Atakan AYDIN, Türker ÖZKAN, Hasan Utkan AYDIN, Murat TOPALAN, Metin ERER, Safiye ÖZKAN, Hoşbay Zeynep YILDIRIM

The results of surgical repair of sciatic nerve injuries

Amaç: Kliniğimize siyatik sinir yaralanması nedeniyle başvuran olguların cerrahi tedavileri ve takip sonuçları değerlendirildi. Çalışma planı: Çalışmaya siyatik sinir yaralanması nedeniyle sinir cerrahisi uygulanan 13 hasta (12 erkek, 1 kadın; ort. yaş 23; dağılım 11-35) alındı Siyatik sinir hasarından sorumlu nedenler beş hastada delici yaralanma, dördünde ateşli silah yaralanması, dördünde trafik kazası idi. Yaralanma seviyesi beş hastada diz seviyesi, sekiz hastada dizüstü seviye idi. Tüm olgularda peroneal sinir tutulumu görülürken, tibial sinir tutulumu 11 olguda görüldü. Sinir onarımı yapılan olguların üçüne nöroliz, altısına primer nörorafi, üçüne sinir grefti uygulandı. Bir hastada ise peroneal bölüme nöroliz, tibial bölüme sinir grefti uygulandı. Kas gücü ve refleks değişimleri tedavinin her aşamasında kaydedildi. Motor kas gücü İngiltere Tıbbi Araştırma Konseyi (British Medical Research Council) sistemine göre değerlendirildi. Duyu değerlendirmesi için Semmes-Weinstein monoflaman testi kullanıldı. Ortalama takip süresi 4 yıl (dağılım 1-6 yıl) idi. Sonuçlar: Tibial sinir tutulumu olan 11 olgunun birinde M1, dördünde M3, dördünde M4 ve ikisinde M5 seviyesinde soleus/gastrokinemius kas gücü elde edildi. Dört hastada plantar duyu elde edilemedi, yedi hastada en az koruyucu duyu sağlandı. Peroneal sinir lezyonu olan 13 olgunun üçünde M0, üçünde M2, birinde M3, üçünde M4, üçünde de M5 seviyesinde anterior tibial kas gücü kazanıldı. Bu hastaların dördünde ayak dorsali anestezik kaldı, altısında koruyucu duyu, üçünde normal duyu elde edildi. Sinir onarımı yapılan fakat yeterli anterior tibial kas gücü elde edilemeyen olgulardan ikisine ayak dorsifleksiyonunun sağlanması için tibialis posterior transferi yapıldı. En iyi sonuçların nöroliz yapılan olgularda elde edildiği gözlendi; primer nörorafi yapılan olgularda orta seviyede, sinir grefti ile onarım yapılanlarda ise daha kötü sonuç elde edildi. Bacak seviyesindeki lezyonların tedavi sonuçlarının gluteal seviyedekilerden daha iyi olduğu gözlendi. Çıkarımlar: Siyatik sinir onarımlarına karşı geçmişteki karamsar yaklaşım hızla değişmektedir. Mikrocerrahideki gelişmeler ve bilimsel olarak etkinliği kanıtlanmış tedavi algoritmalarının kullanılması ile sonuçlarda anlamlı bir iyileşme gözlenmektedir. Tendon transferleri başarıyı artırabilir ve seçilmiş olgularda sinir onarımına eklenebilir.

Anahtar Kelimeler:

Kazalar, trafik, Siyatik sinir, Yaralar, delici, Kas gücü, Tedavi sonucu, Nörom

Siyatik sinir yaralanmalarında cerrahi onarım sonuçları

Objectives: The aim of this study was to evaluate surgical treatment and follow-up results of patients who presented to our department with sciatic nerve injuries. Methods: The study included 13 patients (12 males, 1 female; mean age 23 years; range 11 to 35 years) who underwent surgical treatment for sciatic nerve injuries. The etiologies of sciatic nerve injuries were penetrating trauma in five patients, firearm injuries in four patients, and motor vehicle accidents in four patients. Injuries involved the knee level in five patients, and above-theknee level in eight patients. Peroneal nerve involvement was seen in all the patients, and the tibial nerve was involved in 11 patients. Primary repair was performed in six patients, neurolysis in three patients, and nerve grafting in three patients. One patient underwent neurolysis for the peroneal portion, and nerve grafting for the tibial portion. Muscle strength and reflex changes were recorded at every stage of the treatment. Muscle strength was assessed according to the British Medical Research Council scale. The Semmes-Weinstein monofilament test was used for sensory evaluation. The mean follow-up period was 4 years (range 1 to 6 years). Results: In 11 patients with tibial nerve injuries, the soleus/gastrocnemius strength was measured as follows: M1 in one patient, M3 in four patients, M4 in four patients, and M5 in two patients. Plantar sensation was absent in four patients, while seven patients had at least adequate protective sensation. In 13 patients with a peroneal nerve injury, the strength of the anterior tibial muscle was measured as follows: M0 in three patients, M2 in three patients, M3 in one patient, M4 in three patients, and M5 in three patients. Of these, four patients had persistent insensitivity in the dorsum of the foot, while six patients had protective sensation, and three patients had normal sensation. Two patients with inadequate anterior tibial muscle strength following nerve repair underwent posterior tibial tendon transfer for restoration of foot dorsiflexion. The greatest functional improvement was obtained in cases in which a neurolysis was performed; patients undergoing a primary repair had better outcomes compared to those where nerve grafts were used. The results were better in thigh level injuries than those in the gluteal region. Conclusion: Low expectations after sciatic nerve repair in the past are now being rapidly replaced by a more optimistic approach. Advances in microsurgery and use of treatment algorithms based on scientific research account for this significant improvement in outcomes after sciatic nerve surgery. Tendon transfers can enhance the success rate and be combined with nerve repair in selected cases.

