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12-MARCH-2009  AHMAD ISMAEEL AWWAD  26 YEARS  BULLET INJURY TO THE LOWER THIRD OF LEFT SCIATIC NERVE.

Anamnesis:

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The patient came to the clinic 25-February-2009 complaining of complete loss of function of the left sciatic nerve, after suffering bullet injury 07-December-2008 with subsequent "repair" 15-December-2008.

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On examination the patient showed complete absence of the function of the sciatic nerve below its subdivision. The inlet was from the medial third of the thigh medially and the outlet was at the popliteal fossa. Considering that the relatives were informed that further exploration was decided by the first neurosurgeon, it was decided to undergo exploration.

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Despite the fact, that the previous incision was performed out of the trajectory of the sciatic nerve, it was decided to use it for the planned operation and to use lazy extensions to conform with the needed exposure of the proximal part of the sciatic nerves and the common peroneal and tibial nerves. Dissection started to expose the sciatic nerve above the scar, the the tibial nerve was exposed at the popliteal fossa and from under the gastrocnemius muscle after bisecting the arcade of the solius muscle. The common peroneal nerve was exposed before its division to the deep and superficial branches.

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Using Inomed ISS with DNS and EMG protocol, the was complete denervation of both tibial and common peroneal nerves.

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Neurolysis of the exposed nerves toward the scarous region, confirmed complete absence of the tibial and common peroneal nerves with the last 2-3 cm of the sciatic nerve before its subdivion.

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The tibial nerve was bisected at the scar, and the proximal part was cut several times, until the nerve became having acceptable bundles. The same was done to the left common peroneal nerve and last to the sciatic nerve. The resulting gap was 80 mm between the sciatic and both tibial and common peroneal nerves. Dissection of the sciatic nerve and the tibial nerve was performed around 20 cm above and below to regain some extralength.  The sciatic nerve was subdivided to its major trunks to regain some ample and to avoid severe angulation of the trajectories of the nerves. The perineurium of the tibial nerve and the tibial division of the sciatic nerve were acceptable and intentionally some scar was left adherent to them, so as to use them for tight and strong hold of the anastamosis. The anastamosis of the tibial division of the sciatic nerve was achieved with the tibial nerve with the knee positioned in 70 degrees without tension.

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The proximal part of the common peroneal nerve had good perineurium, but the distal part of the peroneal subdivion was lacking a good perineurium. An anastamosis was performed between these two stumps with the knee flexion 90 degrees.

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During closure with the knee in 90 degrees in flexion, the anastamosis of the peroneal nerve disrupted. It was decide to harvest sural nerve graft 40 mm length 5 bundles collected together and cross anastamosis was performed with common peroneal nerve and the peroneal subdivion of the sciatic nerve. The wounds were closed routinely and complete POP was used to keep the knee in 90degrees position.

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Smooth postoperative recovery.

Comments

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The patient had undergone early exploration of the common peroneal nerve at the first surgery and it was stitched to the muscle sheath.

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The bullet injury usually cause wide-spread injury to the nerves and to have more or less acceptable regeneration of the nerves the stumps must have good fibrillary section.

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To obtain such requirement a huge gaps usually took place and the surgeon must be ready to find the appropriate solutions to the arising problems.

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Notice: Not all operative activities can be recorded due to lack of time.
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[2009] [CNS CLINIC - NEUROSURGERY - JORDAN]. All rights reserved