Search Results (13)

Neurotrophic keratopathy (NK) is a rare degenerative disease caused by impairment of the trigeminal nerve, leading to corneal anesthesia, epithelial breakdown, and progressive vision loss. Conventional treatments primarily focus on symptom management and the prevention of complications, but they do not address the underlying nerve dysfunction. Corneal neurotization (NT) has emerged as a promising surgical intervention aimed at restoring corneal sensation and improving ocular surface homeostasis. This review evaluates the outcomes of corneal neurotization in patients with NK and compares the effectiveness of direct (DNT) and indirect (INT) techniques. Studies have reported significant improvements in corneal sensitivity, with success rates ranging from 60.7% to 100% (mean: 90%). Most patients experienced recovery of corneal sensation, as measured by the Cochet–Bonnet aesthesiometer, with no significant differences in outcomes between DNT and INT. Indirect neurotization using a sural nerve graft was the most commonly employed technique (63% of cases), while the use of acellular allografts demonstrated comparable efficacy and simplified the procedure. Postoperative corneal sensitivity increased significantly, from a preoperative average of 2.717 mm to 36.01 mm, with reinnervation typically occurring within 4–6 months and peaking at 12 months. In vivo confocal microscopy confirmed the presence of nerve regeneration. Neurotization was found to be safe, with minimal donor-site complications, which generally resolved within one year. Although the procedure improves corneal sensation and tear film stability, visual acuity outcomes remain variable due to pre-existing corneal damage. Early intervention is, therefore, recommended to prevent irreversible scarring. However, the number of patients undergoing the procedure remains limited, making it difficult to draw definitive conclusions. Most available studies consist of small case series. Further research with larger sample sizes is needed to refine surgical techniques and optimize patient selection, thereby improving outcomes in the management of NK. Full article

Background and Objectives: The sural nerve (SN) is a pure sensory nerve that supplies the lateral aspect of the ankle and foot. Its anatomical variability has been extensively documented, with multiple classifications describing its different formation patterns. The SN is commonly used for nerve grafting and is a critical structure in lower-limb surgeries. Due to its superficial course, it is vulnerable to iatrogenic injuries, particularly in procedures involving the Achilles tendon. The presence of anatomical variations in SN formation and trajectory has significant implications for surgical planning, diagnostics, and nerve conduction studies. Understanding these formation variations is essential to minimize surgical complications and optimize clinical outcomes. Materials and Methods: A pilot cross-sectional cadaveric study was conducted on nine formalin-fixed adult cadavers at the Department of Anatomy, Histology, and Anthropology, Vilnius University Faculty of Medicine, Lithuania. Standard dissection techniques were employed to examine the formation and trajectory of the SN. Morphometric parameters, including nerve diameter and length, were measured using an RS PTO Digital Caliper with 0.01 mm precision. Variations in SN formation were classified according to the system proposed by P.K. Ramakrishnan et al. Statistical analyses were performed using SPSS 26.0 and RStudio, with a significance threshold set at p ≤ 0.05. Results: The most prevalent SN formation variation observed in the Lithuanian cadaveric sample was Type 3, which was found in 8 out of 18 limbs (44.4%), while Type 6 was not identified. Additionally, a symmetric formation was observed bilaterally in 5 out of the 9 cadavers (55.6%). The SN was significantly thicker in two-contributor formations (3.17 mm) compared to single-contributor formations (1.93 mm, p = 0.001). The SN was also significantly longer in two-contributor formations (25.80 cm) than in single-contributor formations (18.96 cm, p = 0.016). No significant differences in SN morphology were found between left and right lower limbs. Conclusions: This study highlights the substantial anatomical variability of the SN in the Lithuanian population. The findings suggest a correlation between SN diameter and formation type, which may have clinical implications for nerve grafting and surgical planning. The predominance of Type 3 formation and the observed symmetry rate provide valuable anatomical insights for lower limb surgeries. Further large-scale studies are necessary to establish population-specific SN variations and their relevance in clinical practice. Full article

