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A-1281 Peripheral nerve repair: where do we stand?
Dominic Power, UK
Wednesday, June 13, 2018 · 1:03 p.m. · 15m 26s
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00:00:00
good afternoon everyone yeah it's great on it to be invited to contribute to this instructional
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course on those injuries and but i got a house i think to cover
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a huge area so what i was ah city was just a little bit
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of oversight about where rat seen perform that repair and potentially lead
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into some of the later discussions so my colleagues as seen from but i mean we'll be talking about chain disconnect is nerve caps
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and later on products after we'll be talking about the managements of homer an algorithm for reconstruction and
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use our draft number also have um something about pain management for topics on this apostle or
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oh so it number decorations i'm actually research leadership for a research that working by me and in the u. k.
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and we do get some financial support both simply comics and tracks jen for cases recruited into trials
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so i'm gonna touch on is very briefly a little bit about diagnosis improve for
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that 'cause that's the key to this question the diagnosis right the first time
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so that you can get the right patients the right person for appropriate treatment in a timely fashion
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and then i got such a mouthful so i haven't almost exclusive perform the
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fact is something to talk about my worries about what we don't
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currently and where we need to improve i'll touch on management of the nerve cat but they'll be a lot more detail on this later
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and then i'm just going to talk about my personal interest which is how we can use nerve transfers surgery to try and improve outcome
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so we all know that there's a classification system for prefer that injuries and setting is what we use
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in common hyperactive soon your it tracks yeah jaunts missus neural to me says how we know who
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that many patients with exxon to missus injuries do not
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behave similarly and hence someone's classification trying to
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on the stand why some patients may get worse outcome than others depending
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on the depth of injury to the and the neural cheap structure
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but obviously we now have all current concepts run your a pack sick
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injuries and not on your a tactic injuries are the same
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so these can encompasses scheme a a team uh d. ma nation as well as the traditional concepts around backchannel injury
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that was some prefer no dingy we need to understand that makes no of is not one single fibre type
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there are combinations of moderated nominated large and small fibres and if
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you look at the different for the subtype they'll have
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different functions and they've developed specifically to control those functions so
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lot fibres which a moderated to reduce the energy expenditure
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control important functions like fast most uh function
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control through the reflex dog fast pain fibres and sensation but the small fibres are the
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ones that are necessary for jaime static functions such as autonomic function slow painted pressure
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what's you understand that you start to understand some of the concepts ramp reform that injuries such that's
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in your a pack sick injury preferentially picks off
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those high oxygen and energy dependent processes
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so it affects the loss moderated fibres preferentially so we can
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use this not clinical assessments of prefer that injuries
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and what patients just got a full blown axon to make to
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me take injury so all items of damage effectively equally
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we will see this spectrum of loss of fibre type involving
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not only the lodge moderated fibres but also the smaller
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on mon eighty five is there's home is static control mechanisms
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and so in these patients we experience near perfect pain
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a strong tell signed at the sight of injury and dry skin due to loss
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of autonomic function and this is critical to our understanding to perform that injury
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and not to delay the point but if you don't recognise and uh fits on that your
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s. and the that struggling then that node can deteriorate and in europe actually can read
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if you wait too long and you don't do definitive decompress of surgery that can deteriorate become an x. on
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some of the injury or a low grade acts only injury which is compressed is got can deepen
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to become a more severe injury and that's the principle that we need to adhere to prompt recognition of
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injuries and prompt diagnosis when necessary so i call
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it dominates the so basically the decision making
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for surgery on the performance of it for diagnosis if there's any doubt deterioration molly observing
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the patients the patient who things got in your price again g. develops dry skin
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and the reason is deepening should be playing on the on the observation debilitating that pain a patient who's got
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a dislocated joint that's had a lengthy period of this
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occasion props reduction or very severely displays factor fragments
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but also delayed recovery so the patient who's not progressing as you would want them to
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so i'm just gonna touch on the different things that we're gonna discuss this afternoon so we've got probably not repair
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bridging caught station assist devices facetious repair conduits for short
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segments got our draft and we've got autographed and
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we think that the gold standard is biker surgical never pass for white we get your aim is
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we'll do mike residual never had yet many of our patients end up in this
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situation this is a simple low energy clean cut laceration within your enough
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well the thing is that we can change and the things that we can't change two things we can change
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or perhaps the alignments of our pat the quality the repair maybe the tension which will come on to
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we can control the adequacy of the department and the time since injury but
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backed by getting or diagnosis right and appropriate and eating promptly without injury
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what we call controls where the nerves engine parts malaysians do worse
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still knows best median nerve we can't control the bad necessarily
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there are certain things that are outside of our control but there are things in green that we should be focusing on
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well why don't tension so when we cut to know that spins apart we will witness this vertically those as you do know transfer surgery
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and the reason is happens is ten sec thirty seven actual tension within biological structures such they spring apart that when you switch
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that not all of those forces the concentrated rental switches and as such that goes to school and a c. d. f.
