Median nerve neurolysis, resection and reconstruction using Axogen AVANCE processed nerve allograft
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The median nerve is superficially placed at the wrist crease and is vunerable to injury. In this case there was a laceration to the median nerve that had occurred some 24 months previously. There was a delayed presentation and no surgical exposure was undertaken to explore the nerve at the time. The patient reported poor sensory recovery in the hand and constant neuropathic pain in the median nerve territory. There was a swelling within the nerve at the site of previous injury which was sensitive to local touch, eliciting severe neuropathic pain exacerbations with wrist extension and finger flexion. There was intact innervation to the thumb pulp and to the thenar muscles. A diagnosis of partial neuroma in continuity was made and the patient was considered for exploration, resection of the neuroma and reconstruction.
AVANCE (AxoGen Inc. Alachua, Florida, USA) processed nerve allograft was discussed as the patient was not willing to consider use of autologous graft with risk of further neuropathic pain at the donor site. The nerve was therefore reconstructed using an AVANCE allograft after meticulous intraneural dissection allowed preservation of the intact fascicles to the thumb.
In cases where there is some sensory preservation, consideration may be given to neurolysis and wrapping of a neuroma in continuity to diminish local mechanical irritation or nerve tether pain (neurostenalgia). Collagen nerve wraps and bio-resorbable polymer membranes can be used to diminish further post-operative scar tether at the level of the painful neuroma.
Autologous flaps, including the Becker adipo-fascial flap and the radial forearm perforator flap, can be used to provide additional cushioning of the sensitive area in such cases. This case demonstrated complete loss of function in the index and middle fingers and so the option of neurolysis was not considered.
The gold standard nerve graft option is a reversed sensory autologous nerve with the donor nerve selected based on the length of the defect, the number of cables required, the site of surgery and the type of anaesthesia. Autologous nerve graft harvest leaves a numb area of skin at another site and there can be donor proximal nerve stump neuroma formation. The option of autologous nerve graft may be unacceptable to some patients, particularly when they are presenting with significant neuropathic pain and the concern is that the donor nerve site could become another pain driver.
An alternative option is to use AVANCE processed nerve allograft. This is human nerve that is acellular having undergone detergent and enzyme washes. It is screened to avoid infection transmission and then provided sterile and frozen in a number of sizes. The graft is provided by AxoGen Inc Alacachua, Fl, USA.
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Author: Dominic Power, MA MB BChir(Cantab), FRCSEd, FRCSLon, FRCS(Tr & Orth). Consultant Hand and Peripheral Nerve Surgeon Honorary Senior Clinical Lecturer, University of Birmingham, UK
Institution: West Midlands Peripheral Nerve Injury Service, Birmingham Hand Centre, UK.
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