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An update on the management of adult traumatic nerve injuries—replacing old paradigms

A review

Smith, Brandon W., MD; Sakamuri, Sarada, MD; Spain, David A., MD; Joseph, Jacob R., MD; Yang, Lynda J.-S., MD, PhD; Wilson, Thomas J., MD

Journal of Trauma and Acute Care Surgery: February 2019 - Volume 86 - Issue 2 - p 299–306
doi: 10.1097/TA.0000000000002081
REVIEW ARTICLES

ABSTRACT Acute nerve injuries are routinely encountered in multisystem trauma patients. Advances in surgical treatment of nerve injuries now mean that good outcomes can be achieved. Despite this, old mantras associated with management of nerve injuries, including “wait a year to see if recovery occurs” and “there's nothing we can do”, persist. Practicing by these mantras places these patients at a disadvantage. Changes begin to occur in the nerve, neuromuscular junction, and muscle from the moment a nerve injury occurs. These changes can become irreversible approximately 18 to 24 months following denervation. Thus, it is a race to reestablish a functional nerve-muscle connection before these irreversible changes. Good outcomes rely on appropriate acute management and avoiding delays in care. Primary nerve surgery options include direct primary repair, nerve graft repair, and nerve transfer. Acute management of nerve injuries proceeds according to the rule of 3's and requires early cooperation between trauma surgeons who recognize the nerve injury and consultant nerve surgeons. Care of patients with acute traumatic nerve injuries should not be delayed. Awareness of current management paradigms among trauma surgeons will help facilitate optimal upfront management. With the ever-expanding surgical options for management of these injuries and the associated improvement of outcomes, early multidisciplinary approaches to these injuries have never been more important. Old mantras must be replaced with new paradigms to continue to see improvements in outcomes for these patients. The importance of this review is to raise awareness among trauma surgeons of new paradigms for management of traumatic nerve injuries.

From the Department of Neurosurgery (B.W.S., J.R.J., L.J.-S.Y.), University of Michigan, Ann Arbor, Michigan; Department of Neurology and Neurological Sciences (S.S.), Department of Surgery (D.A.S.), and Department of Neurosurgery (T.J.W.), Stanford University, Stanford, California.

Submitted: July 19, 2018, Revised: August 21, 2018, Accepted: September 6, 2018, Published online: June 1, 2018.

Address for reprints: Thomas J. Wilson, MD, Department of Neurosurgery, Stanford University 300 Pasteur Drive, R293 Stanford, CA 94305-5327; email: wilsontj@stanford.edu.

© 2019 Lippincott Williams & Wilkins, Inc.