Contents 1 The Peripheral Nervous System: Gross Anatomy 2 The Microscopic Structure of the Nervous System: Its Function

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1 1 The Peripheral Nervous System: Gross Anatomy The Cranial Nerves The Spinal Nerves The Anterior Primary Rami Thoracic Anterior Primary Rami Lumbar and Sacral Anterior Primary Rami The Posterior Primary Rami The Autonomic Nervous System The Sympathetic System The Parasympathetic Nervous System Afferent Autonomic Pathways Nerves at Risk from Musculo Skeletal Injury References The Microscopic Structure of the Nervous System: Its Function The Neurotrophins Nerve Growth Factor The Peripheral Nerve Fibres Conduction The Basis of the Action Potential: Ion Channels Axonal Transport The Blood Supply of Nerves The Nervi Nervorum Changes in Nerves with Ageing The Somatic Motor System The Somatic Sensory System Cutaneous Sensibility The Skin Cutaneous Sensory Receptors Deep Sensibility The Muscle Spindles The Golgi Tendon Organs Central Connections Visceral Afferents Cortical Maps Synaptic Activity References xiii

2 xiv 3 Reactions to Injury Axonotmesis Neurotmesis The Cell Body and Proximal Stump Wounds of the Perineurium Contralateral Effects The Distal Stump Types of Lesion Produced by Different Physical Agents Acute Ischaemia Ischaemia from Tamponade Ischaemia and Acute Compression Within Neurovascular Fascial Compartments Ischaemia by Acute Compression from Swollen Muscle Ischaemia Caused by Traction Reperfusion Injury Chronic Ischaemia Crush Compression Acute Chronic Nerve Compression Traction or Stretch Injury Thermal Injury Electric Shock Percussion Injury Injection Injury Vibration Injury The Perineurium and Neoplasm or Infiltration Radiation and Peripheral Nerves Envenomation The Peripheral Effects of Denervation Changes at the Higher Levels: The Phantom Limb References Regeneration and Recovery The Response of the Nerve and Axon to Transection The Repair of Large Gaps Other, Non Neural, Material for Grafts: Entubation Nerve Transfer Recovery of Cutaneous Sensation after Nerve Transfer Recovery of the Deep Afferent Pathways after Nerve Transfer Complications of Regeneration Regeneration after Intradural Injury Recovery of Function after Nerve Repair Methods Factors in Prognosis Severity of Injury Delay References Clinical Aspects of Nerve Injury Associated Symptoms and Signs Recognition of the Level and the Depth of Injury Signs Tinel s Sign Eliciting the Tinel Sign in Closed Lesions

3 xv 5.6 Tinel s Sign and Recovery Examination of Sensibility Quantitative Sensory Testing Examination of Muscles Some Pitfalls Our Methods Clinical Examination The Lower Limb Late Signs of Nerve Injury Signs of Reinnervation Records Aids to Diagnosis References Clinical Neurophysiology in Peripheral Nerve Injuries Shelagh Smith and Ravi Knight 6.1 Introduction Electrodiagnostic Techniques Glossary of Electrodiagnostic Procedures Intra-operative Neurophysiological Procedures Electrodiagnostic Techniques and Localisation Limitations and Pitfalls of Electrodiagnostic Investigation Safety Aspects Pathophysiological Correlates Types of Nerve Lesion: the Electrophysiological Consequences Regeneration and Reinnervation Clinical Applications Upper Limb Neuropathies Lower Limb Neuropathies Diffuse Problems References Operating on Peripheral Nerves Indications and Objects of Intervention Special Units: Their Role General Principles of Operation Control of Bleeding Apparatus and Instruments Methods of Repair The Vascular Repair The Nerve Operations The Nerve Repair Methods of Suture Grafting Indications For and Methods of Nerve Transfer Immobilisation Approaches to Individual Nerves The Transverse Supraclavicular Approach: (Anterior, or Anterolateral) The Transclavicular Exposure The Postero-Lateral Route Repair of the Roots of the Spinal Nerves in an Avulsion Lesion The Spinal Accessory Nerve The Suprascapular Nerve The Infraclavicular Part of the Brachial Plexus

