Management of Missile Peripheral Nerve Injuries

Missile peripheral nerve injuries (MPNIs) usually receive secondary consideration, including deferred surgical treatment, mainly because they are not life threatening. Approximately 70% of missile wounds that require exploration include either a complete or partial section of nerve. Surgical management of these wounds is very demanding, requiring considerable attention during the initial examination and a lengthy, intricate surgical procedure, detailed knowledge of peripheral nerve anatomy, experience using microsurgical techniques, and support from a team of experts who provide various diagnostic, therapeutic, and rehabilitation services. Patients are followed for months and even years, at the end of. which time the gain may be barely measurable, because the return of neurological function is a very slow process. :MPNIs are relatively uncommon injuries in peacetime. Current increases in violence and in the availability of firearms have, however, resulted in a rise in the incidence of MPNIs, even in children, with a much higher proportion of low-velocity injuries. During times of war, the incidence of these injuries increases significantly, providing opportunities to gain valuable surgical experience and to make contributions to the knowledge about their epidemiology, pathophysiology, and treatment. Background Galen of Pergamon (130-200) argued that nerve lesions lead to convulsions and are irreparable. Rhases the Experienced (AI Rhazi) (850-923) performed one of the first recorded nerve sutures, the results of which are not known. Some 300 years later, Salicetti from Bologna performed a surgical repair of an injured nerve that is described in the 13th-century text Cyrurgia. Gunshot wounds were first recorded in Europe during the Hundred Years' War (1337-1453). In 1497, the Alsatian army surgeon Hieronymus Brunschwig pronounced these wounds "poisonous." In the 16th century, the French army surgeon Ambroise Pare (1510-1590), who described causalgia and phantom limb pain, was pessimistic about the idea of restoring nerve function after a surgical repair. During the same era, two Elizabethan surgeons, Thomas Gale (1563) and William Glovers (1588), advocated removal of badly traumatized and contaminated tissue. Ferrara performed the first detailed operative procedure for suturing severed nerves in 1608, with split tortoise tendons previously soaked in red wine used as suture material. In 1787, Arnemann of Germany performed the first "modem" suturing of a divided nerve; unfortunately, the distal segment had collapsed and the nerve did not regenerate. Principles of debridement devised by DeSault during the later 18th century were popularized by Larrey, military Surgeon-in-Chief to Napoleon. Gutrie voiced the opinions of British Army surgeons at the Battle of Waterloo when he advised no treatment for completely severed nerves.