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Journal of Neurosurgical Sciences 2004 September;48(3):105-12


lingua: Inglese

Surgical treatment of common peroneal nerve injuries: indications and results. A series of 62 cases

Garozzo D., Ferraresi S., Buffatti P.

Department of Neurosurgery S. Maria della Misericordia Hospital, Rovigo, Italy


Aim. Common per­oneal ­nerve (CPN) inju­ries rep­re­sent the ­most com­mon ­nerve ­lesions of the low­er ­limb and can be due to sev­er­al caus­a­tive mech­a­nisms. Although in ­most cas­es ­they recov­er spon­ta­ne­ous­ly, an irre­ver­sible dam­age of the ­nerve is ­also like­ly to ­occur. Nerve regen­er­a­tion fol­low­ing CPN ­repair is poor­er if com­pared to oth­er periph­er­al ­nerves and ­this can ­explain the reluc­tant atti­tude of ­many phy­si­cians ­towards the sur­gi­cal treat­ment of ­these ­patients. Among the sev­er­al fac­tors advo­cat­ed to ­explain the ­poor out­come fol­low­ing sur­gery, it has ­been sug­gest­ed ­that rein­ner­va­tion ­might be obsta­cled by the ­force imbal­ance ­between the func­tion­ing flex­ors and the par­a­lysed exten­sors ­that even­tu­al­ly ­results in the ­fixed equi­nism of the ­foot, due to the exces­sive con­trac­ture of the ­active mus­cles and the short­en­ing of the ­heel ­cord. Therefore the ear­ly cor­rec­tion of ­these forc­es ­might ­favour ­nerve regen­er­a­tion. Following ­such hypoth­e­sis, the ­authors ­treat irre­ver­sible CPN inju­ries per­form­ing a one-­stage pro­ce­dure of ­nerve ­repair and tibi­al­is ten­don trans­fer. We ­report our expe­ri­ence, describ­ing the indi­ca­tions to sur­gi­cal treat­ment, the oper­a­tive tec­nique and the post­op­er­a­tive clin­i­cal out­come cor­re­lat­ed ­with the caus­a­tive mech­a­nisms of the inju­ries.
Methods. A 62- ­patient ­series con­trolled ­over a peri­od of 15 ­years ­with a ­post-trau­mat­ic pal­sy of the CPN is report­ed. All the ­patients under­went sur­gery. In ­open ­wounds, ­when a ­nerve tran­sec­tion was sus­pect­ed, sur­gery was per­formed at emer­gen­cy (2 cas­es). In ­closed inju­ries, oper­a­tive treat­ment was ­advised ­when no spon­ta­ne­ous regen­er­a­tion ­occurred 3-4 ­months ­after the inju­ry. From 1988 ­till 1991, 9 ­patients ­were elect­ed for sur­gery : in 6 cas­es treat­ment con­sist­ed of neu­ro­ma resec­tion and ­nerve ­repair by ­means of a ­graft. In 3 ­patients it was per­formed ­only a CPN decom­pres­sion at the fib­u­lar ­neck. Since 1991, sur­gi­cal treat­ment has ­always con­sist­ed of ­nerve ­repair asso­ciat­ed ­with a ten­don trans­fer dur­ing the ­same pro­ce­dure. Fifty-­three ­patients ­were elect­ed for sur­gery. Nerve ­repair was ­achieved by ­direct ­suture in 1 ­case and by ­means of a ­graft in 46 ­patients. Decompression of the CPN at the fib­u­lar ­neck was per­formed in 6 ­patients ­where ­nerve con­ti­nu­ity was dem­on­strat­ed.
Results. In the ­first ­group of ­patients, ­nerve ­repair out­come was high­ly dis­ap­pont­ing: no recov­ery in 5 cas­es, rein­ner­va­tion ­occurred in 1 ­patient ­only (M1-2). CPN decom­pres­sion was fol­lowed by com­plete recov­ery in 2 cas­es, no improve­ment was ­observed in 1 ­case. Nerve ­repair asso­ciat­ed ­with tibi­al­is ten­don trans­fer dra­mat­i­cal­ly ­improved the post­op­er­a­tive out­come: at 2 ­year fol­low-up, neu­ral regen­er­a­tion was dem­on­strat­ed in 90% of the ­patients. Surgical out­come ­depends on the caus­a­tive mech­a­nisms of the ­lesion: ­sharp inju­ries and ­severe dis­lo­ca­tions of the ­knee had an excel­lent recov­ery, ­while in ­crush inju­ries and gun­shot ­wounds ­good recov­ery was ­less com­mon.
Conclusion. Surgical treat­ment of CPN inju­ries can now­a­days be high­ly reward­ing. CPN pal­sies in ­open ­wounds ­should under­go sur­gi­cal explo­ra­tion at emer­gen­cy. In ­close inju­ries ­with no spon­ta­ne­ous recov­ery with­in 4 ­months ­after the inju­ry, ­patients ­should be ­advised to ­seek sur­gi­cal treat­ment regard­less the caus­a­tive mech­a­nism of the ­lesion. According to our expe­ri­ence, the asso­ci­a­tion of a trans­fer pro­ce­dure to ­nerve ­repair enhanc­es neu­ral regen­er­a­tion, dra­mat­i­cal­ly improv­ing the sur­gi­cal out­come of ­these inju­ries.

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