Autogenous sural nerve grafts: a harvesting technique

Sensory and functional morbidity following sural nerve harvest in paediatric patients

BACKGROUND

The sural nerve is a common donor site for nerve reconstruction. The only study describing outcomes in paediatric patients was following bilateral sural nerve harvest before the age of 1 year. Bilateral nerve harvest at such a young age may limit patients' ability to perceive a sensory difference. The objective of this study was to understand the sensory and functional deficit after unilateral sural nerve harvest in paediatric patients.

METHODS

A prospective case series was performed in children (age 6-18 years) following unilateral sural nerve harvest. The contralateral foot was used as a control. Sensory Threshold Evaluation was performed by Weinstein Enhanced Sensory Test (WEST) - Foot, and a Functional Sensory and Pain Questionnaire was administered. Sural nerve harvest was performed by a minimally invasive technique using a nerve stripper.

RESULTS

Twenty-eight feet of 14 patients that underwent unilateral sural nerve harvest were assessed. As a group, the 14 feet with sural nerve harvest demonstrated significantly higher thresholds in the four areas tested (p <0.05), thus identifying objective sensory loss at each location. The location of sensory loss in each patient was variable, with heavier sensory thresholds detected in 69.6% of areas tested than those in the corresponding location in the contralateral foot. Greater sensory loss was detected at the proximal lateral foot than at the distal lateral foot. Responses to the questionnaire revealed that only one patient perceived a sensory loss that affected their function.

CONCLUSIONS

Unilateral sural nerve harvest in paediatric patients resulted in measurable sensory loss. Despite loss of innervation, only two patients reported intermittent dysaesthesia or cold sensitivity, and the majority of the patients reported no functional deficit.

Anomalous superficial peroneal nerve and variant cutaneous innervation of the sural nerve on the dorsum of the foot: a case report

BACKGROUND

The superficial peroneal nerve is a branch of common peroneal nerve. There are reports about the variant course and distribution of this nerve. The sural nerve arises from the tibial nerve in the popliteal fossa. The variations of the above nerves described here are unique and provide significant information to surgeons dissecting lower limb.

CASE PRESENTATION

The present case is about some important anatomic variations observed in left lower limb of approximately 55-year-old male cadaver. The variations were; high division of superficial peroneal nerve into medial and lateral branches, lateral branch descending in the anterior intermuscular septum in a peroneal tunnel before piercing the deep fascia and variant distribution of sural nerve on the dorsum of the foot. The probable clinical significances of the variation are discussed.

CONCLUSION

Awareness of anatomical variations of superficial peroneal and sural nerves such as those presented here becomes important to avoid injury in real clinical situations.

Subjective Outcomes Following Sural Nerve Harvest

PURPOSE

The goal of this study was to assess subjective patient recovery of donor site sensory deficit following sural nerve harvest for trigeminal nerve repair surgery.

PATIENTS AND METHODS

A review of 42 consecutive sural nerve graft patient records yielded 26 patients, at least 20 months following sural nerve grafting for trigeminal nerve repair, who participated in a telephone questionnaire survey to assess subjective outcomes. The association between donor site outcome and other factors, including nerve graft recovery, age, gender, pain, cold sensitivity, scar cosmesis and tactile sensitivity, and legal involvement were analyzed, and presurgical and present levels of donor and nerve graft site sensibility were compared.

RESULTS

The perceived area of donor site sensory deficit decreased significantly over time. Postoperative donor site pain and cold sensitivity at low levels were reported by few patients, and the majority have completely resolved. Most patients reported no problems with scar cosmesis or pain. There was a moderate agreement between donor site recovery and nerve graft recovery (kappa = 0.32). Few patients reported satisfaction with one site and not the other or complete dissatisfaction with both sites. Other factors such as age, gender, or legal involvement were not found to correlate with satisfaction level.

CONCLUSIONS

The use of a questionnaire for subjective assessment of neurosensory recovery following nerve graft repair yields outcomes information that is generally not considered in the traditional clinical patient assessment. The majority of patients tolerate sural nerve harvest without significant donor site morbidity.

