Resultados del tratamiento del nervio radial e influencia de factores pronósticos

Gregorio Martínez Villén; Sami Hamam Alcober; Rafael Cardona Malfey

doi:10.1055/s-0037-1607459

Revista Iberoamericana de Cirugía de la Mano, Inhaltsverzeichnis

CC-BY-NC-ND 4.0 · Revista Iberoamericana de Cirugía de la Mano 2017; 45(02): 104-114
DOI: 10.1055/s-0037-1607459

Original Article | Artículo Original

Thieme Revinter Publicações Ltda Rio de Janeiro, Brazil

Resultados del tratamiento del nervio radial e influencia de factores pronósticos

The Outcomes of Radial Nerve Injury Treatment and Influence of Prognostic Factors

Gregorio Martínez Villén

¹Departamento de Cirugía Ortopédica y Traumatología, Unidad de Cirugía Reconstructiva Del Aparato Locomotor, Mano-microcirugía, Hospital Universitario Miguel Servet, Zaragoza, España

,

Sami Hamam Alcober

¹Departamento de Cirugía Ortopédica y Traumatología, Unidad de Cirugía Reconstructiva Del Aparato Locomotor, Mano-microcirugía, Hospital Universitario Miguel Servet, Zaragoza, España

,

Rafael Cardona Malfey

¹Departamento de Cirugía Ortopédica y Traumatología, Unidad de Cirugía Reconstructiva Del Aparato Locomotor, Mano-microcirugía, Hospital Universitario Miguel Servet, Zaragoza, España

› Institutsangaben

Abstract

Resumen

Objetivo Analizar la respuesta de las lesiones del nervio radial y de sus ramas al tratamiento y la influencia de factores asociados dependientes del tipo de daño y de paciente.

Material y Método Sesenta y seis pacientes con lesiones del nervio radial o de sus ramas terminales fueron sometidos a tratamiento conservador, reconstrucción nerviosa, exoneurólis, recolocación nerviosa, cobertura con colgajo graso o transferencia tenomuscular. Hubo 39 hombres y 27 mujeres con una edad media de 45 años. Valoramos la situación motora antes y después del tratamiento con la escala del Louisiana State University Health Sciences Centre (G0 a G5). En las lesiones de la rama superficial del nervio radial fueron recogidas las alteraciones sensitivas y el dolor. La edad, el momento de la cirugía, el tipo de lesión, su nivel y tratamiento, el tiempo de seguimiento y el momento aproximado de la recuperación nerviosa, fueron analizados y relacionados con los resultados.

Resultados Hubo 37 lesiones del nervio radial entre la axila y el codo, 12 del nervio interóseo posterior y 17 de la rama sensitiva superficial. En 10 pacientes observamos recuperación espontánea. En el 82,3% de los casos de reconstrucción del nervio radial el resultado fue bueno o excelente, siendo desfavorable en el 17,7%. Todos los pacientes con reconstrucción del nervio interóseo posterior tuvieron resultado excelente. Las lesiones nerviosas en continuidad tuvieron un 20% más de resultados G4 y G5 que las neurotmesis. Entre los pacientes con lesión de la rama sensitiva superficial, seis quedaron asintomáticos y 11 sintomáticos después del tratamiento. Los pacientes de mayor edad, los grandes defectos nerviosos injertados en las zonas más proximas de la extremidad superior, o con mayor tiempo transcurrido entre la lesión y la reparación evolucionaron peor.

Conclusión El nervio radial es un nervio agradecido al tratamiento.

Abstract

Background The purpose of this study was to present the response of radial nerve lesions and their branches to treatment, observing the influence of associated factors depending to the damage and the patient.

Methods Sixty-six patients with injuries of the radial nerve or its terminal branches had conservative treatment, nerve reconstruction, exoneurolysis, nerve relocation, fat flap or tendon transfer. Thirty-nine were men and 27 women, with a mean age of 45 years. Motor status of the patients was estimated before and after treatment using the Louisiana State University Health Sciences Center scale (G0 to G5). Sensory disturbances or residual pain were recorded for superficial sensory radial nerve injuries. Patient age, timing of surgery, type of lesion and treatment, level of injury, follow-up, and the approximative time of onset of motor recovery were estimated and related to the results.

