Nerve injuries sustained during warfare: part II: Outcomes.
ABSTRACT The outcomes of 261 nerve injuries in 100 patients were graded good in 173 cases (66%), fair in 70 (26.8%) and poor in 18 (6.9%) at the final review (median 28.4 months (1.3 to 64.2)). The initial grades for the 42 sutures and graft were 11 good, 14 fair and 17 poor. After subsequent revision repairs in seven, neurolyses in 11 and free vascularised fasciocutaneous flaps in 11, the final grades were 15 good, 18 fair and nine poor. Pain was relieved in 30 of 36 patients by nerve repair, revision of repair or neurolysis, and flaps when indicated. The difference in outcome between penetrating missile wounds and those caused by explosions was not statistically significant; in the latter group the onset of recovery from focal conduction block was delayed (mean 4.7 months (2.5 to 10.2) vs 3.8 months (0.6 to 6); p = 0.0001). A total of 42 patients (47 lower limbs) presented with an insensate foot. By final review (mean 27.4 months (20 to 36)) plantar sensation was good in 26 limbs (55%), fair in 16 (34%) and poor in five (11%). Nine patients returned to full military duties, 18 to restricted duties, 30 to sedentary work, and 43 were discharged from military service. Effective rehabilitation must be early, integrated and vigorous. The responsible surgeons must be firmly embedded in the process, at times exerting leadership.
- [Show abstract] [Hide abstract]
ABSTRACT: Semmes-Weinstein monofilament (SWM) evaluation for protective sensation in diabetic feet is a widely used tool to guide patient care. Little evidence is available for alternative testing modalities for use when monofilament is not available or is deformed. Multiple varieties of intravenous angiocatheter tubing were subjected to biomechanical testing on a digital scale to assess the force generated once bending was observed by five independently tested raters. A 5.07 SWM (10 g) was tested in similar manner to establish a baseline and validate testing methodology. The 24 gauge × 0.75 in angiocatheter measured the closest to the 5.07 SWM (10 g) at an average force of 22 ± 0.91 g compared with 10.2 ± 0.13 g. Large-gauge angiocatheters measured greater forces. High intra-rater and inter-rater reliability was observed with all values greater than 0.98 (p < 0.001). A 24 gauge × 0.75 in angiocatheter tubing can be used as an alternative to the standard 5.07 SWM (10 g) for testing protective sensation in diabetic feet. Reviewing previously published receiver operating characteristics, this modality would yield estimated sensitivity and specificity values greater than 0.8 and 0.7, respectively, for detecting insensate feet tested at the bilateral metatarsal heads.Military medicine. 04/2014; 179(4):442-4.
- [Show abstract] [Hide abstract]
ABSTRACT: When is common peroneal nerve repair worthwhile? What is the effect of delayed repair? What is the maximum length of graft that can be used? This study aimed to address these questions by assessing the current literature and ascertaining the predictors of outcome that would guide peripheral nerve surgeons in determining the correct treatment of common peroneal nerve injury.Plastic & Reconstructive Surgery 08/2014; 134(2):302e-11e. · 3.33 Impact Factor
Article: Median Nerve Injury and Repair[Show abstract] [Hide abstract]
ABSTRACT: Median nerve injuries in the forearm are reasonably common and can lead to devastating functional sequelae for the hand if they are not managed in a timely and appropriate fashion. Most nerve lacerations should be repaired soon after injury, and current widespread application of microsurgical techniques should lead to reasonable results in most individuals. Despite these advances, many patients do not have ideal outcomes from injuries to the median nerve and are often left with permanent sequelae. This article will discuss current techniques in the management of median nerve injuries, with the goal of preventing or alleviating the potential negative sequelae of these injuries.The Journal Of Hand Surgery 06/2014; 39(6):1216–1222. · 1.66 Impact Factor
VOL. 94-B, No. 4, APRIL 2012 529
Nerve injuries sustained during warfare
PART II: OUTCOMES
W. G. P. Eardley,
M. P. M. Stewart
R. Birch, MChir, FRCS, Consultant-
War Nerve Injury Clinic
J. Etherington, OBE, FRCP, Clinical
Defence Medical Rehabilitation
Centre, Headley Court, Epsom, Surrey
KT18 6JW, UK.
