminarni rezultati nove operativne tehnike.

In Neurosurgical Clinic of Military Medical Academy prospective study about the use of denatured muscle graft in nerve repair is in progress, based on numerous experimental and sporadic clinical literature data. The first, experimental part of the investigation is directed to operative technique details and also to find out the manner and duration of muscle denaturation which provide ideal conditions for regenerating axons sprouting. It is concluded that greater pectoral muscle have to be muscle graft donor for nerve defects shorter than 6 cm, and sartorius muscle for those longer than 6 cm. Denaturation for 30 seconds in liquid nitrogen and after that in distilled water for 3 minutes results in micromorphological status in muscle graft which is optimal for axonal regeneration. In the second, clinical part of the work reparations of missile neurotmesis of radial nerve with denatured muscle grafts are performed. Preliminary results 9 months after operation are quite comparable with results after sural nerve graft reparation.

[Peripheral nerve injuries during the 1991-1993 war period]. / Povrede perifernih nerava u ratnim dejstvima 1991-1993.

In the period 1991 - 1993, 931 casualties with 1435 injured peripheral nerves were surgically treated at the Clinic for Neurosurgery of the Military Medical Academy. The statistical analyses of these series was done according to the type of the injured nerves, the age and sex of the wounded. The cause of injuries, associated and combined injuries, distribution of single and multiple lesions of certain nerves, as well as employed surgical procedures were analyzed.