Modern principles of medical treatment for combat injuries of peripheral nerve

The Department of Neurosurgery of the S. M. Kirov Military Medical Academy has developed and implemented a new concept for providing assistance to the wounded with injuries to peripheral nerves.

During previous military conflicts, wait-and-see tactics for treating such victims were standard. Reconstructive interventions on nerves were performed no earlier than 3–6 months after injury. This was justified by the fact that impaired nerve function is often associated with a contusion mechanism and restoration of conductivity could occur without surgery.

In recent years, neuroimaging methods such as magnetic resonance neurography and ultrasound examination of peripheral nerves have been actively developed at the Military Medical Academy. Their use (immediately upon achieving healing of the surgical wound after primary surgical treatment, and for magnetic resonance neurography – after removal of metal foreign bodies), in addition to electroneuromyography, which is not always informative in the early stages, but traditionally used, makes it possible to confirm or exclude a complete anatomical break of the nerve trunk and determine the pathomorphological form of its damage. While maintaining the morphological integrity of the nerve, the wounded person is prescribed adequate conservative (neurotrophic, analgesic) therapy. In the presence of pathomorphological changes, reconstructive surgical interventions on peripheral nerves are now carried out in the early stages after injury (3–6 weeks). The sooner reconstructive intervention on the nerve is performed, the greater the likelihood and the faster its function will be restored.

The most important element of the new concept of providing care to patients with peripheral nerve injuries is close interaction between neurosurgeons and neurologists, ensuring continuity of care at all stages of treatment. Firstly, it made it possible to timely identify patients with clinical signs of damage to the peripheral nervous system in the flow of incoming surgical patients. Secondly, it has proven its effectiveness in the treatment of neuropathic pain syndrome in this category of patients at the stage before and after neurosurgical intervention. Thirdly, early reconstructive intervention is followed by early restorative treatment under the supervision of a neurologist.

1. Alekseev E.D. Differentiated treatment of modern combat gunshot injuries of peripheral nerves. Dis. ... candidate of medical sciences. Saint Petersburg, 1998. 22 p. (In Russ.).

2. Chernov V.E. Organization of specialized neurosurgical care in armed conflicts. Dis. ... candidate of medical sciences. Saint Petersburg, 2001. 164 p. (In Russ.).

3. Martynov V.N. Main directions of improvement of specialized neurosurgical care in the North Caucasus region. Dis. ... candidate of medical sciences. Saint Petersburg, 2003. 167 p. (In Russ.).

4. Military field surgery: national guidelines. Eds.: I.Yu. Bykov, N.A. Efimenko, E.K. Gumanenko. Moscow: GEOTAR-Media, 2009. 816 p. (In Russ.).

5. УGuidelines for military field surgery. Eds.: A.N. Belskikh, I.M. Samokhvalov. Moscow: GVMU, 2013. 474 p. (In Russ.).

6. Goncharov A.V. Providing surgical care to the wounded in military conflicts. Dis. ... doctor of medical sciences. Saint Petersburg, 2021. 43 p. (In Russ.).

7. Mironovich N.I. General statistical data on gunshot wounds of peripheral nerves. Experience of Soviet medicine in the Great Patriotic War of 1941–1945. Medgiz 1952;20:31–49. (In Russ.).

8. Dreval O.N., Kuznetsov A.V., Dzhindzhikhadze R.S. et al. Clinical guidelines for diagnostics and surgical treatment of injuries and diseases of the peripheral nervous system. Association of Neurosurgeons of Russia. Moscow, 2015. 34 p. (In Russ.).

9. Zhivolupov S.A., Rashidov N.A., Samartsev I.N. et al. Peculiarities of development of denervation-reinervation process in traumatic neuropathies and plexopathies. Vestnik Rossiyskoy Voennomeditsinskoy akademii = Herald of the Russian Academy of Military Medicine 2013;3:190–8. (In Russ.).

10. Zhurbin E.A. Possibilities of ultrasound examination in traumatic injuries of peripheral nerves of the extremities. Dis. ... candidate of medical sciences. Saint Petersburg, 2018. 147 p. (In Russ.).

11. Ogleznev K.Ya., Zhuravleva G.N., Kuznetsov A.V. Magnetic resonance imaging in diagnostics of lesions of the brachial plexus and its peripheral branches. Nevrologicheskiy zhurnal = Neurological Journal 2000;6:28–32. (In Russ.).

12. Freund W., Brinkmann A., Wagner F. MR neurography with multiplanar reconstruction of 3D MRI datasets: an anatomical study and clinical applications. Neuroradiology 2007;49(4):335–41. DOI: 10.1007/s00234-006-0197-6

13. Gosk J., Hendrich B., Wiącek R. et al. Assessment of the usefulness of X-ray myelography and magnetic resonance myelography, performed with an open low-field device, in diagnosing perinatal preganglionic injuries of the brachial plexus. Arch Med Sci 2012; 8(4):678–83. DOI: 10.5114/aoms.2012.28597

14. Tagliafico A., Succio G., Neumaier C.E. MR imaging of the brachial plexus: comparison between 1,5-T and 3-T MR imaging: preliminary experience. Skeletal Radiol 2010;40(6):717–24. DOI: 10.1007/s00256-010-1050-x

15. Chhabra A., Lee P.P., Bizzell C. High-resolution 3-Tesla magnetic resonance neurography of musculocutaneous neuropathy. J Shoulder Elbow Surg 2012;21(2):1–6. DOI: 10.1016/j.jse.2011.06.008

16. Chhabra A., Ahlawat S., Belzberg S. Peripheral nerve injury grading simplified on MR neurography: As referenced to Seddon and Sunderland classifications. Indian J Radiol Imaging 2014;24:217–24. DOI: 10.4103/0971-3026.137025

17. Tagliafico A., Succio G., Serafini G. et al. Diagnostic performance of ultrasound in patients with suspected brachial plexus lesions in adults: a multicenter retrospective study with MRI, surgical findings and clinical follow-up as reference standard. Skeletal Radiol 2013;42(3):371–6. DOI: 10.1007/s00256-012-1471-9

18. Zhurbin E.A., Gaivoronsky A.I., Zheleznyak I.S. et al. Diagnostic accuracy of ultrasound examination in injuries of peripheral nerves of the extremities. Vestnik Rossiyskoy Voenno-meditsinskoy akademii = Herald of the Russian Academy of Military Medicine 2017;3:63–8. (In Russ.).