Results There were 37 injuries of the radial nerve between the axilla and elbow, 12 injuries of the posterior interosseous nerve and 17 injuries of the radial sensory nerve. Spontaneous recovery was observed in ten patients. There were 82.3% favorable and 17.7% poor outcomes after radial nerve reconstruction. All patients with posterior interosseus nerve reconstruction had good or excellent outcomes. Patients with in-continuity injuries had 20% more G4 and G5 outcomes than those with neurotmesis. In superficial sensory radial nerve injuries, six patients were asymptomatic and 11 symptomatic after treatment. Older patients, large nerve defects treated with grafts in the proximal areas of the upper limb, or longer time between the injury and repair, evolved worse.

Conclusion The radial nerve is grateful to treatment.

Palabras Clave

lesiones nervio radial - tratamiento - pronóstico

Keywords

radial nerve injuries - treatment - prognostic

Volltext

Referenzen

Bibliografía
1 Korompilias AV, Lykissas MG, Kostas-Agnantis IP, Vekris MD, Soucacos PN, Beris AE. Approach to radial nerve palsy caused by humerus shaft fracture: is primary exploration necessary?. Injury 2013; 44 (03) 323-326
2 Shao YC, Harwood P, Grotz MR, Limb D, Giannoudis PV. Radial nerve palsy associated with fractures of the shaft of the humerus: a systematic review. J Bone Joint Surg Br 2005; 87 (12) 1647-1652
3 Khan R, Birch R. Latropathic injuries of peripheral nerves. J Bone Joint Surg Br 2001; 83 (08) 1145-1148
4 Kretschmer T, Antoniadis G, Braun V, Rath SA, Richter HP. Evaluation of iatrogenic lesions in 722 surgically treated cases of peripheral nerve trauma. J Neurosurg 2001; 94 (06) 905-912
5 Kretschmer T, Heinen CW, Antoniadis G, Richter HP, König RW. Iatrogenic nerve injuries. Neurosurg Clin N Am 2009; 20 (01) 73-90 , vii
6 Wang JP, Shen WJ, Chen WM, Huang CK, Shen YS, Chen TH. Iatrogenic radial nerve palsy after operative management of humeral shaft fractures. J Trauma 2009; 66 (03) 800-803
7 Adams JE, Steinmann SP. Nerve injuries about the elbow. J Hand Surg Am 2006; 31 (02) 303-313
8 Fitzgerald A, Anderson W, Hooper G. Posterior interosseous nerve palsy due to parosteal lipoma. J Hand Surg [Br] 2002; 27 (06) 535-537
9 Kim DH, Murovic JA, Kim YY, Kline DG. Surgical treatment and outcomes in 45 cases of posterior interosseous nerve entrapments and injuries. J Neurosurg 2006; 104 (05) 766-777
10 Martínez-Villén G, Badiola J, Alvarez-Alegret R, Mayayo E. Nerve compression syndromes of the hand and forearm associated with tumours of non-neural origin and tumour-like lesions. J Plast Reconstr Aesthet Surg 2014; 67 (06) 828-836
11 Atherton DD, Fabre J, Anand P, Elliot D. Relocation of painful neuromas in Zone III of the hand and forearm. J Hand Surg Eur Vol 2008; 33 (02) 155-162
12 Calfee RP, Shin SS, Weiss AP. Neurolysis of the distal superficial radial nerve for dysaesthesia due to nerve tethering. J Hand Surg Eur Vol 2008; 33 (02) 152-154
13 Birch R. Nerve repair. En: Wolfe SW, Hotchkins RN, Pederson WC, Kozin SH. (Ed). Green's operative hand surgery, 6th ed. Philadelphia: Elservier Churchill Livingstone; 2011: 1035-1074
14 Daneyemez M, Solmaz I, Izci Y. Prognostic factors for the surgical management of peripheral nerve lesions. Tohoku J Exp Med 2005; 205 (03) 269-275
15 Lundborg G. A 25-year perspective of peripheral nerve surgery: evolving neuroscientific concepts and clinical significance. J Hand Surg Am 2000; a 25 (03) 391-414
16 Terzis JK, Konofaos P. Radial nerve injuries and outcomes: our experience. Plast Reconstr Surg 2011; 127 (02) 739-751