M. P . M. Stewart, CBE QHS, FRCS
Glas, FRCS (T&O), Col L/RAMC, Lately
Defence Medical Consultant Advisor
in Trauma and Orthopaedics
James Cook Hospital, Middlesbrough,
W. G. P . Eardley, MSc, DIPSEM,
MRCSEd, Specialist Registrar in
Trauma and Orthopaedics
A. Ramasamy, MRCS, MFSEM,
DMCC, Specialist Registrar in Trauma
K. Brown, MSc, MRCS, Specialist
Registrar in Trauma and Orthopaedics
J. Clasper, DPhil, DM, FRCSEd, Col
L/RAMC, Defence Professor of Trauma
Royal Centre for Defence Medicine,
Academic Department of Military
Surgery and Trauma, Birmingham
Research Park, Vincent Drive,
Birmingham B15 2SQ, UK.
R. Shenoy, MD(Res), MRCS,
Clinical Research Fellow
P . Anand, MA, MD, FRCP, Professor
P . Misra, MD, FRCP, Consultant
Peripheral Neuropathy Unit, Imperial
College London, Hammersmith
Hospital, Du Cane Road, London W12
R. Dunn, MBBS, FRCS(Plas),
Consultant Plastic Reconstructive and
Odstock Centre for Burns, Plastic and
Maxillofacial Surgery, Salisbury
District Hospital, Salisbury, Wiltshire
SP2 0BJ, UK.
Correspondence should be sent to
Professor R. Birch; e-mail:
©2012 British Editorial Society of
Bone and Joint Surgery
J Bone Joint Surg Br
Received 19 October 2011; Accepted
after revision 1 December 2011
The outcomes of 261 nerve injuries in 100 patients were graded good in 173 cases (66%), fair
in 70 (26.8%) and poor in 18 (6.9%) at the final review (median 28.4 months (1.3 to 64.2)). The
initial grades for the 42 sutures and graft were 11 good, 14 fair and 17 poor. After subsequent
revision repairs in seven, neurolyses in 11 and free vascularised fasciocutaneous flaps in 11,
the final grades were 15 good, 18 fair and nine poor. Pain was relieved in 30 of 36 patients by
nerve repair, revision of repair or neurolysis, and flaps when indicated. The difference in
outcome between penetrating missile wounds and those caused by explosions was not
statistically significant; in the latter group the onset of recovery from focal conduction block
was delayed (mean 4.7 months (2.5 to 10.2) vs 3.8 months (0.6 to 6); p = 0.0001). A total of
42 patients (47 lower limbs) presented with an insensate foot. By final review (mean
27.4 months (20 to 36)) plantar sensation was good in 26 limbs (55%), fair in 16 (34%) and
poor in five (11%). Nine patients returned to full military duties, 18 to restricted duties, 30 to
sedentary work, and 43 were discharged from military service. Effective rehabilitation must
be early, integrated and vigorous. The responsible surgeons must be firmly embedded in the
process, at times exerting leadership.
The principles governing the surgical treat-
ment of nerve injuries sustained during warfare
were established during the First World War.1,2
They include resection of scar until a healthy
bed is secured, excision of damaged nerve until
healthy stumps are reached, and tension-free
suture by adequate mobilisation and flexion of
adjacent joints, or by grafting. Of grafting,
Tinel2 wrote: ‘when the distance between the
segments of the nerve trunk is too great to per-
mit direct suture the only legitimate operation
is nerve grafting’. The treatment of war
wounds was described by Robert Jones in the
same war3: the wound should be treated by
debridement, excision and delayed closure.4
Jones oversaw the institution of hospitals ded-
icated to rehabilitation,5 where the principles
of reconstruction were defined.6 Further reha-
bilitation units were developed during The Sec-
ond World War. The work of the five special
hospitals designated for the treatment of nerve
injuries was analysed in the Medical Research
Council Report No. 282.7 Results of repairs
were graded by strict, even stringent, criteria.