19. Maletsky E.Yu., Korotkevich M.M., Butova A.V. et al. Measurement of peripheral nerves: comparison of ultrasound, magnetic resonance and intraoperative data. Meditsinskaya vizualizatsiya = Medical Visualization 2015;2:78–86. (In Russ.).

20. Practical neurosurgery: a guide for doctors. Ed.: B.V. Gaidar. 2002. P. 245. (In Russ.).

21. Grigorovich K.A. Surgical treatment of nerve injuries. L.: Meditsina, 1981. 304 p. (In Russ.).

22. Solomin A.N. Injuries of the nerves of the extremities: clinical picture, diagnostics, treatment in peacetime and wartime. Dis. ... doctor of medical sciences. Leningrad, 1975. 37 p. (In Russ.).

23. Samotokin B.A., Solomin A.N. Complications at treatment of injuries of nerves of extremities. L.: Meditsina, 1987. 92 p. (In Russ.).

24. Trishkin D.V., Kryukov E.V., Chuprina A.P. et al. Guidelines for the treatment of combat surgical trauma. Saint Petersburg: Voenno-meditsinskaya akademiya im. S.M. Kirova, 2022. 373 p. (In Russ.).

25. Bersnev V.P., Kokin G.S., Izvekova T.O. Practical guide to nerve surgery: in 2 volumes. Vol. 1. Saint Petersburg, 2009. 291 p. (In Russ.).

26. Bersnev V.P., Kokin G.S., Izvekova T.O. Practical guide to nerve surgery: in 2 volumes. Vol. 2. Saint Petersburg, 2009. 561 p. (In Russ.).

27. Govenko F.S. Surgery of peripheral nerve injuries. Saint Petersburg: Feniks, 2010. 383 p. (In Russ.).

28. Amgad Kh. Anatomy of spinal nerves and accesses to them: trans. with English. Eds.: A.I. Gaivoronsky, I.V. Gaivoronsky, D.V. Svistov. Saint Petersburg: Spetslit, 2020. 151 p. (In Russ.).

29. Isengaliev I.N., Besedin V.D., Khrapov Yu.V. Tendon-muscle transposition in severe irreversible damage to the radial nerve: surgical technique and clinical practice. Meditsinskiy vestnik GVKG im. N.N. Burdenko = Medical Bulletin of the N.N. Burdenko Main Military Clinical Hospital 2021;4(6):23–8. (In Russ.). DOI 10.53652/2782-1730-2021-2-4(6)-23-28

30. Isengaliev I.N., Besedin V.D., Khrapov Yu.V. One-stage restoration of the nerve trunk and tendon-muscle transposition in severe injuries of the radial nerve. Medical care for injuries. New in organization and technologies. The role of the national public professional organization of traumatologists in the healthcare system of the Russian Federation: the sixth All-Russian congress with international participation: collection of abstracts. Saint Petersburg: Sankt-Peterburgskaya obshchestvennaya organizatsiya “Chelovek i ego zdorov’e”, 2021. P. 57. (In Russ.).

31. Gizatullin Sh.Kh., Isengaliev I.N., Ovchinnikova M.B. 70 years of the neurosurgical clinic of the hospital named after N.N. Burdenko. Accumulated experience in the treatment of gunshot wounds of the central and peripheral nervous systems. Meditsinskiy vestnik GVKG im. N.N. Burdenko = Medical Bulletin of the N.N. Burdenko Main Military Clinical Hospital 2022;4(10):32–41. (In Russ.). DOI 10.53652/2782-1730-2022-3-4-32-41.

32. Clinical recommendations (treatment protocols). Prevention of thromboembolic syndromes (Approved and put into effect by the Order of the Federal Agency for Technical Regulation and Metrology dated March 31, 2015 No. 201-st). (In Russ.).

33. Surgical infections of the skin and soft tissues: Russian National Recommendations (ROS, RFSKHI, AKHM, MAKMAH, AFR). V.S. Saveliev et al. Moscow, 2009. 89 p. (In Russ.).

34. McCaffery M., Beebe A. Pain: Clinical Manual for Nursing Practice. Baltimore: V.V. Mosby Company, 1993. 320 p.

35. Order of the Government of the Russian Federation of 16.05.2022 No. 1180-r (as amended on 01.08.2023) “On approval of the list of diseases or conditions (groups of diseases or conditions) for which the use of a medicinal product is permitted in accordance with the indicators (characteristics) of the medicinal product not specified in the instructions for its useˮ. (In Russ.).

36. Shabalov V.A., Isagulyan E.D. What to do with difficult pain? (Electro-stimulation of the spinal cord and brain in the treatment of chronic non-oncological pain). Moscow: NII neyrokhirurgii im. akad. N.N. Burdenko, 2008. 96 p. (In Russ.).

37. Pirogov N.I. Principles of General Military Field Surgery, Taken from Observations of Military Hospital Practice and Memories of the Crimean War and the Caucasian Expedition. Dresden: Print. E. Blokhman and Son, 1865. 468 p. (In Russ.).