Peroneal nerve lesion after sural nerve graft harvest: An unusual complication?case report

After harvesting of the sural nerve, the patient developed a partial palsy of the common peroneal nerve due to a lesion of the peroneal nerve and a neuroma of the sural nerve stump. Motor function recovered after performing neurolysis of the common peroneal nerve and mobilization of the neuroma. The sural nerve, in this case originating from the common peroneal nerve, was harvested using a nerve stripper and four small skin incisions. Direct lesion by the forced use of the nerve-stripping instrument followed by the formation of a neuroma close to the peroneal nerve are the suspected reasons for motor dysfunction. Although many authors report using a nerve stripper as a safe, less invasive method to gain nerve material for transplantation, we recommend lengthening the skin incision so as to be aware of anatomical variations and to refrain from pulling the nerve distally to avoid the described complications.

Minimally invasive technique for sural nerve harvesting: technical description and follow-up

OBJECTIVES

To provide instruction and the results of a minimally invasive technique for sural nerve harvesting in preparation for interposition nerve grafting during radical retropubic prostatectomy.

METHODS

Twelve men underwent nerve harvesting performed using a tendon stripper. The short-form McGill Pain Questionnaire was completed preoperatively and at 6 months postoperatively.

RESULTS

No significant morbidity from the leg resulted as a result of the sural nerve harvest. The results of the short-form McGill Pain Questionnaire demonstrated no significant sensory or affective changes in the leg. The average operative time for the entire harvesting procedure, including skin closure, was 15 minutes. The estimated blood loss was less than 5 mL (range 2 to 10). No wound infection or skin erythema was observed. The discharge to home was not delayed compared with the usual length of stay after radical retropubic prostatectomy.

CONCLUSIONS

This minimally invasive sural nerve harvesting technique is easy to perform and has minimal morbidity.

Harvesting of the sural nerve with a tendon stripper

The nerve most commonly used for peripheral nerve reconstruction is the sural nerve. The nerve can be dissected free through one long calf incision, by utilizing multiple small incisions, or by using a tendon stripper. We studied 12 above-knee amputation specimens harvesting the nerve in the ways described. We found that the length of nerve harvested averaged 32, 36, and 25 cm for the open, limited open, and stripper techniques, respectively. Epineurial damage occurred with the stripper, but no perineurial damage was documented histologically. We concluded that the closed method (stripper) of harvesting sural nerve would provide quality graft material, but of unpredictable length. When reliably long segments of nerve are required, at least a limited open or an open approach for harvest is recommended.

Endoscopic sural nerve harvest in the pediatric patient

A technique of endoscopic sural nerve harvest was devised to minimize the donor-site scarring in pediatric patients requiring peripheral nerve-grafting procedures. The harvests were performed under tourniquet control using two 2-cm incisions for access at the lateral malleolus and the midcalf. Endoscopic visualization and blunt dissection of the nerve were achieved with a 4-mm Hopkins telescope with 30-degree angled lens (Karl Storz GmbH, Tuttlingen, Germany) stabilized in an Emory retractor and attached to a video camera. The medial sural nerve was divided in the popliteal fossa proximally under endoscopic visualization. The lateral sural nerve was identified and harvested when present. Between June of 1994 and March of 1995, 18 patients underwent 27 sural nerve harvests using the endoscopic technique. Mean patient age was 3.3 years (range 4 to 197 months). Indications for surgery included obstetrical brachial plexus palsy (12), facial palsy (5), and ulnar nerve neuroma (1). Nerve-graft length harvested ranged from 13 to 41 cm. Mean tourniquet time per limb was 92 minutes. No nerve graft injury was noted on examination under the operating microscope. Postoperative pain, swelling, and ecchymosis were minimal. Donorsite scarring has been aesthetically satisfactory to date.

Anatomy of the sural nerve complex

The anatomy of the sural nerve complex in 20 cadaveric limbs was determined by dissection. The nerve usually consists of four named components: the medial sural cutaneous nerve, the lateral sural cutaneous nerve, the peroneal communicating branch, and the sural nerve. In most instances (80%), the sural nerve is formed in the distal portion of the leg by the union of the medial sural cutaneous nerve and the peroneal communicating branch. In 20% of cases, the peroneal communicating branch is absent. In such cases, the sural nerve is derived from the medial sural cutaneous nerve alone. The lateral sural cutaneous nerve is laterally situated and usually divides into medial and lateral branches. In a few cases, its medial division may contribute to the sural nerve through the peroneal communicating branch. The peroneal communicating branch can be of substantial caliber and may be useful as a source of nerve graft without complete sacrifice of the sural nerve. We describe a technique of isolation of the peroneal communicating branch for use as a nerve graft.