Restoration of sensitivity after removal of the sural nerve: a new application of lateroterminal neurorraphy

PREVIOUS NOTE

Restoration of sensitivity after removal of the sural nerve. a new application of lateroterminal neurorraphy

Fausto Viterbo; Aristides Palhares; Luis Fernando Franciosi

Discipline of Plastic Surgery, Botucatu Medical School, UNESP, Botucatu, SP, Brazil

^{Address for Correspondence}

RESUMO

Os autores propõem o emprego da neurorrafia término-lateral do coto distal do nervo sural na face lateral do nervo fibular superficial para evitar anestesia ou hipoestesia na face lateral do pé após a retirada do nervo sural para enxertia. A proximidade anatômica entre os nervos em questão tornam o procedimento simples, sem aumentar o tempo cirúrgico. A neurorrafia término-lateral proposta não prejudica as estruturas inervadas pelo nervo doador.

INTRODUCTION

The sural nerve is possibly the most usual source of nerve grafts.

Its anatomical situation, extension and morphological characteristics are adequate to make it the first option for almost all cases where a nerve graft is indicated. To the contrary, its removal always produces an anesthesia zone, since it is responsible for the sensitive innervation of a great region of the foot (1,2,3,4,5,6,7,8,9,10,11). The anesthesia varies in extension among patients. This disturbance is commonly well accepted by the patients, and the surgeons consider it a minor problem since up to now there was no way of avoiding it.

Viterbo (1992) (12,13) and Viterbo and cols. (1992) (14) recently developed a new form of neurorraphy that might change this concept. It is a latero-terminal or a termino-lateral neurorraphy which utilize a healthy nerve as axon donor. The procedure does note change the donor nerve structure or function.

Based on this technique we tested the neurorraphy between the distal ending of the sural nerve termino-laterally to the superficial fibular nerve in order to avoid producing the anesthesia area consequent to its removal (Figs. 1, 2 and 3). The anatomical proximity between the nerves made the procedure easy and did not increase the surgical time.

CLINICAL CASE

Two patients were submitted to the procedure up to now.

Case 1. S.C.A, 28 years old, ID: 275.653-5, male, suffered a motorcycle accident 4 years earlier, with various fractures in the left supper limb. Since that time he is enable to move that limb and shows almost full absence of sensitivity. Electromyography and myelographic exams confirmed lesions by multiradicular proximal cervical avulsion, concomitantly of C5-8 and Ti. Recent electromyography examination (April 07, 1993) Showed signs of regeneration in C7-8 and Ti, but not of C5-6.

In the day April, 7 1993, he was submitted to exploration of the brachial plexus. Since no discontinuities were found in the roots involved, we made various autografts with termino-lateral neurorraphies (12,13,14) between the phrenic nerve and the roots of C5-6. The purpose was to allow phrenic nerve fibers to grow through the graft into the C5-6 roots.

In the same opportunity we produced termino-lateral neurorraphy between the distal ending of the sural nerve and one of the branches of the superficial fibular nerve, close, to the lateral maleolus, after removing an epineural window.

In the immediate post-operative period it was surprising to note that the patient did not refer any anesthetic area in the region innervated by the sural or in any other the sensitivity was tested by gentle touching and by metal needle no complication was observed.

Case 2. C.M.B.F., 47 years old, ID: 271.143-5, female, born and resident in Avaré, SP. She was submitted to resection of a Neurinoma which resulted total hearing loss and facial paralysis, both in the left side. In June 2, 1993, she was submitted to reparation of the facial paralysis through sural nerve transfacial graft termino-lateral neurorraphies, as proposed by Viterbo (1992) (15,16). In the same occasion, a termino-lateral neurorraphy was made with the distal ending of the sural nerve and a branch of the superficial fibular nerve. Since both sural nerves had been removed, the neurorraphy was made bilaterally. Again in the immediate post-operative period, the patient did not refer any anesthetic area in the sural nerve region of innervation or in any other area the sensitivity inspections were conducted as for the other patient.

CONCLUSION

In spite of the follow up periods having not been long enough and the number of operated cases being small for establishing unquestionable conclusion, we feel safe to report that the termino-lateral neurorraphy between the distal ending of the sural nerve to a branch of the superficial fibular nerve is able to prevent the sensorial sequel of the sural nerve removal the post-operative morbidity and the operative time are not increased.

ACKNOWLEDGMENTS

We thank very much to Prof. Dr. Romeu C. Guimarães to the final revision of the text and to Marcia Mazzoni for the designs.

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Address for Correspondence:

Dr. Fausto Viterbo

Rua José Dal Farra, 592 - Botucatu - SP - Brasil

CEP 18603-790

Publication Dates

• Publication in this collection
  03 July 2009
• Date of issue
  Dec 1994