About 50% of all cases treated by direct suture
made an effective recovery. Seddon8 reported a
similar rate of recovery in 67 cases where
grafts were used. Woodhall and Beebe9
brought together the experience of the military
surgeons of the United States. In a review of
3148 nerve sutures in war wounds they
reported that ‘delay in suture involves a loss of,
on average, about 1% of maximal performance
for every six days of delay’.9 From their experi-
ence of the war in Vietnam, Omer et al10-12
found that the outcome after grafting was dis-
appointing and concluded that pedicled nerve
grafts gave better results.
A review of papers describing 13 000 nerve
injuries resulting from conflict suggested that
the first operation to the wound is most impor-
tant and that arterial injuries must be repaired
and sepsis prevented.13 Unfavourable factors
include delay before repair, extensive damage
to the nerve, adjacent soft tissues and to the
skeleton, the presence of arterial injury and the
level of the lesion. The mortality of those
injured in war has decreased and the severity of
the problems facing survivors has conse-
Patients and Methods
The grading of outcome for individual nerves
is set out in Tables I to IV.13,16,17 There were
261 nerve injuries in 100 patients (98 men
and two women). Their mean age at presenta-
tion was 26.5 years (18.1 to 42.6). Injured
nerves included 134 nerves of the upper limb
and 127 nerves of the lower limb. A total of
213 nerve lesions (82%) in 90 patients
530R.BIRCH, W.G.P. EARDLEY, A.RAMASAMY, K.BROWN, R.SHENOY, P.ANAND, J.CLASPER, R.DUNN, J.ETHERINGTON, P.MISRA, M.P.M.STEWART
THE JOURNAL OF BONE AND JOINT SURGERY
occurred in open wounds. Two or more main nerves were
damaged within the same zone of injury in 70 patients.
The ulnar nerve was the most commonly injured at the
elbow, while the tibial and common peroneal nerves were
particularly vulnerable in the buttock and around the
knee. For the purpose of this study the outcome was
graded into four categories: 1, fully fit for military duty; 2,
restricted duties; 3, sedentary duties; and 4, unfit for mil-
Statistical analysis. Statistical analysis was performed
using SPSS version 18.0 (SPSS Inc., Chicago, Illinois). For
categorical data chi-squared tests were used, with Fisher’s
exact value calculated where frequencies were < 5. For con-
tinuous non-parametric data the Mann–Whitney test
was used. A p-value < 0.05 was considered statistically
Median values have been used for duration of follow-
up as early recovery in some patients led to an early dis-
charge from follow-up, skewing the mean data.
Nerve injuries. Of the 261 nerve injuries, 173 (66.3%) were
graded good, 70 (26.8%) fair and 18 (6.9%) poor at a
median follow-up of 28.4 months (1.3 to 64.2). The
18 poor results comprised seven common peroneal nerve
injuries, four tibial nerve, four ulnar nerve, two median and
one radial nerve injury (Table V). Factors contributing to a
poor outcome included destruction of the target tissue, fail-
ure of regeneration and persistent severe pain.
Nerve operations. Of the 261 injured nerves, 46 were
repaired, 35 at a mean of 8 days (1 to 14) after injury and
11 at a mean of 90 days (35 to 184). There were ten sutures,
all of which were primary. A total of 25 primary grafts were
performed at a mean of eight days (1 to 17), and seven
(delayed) at a mean of 90 days (35 to 184). There were also
three muscular neurotisations and one intercostal nerve
transfer, resulting in a total of 46 nerve repairs.