The sural nerve provides sensory innervation to the skin on the distal posterolateral third of the lower extremity. The morphological variants are characterized by high variability. However, it most commonly arises from a union of the medial sural cutaneous nerve and the peroneal communicating branch of the common fibular nerve. This article overviews the anatomical and clinical significance of the sural nerve. Despite the remarkable development of genetic diagnostics, sural nerve biopsy is still a very important tool to diagnose peripheral neuropathies such as diabetic, vascular and inflammatory neuropathies. Furthermore, the sural nerve is also commonly transplanted due to its characteristics. Such a procedure is applicable in cases of segmental nerve loss, but it is also used to restore potency in patients after radical prostatectomy. The knowledge of anatomical variants of the sural nerve is also crucial as it allows to minimize its damage during surgical procedures. Furthermore, during an ankle surgery, a nerve block can be used to complement anesthesia. The major aim of this work is to review contributions of the sural nerve to physiological and pathophysiological processes. Full article

Following nipple-sparing mastectomy (NSM), patients commonly experience significant impairment or total loss of nipple sensitivity, which negatively impacts the patients’ quality of life, whereas patients who retain nipple sensation postoperatively experience enhanced physical, psychosocial, and sexual well-being. Reinnervation techniques such as nerve allografting have been utilized to retain sensation. Despite the benefits of nerve allografts, such as lack of donor site morbidity, ease of use, and potentially shorter surgery time, there are shortcomings, such as the cost of commercially available acellular nerve allografts, and, most importantly, decreased sensory and motor function recovery for acellular nerve allografts with a diameter greater than 3 mm or a length greater than 50 mm. We present a technique where we performed immediate implant-based breast reconstruction combined with nipple–areola complex reinnervation using an autologous nerve graft. Following the procedure, the patient had improved sensory outcomes in the reconstructed breast and good quality-of-life indices. This report highlights the potential for sural nerve autografts in restoring breast sensation following mastectomy. Full article

Background: Parotidectomies are indicated for a variety of reasons. Regardless of the indication for surgery, facial reanimation may be required because of facial nerve sacrifice or iatrogenic damage. In these cases, facial restoration performed concurrently with ablative surgery is considered the gold standard, and delayed reanimation is usually not attempted. Methods: A retrospective review of all patients who underwent parotidectomies from 2009 to 2022 in a single institution was performed. Indications, surgical techniques, and outcomes of an algorithmic template were applied to these cases using the Sunnybrook, Terzis scores, and Smile Index. A comparison was made between immediate vs. late repairs. Results: Of a total of 90 patients who underwent parotidectomy, 17 (15.3%) had a radical parotidectomy, and 73 (84.7%) had a total or superficial parotidectomy. Among those who underwent complete removal of the gland and nerve sacrifice, eight patients (47.1%) had facial restoration. There were four patients each in the immediate (n = 4) and late repair (n = 4) groups. Surgical techniques ranged from cable grafts to vascularized cross facial nerve grafts (sural communicating nerve flap as per the Koshima procedure) and vascularized nerve flaps (chimeric vastus lateralis and anterolateral thigh flaps, and superficial circumflex perforator flap with lateral femoral cutaneous nerve). Conclusions: The algorithm between one technique and another should take into consideration age, comorbidities, soft tissue defects, presence of facial nerve branches for reinnervation, and donor site morbidity. While immediate facial nerve repair is ideal, there is still benefit in performing a delayed repair in this algorithm. Full article

The article introduces neurotrophic keratopathy (NK), a condition resulting from corneal denervation due to various causes of trigeminal nerve dysfunctions. Surgical techniques for corneal neurotization (CN) have evolved, aiming to restore corneal sensitivity. Initially proposed in 1972, modern approaches offer less invasive options. CN can be performed through a direct approach (DCN) directly suturing a sensitive nerve to the affected cornea or indirectly (ICN) through a nerve auto/allograft. Surgical success relies on meticulous donor nerve selection and preparation, often involving multidisciplinary teams. A PubMed research and review of the relevant literature was conducted regarding the surgical approach, emphasizing surgical techniques and the choice of the donor nerve. The latter considers factors like sensory integrity and proximity to the cornea. The most used are the contralateral or ipsilateral supratrochlear (STN), and the supraorbital (SON) and great auricular (GAN) nerves. Regarding the choice of grafts, the most used in the literature are the sural (SN), the lateral antebrachial cutaneous nerve (LABCN), and the GAN nerves. Another promising option is represented by allografts (acellularized nerves from cadavers). The significance of sensory recovery and factors influencing surgical outcomes, including nerve caliber matching and axonal regeneration, are discussed. Future directions emphasize less invasive techniques and the potential of acellular nerve allografts. In conclusion, CN represents a promising avenue in the treatment of NK, offering tailored approaches based on patient history and surgical expertise, with new emerging techniques warranting further exploration through basic science refinements and clinical trials. Full article

