Surgical techniqueSurgical Technique of Harvesting Vascularized Superficial Radial Nerve Graft
Section snippets
Indications
Currently, our indication for use of a vascularized superficial radial nerve graft in brachial plexus surgery is C5 to C7 paralysis. In such cases, the ulnar nerve is functional and should be preserved. In total brachial plexus palsy reconstruction, when one runs out of other vascularized nerve graft materials, superficial radial nerve can be used. In case of contralateral nerve transfer in brachial plexus surgery, the first choice for vascular nerve graft is the ulnar nerve because of its
Preoperative Preparation
Before harvesting the vascularized superficial radial nerve graft, a careful preassessment is necessary to evaluate the blood supply of the hand. An Allen's test is performed to assess the patency of the ulnar artery and the completeness of the superficial palmar arch. Doppler examination and arteriography of the radial and ulnar arteries should be performed in case of injury or disease.
Vascular Anatomy of Superficial Radial Nerve
According to the anatomic study of the pattern of this extrinsic vascular system by Breidenbach and Terzis,4 the superficial radial nerve has an extrinsic blood supply consisting of a single dominant system, radial artery (RA) and its venae comitantes. The RA, one of the terminal branches of the brachial artery, arises in the cubital fossa and passes downward and is laterally overlapped by the brachioradialis muscle. The artery is accompanied by 2 or more venae comitantes. The radial recurrent
Surgical Technique
The patient is placed in a supine position with the shoulder abducted on a separate hand table. The forearm is surgically prepared circumferentially and draped from the mid-arm to the hand. The surgical procedure is performed under pneumatic tourniquet, and the forearm is extended and kept in mid-prone position. The skin is incised in a curvilinear or zigzag fashion along the lateral aspect of the forearm starting from 2 cm proximal to the wrist crease and then extended proximally over the
Complications
In the 20 vascularized superficial radial nerve graft surgeries performed at our center since 2007, none of the patients had any vascular compromise or ischemic complications of the hand. No wound infections of the hand occurred. Two hematomas occurred, but neither required drainage. Careful hemostasis and placement of a surgical drain minimizes hematoma formation. Neuromas, wound separation, and infection are potential complications that are rare if care is taken during dissection and wound
Discussion
Nerve grafting techniques include use of either a free nerve graft or a vascularized nerve graft in the form of pedicle grafts or as a free vascularized graft transfer.5 A vascularized nerve graft may be considered for its ability to provide immediate intraneural perfusion in a poorly vascularized bed and to reconstruct large nerve gaps.6, 7
Use of large nerve trunks as free nonvascularized grafts leads to ischemic degeneration and marked fibrosis, which interferes with passage of regenerating
References (13)
Techniques for nerve grafting
Hand Clin
(2000)- et al.
Experimental comparison of vascularized and nonvascularized nerve grafting
J Hand Surg
(1988) - et al.
A comparison of vascularized and conventional sural nerve grafts
J Hand Surg
(1992) Free vascularized nerve transfer in the upper extremity
Hand Clin
(1999)- et al.
The free vascularized nerve graftA further experimental and clinical application of microvascular techniques
Plast Reconst Surg
(1976) - et al.
Vascularized nerve graft: an experimental and clinical review
Ann Plast Surg
(1987)
Cited by (8)
Hand Sensibility after Transradial Arterial Access: An Observational Study in Patients with and without Radial Artery Occlusion
2019, Journal of Vascular and Interventional RadiologyCitation Excerpt :However, no correlation between this subtle abnormal sensibility and subjective loss of hand function by a validated questionnaire was found. In the per hand analysis, RAO was an independent predictor of abnormal sensibility; however, hampered perfusion after RAO as a cause of neurologic dysfunction is unlikely, as the arteriae nervorum supplying the SRN arise from the radial artery and their takeoff is proximal to the radial puncture side (20). Also, in a previously published study, no reduced hand perfusion or ischemia was found in patients with RAO (21).
Use of a harvested radial artery graft with preservation of the vena comitantes to reduce spasm risk and improve graft patency for extracranial to intracranial bypass: Technical note
2016, Clinical Neurology and NeurosurgeryCitation Excerpt :Selber et al. studied 370 radial forearm flaps between 1998 and 2008 and found that when the venae comitantes has adequate caliber it should be selected as the sole venous outflow for radial forearm flaps [22]. This study and others have shown the importance of appropriate venous drainage to prevent flap failure [12,17,23]. Additionally, beyond simple venous drainage, paired artery-vein complexes may provide each other with physiological equilibrium through the maintenance of a surrounding bio-chemical milieu necessary for the function of the flap.
Use of a bipedicled nerve flap taken from the dorsum of the digit for reconstruction of neurocutaneous defect in the adjacent finger
2013, Journal of Plastic, Reconstructive and Aesthetic SurgeryCitation Excerpt :Using our flap, postoperative insufficiency of the blood supply or venous congestion was not noted in all cases. Many clinical studies have demonstrated the superior outcomes achieved using vascularised instead of unvascularised nerve grafts.25–27 Our nerve graft attached with the bipedicled flap is vascularised, because retaining a wide subcutaneous tissue strip between the flap and the nerve graft seems to be adequate to provide blood supply to the nerve.
Histomorphometry of the Sural Nerve for Use as a CFNG in Facial Reanimation Procedures
2023, Journal of Clinical MedicineBrachial plexus injury: Recent diagnosis and management
2021, Open Access Macedonian Journal of Medical SciencesThe role of vascularization in nerve regeneration of nerve graft
2020, Neural Regeneration Research
No benefits in any form have been received or will be received related directly or indirectly to the subject of this article.