Introduction: Our goals were to observe and evaluate the outcome of pain reduction and long length acellular cadaver allograft use in the repair of sciatic nerve injuries of patients injured in recent military conflicts. Traumatic injury to the sciatic nerve is associated with widespread soft tissue and bone injuries, significant neurologic impairment, severe neuritic pain, and a prolonged recovery.
Methods: Retrospective review of 5137 combat related extremity injuries, 2007-2013, with 13 having sciatic nerve injury without amputation of the affected side.
Results: Thirteen patients were identified with combat-related sciatic nerve injuries, all were male, mean age was 28. The mechanisms of injury were 9 gunshot wounds (69%), 2 rocket propelled grenade blasts (15%) and 2 improvised explosive device blasts (15%). Three patients (23%) were found to have a neuroma in continuity, and required only neurolysis. Eight, patients (53%) with nerve transections and neuroma formation had long length (5-7 cm) cadaver allograft grafts placed, one patient had a sural nerve autograft (5 cm), and 1 patient underwent end to end direct nerve repair. Five (38%) patients underwent surgery 21 to 30 days after the time of injury (early), and eight (61%) patients had surgery greater than 150 days after injury (standard). There was no difference in the amount of nerve resection between the early and late groups, and both had equivalent pain and narcotic use reductions at 6 weeks and 6 months. There were no graft infections or rejections.
Conclusions: Traditional teaching is to delay nerve repair for at least six months to provide opportunity for the damage to the injured nerve to fully declare itself. Our experience suggests that combat related sciatic nerve injuries can be operated on 21-30 days post-injury, with benefit toward reduction of neuritic pain, and long-length cadaveric allografts may be placed without infection/rejection.
Patient Care: There is limited data that describes the treatment of these significant and devastating nerve injuries. The significance of severe neuritic pain after sciatic nerve injury should not be underestimated. We hope our small study sheds light on a relatively poorly understood area of patient care, and inspires future study on the timing (early vs. deliberately delayed) of nerve repair and on the potential of emerging cadaveric nerve allograft products.
Learning Objectives: By the conclusion of this session, participants should be able to:
1) Briefly describe the epidemiology of wartime peripheral nerve injuries
2) Discuss the significance of neuritic pain in those suffering sciatic nerve injury
3) Describe the general characteristics of cadaveric peripheral nerve allograft
4) Discuss the arguments, for and against, regarding the consideration of surgery to manage neuritic pain after trauma to a major peripheral nerve
References: 1. Birch R, Misra P, Stewart MPM, Eardley WGP, Ramasamy A, Brown K, et al.: Nerve injuries sustained during warfare: part I--Epidemiology. J Bone Joint Surg Br 94:523–528, 2012
2. Brooks DN, Weber RV, Chao JD, Rinker BD, Zoldos J, Robichaux MR, et al.: Processed nerve allografts for peripheral nerve reconstruction: a multicenter study of utilization and outcomes in sensory, mixed, and motor nerve reconstructions. Microsurgery 32:1–14, 2012
3. Campbell WW: Evaluation and management of peripheral nerve injury. Clin Neurophysiol 119:1951–1965, 2008
4. Cho MS, Rinker BD, Weber RV, Chao JD, Ingari JV, Brooks D, et al.: Functional outcome following nerve repair in the upper extremity using processed nerve allograft. The Journal of Hand Surgery 37:2340–2349, 2012
5. Fu SY, Gordon T: Contributing factors to poor functional recovery after delayed nerve repair: prolonged denervation. J Neurosci 15:3886–3895, 1995
6. Fujimoto E, Ohshima C, Okamoto K, Ide C: Possibility of using nerve segments dissected from human cadavers for grafting: preliminary report. Anat Sci Int 81:34–38, 2006
7. Furey MJ, Midha R, Xu Q-G, Belkas J, Gordon T: Prolonged target deprivation reduces the capacity of injured motoneurons to regenerate. Neurosurgery 60:723–32– discussion 732–3, 2007
8. Jonsson S, Wiberg R, McGrath AM, Novikov LN, Wiberg M, Novikova LN, et al.: Effect of delayed peripheral nerve repair on nerve regeneration, Schwann cell function and target muscle recovery. PLoS ONE 8:e56484, 2013
9. Kang JR, Zamorano DP, Gupta R: Limb salvage with major nerve injury: current management and future directions. J Am Acad Orthop Surg 19 Suppl 1:S28–34, 2011
10. Kim DH, Murovic JA, Tiel R, Kline DG: Management and outcomes in 353 surgically treated sciatic nerve lesions. J Neurosurg 101:8–17, 2004
11. Mack AW, Freedman BA, Groth AT, Kirk KL, Keeling JJ, Andersen RC: Treatment of open proximal femoral fractures sustained in combat. The Journal of Bone and Joint Surgery 95:e13(1–8), 2013
12. Miric DM, Bumbasirevic MZ, Senohradski KK, Djordjevic ZP: Pelvifemoral external fixation for the treatment of open fractures of the proximal femur caused by firearms. Acta Orthop Belg 68:37–41, 2002
13. Murovic JA: Lower-extremity peripheral nerve injuries: a Louisiana State University Health Sciences Center literature review with comparison of the operative outcomes of 806 Louisiana State University Health Sciences Center sciatic, common peroneal, and tibial nerve lesions. Neurosurgery 65:A18–23, 2009
14. Plagge H, Ruppen W, Ott N, Fabbro T, Bornand D, Deuster S: Dose calculation in opioid rotation: electronic calculator vs. manual calculation. Int J Clin Pharm 33:25–32, 2011
15. Roganovic Z: Missile-caused complete lesions of the peroneal nerve and peroneal division of the sciatic nerve: results of 157 repairs. Neurosurgery 57:1201–12– discussion 1201–12, 2005
16. Roganovic Z, Pavlicevic G, Petkovic S: Missile-induced complete lesions of the tibial nerve and tibial division of the sciatic nerve: results of 119 repairs. J Neurosurg 103:622–629, 2005
17. Siemionow M, Brzezicki G: Chapter 8: Current techniques and concepts in peripheral nerve repair. Int Rev Neurobiol 87:141–172, 2009
18. Smith JK, Miller ME, Carroll CG, Faillace WJ, Nesti LJ, Cawley C, et al.: High resolution ultrasound in combat- related peripheral nerve injuries: A case series, Philadlphia, PA, 2014, Vol. 66
19. You S, Petrov T, Chung PH, Gordon T: The expression of the low affinity nerve growth factor receptor in long-term denervated Schwann cells. Glia 20:87–100, 1997