RU2153295C2 - Method for performing autoneuroplastic operations - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves placing transplants in retrograde way between the central and peripheral ends of nerve taking into account their anatomic structure and ends orientation. The injured nerve ends are attached to sublayer tissues through epineural flaps. The transplants are surrounded with subcutaneous fat tissue fragments having vascular pedicle. EFFECT: improved blood supply and peripheral nerve regeneration; high strength of anastomosis; prevented cicatrix formation. 2 dwg

Description

 The invention relates to medicine, surgery of peripheral nerves and can be used to restore the anatomical integrity of a large nerve defect.

 A known autoplasty method according to Milles / Milles H., Meissl G., Berger A. The interfascicular nerve-grafting of the median and ulnar nerves.- J. Bone Joint Surg., 1972, 54-A, N 4, 727-750; Grigorovich / Grigorovich K.A., Nerve Surgery: Selected Chapters.- L., 1969, p. 171-174, when after refreshing the ends of the nerve with its large defect, the nerve bundles of the autografts with the proximal and distal segments of the damaged nerve are micro-surgically anastomosed. In this case, axons from the central end of the nerve through the endoneural tubes of the grafts germinate to the peripheral end of the nerve. However, autografts with nerve ends are placed without regard to their anatomical orientation. If axons from the central end of the nerve grow into the central end of the autograft and move along its endoneural tubes, then some of them will not reach the peripheral end of the graft, but will come to its lateral surface along the side branches that were cut off during the sampling of a segment of the skin nerve, taken as an autograft. The longer the transplant, the more lateral branches are cut off, and therefore, the majority of the regenerating axons from the central end of the damaged nerve will go through the endoneural tubes, which will lead them to the lateral surface of the graft, and not to its peripheral end, where the axons grow into the peripheral end of the damaged nerve and provide regeneration. The fewer regenerating axons that enter from the central end of the nerve through the autograft to the peripheral end, the worse the function of the damaged nerve is restored.

 In addition, after autoplasty by this method, the ends of the nerve lying freely gradually decrease after some time, which causes tension on the suture line between them and the autografts, which in turn gradually shrink and decrease in length. All this together leads to the failure of the anastomoses and the deterioration of regeneration.

 Another disadvantage of this method of autoplasty is the possibility of scarring and necrotization of autografts. The latter feed on interstitial fluid until regenerative axons from the central end of the nerve grow into them. The longer the transplants, the more time it takes for axons to grow through them, the greater the likelihood of necrosis and subsequent resorption of the peripheral ends of the autografts.

 The prototype of the proposed method is a method of autoneuroplasty (a.s. 1286181 from 09.09.86, Bull. VAK N 4 from 01.30.87), in which, in order to improve regeneration by more accurately matching fascicles and increasing the strength of their anastomoses, the graft segments are fixed interconnected seams at points spaced from the lines of the anastomoses at a distance greater than the diameter of the damaged nerve, and additionally apply epineural stabilizing sutures between the proximal and distal ends of the damaged nerve.

In the proposed method, the anatomical orientation and structure of the segments of the skin nerves are completely not taken into account, during the collection of which numerous side branches are cut off. The passage of regenerating axons from the central end of the nerve through the endoneural tubes of the lateral branches in the transplants leads to an interruption of their path at the cutoff sites of these lateral branches on the lateral surface of the grafts and to a decrease in their number at the peripheral end of the nerve, and, consequently, to a deterioration of the regeneration process
Fixation of the transplant segments among themselves makes them a single conglomerate, inside of which the flow of interstitial fluid for their nutrition is difficult. In addition, this conglomerate of grafts dramatically complicates the handling of microsurgical sutures between the grafts and fascicles of the nerve ends. It excludes the possibility of freely laying each graft without rotation along the axis between the ends of the damaged nerve.

 Stabilizing epineural seams between the proximal and distal ends of the nerve prevent the divergence of the ends of the nerve. However, they are foreign bodies lying all along the grafts. The reaction to this long suture material can contribute to scarring and poor nutrition, as well as blood supply to autografts, which negatively affects the regeneration process.

 In the method of autoplasty, taken as a prototype, there are no conditions for the prevention of scarring and improve blood supply to autografts.

 The invention is directed to the creation of a method of autoneuroplasty, providing improved regeneration by reaching all the axons that have grown into the grafts, the peripheral end of the nerve; increased strength of the anastomoses due to the fixation of the ends of the nerve with epineural flaps to the underlying tissues; preventing scarring and improving blood supply to autografts by covering them with subcutaneous fat on a vascular pedicle.

 For this, between the proximal and distal segments of the nerve, autografts are placed retrograde taking into account their anatomical structure and orientation of the ends. The very ends of the damaged nerve themselves are fixed for epineural flaps to the underlying tissues. In addition, grafts are surrounded by fragments of subcutaneous fat on the vascular pedicle.

