A Practical Approach to Nerve Grafting in the Upper Extremity

In this era of tissue bioengineering an autogenous nerve graft may be considered the ultimate biocompatible, resorbable nerve conduit, with a basil lamina, preformed guidance channels, a reserve of viable Schwann cells, and nerve growth factors. In addition, it is capable of developing an intrinsic circulation. The nerve graft provides a regenerating axon with a means for passage to the distal nerve stump, while protecting it from the surrounding environment. There is no foreign body reaction and no graft-versus-host response. An enterprising biotechnology company undoubtedly would have no difficulty marketing this product. The results obtained with nerve autografts constitute the gold standard by which nerve conduits are designed and measured. Despite this seemingly utopian picture, the donor site morbidity and the limitations of nerve grafting have led to a search for alternate methods. This search has been addressed eloquently by Strauch and Chui and their coauthors elsewhere in this issue. This article focuses on the ways in which the nerve responds to injury and how it regenerates, followed by some practical considerations for autologous nerve grafting.