Table Of ContentG.Penkert · H.Fansa
Peripheral Nerve Lesions
Nerve Surgery and Secondary Reconstructive Repair
Springer-Verlag Berlin Heidelberg GmbH
G.Penkert · H.Fansa
Peripheral Nerve Lesions
Nerve Surgery and
Secondary Reconstructive Repair
With 359 Figures
123
ISBN 978-3-642-07939-9
Library ofCongress Cataloging-in-Publication Data
GötzPenkert Prof.Dr.med. Penkert,G.Peripheral nerve lesions:nerve surgery and sec-
ondary reconstructive repair/G.Penkert,H.Fansa. p.; cm.
Friederikenstift Hannover
Includes bibliographical references and index.
Neurochirurgische Klinik
ISBN 978-3-642-07939-9 ISBN 978-3-662-09232-3 (eBook)
Humboldtstr.5 DOI 10.1007/978-3-662-09232-3
30169 Hannover
1.Nerves,Peripheral–Surgery.2.Nerves,
Germany
Peripheral–Wounds and injuries–Surgery.3.Nerves,Periph-
eral–Regeneration.I.Fansa,H.,1969– II.Title. [DNLM: 1.
Hisham Fansa Privvv.-Doz.Dr.med. Peripheral Nerves–surgery. 2. Peripheral Nervous System–
Städtische Kliniken Mitte surgery.WL 500 P41lp 2004] RD595.P466 2004 617.4’83–dc22
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Preface
The introduction of the microscope and microsur- We probably should also acknowledge that some-
gery in the management ofsurgically treated periph- times evenmore detail could have been provided on
eral nerve lesions revolutionized the procedure,prog- certain topics,particularly on the description ofthe
nosis,and results in this field.Several authors have surgical approaches chosen. But it became much
published their vast experience,and these reports more difficult than initially anticipated to create a
have been given preference in the present work. mental picture of a surgical procedure through
The purpose ofthis book is not to add one more words.Nevertheless,we hope to motivate younger
volume to the literature,but to help younger surgeons surgeons to enjoy this interesting esthetic medical
who are beginning their education to understand field,which can truly improve the quality of a pa-
logically how to appraise nerve lesions and how to op- tient’s life.They will not only need great patience dur-
erate on nerves without harming them.Some experts ing these time-consuming operations,but also better
will perhaps criticize simplifications, particularly support within their individual hospital settings and
concerning the introductory remarks or descriptions health systems.
of different histological reactions to tissue trauma, Management ofnerves requires interdisciplinary
butwe intended to help younger physicians focus on cooperation.Artificial barriers between different dis-
the important theories and facts that influence preop- ciplines usually put a halt to scientific development
erative decision making and the type of operative and progress.Therefore,we intend to build a bridge
procedure to be chosen.We did not aim at total com- between all the disciplines involved in peripheral
pleteness but rather at clarity. nerve injuries and the disciplines specializing in re-
Ofcourse,we realize that other authors have de- constructive surgery.The possibilities offered today
scribed different approaches to the various lesions, by microsurgery on nerves and reconstructive sur-
but we have tried to present our own experience over gery must be part ofa single worldwide concept in
two decades with clear explanations.We may differ the future.We therefore add detailed reconstructive
somewhat fromother writers,which shows that dif- surgical procedures and hope that the reader comes
ferentopinions are quite normal in a medical field away with aclear idea ofthe advice and treatment
where the surgeon sometimes has to wait more than tobeoffffered to patients.An interdisciplinary collab-
1year for postoperative results.The process oflearn- oration between neurologists, neurophysiologists,
ing from failures or being encouraged by good results microneurosurgeons, and reconstructive surgeons
is a long one when dealing with peripheral nerve le- must spread throughout the world.
sions.
Acknowledgements
My greatestgratitude and respect goes to Prof.Mille- I wish to thank Prof.Penkert for his trust and the op-
si,director ofthe Hand,Plastic,and Reconstructive portunity to include a chapter on muscle and tendon
Surgery Department ofVienna University,who be- transfers.Always devoted to an optimal functional
came my first teacher ofperipheral nerve lesions and outcome in his patients,Prof.Penkert never hesitated
surgery in the mid-1970s.As the pioneer ofmicrosur- to follow the necessary interdisciplinary approach.
gical nerve grafting,he offered me the most generous Great respect goes to my surgical teacher,Prof.
view ofhis remarkable experience,proved in the op- Schneider,ofthe Plastic and Reconstructive Surgery
erating room and published in a large number ofar- Department, University of Magdeburg, Germany,
ticles and books.Later,he was always available when who always supported me.To show my gratitude I
thorny scientific questions were to be discussed and would like to dedicate my work in this book to him.
solved.