The initial grades for the ten sutures were six good, two
fair and two poor. The final grades were seven good, two
Table I. Grading of outcome in lesions of the radial nerve, based on Shergill et al17 (MRC, Medical Research Council)
For high lesions above nerves to
For intermediate lesions, between medial head of
triceps and brachioradialisFor low lesions, the posterior interosseous nerve
Good Elbow extension ≥ MRC grade 4Wrist extension ≥ MRC grade 4Full independent extension of the digits ≥ MRC
Wrist extension ≥ MRC grade 3 Finger and thumb extension ≥ MRC grade 3
FairElbow extension ≥ MRC grade 3
Wrist extension MRC grade 2
Wrist extension ≥ MRC grade 3
Finger and thumb extension ≥ MRC grade 2
Extension of digits ≥ MRC Grade 3
Poor Less than aboveLess than aboveLess than above
Table II. Grading of results in median and ulnar nerves repaired in the infraclavicular
region, the axilla and the arm (high lesions) (MRC, Medical Research Council)
Long flexor muscles MRC ≥ 4
Localisation to digit, without
Return of sweating
FCU and FDP little and ring MRC ≥ 4
Intrinsic muscles MRC ≥ 2
Localisation to little and ring fingers
Return of sweating
FairLong flexor muscles MRC ≥ 3FCU and FDP little and ring fingers
MRC ≥ 3
No intrinsic muscle functionProtective sensation, moderate
or no hypersensitivity
Sweating diminished or absentProtective sensation little and ring
No, or moderate hypersensitivity
Little or no sweating
Poor Long flexor muscles MRC ≤ 2FCU and FDP little and ring fingers
No intrinsic muscle functionProtective sensation but severe
Protective sensation with severe
hypersensitivity or no sensation
* FCU, flexor carpi ulnaris; FDP , flexor digitorum profundis
NERVE INJURIES SUSTAINED DURING WARFARE 531
VOL. 94-B, No. 4, APRIL 2012
fair and one poor, after two revision repairs and one neu-
rolysis with a free vascularised fasciocutaneous flap.
The initial grades for the 32 grafts were five good, 12 fair
and 15 poor. The final results were eight good, 16 fair and
eight poor after five revision repairs and ten neurolyses. A
free vascularised fasciocutaneous flap was used in ten of
these 15 patients with revision surgery.
The results after two of three muscular neurotisations
were fair; the third failed, as did the only intercostal trans-
fer. The overall results of all 46 repairs were good in
15 (32.6%), fair in 20 (43.5%), and poor in 11 (23.9%)
(Figs 1 and 2).
Persisting severe neuropathic pain was the most common
indication for revision operation. Relief of pain was the
main aim in six revision repairs, 11 neurolyses of previously
repaired nerves and 19 neurolyses of injured but not previ-
ously repaired nerves.
Quantitative sensory testing. A total of 17 patients
(49 nerves) were studied at Hammersmith Hospital, Lon-
don, United Kingdom, using quantitative sensory testing,
which included the assessment of thermal and monofila-
ment perception thresholds. Sensory abnormalities over the
cutaneous territories supplied by the nerves included touch
(monofilament) allodynia in seven nerves, elevated
monofilament thresholds in 33, pinprick hyperalgesia in
six, and reduced pinprick sensation in 23. Thermal thresh-
old testing revealed elevated warm threshold in 38 nerves,
elevated cool threshold in 34 and cool allodynia over the
territory of the injured nerve in five.
Pain. A total of 36 patients experienced persisting and
severe neuropathic pain and revision operations were
undertaken in these. Of these, 30 patients experienced such
relief post-operatively that analgesic medication was con-
siderably reduced or abandoned. The operations included
six revision repairs, 11 neurolyses of repaired nerves, and
neurolysis of lesioned but not previously repaired nerves in
19 patients. The causes of persisting pain included dis-
placed bone fragments, heterotopic bone, retained frag-
ments of suture material, and most commonly, scar tissue
that enveloped and constricted the nerve. A fasciocutane-
ous flap was used in 15 patients, in 11 to enhance nerve
regeneration and in four for a painful scar. No case of false
aneurysm or arteriovenous fistula was encountered.
