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| NI FEATURE: FACING ADVERSITY…TOMORROW IS ANOTHER DAY! - COMMENTARY |
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| Year : 2019 | Volume
: 67
| Issue : 7 | Page : 140-141 |
Management protocol in the case of iatrogenic peripheral nerve injuries
Sumit Sinha
Department of Neurosurgery, Paras Hospital, Gurugram, Haryana, India
| Date of Web Publication | 23-Jan-2019 |
Correspondence Address:
Dr. Sumit Sinha
Department of Neurosurgery, Paras Hospital, Gurugram, Haryana
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0028-3886.250696
How to cite this article:
Sinha S. Management protocol in the case of iatrogenic peripheral nerve injuries. Neurol India 2019;67, Suppl S1:140-1 |
Iatrogenic nerve injuries are injuries caused by medical intervention or caused accidentally during the course of treatment. They carry an enormous medical, social and medicolegal importance and account for approximately 20% of all traumatic nerve lesions. The authors have attempted to address the aetiology, diagnosis and management strategies of these lesions along with a brief description of the medico-legal implications, which these injuries are associated with.[1]
The causes of iatrogenic injuries can be non-operative or operative.[1],[2] The non- operative causes of iatrogenic injuries are injection injury, injuries caused due compression by a tourniquet, hematoma, dressing, orthotic device, or injury due to radiation induced damage.
The operative causes may be pressure damage due to a faulty patient positioning or most commonly (94%), a direct intra-operative damage. Intra-operatively, the nerves can be transected, ligated, crushed underneath the screws, damaged during the removal of the spinal implants or stretched by retractors. Certain surgical procedures have a propensity towards nerve damage, such as, arthrodesis, lymph node excision in posterior triangle of the neck (accessory nerve), carpal tunnel surgery (median nerve), and varicose vein or inguinal hernia surgery (femoral nerve). The high-risk sites likely to be affected include the carpal tunnel, posterior triangle of the neck and knee, the popliteal fossa, the elbow (ulnar nerve) and the fibular head (common peroneal nerve). The nerves run superficially in these regions and are prone to either a direct damage during the surgical procedure or may be damaged indirectly due to faulty positioning or placement of a cast.
The most frequently injured nerves are the median, spinal accessory, peroneal, radial, genitofemoral, ilioinguinal, radial, as well as the ulnar nerve, and the brachial plexus.
There has been a trend towards a delayed referral of these injuries by the treating physicians due to the inability to recognize or manage these injuries. The importance of an early diagnosis and identification of these injuries cannot be over-emphasized. Several studies in literature have shown a successful outcome for these injuries with an early intervention (preferably within 3-4 months, and at the latest by 6 months).[3] The radial nerve, tibial nerve and accessory nerve lesions have a good prognosis, while the sciatic nerve and peroneal nerve lesions have a poor prognosis.[4],[5] The factors influencing prognosis regarding recovery in these injuries depend upon: The severity of injury, the lesion site, the mechanism of injury, and the type of surgical procedure. Proximal injuries and blunt transections have a poorer prognosis. The patients with pressure palsies because of improper positioning during surgery, frequently have incomplete palsies. 90% of these injuries heal spontaneously over months.
The management principles are the same as for traumatic nerve injuries. The ideal time to repair a nerve that is recognized to be transected during surgery is during the same surgery or the latest within 2-3 weeks.[6],[7] If there is a clean-cut transection, end-to-end coaptation is done in the same sitting. However, if the cut ends are ragged, an early secondary repair is performed within 3 weeks. This ideal situation is seldom encountered as the nerve damage is not noticed until after the surgical procedure and usually the wait for spontaneous recovery extends for too long a duration. If the nerve damage is noticed after the surgical procedure, the patient undergoes monthly clinical examinations for any signs of improvement. If the function does not improve in the next weeks or months or if the Tinel's sign does not shift distally, an exploratory operation is warranted in 3 weeks. The role of preoperative or intraoperative ultrasound and neurophysiology is crucial to suggest the presence of a severed nerve or a neuroma-in-continuity.[8] If the ultrasonography does not indicate a severed nerve or a neuroma-in-continuity, a clinical and neurophysiological follow up is continued. If no improvement occurs after 3 months, surgical exploration and repair is warranted after 6 months at the latest. The outcome of nerve repair after the end of 6 months is dismal, with the notable exception being of spinal accessory nerve, where useful nerve function can still be expected as later as 9 months after the injury.[5]
The combination of morphological assessment (neurosonography) with functional assessment (nerve conduction studies) is of paramount importance in the management of traumatic peripheral nerve injuries. If on sonography, the nerve appears intact, then intraoperative nerve conduction studies the functionality of the nerve. If conduction is impaired (signifying the presence of a neuroma-in-continuity), then nerve grafting is done. If the conduction is somewhat preserved, neurolysis is performed.
| » References | |  |
| 1. | Kumar A, Shukla D, Bhat DI, B Indira Devi B. Iatrogenic peripheral nerve injuries. Neurol India 2019;67:S135-9.  |
| 2. | Kretschmer T, Heinen CW, Antoniadis G, Richter HP, Konig RW: Iatrogenic nerve injuries. In: Spinner RJ, Winfree CJ, eds.: Neurosurg Clin N Am. Philadelphia: W.B. Saunders Company 2004;20:73-90. |
| 3. | Kretschmer T, Antoniadis G, Braun V, Rath SA, Richter HP. Evaluation of iatrogenic lesions in 722 surgically treated cases of peripheral nerve trauma. J Neurosurg 2001;94:905-912. |
| 4. | Shao Y, Harwood P, Grotz M, Limb D, Giannoudis P. Radial nerve palsy associated with fractures of the shaft of the humerus: A systematic review. J Bone Joint Surg Br 2005;87:1647-52. |
| 5. | Camp SJ, Birch R. Injuries to the spinal accessory nerve: A lesson to surgeons. J Bone Joint Surg Br 2011;93:62-7. |
| 6. | Kim DH, Murovic JA, Tiel R, Kline DG. Management and outcomes in 353 surgically treated sciatic nerve lesions. J Neurosurg 2004;101:8-17. |
| 7. | Camp SJ, Birch R. Injuries to the spinal accessory nerve: A lesson to surgeons. J Bone Joint Surg Br 2011;93:62-7. |
| 8. | Koenig RW, Schmidt TE, Heinen CP, Wirtz CR, Kretschmer T, Antoniadis G, et al. Intraoperative high- resolution ultrasound: A new technique in the management of peripheral nerve disorders. J Neurosurg 2011;114:514-21. |
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