Vinnitsa National Medical University
Course of Neurosurgery
Methodological recommendations on the theme:
Reconstractive neurosurgery. Traumatic affections of the peripheral nervous system.
General symptomatology. And diagnostics of injuries of the main nerves. Indications
to surgery and kinds of operative interventions.
Approved at a methodological meeting of the course of
Neurosurgery
The minute № 1
Head of the department
Moskovko S.P.
Head of the course
Olkhov V.M.
Theme: " Reconstractive neurosurgery. Traumaic affections of the peripheral
nervous system. General symptomatology and diagnostics of injuries of the main
nerves. Indications to surgery and kinds of operative interventions''
Duration of the class: 2,7 hours.
1 Importance of the theme: Traumatic affections of the peripheral nerves are one of the
major problems of neurosurgery.
Injuries of the peripheral nerves occur mainly in persons of young and middle age.
The timely diagnostics, the qualified medical aid at different stages, including surgery are
very important.
2. The educational aims:
To know:
1. Classification of traumatic affections of the peripheral nerves.
2. Manifestation of injuries of the main nerves.
3. Indications to surgery and kinds of operative interventions.
4. Peculiarities of carrying out primary surgical treatment of the wound with affection of
the peripheral nerves
To be able:
1. To examine the patient with the supposed injury of the peripheral nerve.
3. Materials for preparations of the students.
3.1. The basic knowledge, skill, which are necessary for independent studying and
mastering the theme and which are based on interdisciplinary connections:
№№
1.
Discipline
Anatomy
To know
To be able
Anatomy of the
Peripheral nerves
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Neurology
Neurologic symptoms
Traumatic affection of the peripheral
nerves
3.2. The contents of the theme: variant №4
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3.3. The recommended literature:
- The main:
3.4. A map for independent preparation of the student by using literature on the theme Traumatic affections of the peripheral nervous system. General symptomathology
and diagnostics injuries of the main nerves. Indications to surgical treatment.
The primary aim
1
Kinds of injury
of the peripheral
nervous system
Symptomatology
IN PARTIAL
INJURIES OF
THE NERVES
MANIFESTATI
ON
Instruction
s
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Answers
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Traumas of the peripheral nerves are divided into open
and closed. The open are: stab, cut, chipped, fragmental,
injured, crushed wounds; the closed are concussion,
injury, compression, strain, rupture and dislocation. From
the morphological point of view, there are distinguished a
complete and partial anatomic rupture of the peripheral
nerve.
Damage of the nerve is manifested by the complete or
partial block of conductivity which results in a different
degree of disorder of motor, sensitive and vegetative
function of the nerve.
In partial damages of nerves there are symptoms of
irritation in the sphere of sensitivity and vegetative
reactions (hyperpathy, causalgia, hyperkeratosis).
Neuropraxia (praxis–work, apraxia– inability, inactivity
is a temporary loss of physiological function –
conductivity of the nerve after mild injury. Motor
disorders are mainly clinically observed. On the part of
sensitivity first of all paresthesias are marked. Vegetative
disorders are absent or are not expressed. Restoration
occurs within several days. This form corresponds to
concussion
Axonotmesis is a more complex form of damage due to
compression or strain. Anatomic integrity of the nerve is
saved, but morphologicall there is wallerian degeneration
is more distal to the site of damage.
Neuropraxia and axonotmesis are treated
conservatively.
Neurotmesis is a complete rupture of the nerve or severe
injury with a rupture of its separate nervous trunks, due to
what regeneration is impossible without surgical
intervention.
Process of decomposition of the nervous fibres, described
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Complete
rupture of the
nerve.
The acute period
Disturbance
Sensitivity
Disturbance
Treatment.
in 1850 by the French scientist Waller, now is termed –
Wallerian degeneration. Reverse process –
regeneration of the nerve occurs under condition of
exact set of fascicles– sensitive and motor accordingly)
both pieces of the nerve, it proceeds rather slowly (at a
speed of approximately 1 mm day).
The clinical and electrophysiological picture in damages
of the peripheral nerves depends essentially on the time
interval which has passed since the moment of the trauma.
The acute period of the trauma is the period in which
all factors of a trauma on the whole in are manifested a
clinical picture rather than damage of the nerves: shock
respance to pain, blood loss, presence of a secondary
infection, mental trauma etc. The Acute period lasts 15-20
days.