Causalgia was relieved in two patients by repair or
decompression of the nerves and repair of the main artery.
Pain persisted in the third until an infected nonunion of the
clavicle and indolent healing of the skin were corrected.
Spontaneous resolution can occur,18 and did so in seven
Table III. Assessment of recovery of the common peroneal nerve (MRC, Medical
Grade Motor recoverySensory recovery
version MRC ≥ 4
No spontaneous pain; no hypersensitivity
FairDorsiflexion MRC 3 to
4 OR OR
Eversion MRC 3 to 4
eversion MRC 2 to 3
No spontaneous pain
No, or only mild, hypersensitivity
Poor Less than the aboveSpontaneous pain or significant sensitivity
Table IV. Grading of outcome for the tibial nerve: all levels (MRC, Medical Research Council)
Heel flexors MRC ≥ 4, tibialis posterior, flexor digitorum
longus, and flexor hallucis longus MRC 3
Return of sweating
No fixed deformity, no trophic disturbance
Protective sensation with no more than mild hyper-
sensitivity; no spontaneous pain
FairHeel flexors MRC ≥ 3Protective sensation, hypersensitivity not interfering
with daily activities
No useful recovery in long flexor muscles
Incomplete return of sweating
No serious trophic disturbance, no fixed deformity
Normal shoes with or without foot drop splint for common
Poor No useful motor recovery; and /or significant fixed deformity;
and/or trophic ulceration
No return of sensation; and/or significant hypersensi-
tivity interfering with daily activities
532R.BIRCH, W.G.P. EARDLEY, A.RAMASAMY, K.BROWN, R.SHENOY, P.ANAND, J.CLASPER, R.DUNN, J.ETHERINGTON, P.MISRA, M.P.M.STEWART
THE JOURNAL OF BONE AND JOINT SURGERY
patients after wound treatment at the field and receiving
Neurostenalgia was relieved by removal of the cause in
nine of ten patients, in five cases following a fasciocutane-
ous flap. Pain persisted in the remaining patient, who came
to below-knee amputation.
Of the 23 patients with post-traumatic neuralgia,
18 were improved by repair of the nerve and by improving
its bed. One patient came to below-knee amputation and
one required spinal cord stimulation. Pain persisted in three
patients, who continue to take analgesic drugs and remain
Conduction block/neurapraxia. Among the 261 lesions,
116 nerves (in 49 patients) had prolonged conduction
block (PCB)/neurapraxia. The mean time to onset of recov-
ery was 4.17 months (0.6 to 10.2). A total of 90 of these
116 nerves (78%) with PCB showed signs of recovery
within six months of injury. Penetrating missile wounds
accounted for 45 of these nerve injuries, explosion in the
other 71. The mean time to recovery in the former was
3.8 months (0.6 to 6) compared with 4.7 months (2.5 to
10.2) in the latter (Mann-Whitney test, p = 0.0001).
Return of plantar sensation. In 42 patients (47 lower limbs,
18%) the initial presentation was with an insensate foot. At
a mean of 27.4 months (20 to 36), recovery of sensation
was graded good in 26 limbs (55.3%), fair in 16 (34.1%),
and poor in five (10.6%). A total of 18 of these lesions were
PCB, 16 axonotmesis and 13 neurotmesis, and nine of these
nerves underwent repair. The poor results were seen in four
nerves which could not be repaired, and one repaired nerve.
Return to duties. Nine patients returned to full military ser-
vice, 18 to restricted duties, 30 to sedentary work, and
43 were graded unfit for military service.