My gratitude isalso extended to the foundation of dr.Hisham Fansa
Volkswagen of Hannover,Germany,which enabled
me to spend 1.5years with Millesi and his co-workers.
Once more,my greatest respect goes to Prof.Samii,
director of Hannover’s neurosurgical departments,
who became my second teacher and,from the begin-
ning,was very generous in allowing me to indepen-
dently give advice to all patients affected by peripher-
al nerve lesions,to choose and provide treatment,and
todocument each case with top technical equipment,
as well as being available on a daily basis for neuro-
surgical questions and problems to be solved.
Gratitude must also beextended to another mem-
ber ofSamii’s team,Mr.S.Brinkmann,who saw to the
vast number ofintraoperatively acquired micropho-
tos,only some ofwhich were used in this book.
I must especially thank my wife,Ortrud,who spent
innumerable evening hours writing and correcting
this manuscript.
Great recognition goes to my colleague,Dr.Hi-
sham Fansa,who was ready to help bridge the gap be-
tween plastic and reconstructive surgeons as well as
alternative peripheral nerve surgeons such as neuro-
surgeons,andwho thus provided a superb contribu-
tion,reflecting his capabilitiesas a vital complement
to nerve surgery.
I also owe thanks to Springer-Verlag Heidelberg
and its staff,who placed great confidence in our work.
Without their cooperation and help,this book would
not have reached completion.
prof.Götz Penkert
Contents
Part I General Considerations in Nerve Surgery Part II Specific Types of Nerve Lesioins
1 Historical Development 5 EntrapmentSyndromes . . . . . . . . . . . 27
of Peripheral Nerve Surgery . . . . . . . . . 3
5.1 Thoracic Outlet Syndrome . . . . . . . . . 28
2 Anatomyand Histological Reaction 5.2 Costoclavicular Syndrome . . . . . . . . . 31
of Traumatized Nerves . . . . . . . . . . . . 5 5.3 Hyperabduction Syndrome . . . . . . . . . 31
5.4 Suprascapular Nerve Entrapment . . . . . 32
2.1 Macroscopic Anatomy ofthe 5.5 Ulnar Nerve Entrapment
Peripheral Nerve System . . . . . . . . . . 5 at Elbow Level . . . . . . . . . . . . . . . . 35
2.2 Microscopic Anatomy ofthe 5.6 Median Nerve Entrapment
Peripheral Nerve System . . . . . . . . . . 6 at Elbow Level . . . . . . . . . . . . . . . . 39
2.3 Types and Degrees ofNerve Lesion . . . . 7 5.7 Anterior Interosseous
2.4 Scar Tissue Reactions Nerve Entrapment . . . . . . . . . . . . . . 41
Following Nerve Lesion . . . . . . . . . . . 9 5.8 Posterior Interosseous
Nerve Entrapment . . . . . . . . . . . . . . 42
5.9 Superficial Radial Nerve Entrapment . . . 45
3 Clinical Presentation of Nerve Lesions . . . 11 5.10 Median Nerve Entrapment
at Wrist Level . . . . . . . . . . . . . . . . . 45
3.1 Management ofDiagnosis . . . . . . . . . 11 5.11 Ulnar Nerve Entrapment
3.2 Surgical Types ofNerve Lesion at Wrist Level . . . . . . . . . . . . . . . . . 50
and Treatment Modalities . . . . . . . . . . 11 5.12 Lateral Cutaneous Nerve Entrapment
3.2.1 Entrapment Syndromes . . . . . . . 11 ofthe Thigh . . . . . . . . . . . . . . . . . 52
3.2.2 Traumatic Nerve Lesions 5.13 Pudendal Nerve Entrapment . . . . . . . . 55
in Continuity . . . . . . . . . . . . . 12 5.14 Sciatic Nerve Entrapment
3.2.3 Traumatic Nerve Lesions at the Pelvic Outlet . . . . . . . . . . . . . . 57