 The inventive method differs from the prototype in that all nerve autografts are placed between the central and peripheral ends of the nerve “at random”, and, taking into account their anatomy, retrograde, that is, the peripheral end of the nerve graft is sutured to the central end of the damaged nerve, and to the peripheral end nerve - the central end of the graft. In addition, the ends of the damaged nerve before applying anastomoses between them and the grafts are fixed for epineural flaps to the underlying tissues. Autologous nerves themselves are framed with fragments of subcutaneous fat on a vascular pedicle.

 Hemming the central end of the nerve to the central end of the graft leads to the fact that part of the regenerating axons grows in the transverse section of the graft into the endoneural tubes corresponding to the lateral branches, and after passing some distance, ends its course at the cutoff points of these lateral branches on the lateral surface of the graft without reaching the peripheral end of the graft.

 Thus, the more grafts are placed between the ends of the damaged nerve without taking into account the orientation of their ends and the longer the grafts are, the more regenerating axons will not reach the peripheral end of the damaged nerve and will not provide the regeneration process.

 Suturing the peripheral end of the graft to the central end of the damaged nerve leads to the fact that all regenerating axons grown into the endoneural tubes of the peripheral end of the graft reach its transverse section at the central end, and therefore can grow into the peripheral end of the damaged nerve and provide more complete regeneration .

 Fixation of the ends of the damaged nerve for epineural flaps to the underlying tissues prevents the divergence of the ends of the nerve after autoplasty. The occurrence of the slightest tension can lead to the failure of microsurgical anastomoses.

 Thus, the proposed fixation contributes to the entire term of axon germination through transplants to relieve tension on the suture line between the transplants and the ends of the nerve.

 Plating autografts with fragments of subcutaneous fat on the vascular pedicle prevents their scarring by other tissues. Free autografts in adipose tissue feed better and are supplied with blood, which means they are less prone to necrosis (a.c. N 825025, Bull. VAK N 16 of April 30, 1981). In addition, fatty tissue for skin nerves, which are taken as autografts, is the medium of their natural location in the body, and therefore, the most optimal.

 The invention is illustrated by drawings, where in FIG. 1 schematically shows an autograft from a cutaneous nerve, in which, on a transverse section of the central end 1, there are beams belonging to the lateral branches 2, which are cut off on the lateral surface of the graft when it is taken. These bundles of lateral branches do not reach the peripheral transverse section 3 of the graft.

 In FIG. 2 shows autografts 4, the central ends of which 1 are sewn to the peripheral end of the nerve 5, and the peripheral ends 3 to the central end of the nerve 6. Both ends of the nerve 5 and 6 for the epineural flaps 7 are stitched to the underlying tissues with several sutures 8. The grafts 4 are freely located on a fragment of subcutaneous fat 9. placed under them. Another fragment of subcutaneous fat 10 is placed on top of the transplants 4.

 The method is as follows.

 After revealing a large defect of the nerve trunk during surgery, they begin to refresh the ends of the nerve with cutting out the epineural flaps. At the central end of the nerve, on the lower surface of the neuroma, a flap is cut out from its sheath and epineuria about 1/6 of the circumference of the nerve with a width slightly longer than the length of the neuroma. This flap is turned away along the nerve in the proximal direction and along the edge of the transition of the flap into the epineurium of the nerve, make the transverse intersection of the central end of the nerve to obtain distinct bundles in the transverse section. When refreshing the peripheral end of the nerve, a flap is also cut out on the posterior surface of its edge from the epineurium with a width of about 1/6 of the circumference of the nerve. After bending the flap in the distal direction along the nerve, a transverse intersection of the peripheral end of the nerve to distinct bundles is performed.

 Then, the central and peripheral ends of the nerve are hemmed by flaps 7 to the underlying tissues with a thread 3 / 0-4 / 0 in a slightly stretched state with three or four sutures 8.

 After that, counter fragments of subcutaneous fat 9 and 10 are formed, for which a fragment of subcutaneous fat 9 is cut from one edge of the surgical wound with a good vessel, which is brought to the place between the ends of the damaged nerve so that it can lie on it autografts 4. A fragment of subcutaneous fat 10 cut out on the other side of the surgical wound is subsequently covered with sewn autografts 4.

 Then they begin to take the nerve for autologous transplantation, as a rule, they use the calf nerve. To do this, from the incision behind the outer ankle using a special tool to isolate and cut the calf nerve (a.s. 1581293 from 04/01/90), the calf nerve is taken from one or two legs. After this, grafts 4 are cut from a taken segment of the calf nerve, 15% longer than the distance between the central 6 and peripheral 5 ends of the damaged nerve. Then, the bundles of the peripheral end of each graft 3 are sutured to the bundles of the central end of the nerve 6 using microsurgical techniques and optical enlargement, and the bundles of the central end of each graft 1 are sutured to the corresponding bundles of the peripheral end of the nerve 5. Each graft 4 is freely placed on a subcutaneous fat fragment fiber 9.