Case report 1: late onset of neurostenalgia and deepening
nerve lesion; relief following a fasciocutaneous flap. A 30-
year-old serviceman was injured in a helicopter crash, sus-
taining fractures to the second to eighth right ribs and right
clavicle, a brain injury, and full-thickness burns to the right
arm and chest (8% of total body surface area). Emergency
treatment included fasciotomy of the right forearm. Wound
cover was achieved by split skin grafting. After eight
months he complained of increasingly severe pain about the
elbow and deterioration of sensation and power in the
hand. Function in the ulnar nerve was poor. There was
blunting of median nerve sensation. A further operation
was performed 14 months after initial injury. The median
and ulnar nerves were tethered by scar and the epineurial
vessels of the ulnar nerve obliterated. These filled before a
fasciocutaneous flap based on the patent brachial artery
was undertaken (Fig. 3). There was considerable improve-
ment in pain and sensation post-operatively, and seven
months later median and ulnar nerve function was normal.
Case report 2: prolonged conduction block and axonotmesis
of the left brachial plexus; delayed onset of post-traumatic
neuralgia of the right radial nerve. An 18-year-old rifleman
sustained massive multiple injuries from an improvised
explosive device. These included bilateral high transfemo-
ral amputations, amputation through the left forearm,
extensive facial wounds with fracture of the mandible, and
bilateral lung contusions. There was a wound in the right
axilla. Emergency treatment included tracheotomy,
Table V. Results by nerve
Nerve affected (n)Good FairPoor
C5 (n = 6)
C6 (n = 7)
C7 (n = 7)
C8 (n = 6)
T1 (n = 4)
Nerve to serratus anterior (n = 1)
Suprascapular (n = 6)
Circumflex (n = 6)
Musculocutaneous (n = 3)
Radial (n = 24)
Median (n = 29)
Ulnar (n = 35)
Femoral (n = 5)
Superior gluteal (n = 7)
Inferior gluteal (n = 7)
Common peroneal (n = 46)
Tibial (n = 47)
L4 (n = 2)
L5 (n = 2)
S1 (n = 2)
S2 (n = 2)
S3 (n = 2)
S4 (n = 2)
Photograph of a 21-year-old patient at six weeks after injury. The patient
had bilateral lesions of the median nerve from penetrating missile
wounds. The right brachial artery was repaired as an emergency. The
right median nerve was repaired within 48 hours. Recovery was good.
The injury to the left median nerve was accompanied by destruction of
the flexor muscles and fractures. Recovery was poor. Markings on the
patient in darker ink represent complete sensory loss and lighter ink rep-
resents incomplete sensory loss.
NERVE INJURIES SUSTAINED DURING WARFARE533
VOL. 94-B, No. 4, APRIL 2012
laparotomy, and debridement of the wounds to the limbs,
which were closed with split skin grafts. There was a com-
plete and painful left-sided supraclavicular brachial plexus
palsy and an incomplete and painful lesion of the right
radial nerve. After nine weeks there was recovery into C5,
which coincided with relief of pain, and he was able to
abduct his shoulder. Tinel’s signs for the radial, median and
ulnar nerves were detectable in his arm. Reinnervation of
infraspinatus, teres minor and posterior deltoid was con-
firmed by electromyography (EMG) at 4.75 months. Biceps
and triceps remained denervated. Planned exploration of
the brachial plexus was delayed because he required a
laparotomy for bowel obstruction. Electromyography at
10.75 months confirmed reinnervation of triceps and the
residual flexor muscles of the forearm. At one year biceps
was recovering. By this point the right radial nerve had
recovered, but there was constant severe pain in the distri-
bution of the cutaneous nerves of the arm and forearm. He
could not use his sole remaining limb. Conduction in the
superficial radial nerve was diminished. Quantitative sen-
sory testing (QST) demonstrated elevated thresholds to pin-
prick and light touch in the territory of the superficial radial
nerve: the thermal thresholds were normal. At 14 months
the axillary scar was replaced by an ipsilateral pedicled
thoracodorsal artery perforator fasciocutaneous flap. The
cutaneous nerves were embedded in scar (Fig. 4).