Without Continuity . . . . . . . . . 15 5.15 Obturator Nerve Entrapment . . . . . . . . 58
3.2.4 Nerve Rotation . . . . . . . . . . . . 19 5.16 Saphenous Nerve Entrapment . . . . . . . 60
3.3 Timing ofOperation . . . . . . . . . . . . . 20 5.17 Common Peroneal Nerve Entrapment
3.4 Operation in a Bloodless Field . . . . . . . 21 at the Knee . . . . . . . . . . . . . . . . . . 61
3.5 Postoperative Treatment . . . . . . . . . . 22 5.18 Tibial Nerve Entrapment
at the Ankle . . . . . . . . . . . . . . . . . . 63
5.19 Deep Peroneal Nerve Entrapment
4 Scientific Outlook . . . . . . . . . . . . . . 23 at the Ankle . . . . . . . . . . . . . . . . . . 65
5.20 Plantar Digital Nerve Entrapment . . . . . 67
Contents
X
6 Trauma-Related Limb Nerve Lesions . . . 69 PartIII Muscle and Tendon Transfer
in Peripheral Nerve Lesions
6.1 Accessory Nerve . . . . . . . . . . . . . . 69
6.2 Brachial Plexus . . . . . . . . . . . . . . . 72 10 Muscle and Tendon Transfer . . . . . . . . 127
6.2.1 Addendum . . . . . . . . . . . . . 85
6.3 Long Thoracic,Suprascapular, 10.1 Introduction . . . . . . . . . . . . . . . . 127
Dorsal Scapular,Thoracodorsal Nerves . . 85 10.2 General Principles . . . . . . . . . . . . . 127
6.4 Axillary (Circumflex) Nerve . . . . . . . . 86 10.2.1 Prerequisites . . . . . . . . . . . . 127
6.5 Musculocutaneous Nerve . . . . . . . . . 88 10.2.2 Evaluating Muscles for Transfer . . 128
6.6 Radial Nerve . . . . . . . . . . . . . . . . 89 10.2.3 Technical Considerations . . . . . 129
6.7 Median and Ulnar Nerves . . . . . . . . . 94 10.2.4 Postoperative Course . . . . . . . . 131
6.8 Sciatic Nerve . . . . . . . . . . . . . . . . 96 10.2.5 Timing ofOperation . . . . . . . . 131
6.9 Femoral Nerve . . . . . . . . . . . . . . . 98
6.10 Tibial Nerve . . . . . . . . . . . . . . . . . 100
6.11 Medial and Lateral Plantar Nerves . . . . 101 11 Transfers for Functional Reconstruction . 133
6.12 Peroneal Nerve . . . . . . . . . . . . . . . 101
11.1 Scapula Muscles . . . . . . . . . . . . . . 133
11.1.1 Shoulder Abduction
7 Facial Nerve . . . . . . . . . . . . . . . . . 105 (Accessory Nerve) . . . . . . . . . 133
11.1.2 Dorsal Scapular and
7.1 Macroscopic Anatomy . . . . . . . . . . . 105 Thoracodorsal Nerves . . . . . . . 134
7.2 Microscopic Anatomy . . . . . . . . . . . 105 11.1.3 Scapula Winging
7.3 Facial Reanimation . . . . . . . . . . . . . 106 (Long Thoracic Nerve) . . . . . . . 134
7.3.1 Facial Nerve Repair . . . . . . . . . 106 11.2 Shoulder . . . . . . . . . . . . . . . . . . . 135
7.3.2 Nerve Transfer (Hypoglosso-Facial 11.2.1 Shoulder Abduction
Nerve Anastomosis) . . . . . . . . 107 (Axillary and Suprascapular
Nerves) . . . . . . . . . . . . . . . 135
11.2.2 External Rotation
8 Nerve Tumors . . . . . . . . . . . . . . . . 111 (Suprascapular and
Axillary Nerves) . . . . . . . . . . 137
8.1 Symptoms and Diagnosis . . . . . . . . . 111 11.2.3 Internal Rotation
8.2 Therapy and Prognosis . . . . . . . . . . . 111 (Medial and Lateral Thoracal,
8.3 Special Comments on Histology . . . . . 113 Thoracodorsal,and Subscapular
8.3.1 Schwannomas (Neurinomas) . . . 113 Nerves) . . . . . . . . . . . . . . . 141
8.3.2 Neurofibromas . . . . . . . . . . . 115 11.3 Elbow . . . . . . . . . . . . . . . . . . . . 141