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and if you wait if there's a delay to surgery than the changes its
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modulus of austin city the gap increases and the noticed a thought
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so there's more force concentration rounder pass side i did you wait too long thing that needs
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to providing and i you definitely got a gap and that cat needs managing with graft
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and the problem is teaching us is you get scar tissue as a reaction to that stress concentration around your teachers
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and laces grading system looks at the up in your school or
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the n. m. d. perry neural scar and score involving
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into the sick that in your room and you can see in the picture here this is a that repaired it's
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failed program class appearance of fibrous tissue which prevents observer
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regeneration and i believe this is largely tension driven
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so this is a clean cut median nerve injury associate with some facts tendons over patted the rest
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but as you can see the new remedies will be on the side of the original repair
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and this is because of tension continuing to act on that repair slides or surgical failure of the repairs side
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so when you cut the meeting that in a fresh frozen could have a menu
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cycle the rest into hyper extension big gap is typically about eighty millimetres
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i didn't repair that have an concentrate those forces across that narrows irving where you've structured
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this procedure with twelve the twelve teachers you get progressive idea of either the
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sutures break all the cuts out so the nerve doesn't behave well there's no no
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i've lost the this is just we're concentrating those forces on repairs side
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so this may explain why we get new rooms in continuity excessive force was acting across or repair side
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so my research my for process a lot can we achieve a robust tension free repair
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can we actually avoid putting stitches and uh i've got a trout has seen we'll talk about
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which is actually building on previous work but is effectively trying to take in that repair
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hands bridging will supporting that now have using conduits so these
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conduit to use just caught station assists rather than to
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bridge gaps on the hope is that we can actually reduce the number of speeches in the repair side
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and we can ultimately results in the situation of the situ less
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tension free repair for this trial is recruiting at the moment
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and there's good evidence behind this so this is a papers do without china option the
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backend of last year demonstrating the review repair and uh evan wrap it with a
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calm the weights you actually reduced thoughts have that and pain and complications associated with that
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in your fee and this is in the replant series but it doesn't necessarily
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improve the sense recovery that may be more dictated by the degree of cooled
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off and his work from michael bucks ninety thousand here in copenhagen
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that details the main median uh phenomena prepare in the form of the gap up to six millimetres
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can do perfectly well you can get good regeneration without necessarily having
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sutures we need to build on this work i believe
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so where are we in prefer no repair we've all seen scott's properly the rise and fall of a surgical technique a huge enthusiasm with early
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adopters a few dodgy damaging reports and then proceed just drop out of
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use this can be used for many many procedures in surgery
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i probably would come to it's it was the idea that we could avoid using cross
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so we could use conduits forever think that's a fact we probably have become
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more temperate in how we would use conduit some maybe in the future
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we will get to the stage where we can improve neural regeneration over longer distances more sustained
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this is the paper from our action for looking at come to
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it's published in the journal american journal last year suggesting that
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although there's this enthusiasm we probably get disillusioned and we finding
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a platter productivity which one are testing will expand on
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about how we can perhaps use conduits is quite to should be quite station it's if it's not necessarily just for bridging gaps
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but not all things are equal to this exact oxygen connect at this is a college in connector which is
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being used in a and if you had a very the repair model where there's no no loss
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no it's very nice to consider speechless repair with a cot station assessed
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but if as excessive tension it will still fail as you can see in the sequence here this is hyper
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extending the repair with force you just at each end so tension is still an issue so it's
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not only citrus repair but also assessing and managing the tension is the key
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so how can we do to detention enough well clearly we can use conduits in create a supported
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segment perhaps leaving the small micro gap but we can potentially putting our craft an autographed
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most of us we go to new or fees but isn't that bad well actually forty six years ago and i'm a lazy wrote about this
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you know if you can put a good croft across and uh they can be should here yeah
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to a prime repair and in fact tension acting across repair