4 xvi The Circumflex Nerve Median and Ulnar Nerves in the Arm and the Axilla The Radial Nerve The Posterior Interosseous Nerve The Lower Part of the Median Nerve The Lower Part of the Ulnar Nerve Nerves in the Abdomen and Pelvis The Sciatic Nerve The Tibial and Common Peroneal Nerves in the Popliteal Fossa and Below The Lower Tibial Nerve and the Plantar Nerves Entrapment Neuropathy The Thoracic Outlet Syndromes The Suprapleural Membrane (Sibson s Fascia) The First Rib The Seventh Cervical Rib Considerations About Operation Carpal Tunnel Syndrome Technique of Operation (Open Method) Operations for Ulnar Neuropathy at the Elbow The Less Common Entrapment Syndromes Upper Limb Some Entrapment Neuropathies in the Lower Limb Meralgia paraesthetica Entrapment of the Pudendal Nerve The Piriformis Syndrome The Tarsal Tunnel Syndrome Morton s Metatarsalgia Pitfalls in Operating on Tumours of Peripheral Nerves The Solitary Benign Schwannoma (Neurolemmoma, Neurinoma) The Intraneural Ganglion The Solitary Neurofibroma Malignant Peripheral Nerve Sheath Tumours (MPNST) References Compound Nerve Injury The Wound War Wounds: Current Practice The Vascular Lesion The Shoulder The Elbow The Knee The False Aneurysm and Arteriovenous Fistulae Ischaemia and the Nerve Iatrogenous Ischaemic Injury Skin Penetrating Missile Injuries Suture and Grafting During World War Two: The MRCR Evidence Grafts Experience from St Mary s and the Royal National Orthopaedic Hospitals The Brachial Plexus Pain The Peripheral Nerves Recent Experience

5 xvii 8.5 Neurovascular Injuries: Amputation Revascularisation The Brachial Plexus The Closed Infraclavicular Lesion Nerves and Bone and Joint Injuries The Nerve and the Pattern of Fracture The Shoulder Girdle and Gleno-Humeral Joints The Clavicle Dislocation of the Gleno-Humeral Joint The Radial Nerve and Fractures of the Humerus Incidence Conclusions The Musculocutaneous Nerve Elbow Iatrogenous Injuries in the Adult The Forearm The Lower Limb The Femoral Nerve The Lumbo Sacral Plexus The Hip The Common Peroneal and Tibial Nerves More Recent Experience at the Royal National Orthopaedic Hospital References The Closed Supraclavicular Lesion Mechanisms of Injury Anatomy Course in the Neck Micro Anatomy Functional Distribution Lesions of the Spinal Cord The Evolution of Our Policy of Treatment of Closed Traction Lesions of the Brachial Plexus The Definition of Pre and Postganglionic Lesion: Prognosis for Recovery Epidemiology Diagnosis Conduction studies: The Current Situation The Operation Some of the Techniques Used for Repair Strategies of Repair The Upper Lesion: Rupture or Avulsion of C5, C6 (C7) with Intact (C7) C8, T The Lower Lesion: Intact C5, C6 (C7), Rupture or Avulsion C8, T The Middle Group The Complete Lesion Free Functioning Muscle Transfer (FFMT) The Bilateral Lesion Results Methods Definitions Conventional Nerve Transfers Repair of Avulsed Ventral Roots Recovery of Function by Patients Age

6 xviii 9.12 Relief of Pain by Repair Return to Work Reimplantation of Avulsed Spinal Nerves The First Clinical Case George Bonney, 1977 (from the first edition of this work) Subsequent Work by Thomas Carlstedt References Birth Lesions of the Brachial Plexus The Lesion of the Spinal Nerve in Birth Lesion of the Brachial Plexus (BLBP) The Central Affect Methods of Study Diagnosis Epidemiology Incidence Risk Factors Recovery in the Complete Lesion Group Group Treatment Supplementary Investigations Neurophysiological Investigations (NPI) Imaging Nerve Operations The Indications for Operation The Incomplete Lesion: Groups 1 and The Operation Methods of Repair Post-operative Care Results of Nerve Operations Experience at St Mary s Royal National Orthopaedic Hospital Late Reinnervation Cocontraction Deformities Posterior Subluxation (PS) and Posterior Dislocation (PD) of the Gleno-humeral Joint with Related Contractures Onset and Progression of the Secondary Deformities Diagnosis and Classification Medial Rotation Contracture The Development of Our Preferred Operation for Posterior Subluxation or Dislocation of the Gleno-Humeral Joint The Operation for Reduction of the Posterior Subluxation and Dislocation of the Gleno-Humeral Joint Deformities at the Elbow and Forearm Conclusion References Iatrogenous Injuries Part 1: General Considerations Rolfe Birch 11.1 Incidence and Audit Causes Generalised Disorders Alcohol