8.3.3 Plexiform Neurofibromas . . . . . 115 11.3.1 Elbow flexion
8.3.4 Malignant Neural Sheath Tumors . 116 (Musculocutaneous
8.3.5 Ganglion Cysts . . . . . . . . . . . 116 and Radial Nerve) . . . . . . . . . 141
8.3.6 Glomus Tumors . . . . . . . . . . . 118 11.3.2 Elbow Extension (Radial Nerve) . 144
8.3.7 Local Hypertrophic Neuropathy – 11.4 Wrist and Hand . . . . . . . . . . . . . . . 144
Perineurioma . . . . . . . . . . . . 118 11.4.1 Extension ofWrist,Fingers,
and Thumb (Radial Nerve) . . . . 145
11.4.2 High Median Nerve Palsy . . . . . 149
9 Pain Related toNerve Trauma . . . . . . . 119 11.4.3 Opposition ofThumb
(Median Nerve) . . . . . . . . . . . 149
9.1 Definition ofTypes ofPain . . . . . . . . 119 11.4.4 High Ulnar Nerve Palsy . . . . . . 153
9.2 Treatment Modalities . . . . . . . . . . . . 120 11.4.5 Distal Ulnar Nerve Palsy . . . . . . 153
9.2.1 Neurolysis and Nerve Repair . . . 120 11.4.5.1Adduction ofThumb
9.2.2 Centro-Central Grafting . . . . . . 121 and Abduction
9.2.3 Peripheral Neuromodulation . . . 123 ofIndex Finger . . . . . . 153
Contents
XI
11.4.5.2Intrinsic Muscles 12 Principles of Free Neurovascular
and Claw Hand . . . . . . 156 Muscle Transplantation . . . . . . . . . . 173
11.4.5.3Abducted Little Finger
(Wartenberg Sign) . . . . 159 12.1 Facial Nerve . . . . . . . . . . . . . . . . . 173
11.4.6 Combined Nerve Palsies . . . . . . 159
11.4.6.1Combined Distal Median
and Ulnar Nerve Palsy . . 159 13 Intramuscular Neurotization . . . . . . . . 177
11.4.6.2Combined Proximal
Median and Ulnar
Nerve Palsy . . . . . . . . 159 References . . . . . . . . . . . . . . . . . . . . . 179
11.4.6.3Combined Proximal
Median and Radial
Nerve Palsy . . . . . . . . 160 Subject Index . . . . . . . . . . . . . . . . . . . 183
11.4.6.4Combined Proximal Ulnar
and Radial Nerve Palsy . . 160
11.4.6.5Special Pattern
ofParalysis . . . . . . . . . 160
11.5 Hip . . . . . . . . . . . . . . . . . . . . . . 163
11.5.1 Abduction,Extension ofthe Hip
(Superior and Inferior
Gluteal Nerves) . . . . . . . . . . . 163
11.5.2 Hip Flexion (Femoral Nerve) . . . 164
11.6 Knee . . . . . . . . . . . . . . . . . . . . . 164
11.6.1 Knee Extension
(Femoral Nerve) . . . . . . . . . . 164
11.7 Foot and Ankle . . . . . . . . . . . . . . . 166
11.7.1 Dorsiflexion ofthe Foot
(Peroneal Nerve) . . . . . . . . . . 166
11.7.2 Plantar Flexion
(Tibial Nerve) . . . . . . . . . . . . 167
11.8 Facial Nerve . . . . . . . . . . . . . . . . . 171
Abbreviations
ADM Abductor digiti minimi muscle
AP Adductorpollicis muscle
APB/L Abductor pollicis brevis or longus muscle
BR Brachioradialis muscle
DIP Distal interphalangeal joint
ECRB/L Extensorcarpi radialis brevis
orlongus muscle
ECU Extensorcarpi ulnaris muscle
ED Extensordigitorum muscle
EDM Extensordigiti minimi muscle
EI Extensorindicis muscle
EPB/L Extensor pollicis longus or brevis muscle
FCR Flexor carpi radialis muscle
FCU Flexor carpi ulnaris muscle
FDP Flexor digitorum profundus muscle
FDS Flexor digitorum superficialis muscle
FPB/L Flexor pollicis brevis or longus muscle
IP Interphalangeal joint
MP Metacarpophalangeal joint
MTT Muscle and tendon transfer
PIP Proximal interphalangeal joint
PL Palmaris longus muscle
PT Pronator teres muscle
WC Workingcapacity