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site is far worse than having a well placed croft
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so why don't we adopted this will brokerages of hot it was max planck said you need
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to wait for the all got to die out for the new techniques to be adopted
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perhaps that's where we are we need to revisit the gold standard of nerve crafting
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and uh prepare a perhaps look more critically how we can detention us
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and of course we now have an option available which makes it more acceptable to patients because as the opportunity for us to use our craft
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a short segments into position without having to harvest the patients i don't
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know if we've got conduits that are developing improving the performance
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when you take a short segments other crossed in in suppose it's a big gap this is cycled
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to faye f. this is just sit should with a couple of micro neural speech is a teacher and in
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actual fact it doesn't the hiss so well that we've used us each of them use with the connector
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this fe via this croft does not fail because the tensions be mitigated
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and so i believe that we can even move towards glue repairs and
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connect assisted repairs without speech is using short segment detention cross that
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this is where we need to do the research unfocused going forward so
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the whole series of techniques available to us from prime repair
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bridging caught station assists short segment cross how to craft and
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what got that where where do we actually see it
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i'm sure about that stuff will touch on the evidence to process nevada graft in my pack this is
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limited by reimbursement in the u. k. but it does have a role in sensory motor and mixed
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i believe the gold standard is rapidly becoming our craft for this
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with the situation a patient with a painful neural net
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why inflict and oven that enjoy the patient basically when you main
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reason for operating is the paid not necessarily for sentry outcome
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it allows you to do and how it caught the spoke to bribe meant once you're happy that you define the cat you can put in
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the autograph to the appropriate lent so you're not limited by you don't know how oversight this was you know to to put two
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centimetres in this situation the seven years post academic injury to
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the meeting uh fit the rest during carpal tunnel release
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this patients been living with people are taking a pain to sell them the idea that i'm going to
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open um maybe open you like as well it takes nerve graft i'll make another area of your
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arm high risk of numbness and pain is a difficult one but autographed here is a pain management
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strategy where i'm not really bothered whether the g. p. d. is six millimetres like millimetres or
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fifty millimetres hunting operation for pain so in the u. k. i use autographed and
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i use it fits into maturity ms i use it fell promptly surgery
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i've got lots of complex trauma cases whether just isn't enough products
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holidays now of um i'm sure again and talk to
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stuff will talk about some of his indications in homer's well that is rapidly changing and
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if we look at the nice review we came out in november last year this
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basically set the scene for u. k. saying well there's been safety and efficacy data
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um so the footage from the repair and reconstruction howard leftist entirely
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pretty pretty uses outside kitchen as you need to do
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governments or get research in the same way that you do when and and i think is being evaluated
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also this craft still remains all gold standard large gaps critical gaps
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we can't get assault is the gold standard and we
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need to have data and the h. from comparative studies looking how to craft an autographed if we're going to look
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really critically makes much sense you know and there is data emerging on this but there are situations where autographed doesn't wipe
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take the well we all face them devotion injuries very proximal
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no injuries very pour surgical beds failed primary surgery
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you don't agree off but then later channels progression is low so in these
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situations i will use no transfers is not junk surfer critical discourse
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function it's increasingly large part of our pack this enough transfer those it
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and do it as effectively taking a facile from intact knife
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and we worry it since the motor function that's not working in the
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hope you get rapidly innovation recovery this can be used as
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an adjunct for critical function when there's a proximal the the region it's very so the so that's my if if you
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i'd like to wait for any questions later paths all panel can take them
Conference Program
A-1281 Peripheral nerve repair: where do we stand?
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June 13, 2018 · 1:03 p.m.
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A-1282 Peripheral nerve repair; the conduit option and management of end neuroma's
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A-1283 Evolution of my Algorithm for treating traumatic peripheral nerve injuries
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A-1303 Evolution of my algorithm for the surgical management of pain
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June 13, 2018 · 2:03 p.m.
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