The remote period of the trauma characterized by
formation of the main pathomorfologic changes in the
fibres of the nerve called wallerian degeneration, begins
on the thirds - the fourth week after the trauma.
In the acute period of the trauma the most informative
sign of injury of the nerve is: disturbance of sensitivity
in the zone of innervation.
The best results of treatment are achieved in carrying out
adequate surgery on the day of trauma. Operation is
possible in observance of conditions: presence of the
experts, necessary equipment, suture a material and the
magnifying optics, appropriate anaesthesiological
maintenance, absence of complications of the wound.
Disturbance of movement in complete damages of the
main nerves of extremities is manifested by a picture of
the peripheral paralysis of muscles (atony, areflexia,
atrophy).
Study of sensitivity is often in decisive diagnostics of
affection of the nerve.
Trophic disarders in damages of the nerves are
manifested by perspiration disturbances, immediately
after traumas hyperthermia in the zone of innervationy
with the subsequent reduction of temperature, thinning of
the skin, disappearance of its folds.
Tenderness on palpation and percussion along the
peripheral piece of the injured nerve is a characteristic
sign of regeneration of the nerve after its sewing together
(symptom of Tinnel). The kind and degree of damage of
the nerve promotes further tactics of treatment:
conservative or surgical.
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The basic method of treatment of traumatic affections of
peripheral nerves is – surgical.
Surgical treatment consists of neurolysis
– Internal neurolysis, or endoneurolysis –is a removal of
fascicles from the nervous trunk.
Uturing the nerve together... The fascicles are set and
suturation is carried out exclusively under a microscope.
Operation finishes with immobilization of the extremity
with the help of a plaster bandage. Immobilization for two
– three weeks.
3.5. Materials for self-control.
3.5.1. Questions.
1. What is the open and closed traumatic injuries of the peripheral nerves?
2. Name symptoms of traumatic affection of the main nerves.
3. On the basis of what inspections are diagnoses of traumatic affections of the
peripheral nervous system made?
4. What kinds of operative intervention do you know?
3.5.2. Test tasks for self-control.
The patient of 20 years old has come with complaints of absence of movements in the left
humeral and ulnar joints, with preservation of movements in the fingers and hand,
reduction of sensitivity on the external surface of the shoulder, forearm, hand. One month
ago he had a fracture of transversal processes С5-С6. What is preliminary diagnosis?
+А. Posttraumatic upper humeral left-hand plexiris
B. A posttraumatic neuritis of the left median nerve.
C. A posttraumatic neuritis of the left radial nerve
D. A posttraumatic neuritis of the left ulnar nerve
E. A posttraumatic neuritis of the left median and radial nerves
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The patient has come with complaints of restriction of bending of the hand, absence of
bending of the terminal phalanxes of the 4th and 5th fingers, impossibility of opposition of
the 5th and 1st fingers. On examinationi the hand is claw-like: a hypesthesia in the zone of
the 4th, 5th fingers and hand on the palmar and back surfaces, cicatrixon the upper third of
the medial surface of the left forearm. The preliminary diagnosis?
A. Posttraumatic inferior humeral left-hand plexitis
B. A posttraumatic neuritis of the left median nerve
C. A posttraumatic neuritis of the left radial nerve
+D. A posttraumatic neuritis of the left ulnar nerve
E. A posttraumatic neuritis of the left median and radial nerves
The patient has come with complaints of restriction of bending of the 1-th and the 2-nd
fingers, impossibility of clenching a fist. On examination the hand was edematous with
impossibility of pronation the forearm and with hypesthesia of the palm and the back
surfaces of the 1-st,2-nd,3 –rd fingers, with vasomotor trophic changes and rough cicatrux
at the inferior of the one/ third of right shoulder.
What is the preliminary diagnosis?
A. Posttraumatic inferior humeral left-hand plexitis.
B. Posttraumatic neuritis of the left median nerve.
C. Posttraumatic neuritis of the left radial nerve.
D. Posttraumatic neuritis of the left ulnar nerve.
E. Posttraumatic neuritis of the left median and radial nerves
3.6. Subjects of the Research Themes: " RECONSTRACTIVE NEUROSURGERY. Traumatic
affections of the peripheral nervous system. General symptomatology and diagnostics of
damages of the main nerves. Indications to surgery.”
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