Rehabilitative Surgery by Andrew I. Elkwood Matthew Kaufman & Lisa F. Schneider

Author:Andrew I. Elkwood, Matthew Kaufman & Lisa F. Schneider
Language: eng
Format: epub
Publisher: Springer International Publishing, Cham

Introduction to Surgical Planning

Surgical Timing

Another difficult aspect to approaching any patient with a nerve deficit is determining the correct time for operative intervention. Many patients will improve without intervention. However, by 12–18 months after the injury, all the motor end plates will have undergone irreparable atrophy [35, 36]. How should the correct patient and correct timing of the operation be determined? If a patient has a sharp injury, e.g., a knife wound to the brachial plexus, the intervention should be performed as soon as possible. If the injury involves a gunshot wound or blunt mechanism, it can often be unclear whether the deficit is secondary to neuropraxia or a true, irremediable injury. Another complicating factor is that many injuries are mixed and may contain elements of several different Sunderland grades of nerve injury [37].

We believe that early and aggressive surgical treatment is the optimal approach in order to restore function [26]. Our practice in these injuries is to obtain a baseline electromyography (EMG) at 6 weeks, with a repeat exam at 3 months. If there has been no improvement over 3 months, the operation is performed immediately. Typically, these more severely injured patients will also have a clear, non-advancing Tinel’s sign where neuropraxia patients often have no overt Tinel’s [38]. What to do if some improvement is observed yet the patient has not returned to normal, baseline nerve function? If the patient is only 95 % improved by 6 months or if there is anything more than a subtle difference remaining by 9 months, we also recommend surgical intervention. These patients also require ongoing physical therapy from the time of their initial diagnosis. Patients who have inadequate therapy may develop contractures that create functional deficits [9].

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