Article
Management of sciatic nerve lesions after bony trauma and surgery – use of the extensible endoscope aided approach
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Authors
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Thomas Kretschmer
- Evangelisches Krankenhaus Oldenburg, Universitätsklinik für Neurochirurgie, Oldenburg, Deutschland
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Thomas Schmidt
- Universitätsklinik für Neurochirurgie Oldenburg, Evangelisches Krankenhaus-Universität Oldenburg, Oldenburg, Deutschland
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Christian Heinen
- Universitätsklinik für Neurochirurgie, Medizinischer Campus Carl-von-Ossietzky-Universität Oldenburg, Evangelisches Krankenhaus, Oldenburg, Deutschland
| Published: | June 9, 2017 |
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Outline
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Objective: Proximal sciatic nerve lesions pose a high risk for incomplete or failed regeneration and frequently present with severe pain in partial and fracture related injuries. Peroneal division lesions have a far lower regeneration potential than tibial division lesions. Lesion depth and thus potential for recovery is very difficult to assess. This results in therapeutic nihilism and a wait and see strategy also for those patients that have no chance for spontaneous recovery. Relating to our personal series, which is based on early exploration and an expandable less invasive approach, we describe our management and the techniques employed.
Methods: Within a 6.5-year period we operated on 223 traumatic nerve lesions. Among them 14 sciatic nerves (6%). One crime related stab injury in discontinuity was grafted but excluded from this evaluation. All of the lesions were painful, in 8/13 to a severe extent (61%). All of them had at least a complete loss of peroneal motor function. All of them underwent a biportal approach apart from one, who received lengthy grafts at thigh level (war/blast injury).
Results: All patients at least underwent decompression and 11/13 had additional external neurolysis (2 without obvious external signs of scarring). In 11 patients the approach needed to be extended. Three patients were grafted, one in form of a split repair. One nerve underwent epineuriotomy, one had an additional pedicled fat flap to shelter nerve from implanted hip prosthesis. Eleven of 13 Patients stated to have had some benefit from surgery. All of the grafted patients had improvement with their pain syndrome. If external scar is the reason for motor impairment, decompression and neurolysis have the potential to also improve foot lift, which was however not the case after grafting the peroneal division.
Conclusion: External scarring with otherwise intact internal nerve structure is a frequent finding that holds a good prognosis if microsurgically treated with decompression and neurolysis. A major goal of high sciatic nerve reconstruction is restoration of protective sensory function to the sole of the foot as well as pain relief. There is good reasoning for early and stepwise exploration of major or painful sciatic nerve lesions.