7 xix Diabetes Connective Tissue Disease Warning and consent Teaching and Training Specialisation Continuity of Care: Timing of Operation Nerve Lesions in Total Hip Arthroplasty The Nerve Lesion Findings in the 110 Patients Seen Between 2001 and Indications for Urgent Reexploration Radiation Neuropathy The Place of Operation Prevention of Iatrogenous Lesions Teaching and Training Audit and Consent Conduct of Affairs Recognition and Action Iatrogenous Injuries Part 2: Minimising and Managing Iatrogenous Trigeminal Nerve Injuries in Relation to Dental Procedures Tara Renton 11.6 Introduction Signs and Symptoms Mechanisms of Nerve Injuries Local Analgesic Related Trigeminal Nerve Injuries Implant Related Nerve Injuries Management of Implant Related Nerve Injuries Endodontic Related Nerve Injury Third Molar Surgery Dental Extraction of Other Teeth Proximal to IAN Canal Socket Medications Post Operative Infection Related Nerve Injuries Management of Trigeminal Nerve Injuries Evaluation of Trigeminal Nerve Injuries Possible Interventions and Timing Possible Management Tools Reassurance Counselling/Cognitive Behavioural Therapy Medical Intervention Surgical Intervention Reasoning for Early Nerve Repair Surgical Technique Medico Legal Issues Improved Consent Improved Management of These Injuries Can We Prevent These Injuries? References Pain Nocicipient The Gate Theory Events After Nerve Injury Central Pain: The Preganglionic Injury of the Brachial Plexus The Sympathetic Nervous System and Pain

8 xx 12.2 Complex Regional Pain Syndrome (CRPS) Type 1 and (CRPS) Type CRPS Type 2 (Causalgia) The Painful, Stiff, Swollen Part After Fracture or Soft Tissue Injury (CRPS Type I, Reflex Sympathetic Dystrophy) Diagnosis Drugs and Other Measures Short of Operation Indications for Operation Causalgia Neurostenalgia Post Traumatic Neuralgia Interventions upon the Central Nervous System Interventions on the Central Nervous System: Stimulation Interventions upon the Central Nervous System: Ablation Summary References Reconstruction Requirements The Tension of Transfer Fixed Deformity Correction of Fixed Deformity Principles of Operation The Equino-varus Deformity of Ankle and Foot Flexor Muscle Slide, by the Technique of Books Fixed Extension at the Metacarpo-phalangeal Joints Release of Contracted Small Muscles of the Hand Methods of Reconstruction The Shoulder Girdle Extension of the Elbow Flexion of Elbow The Operations Paralysis of the Extensors to the Wrist and Fingers, and of the Abductors and Extensors to the Thumb Pre and Post-operative Care The Operations The High Median Palsy Abduction and Opposition of the Thumb The High Ulnar Palsy Combined Nerve Lesions and the Hand The Lower Limb The Insensate Foot Abduction and Flexion at the Hip The Knee Foot and Ankle: The Drop Foot from Common Peroneal Palsy Vascularized Bone and Muscle Transfer Amputation Conclusion References Rehabilitation Communication History

9 xxi 14.3 The Rehabilitation Team The Method of Work Some Technical Aspects Motivation Rehabilitation in Progressive Neurological Disease The Choice of Intervention Patients with Neuropathic Pain Paralysis not Physically Determined Conversion Paralysis The Munchausen Syndrome Malingering Rehabilitation in the War Wounded Outcomes The Future References Index

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