Observations on Pain Control and Long Length Acellular Allograft Use in the Early Treatment Of Combat Related Injuries of the Sciatic Nerve
Patrick E. Jones, MD1; R. Michael Meyer, BS2; Walter J. Faillace, MD1; Patricia L. McKay, MD1; Leon J. Nesti, MD, PhD1
1Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda, MD; 2Uniformed Services University of the Health Sciences, Bethesda, MD
Object: The goals of this study were to retrospectively observe and evaluate the outcome of pain reduction and long length, acellular, processed cadaver allograft use in the surgical repair of sciatic nerve injuries of patients injured in recent military conflicts. Traumatic injury to the sciatic nerve sustained in military conflict tends to be severe with protean consequences. This injury is often associated with widespread soft tissue and bone injuries, significant neurologic impairment, severe neuritic pain, and a prolonged recovery time. There is limited data that describes the treatment of these significant and devastating nerve injuries.
Methods: We retrospectively reviewed the surgical records of 5137 combat related extremity injuries at three institutions between June 2007 and June 2013 to identify those patients with combat-related sciatic nerve injury without amputation of the affected side. Patients included in this study underwent a thorough chart review including pain assessments, radiographs, surgical reports, and intraoperative photographs to determine severity of injury, and the timing from injury to surgery, to assess outcome.
Results: Thirteen patients were identified as having combat related sciatic nerve injuries, all patients were male, mean age was 28 years. The mechanisms of injury were 9 gunshot wounds (69%), 2 rocket propelled grenade (RPG) blasts (15%) and 2 improvised explosive device (IED) blasts (15%). Three patients (23%) with dense sensory-motor loss were found to have a neuroma in continuity, and required only neurolysis. Eight, patients (53%) with nerve transections and neuroma formation had long length (5-7 cm) cadaver allograft grafts placed, one patient had a sural nerve autograft (5 cm), and 1 patient underwent end to end direct nerve repair. In comparing those patients who had early versus standard timing of nerve surgery, there was no difference in the amount of damaged nerve resected and both groups had equivalent reductions of pain and narcotic use at 6 weeks and 6 months postoperatively. There were no complications due to graft infection or rejection in either group.
Conclusions: Traditional teaching is to delay sciatic nerve injury repair for at least six months to provide the damaged nerve a period of self-recovery and to allow structural damage to the injured nerve to fully declare itself. Our experience demonstrates that combat related sciatic nerve injuries can be reliably operated on 21 to 30 days post injury, with great benefit toward reduction of severe neuritic pain.
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