The lesion of the left brachial plexus was a mixture of
conduction block and axonotmesis. Pain improved as the
nerve recovered, which enabled the subsequent use of a
myoelectric prosthesis. Thus, the worsening post-traumatic
neuralgia in the right upper limb arose from lesions to the
cutaneous nerves in the axilla in which the thinly myeli-
nated afferent fibres were affected. It was abolished by exci-
sion of the scar and resurfacing.
The technique of tagging divided stumps to the adjacent tis-
sue plane facilitated subsequent exploration and minimised
retraction of stumps. In cases with extensive skin loss it
seems preferable to defer the nerve repair until the patient is
fit enough to endure another prolonged operation. Nerve
grafts must obtain their blood supply from the bed in which
Plantar sensation. The severely injured lower limb often
imposes a rapid decision between salvage and amputation: it
is often difficult to decide whether the limb is viable. The
absence of plantar sensation has been an important variable
in the decision-making process.20 Our findings confirm those
from the Lower Extremity Assessment Project.21 Plantar sen-
sory loss is not a sound indication for amputation.
Depth of lesion and quantitative sensory testing. QST proved
useful in detecting preservation of some types of nerve
fibre, which showed that the nerve had not been wholly
divided; in detecting recovery into some nerve fibres; in
demonstrating the differential susceptibility of different
nerve fibres in prolonged conduction block; and by reveal-
ing the behaviour of nociceptor fibres. The characteristic
features of conduction block caused by a penetrating missile
Photograph of a 28-year-old patient at ten weeks after injury. There was
a penetrating missile wound to right forearm, which destroyed the flexor
muscles and damaged both median and ulnar nerves. The median nerve
was grafted and a lateral thigh flap was performed after five days. Both
nerves recovered. There was no pain at any time. There was a minor
wound in the left forearm. Markings on the patient in darker ink represent
complete sensory loss and lighter ink represents incomplete sensory
Photograph of the patient in the first case report with neurostenalgia.
Pain was relieved after excision of scar and insertion of a fasciocutane-
534R.BIRCH, W.G.P. EARDLEY, A.RAMASAMY, K.BROWN, R.SHENOY, P.ANAND, J.CLASPER, R.DUNN, J.ETHERINGTON, P.MISRA, M.P.M.STEWART
THE JOURNAL OF BONE AND JOINT SURGERY
include paralysis which exceeds loss of sensation; the nerves
responsible for proprioception are more profoundly affected
than those conveying the sensation of light touch; vasomotor
and sudomotor function are least affected.22 Recovery is usu-
ally well advanced by the sixth day, but with more severe pres-
sure or distortion there is local demyelination and more
conduction block.23,24 The structural effects of focal compres-
sion are not caused by ischaemia25: this lesion was more com-
mon in cases of prolonged conduction block. It is more
difficult to account for the conduction block following blast
injuries in which the patient is exposed, at close range, to the
shock wave of an explosion without any fracture and with no
signs of significant injury to the soft tissues. The underlying
mechanism is under investigation.
The slowly developing conduction block in patients with
neurostenalgia is probably partly due to ischaemia, because
relief of pain and recovery of cutaneous sensibility are rapid.