Parkinson’s disease (PD) is a severe neurological disease for which there is no effective treatment or cure, and therefore it remains an unmet need in medicine. We present data from four participants who received autologous transplantation of small pieces of sural nerve tissue into either the basal forebrain containing the nucleus basalis of Meynert (NBM) or the midbrain substantia nigra (SN). The grafts did not exhibit significant cell death or severe host-tissue reaction up to 55 months post-grafting and contained peripheral cells. Dopaminergic neurites showed active growth in the graft area and into the graft in the SN graft, and cholinergic neurites were abundant near the graft in the NBM. These results provide a histological basis for changes in clinical features after autologous peripheral nerve tissue grafting into the NBM or SN in PD. Full article

Facial palsy (FP) is a debilitating nerve pathology. Cross Face Nerve Grafting (CFNG) describes a surgical technique that uses nerve grafts to reanimate the paralyzed face. The sural nerve has been shown to be a reliable nerve graft with little donor side morbidity. Therefore, we aimed to investigate the microanatomy of the sural nerve. Biopsies were obtained from 15 FP patients who underwent CFNG using sural nerve grafts. Histological cross-sections were fixated, stained with PPD, and digitized. Histomorphometry and a validated software-based axon quantification were conducted. The median age of the operated patients was 37 years (5–62 years). There was a significant difference in axonal capacity decrease towards the periphery when comparing proximal vs. distal biopsies (p = 0.047), while the side of nerve harvest showed no significant differences in nerve caliber (proximal p = 0.253, distal p = 0.506) and axonal capacity for proximal and distal biopsies (proximal p = 0.414, distal p = 0.922). Age did not correlate with axonal capacity (proximal: R = −0.201, p = 0.603; distal: R = 0.317, p = 0.292). These novel insights into the microanatomy of the sural nerve may help refine CFNG techniques and individualize FP patient treatment plans, ultimately improving overall patient outcomes. Full article

In peripheral nerve injuries (PNI) with substance loss, where tensionless end-to-end suture is not achievable, the positioning of a graft is required. Available options include autografts (e.g., sural nerve, medial and lateral antebrachial cutaneous nerves, superficial branch of the radial nerve), allografts (Avance^®; human origin), and hollow nerve conduits. There are eleven commercial hollow conduits approved for clinical, and they consist of devices made of a non-biodegradable synthetic polymer (polyvinyl alcohol), biodegradable synthetic polymers (poly(DL-lactide-ε-caprolactone); polyglycolic acid), and biodegradable natural polymers (collagen type I with/without glycosaminoglycan; chitosan; porcine small intestinal submucosa); different resorption times are available for resorbable guides, ranging from three months to four years. Unfortunately, anatomical/functional nerve regeneration requirements are not satisfied by any of the possible alternatives; to date, focusing on wall and/or inner lumen organization/functionalization seems to be the most promising strategy for next-generation device fabrication. Porous or grooved walls as well as multichannel lumens and luminal fillers are the most intriguing options, eventually also including the addition of cells (Schwann cells, bone marrow-derived, and adipose tissue derived stem cells) to support nerve regeneration. This review aims to describe common alternatives for severe PNI recovery with a highlight of future conduits. Full article

Negative expectations regarding nerve reconstruction in the elderly prevail in the literature, but little is known about the effectiveness of nerve transfers in patients with brachial plexus injuries aged over 60 years. We present a series of five patients (1 female, 4 male) aged between 60 and 81 years (median 62.0 years) who underwent nerve reconstruction using multiple nerve transfers in brachial plexopathies. The etiology of brachial plexus injury was trauma (n = 2), or iatrogenic, secondary to spinal surgical laminectomy, tumor excision and radiation for breast cancer (n = 3). All but one patient underwent a one-stage reconstruction including neurolysis and extra-anatomical nerve transfer alone (n = 2) or combined with anatomical reconstruction by sural nerve grafts (n = 2). One patient underwent a two-stage reconstruction, which involved a first stage anatomical brachial plexus reconstruction followed by a second stage nerve transfer. Neurotizations were performed as double (n = 3), triple (n = 1) or quadruple (n = 1) nerve or fascicular transfers. Overall, at least one year postoperatively, successful results, characterized by a muscle strength of M3 or more, were restored in all cases, two patients even achieving M4 grading in the elbow flexion. This patient series challenges the widely held dogma that brachial plexus reconstruction in older patients will produce poor outcomes. Distal nerve transfers are advantageous as they shorten the reinnervation distance. Healthy, more elderly patients should be judiciously offered the whole spectrum of reconstructive methods and postoperative rehabilitation concepts to regain useful arm and hand function and thus preserve independence after a traumatic or nontraumatic brachial plexus injury. Full article

