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Nerves can sometimes heal themselves, however this ability to recover depends on the type of injury.
While waiting to see if a nerve will recover enough and quickly enough to work, it is often important that patients undergo physiotherapy to stop joints and muscles getting stiff.
If a motor nerve is injured, it is important to restore its input into to the affected muscle or muscles within 18 months. This sometimes requires surgical intervention.
Exploration - All surgery starts with exploration and a visual assessment of the damaged nerve to see what the problem is.
Direct nerve repair – sometimes, after a recent nerve injury, the two cut ends of the nerve can be found and one stitched to the other. We call this neurorraphy.
Neurolysis, decompression– If there is a lot of scarring around the nerves sometimes just releasing that (neurolysis) or releasing any tight areas (decompression) can help.
Nerve Grafting – If there is too big a gap between the cut ends of an important nerve, we can find a nerve you don’t need from somewhere else and use it to bridge the gap. This is called grafting.
Nerve transfer – In this procedure, a nerve that is working well nearby (that you can do without) can be transferred onto the nerve that’s not working.
Neuroma excision - If there is scarring the signals will not pass through the scarring (neuroma). Sometimes, the scarring can be removed and the cut ends of the nerve repaired (a neurorraphy) to allow the flow of the signals once healed.
At other times, the gap between the non-injured, healthy nerve ends are too far apart. To allow the signals to flow between these ends a nerve taken from elsewhere can be used as a bridge (nerve graft). Sometimes, on the other hand, a nerve transfer can be used. It is not uncommon for both nerve grafting and nerve transfers to be performed at the same time in surgery.
Following surgery, the patient will usually have to not move the limb that has been fixed. How long for depends on various factors – it can be for between 1 day and 4 weeks! Thereafter, very commonly, hand therapy is needed to prevent things stiffening up. Usually, interestingly, pain is not very bad after surgery, and simple pain killers like paracetamol and ibuprofen will be enough for 2 or three days afterwards
This can take a long time! We often say that nerves grow at about 1mm per day. So if a nerve is injured in the elbow that moves the hand is repaired, and the distance from the elbow to the hand is 20 cm that can mean it would be 200 days from the date of surgery, often longer! That’s a long time to wait. Whilst the recovery of nerves is not guaranteed and can take a long time, luckily, children in general seem to do better than grown-ups and for the same injury, often get better results!
Sometimes, someone will have a significant nerve injury, but we can’t reconstruct the nerve usefully. For example, if the patient is seen too late to repair the nerve, or if the nerve is cut so far away from its target muscle by the time it got there it would be greater than 18 months from the injury. So what do we do…?
Well, it’s by no means the end of the road! Firstly, good therapy is critical and can make a massive difference. Sometimes it can work so well that even though the patient does not regain working muscle, they get such good movement they don’t need anything else! But if that is not the case, we then have to turn to using musculoskeletal procedures.
Musculoskeletal procedures are ones where rather than moving the nerves around to reconstruct a lost function, we move muscles and tendons, or even re-shape bones to help compensate for the lost function. Musculoskeletal procedures include muscle transfers, tendon transfers, and joint fusions.
Muscle and Tendon transfers – the principle of this is very like a nerve transfers. If a muscle is not working, a neighbouring “musculotendinous unit” that is expendable can be transferred to the bone that the muscle that’s not working normally moves. Sometimes, if there are no nearby muscles can be used, one from a different part of the body can be transferred – this is called a free muscle transfer.
Joint fusion – sometimes if the paralysed muscles normally stabilize a joint, the joint can become unstable and floppy. In order to make it more stable we may fuse the two bones either side of the joint. While this does make the joint more stable, it makes it less mobile.
Osteotomies – All of our muscles move bones in balance – one group of muscles move the bones in one direction, and another the opposite way.
Sometimes, after a long period of time where one group of muscles is working well and the other not, the muscles are pulling on the bones in can change their shape. And if that happens, even if we can get the muscles working again, we may have to do operations on the bones to put them back where they should be.
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