 After the transverse sections of the peripheral or central end of the nerve are completely blocked by the transplants, autoplasty is completed by covering the grafts 4 from above with a fragment of subcutaneous fat 10.

 The surgical wound is sutured. Apply an aseptic dressing. Mobilize a limb in a physiological position.

The proposed autoneuroplasty method has passed clinical trials in 17 patients. All patients in this group received a more complete restoration of damaged nerve function compared with a control group of 21 patients, where the results are significantly worse, despite similar conditions affecting regeneration,
Example. Patient G., 51 years old. The medical history N 12747 - 1989. Entered the neurosurgical department 06.09.89, with iatrogenic damage to the ulnar nerve in the region of the right elbow joint. On 7.06.89, a modified section of the ulnar nerve 12 cm long was resected.

 09/19/89, the operation was performed. According to the old incision on the medial surface in the lower third of the right shoulder, the central end of the ulnar nerve, which ends in a neuroma, is distinguished. The latter was cut off to distinct bundles with an epineural flap, for which the central end of the nerve was fixed to the medial intermuscular septum with three sutures with 4/0 thread. From the section along the inner surface in the upper third of the right forearm, the peripheral end of the ulnar nerve is distinguished, which is freshened up to distinct bundles, leaving an epineural flap. For this flap, the peripheral end was fixed to the fascia of the forearm with two sutures with a 4/0 thread. After this, diastasis with the ends of the ulnar nerve through the ulnar fossa was 13 cm, and through the ulnar sulcus - more than 20 cm. Therefore, it was decided to place autografts in the shortest way - through the ulnar fossa. For this, a tunnel is made under the skin of the ulnar fossa in the subcutaneous fat. The bottom of the wound on the shoulder at the central end of the nerve is filled with a fragment of subcutaneous fat on the vascular pedicle, which is cut out from the fiber of the wound edge. The same fragment of subcutaneous fat is cut out and laid in a wound on the forearm at the peripheral end of the nerve.

 Then, from both legs from 3 cm long sections behind the external ankles, the calf nerves 35 cm long were taken with a special tool, of which 4 autografts of 15 cm each were cut. These grafts were taken in turn in the subcutaneous tunnel of the ulnar fossa and laid on fragments of subcutaneous fat at the ends of the nerve. After that, using the microsurgical technique and optical magnification, the bundle groups of the central ends of the grafts were stitched together with the bundle groups of the peripheral end of the nerve, and the bundles of the peripheral ends of the grafts with bundles of the central end of the nerve. At the same time, transverse sections of the nerve were almost completely blocked by transplants. Then, in the wound on the shoulder and forearm, another fragment of subcutaneous fat was cut out, with which autografts were covered on top.

 Sutures on the skin of all wounds. Aseptic dressings. Plaster cast on the shoulder and forearm in the extension position in the elbow joint.

 On the 10th day, all seams and gypsum mobilization were removed.

 When examining a patient after 1 year and 4 months after surgery, flexion of the main and final phalanges of the IV and V fingers is 3 points. Bringing and breeding of all fingers - 3 points. Bringing a straightened thumb - 3 points. Sensitivity on the palmar surface of the V and IV fingers - 3 points.

 After another 8 months, the patient noted the disappearance of muscle hypotrophy of the elevation of the little finger and the muscles leading to the thumb. Bending of the phalanges of the IV and V fingers - 4 points. Bringing and breeding fingers 3-4 points. Bringing the thumb - 4 points. Sensitivity on the palmar surface of the IV and V fingers increased to 4 points.

 Thus, after 2 years, an almost complete restoration of the useful function of the ulnar nerve after auto-neuroplasty according to the proposed method was observed.

Using the claimed method of autoneuroplasty allows you to:
to achieve more complete regeneration of the damaged nerve by reaching all the axons that have grown into the grafts, the peripheral end of the nerve;
to increase the strength of anastomoses due to the fixation of the ends of the nerve with epineural flaps to the underlying tissues;
prevent scarring and improve blood supply to autografts by covering them with subcutaneous fat on a vascular pedicle.

Claims (1)

 The method of autoneuroplasty by microsurgical anastomosis of nerve graft bundles with bundles of the central and peripheral ends of the damaged nerve, characterized in that the graft nerves are laid retrograde taking into account their anatomical structure, the nerve ends are fixed for epineural flaps to the underlying tissues, and the grafts are covered with subcutaneous fat fragments fiber on the vascular pedicle.

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