Charcot neuroarthropathy (CN) is a progressive neuropathic complication of diabetes mellitus. Patients undergoing pancreatic transplantation are at risk of developing CN, and CN is known to be a poor prognostic factor for graft loss and patient death. This study aimed to investigate the factors associated with CN in patients who had undergone pancreatic transplantation. We analyzed the data of 61 patients who underwent pancreatic transplantations to investigate the relationship between patient background, nerve conduction velocity tests prior to transplantation, and CN onset. Of these patients, six developed CN. The cumulative incidence rates at 1, 3, and 5 years after transplantation were 3.3, 6.9, and 9.0%, respectively. Sensory neuropathy was severe in six patients with CN, with no sural nerve waveform detected. CN development was not observed when the sural nerve waveforms were visualized. However, when no sural nerve waveforms were observed, the incidence of CN significantly increased due to high-dose corticosteroid administration (p = 0.036). High-dose corticosteroids are associated with the development of CN in the presence of severe neuropathy. Corticosteroid administration is associated with bone metabolism; therefore, appropriate therapeutic intervention is required. Full article

Background: Nerve recovery after a complex trauma is affected by many factors and a poorly vascularized bed is often the cause of failure and perineural scar. Many techniques have been devised to avoid this problem and the possibility to transfer a nerve with a surrounding viable sliding tissue could help in this purpose; Methods: We performed an anatomic study on 8 injected specimens to investigate the possibility to raise a medial sural artery perforator (MSAP) flap including the sural nerve within its vascularized sheath; Results: In anatomic specimens, a visible direct nerve vascularization was present in 57% of legs (8 out of 14). In 43% a vascular network was visible in the fascia layer. There were no vascular anomalies. In one patient the MSAP flap was raised including the sural nerve with its proximal tibial and peroneal components within the deep sheath. The tibial and peroneal component of the sural nerve were anastomized independently with the common digital nerve of 4th and 5th fingers and with the collateral nerve for the ulnar aspect of the 5th. After 9 months, the patient showed an improving nerve function both clinically and electromyographically without any problem due to nerve adherence; Conclusions: Given the still debated advantage of a vascularized nerve graft versus a non-vascularized one, this flap could be useful in those cases of composite wounds with nerve lesions acting as a “nerve through flap”, in order to reduce nerve adherence with a viable surrounding gliding tissue. Full article

Background: Proximal radial nerve lesions located between the brachial plexus and its division into the superficial and deep branches are rare but severe injuries. The majority of these lesions occur in association with humerus fractures, directly during trauma or later during osteosynthesis for fracture treatment. Diagnostics and surgical interventions are often delayed. The best type of surgical treatment and the outcome to be expected often is uncertain. Methods: Twelve patients with proximal radial nerve lesions due to trauma or prior surgery were included in this study and underwent neurolysis (n = 6) and sural nerve graft interposition (n = 6). Retrospective analysis of the collected patient data was performed and the postoperative course was systematically evaluated. The Disabilities of the Arm, Shoulder, and Hand (DASH) and the LSUHS (Louisiana State University Health Sciences) scores were used to determine regeneration after surgery. Comparison between the patients’ and calculated normative DASH scores was performed. Results: All patients had a traumatically or iatrogenically induced proximal radial nerve lesion and underwent secondary treatments. The average time from radial nerve lesion occurrence to surgical intervention was approximately four months (1.5–10 months). Eight patients (66.67%) had a humeral fracture. During follow up, no statistically significant difference between the calculated normative and the patients’ DASH scores was observed. The LSUHS scores were at least satisfactory. Conclusions: Neurolysis or sural nerve graft interposition performed within a specific period of time are the primary treatment options for radial nerve lesions. They should be performed depending on the lesion type. Regeneration to a satisfactory degree was observed in all patients, and the majority achieved full recovery of sensory and motor functions. This was the first study to highlight the efficiency of neurolysis and sural nerve graft interposition as secondary treatment interventions, especially for radial nerve lesions. Full article