Gradual Nerve Elongation Under Tension to Achieve Direct, Large Gap Repair
Stanley Bazarek, MD, PhD, Brigham & Women's Hospital, Boston, MA and Justin M Brown, MD, Massachusetts General Hospital, Boston, MA
Title: Gradual Nerve Elongation Under Tension to Achieve Direct, Large Gap Repair
Introduction: Direct nerve repair is favored over the use of a graft, but grafting is considered unavoidable with large gaps. Rodent models have shown that stretching may provide a mechanical stimulus for nerve elongation, including axons and connective tissue layers. Although nerve tension at the anastomosis site has been associated with poor outcomes in a number of studies, mild tension is well tolerated. Manipulation of joint position may bring a distal nerve segment close enough to achieve direct repair. This position can be progressively relaxed to provide consistent stretch stimulation for nerve growth until full range of motion is achieved. This technique may also apply to nerve transfers following brachial plexus or spinal cord injury to achieve long distance muscle reinnervation within the critical time window.
Materials & Methods: Nerve repair with joint was performed for several nerves with gaps ranging from 4 cm to 10 cm, including direct repair of sciatic, common peroneal, and radial nerve. We have also performed several brachialis to anterior Interosseous nerve transfers for tetraplegia with a gap that was overcome using elbow flexion. All patients were immobilized in braces with elbow or knee flexion at 90 degrees and range of motion was gradually increased over 12 weeks until full extension was achieved and brace removed.
Results: All patients that underwent nerve repair under tension completed the 12 week post-operative brace ROM progression without issue. All patients achieved desired innervation with MRC grade of 3 or above, confirming successful reinnervation of the target muscle.
Conclusions: Nerve elongation under tension is a potential alternative to grafting to achieve large gap nerve repair with superior outcomes.
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