Neuropathic pain. The events that underlie neuropathic
pain after nerve injury include: 1) spontaneous firing in
nociceptor and other neurons, and abnormally increased
firing in response to noxious stimulation26-28; 2) sensitisa-
tion of the axons, their cell bodies in the dorsal root gan-
glion and the dorsal horn of the spinal cord, so that pain
and sensory disturbance are increasingly experienced in
new areas outside the distribution of the injured nerve29-31;
3) sensitisation of mechanoreceptive neurons or a change in
their behaviour so that non-painful stimuli are perceived as
pain32,33; and 4) afferent and efferent fibres in the sympa-
thetic system, which are conveyed with the nerve trunks,
are involved in the injury, and may to some extent provoke
or maintain symptoms and signs arising from abnormalities
at the level of lesion or more centrally.34
The spread of pain beyond the lesion of the injured nerve
is a common example of central sensitisation. Increased
somatic C-fibre and Aδ-fibre input in the spinal cord35 may
account for the enhanced biceps reflex seen in one patient
with neurostenalgia from a median nerve injury. This,
together with his pain, was abolished by revision repair and
a fasciocutaneous flap. The convergence of visceral and
somatic afferents into lamina V of the spinal cord36 may
explain the worsening of pain with filling of the bladder
and bowel experienced by one patient with a high sciatic
injury who eventually needed spinal cord stimulation. This
phenomenon has been seen in other patients since the com-
pletion of this study, and is under investigation.
Important principles in the treatment of neuropathic
pain include37: 1) removal of the cause; 2) promotion of
healing or regeneration; 3) correction of the micro-environ-
ment of the nerve; 4) restoration of afferent pathways;
5) modulation of the central inhibitory pathways; 6) reduc-
tion of sympathetic overactivity; and 7) changing pain
thresholds by modification of emotional or behavioural
components of pain interpretation.
Surgery is required for the first four of these, and it may
be necessary for the reduction of sympathetic overactivity.
It is particularly effective for neurostenalgia, which may be
relieved by surgery years after onset,38 and in causalgia.
Sympathectomy can be effective for patients with
causalgia39,40 but was not carried out in these patients.41 In
general, the pharmacological treatment of nerve pain is dis-
appointing: about 60% of patients do not experience even
moderate improvement.42-44 In these military patients
drugs were given in appropriately high doses, with close
monitoring of their effects.
The successful treatment of pain in these patients
requires close collaboration between the treating surgeons
and physicians with a particular interest in pain manage-
ment. It is important to remember that the persistence of
neuropathic pain after focal injury to a nerve indicates that
the agent responsible for that injury is still active.
Rehabilitation. Rehabilitation of the war-wounded starts at
the time of injury, where early assessment is undertaken by
Photographs of the patient in the second case report, showing a) post-traumatic neuralgia caused by axillary scar, and b) after a pedicled fasciocuta-
neous flap was undertaken, resulting in relief of pain.
NERVE INJURIES SUSTAINED DURING WARFARE535
VOL. 94-B, No. 4, APRIL 2012
deployed medical rehabilitation teams based at the nearest
field hospital or even further forward, so that a plan for
rehabilitation is in place by the time the injured service men
and women return to their base hospital.45 The level of out-
come is expected to be higher than in civilian practice. The
whole patient must be considered: treatment cannot be
compartmentalised into one area of therapy alone, and the
psychological effects of near-death, of losing friends, of dis-
figurement, often heightened by ‘mild’ brain injury, have a
major bearing on the patient’s ability to learn new activities
or return to work. Patients are admitted to Headley Court
once their general condition is stable and they are free from
serious infection. Uncertainty about the future of their
limbs, which are painful and weak or even paralysed, is
extremely demoralising for these patients. The War Nerve
Injuries Clinic serves to provide a definitive prognosis for
recovery and to implement speedily a coordinated and inte-
grated plan of treatment to relieve pain and improve prog-
nosis. That only nine of our patients were deemed fit
enough to return to full duties is a reflection of the severity
of their injuries.
The authors wish to thank Dr C. Cordivari (Queens Square) for ensuring the
rapid investigations of patients by electrodiagnostic methods. The patients
illustrated in Figures 1 and 2 were treated by Mr D. Power, FRCS and Mrs J.
Webb, FRCS at the Queen Elizabeth Hospital, Birmingham. The figures are
reproduced from Surgical disorders of the peripheral nerves, 2nd edition, 2011,
by kind permission of Springer UK.
No benefits in any form have been received or will be received from a com-
mercial party related directly or indirectly to the subject of this article.
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