V.P. Bersnev, G.S. Kokin, Ya.N. Lisovets
(Polenov Research Neurosurgical Institute, Saint Petersburg
Saint Petersburg Medical Academy of Postgraduate Education)
Retrospective analysis of surgical treatment of 467 patients with associated injuries 0f extremity nerves and vessels is given. All of them were operated in the Department of Surgery of the Peripheral Nervous System (the Polenov Research Neurosurgical Institute) in 1986-2003. Reconstructive interventions on a major vessel were performed in 85 cases at different time of trauma. They were necessitated by decompensated ischemia.
Vascular injury is referred to a group of severe trauma due to a high risk of development of complications and fatal outcomes and is often accompanied by traumatic lesions of nerves, bones, tendons and soft tissues. That is why surgical treatment is connected with certain difficulties. Sometimes a type of surgical treatment can be determined only duding intervention. A choice of a surgical method is effected by an injury level, a degree of damage of nerve trunks and vessels, a state of blood flow and adjacent tissues.
We used the following types of surgical treatment of nerves and vessels: suturing of a nerve, suturing and transposition of a nerve, neurolysis, neuroautoplasty, suturing of an artery, vessel ligation, angiolysis, angioplasty. In some cases interventions had an atypical character; sometimes it was necessary to perform repeated or multiple reconstructive operations. Due to this fact, we obtained more specific information on some peculiarities of surgical tactics in associated injuries of extremities.
Replacement of a nerve defect with a neurotransplant has considerable limitations because of local ischemia of tissues and a marked scarry-adhesive process. Sometimes a vessel or vascular autotransplant is within tissues, which have lost their normal anatomy, are affected by cicatrices and characterized by a high risk of their wounding. At the same time there is no doubt in anatomic integrity of a nerve trunk. In such cases it would be better to expose neither a nerve nor a trunk, but to use additional intraoperative diagnostic methods. This will give considerable reduction of a risk of ischemic complications. First of all, such methods include electrodiagnosis and intraoperative Doppler. Surgical peculiarities also include an esthetic aspect, as approaches are often performed on open areas of a body. Multiple interventions on a skin result in forming numerous and often hypertrophic cicatrices. Taking into account a modern approach to quality of rendered medical care, one should use potentialities of cosmetic surgery.
Thus, treatment of patients with associated trauma of extremity nerves and vessels is a complicated surgical problem, which demands continuous study for optimization of treatment-and-rehabilitation measures and improvement of patientsí life quality.