17 Pan CH, Chuang DC, Rodríguez-Lorenzo A. Outcomes of nerve reconstruction for radial nerve injuries based on the level of injury in 244 operative cases. J Hand Surg Eur Vol 2010; 35 (05) 385-391
18 Kim DH, Kam AC, Chandika P, Tiel RL, Kline DG. Surgical management and outcome in patients with radial nerve lesions. J Neurosurg 2001; 95 (04) 573-583
19 Kallio PK, Vastamäki M, Solonen KA. The results of secondary microsurgical repair of radial nerve in 33 patients. J Hand Surg [Br] 1993; 18 (03) 320-322
20 Birch R, Achan P. Peripheral nerve repairs and their results in children. Hand Clin 2000; 16 (04) 579-595
21 Lundborg G. Brain plasticity and hand surgery: an overview. J Hand Surg [Br] 2000; b 25 (03) 242-252
22 Matejcík V. Peripheral nerve reconstruction by autograft. Injury 2002; 33 (07) 627-631
23 Shergill G, Bonney G, Munshi P, Birch R. The radial and posterior interosseous nerves. Results fo 260 repairs. J Bone Joint Surg Br 2001; 83 (05) 646-649
24 Millesi H. Nerve grafting. En: Slutsky DJ, Hentz VR. (Ed). Peripheral nerve surgery: practical applications in the upper extremity. Philadelphia: Elservier Churchill Livingstone; 2006: 39-59
25 Bertelli JA, Ghizoni MF. Results of nerve grafting in radial nerve injuries occurring proximal to the humerus, including those within the posterior cord. J Neurosurg 2015; 124: 1-7
26 Martínez Villén G. Caso clínico. En Llusa M, Palazzi S, Valer A. (Ed). Anatomía quirúrgica del plexo braquial y de los nervios periféricos de la extremidad superior. Madrid: Panamericana SA; 2013: 113
27 Ingary JV, Green DP. Radial nerve palsy. En: Wolfe SW, Hotchkins RN, Pederson WC, Kozin SH. (Ed). Green's operative hand surgery, 6th ed. Philadelphia: Elservier Churchill Livingstone; 2011: 1075-1092
28 Postacchini F, Morace GB. Fractures of the humerus associated with paralysis of the radial nerve. Ital J Orthop Traumatol 1988; 14 (04) 455-464
29 Kim DH, Han K, Tiel RL, Murovic JA, Kline DG. Surgical outcomes of 654 ulnar nerve lesions. J Neurosurg 2003; 98 (05) 993-1004
30 Taha A, Taha J. Results of suture of the radial, median, and ulnar nerves after missile injury below the axilla. J Trauma 1998; 45 (02) 335-339
31 Roganovic Z, Pavlicevic G. Difference in recovery potential of peripheral nerves after graft repairs. Neurosurgery 2006; 59 (03) 621-633 , discussion 621–633
32 Murovic JA. Upper-extremity peripheral nerve injuries: a Louisiana State University Health Sciences Center literature review with comparison of the operative outcomes of 1837 Louisiana State University Health Sciences Center median, radial, and ulnar nerve lesions. Neurosurgery 2009; 65 (4, Suppl) A11-A17
33 Doyle JR. Forearm. En: Doyle JR, Botte MJ. , editors. Surgical anatomy of the hand and upper extremity. Philadelphia: Lippincott Williams and Wilkins; 2003: 407-460
34 Bevin AG. Early tendon transfer for radial nerve transection. Hand 1976; 8 (02) 134-136
35 Ropars M, Dréano T, Siret P, Belot N, Langlais F. Long-term results of tendon transfers in radial and posterior interosseous nerve paralysis. J Hand Surg [Br] 2006; 31 (05) 502-506
36 Altintas AA, Altintas MA, Gazyakan E, Gohla T, Germann G, Sauerbier M. Long-term results and the Disabilities of the Arm, Shoulder, and Hand score analysis after modified Brooks and D'Aubigne tendon transfer for radial nerve palsy. J Hand Surg Am 2009; 34 (03) 474-478
37 Brodman HR. Tendon transfer for old radial nerve paralysis. AMA Arch Surg 1958; 76 (01) 24-27
38 Martínez-Villén G, Muñoz-Marín J, Pérez-Barrero P. Are tendon transfers justified in very old hand radial palsies?. J Plast Reconstr Aesthet Surg 2012; 65 (10) e293-e296