Keywords:

Accidents, Traffic, Sciatic Nerve, Wounds, Penetrating, Muscle Strength, Treatment Outcome, Neuroma,

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1. Villarejo FJ, Pascual AM. Injection injury of the sciatic nerve (370 cases). Childs Nerv Syst 1993;9:229-32.
2. Haidukewych GJ, Scaduto J, Herscovici D Jr, Sanders RW, DiPasquale T. Iatrogenic nerve injury in acetabular frac ture surgery: a comparison of monitored and unmonitored procedures. J Orthop Trauma 2002;16:297-301.
3. Millesi H. Lower extremity nerve lesions. In: Terzis JK, editor. Microreconstruction of nerve injuries. Philadelphia: W. B. Saunders; 1987. p 239–51.
4. Patil PG, Friedman AH. Surgical exposure of the sciatic nerve in the gluteal region: anatomic and historical comparison of two approaches. Neurosurgery 2005;56(1 Suppl):165-71.
5. Woodhall B, Beebe GW, editors. Peripheral nerve regeneration: a follow-up study of 3656 World War II injuries. Washington, DC: VA Medical Monograph, US Government Printing Office; 1956.
6. Gousheh J, Arasteh E, Beikpour H. Therapeutic results of sciatic nerve repair in Iran-Iraq war casualties. Plast Reconstr Surg 2008;121:878-86.
7. Kim DH, Murovic JA, Tiel R, Kline DG. Management and outcomes in 353 surgically treated sciatic nerve lesions. J Neurosurg 2004;101:8-17.
8. Kim DH, Murovic JA, Tiel RL, Kline DG. Management and outcomes in 318 operative common peroneal nerve lesions at the Louisiana State University Health Sciences Center. Neurosurgery 2004;54:1421-8.
9. Garozzo D, Ferraresi S, Buffatti P. Surgical treatment of common peroneal nerve injuries: indications and results. A series of 62 cases. J Neurosurg Sci 2004;48:105-12.
10. Trumble TE, Vanderhooft E, Khan U. Sural nerve grafting for lower extremity nerve injuries. J Orthop Trauma 1995;9:158-63.
11. Kim DH, Ryu S, Tiel RL, Kline DG. Surgical management and results of 135 tibial nerve lesions at the Louisiana State University Health Sciences Center. Neurosurgery 2003;53:1114-24.
12. Kline DG, Kim D, Midha R, Harsh C, Tiel R. Management and results of sciatic nerve injuries: a 24-year experience. J Neurosurg 1998;89:13-23.
13. Korompilias AV, Payatakes AH, Beris AE, Vekris MD, Afendras GD, Soucacos PN. Sciatic and peroneal nerve injuries. Microsurgery 2006;26:288-94.
14. Bourrel P. Transplantation of the m. tibialis posterior on the m. tibialis anterior and of the common flexor of the toes on the m. extensor hallucis longus and the common extensor of the toes in external popliteal sciatic paralysis. Apropos of 27 cases. Ann Chir 1967;21:1451-60. [Abstract]
15. Wiesseman GJ. Tendon transfers for peripheral nerve injuries of the lower extremity. Orthop Clin North Am 1981; 12:459-67.
16. Wood MB. Peripheral nerve injuries to the lower extremity. In: Gelberman RH, editor. Operative nerve repair and reconstruction. Philadelphia: J.B. Lippincott; 1991. p 489–504.
17. Ferraresi S, Garozzo D, Buffatti P. Common peroneal nerve injuries: results with one-stage nerve repair and tendon transfer. Neurosurg Rev 2003;26:175-9.
18. Özkan T, Tunçer S, Öztürk K, Aydın A, Özkan S. Surgical restoration of drop foot deformity with tibialis posterior tendon transfer. [Article in Turkish] Acta Orthop Traumatol Turc 2007;41:259-65.