Electrical fascicle identification as an adjunct to nerve repair

In view of the tragic consequences of median nerve and/or ulnar nerve paralysis and the biologic problems inherent in nerve healing, it seems logical that the surgeon should make a serious effort to control those problems that lie within his or her power: to identify and align those principal sensory and motor pathways in the severed nerve ends. I find that this is feasible. For over 15 years, I have used the electrical fascicle identification method, repairing 49 major upper extremity nerves. (A single radial nerve case was lost to follow-up.) As with any new technique, problems have been identified: incomplete information and confusing information, both of which require careful interpretation and some knowledge of internal nerve topography. Other problems have included the occasional patient who awakens on the operating table, confused and apprehensive, requiring some patience by surgeon and anesthetist. Perhaps this latter group should be done under Bier block intravenous anesthesia, if they can be identified beforehand. I believe that the electrical fascicle identification technique is sufficiently useful that I do not like to repair a major nerve without it. When distal stump motor identification is not feasible because of time delay or other reason, then anatomic dissection is used to locate the motor fascicle (and also digital nerve sensory fascicles, if necessary). My results have been significantly better than in the era of standard epineurial nerve repair. The median nerve is not only the most important nerve in the upper extremity, but also the most elusive in which to restore intrinsic motor recovery. Yet, today, I am able to restore opponens-abductor motor function in more than 90 per cent of median nerve lacerations repaired using electrical fascicle identification. Ulnar nerve loss, with its profound motor weakness, is almost as devastating. The modest number of ulnar nerves repaired by electrical fascicle identification in this present study (20 cases) suggests that low-level injuries recover more rapidly (1 to 2 years) than did the standard epineurial sutures and also that two relatively high-level injuries near the elbow have shown surprisingly good intrinsic motor recovery--something that epineurial suture did not accomplish.