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HE BLOOD SUPPLY of NERVES by ARCHIBALD DURWARD, F.R.S.(Ed.), M.D., M.B., Ch.B

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HE BLOOD SUPPLY of NERVES by ARCHIBALD DURWARD, F.R.S.(Ed.), M.D., M.B., Ch.B Postgrad Med J: first published as 10.1136/pgmj.24.267.11 on 1 January 1948. Downloaded from II ,HE BLOOD SUPPLY OF NERVES By ARCHIBALD DURWARD, F.R.S.(Ed.), M.D., M.B., Ch.B. Professor of Anatomy, University of Leeds. Considerable attention has been given to the one would stress that this does not alter the blood supply of nerves in the past few years. This essential plan, namely, that each nerve receives does not imply that nothing was previously known; along its course a variety of nutrient arteries com- Adams (I942) reviewed the literature on the blood ing from adjacent vessels. It is true that in certain supply of nerves and brought together the widely positions more sizable arteries are occasionally scattered and surprisingly extensive information found associated with nerves, e.g., the sciatic and on that topic. Much of the present-day interest median, and such vessels running on the nerve for naturally derives from the great numbers of peri- considerable distances are to be regarded rather pheral nerve casualties which have arisen in the as embryological persistences and do not imply war. A more detailed conception of the whole that the nerves concerned are receiving any pattern of the vascularization of peripheral preferential vascular supply. nervous tissues is now available and a good deal A detailed and lucid account of the anatomy of of e x p e r i me nt a evidence in this field has the nutrient arteries to the nerves of upper limb accumulated. and to certain nerves of the lower limb has recently There undoubtedly has been some kind of been Sunderland a and that the blood of nerves was of given by (i945, c). assumption supply by copyright. no great moment. Peripheral nerves have been Epineural Vessels treated surgically with a total lack of respect for the arteries or the veins associated with them. On reaching the nerve, these small local nutrient Similar treatment has not been accorded to the gut arteries generally divide into ascending and de- or the central nervous system. That extensive scending branches which course in the epineurium. operations can be, and commonly are, successfully There may be a number of such epineural vessels, carried out on peripheral nerves, with little or no often visible to the naked eye. Sometimes such thought as to their blood supply, strongly suggests vessels pass deeply into the nerve and run between that the pattern of vessels in nerves is peculiar and the fasciculi. From these primary divisions of the is so disposed as to allow extensive mobilization nutrient artery secondary branches are given off http://pmj.bmj.com/ without essential devascularization. The surgeon penetrating more deeply and dividing further. has long acted, maybe unwittingly, on this The vessels concerned are arranged predominantly assumption. This paper will be concerned with in a longitudinal fashion in the perineural or inter- a review of our knowledge regarding the blood fasicular connective tissues. Finally, by repeated supply of nerves and of recent experimental work branchings, the finest vessels penetrate within the in this field. fasciculi and form there a capillary bed, again arranged mainly in a longitudinal fashion with Nutrient Arteries of Nerves numerous cross connections. Vessels of pre- on September 23, 2021 by guest. Protected .capillary size may be found at times within the There are no major arteries specifically devoted actual fasciculi but most the intra- to the supply of nerves. Each nerve, large or generally small, receives nutrient twigs from adjacent fascicular vessels are of the capillary order. arteries. Such nutrient vessels are generally short, and although their size is variable, many of The Intrafascicular Plexus them may be seen with the naked eye. These are This intrafascicular plexus is common to all the local sources of supply presenting as much varia- nutrient arteries and is continuous throughout the tion in actual position as do vessels elsewhere. length of the nerve. It is fed, or reinforced at Some are more or less predictable in position, e.g., various levels, by the nutrient arteries, but no one at the elbow in the case of the ulnar nerve, and in nutrient artery may be considered as dominating the spiral groove in the case of the radial nerve any portion of the plexus. The arrangement out- (Sunderland, I945), but from case to case a good lined above is virtually the antithesis of the ' end deal of variation may be found, and variations on artery ' conception : it is an arrangement whereby the two sides of the body are not uncommon. But a rich continuous capillary bed occupies the length Postgrad Med J: first published as 10.1136/pgmj.24.267.11 on 1 January 1948. Downloaded from 12 POST GRADUATE MEDICAL JOURNAL January T948 of the nerve and receives regional reinforcements cordant results obtained by Adams might readily here and there. be explained either by destruction of, or damage The view that the circulation within the nerve done to, epineural vessels during manipulation, or might be dominated in particular segments by the perhaps, more likely, to thrombosis within the local nutrient artery has in the past been put for- ligated vessels spreading into the epineural vessels ward, and, were it a fact, would be of considerable or beyond and so involving the longitudinal surgical importance. The extensive mobilizations vascular pathway within the nerve. This sug- of nerves carried out in operations scarcely lend gestion, though speculative, is supported by support to the view, and certain experimental Sunderland ( 1 945, b) who states : ' If the nerve is findings in animals very strongly suggest that the roughly and carelessly stripped from its bed, role of any particular nutrient artery in the supply these delicate channels are likely to be torn .. of its own region of the nerve is virtually non- interrupting thereby the superficial system on the essential. In this connection Adams (1943) re- surface of the nerve, a disturbance which, in ported that in the rabbit's sciatic nerve the de- turn, is liable to embarrass the intraneural struction of the nutrient arteries in the thigh led circulation.' to negligible degenerative changes in the majority (b) In another series of rabbits the sciatic of the animals investigated; he had, however, a nerve, after mobilization in the thigh and ligation small minority of animals in which quite extensive of all nutrient arteries, was ligatured at the level degeneratiors occurred and this minority, though of the knee. This left the sciatic nerve completely small, left open a doubt as to whether there might devoid of any nutrient supply along its course in be some significant variation in the supply of the the thigh and also it ensured the complete oblitera- nerve in the cases concerned which might have led tion of the longitudinal vascular bed within the to the dominance of one nutrient artery, or, again, nerve at the site of the ligature. Previous experi- as to whether there might not be some other factor ments (e.g., Adams, 1943) had made it clear that coming into play to give the discordant result. the mere ligation of the nutrient vessels did not necessarily lead to any extensive degenerationby copyright. Experimental Study of Blood Supply within the nerve. The object of this series of The writer has investigated the problem from experiments was to take the nerve with its two angles in the rabbit's sciatic nerve. regional sources obliterated and then, in addition, (a) In one series of animals the nerve was embarrass the intraneural circulation by preventing mobilized completely along its course from the the free flow of blood throughout the length of the buttock to the knee and all nutrient arteries segment under observation. The animals were approaching the nerve severed. In addition the allowed to survive for ten days and nerves in the obvious epineural vessels were severed so as to thigh were then examined, either histologically or interrupt, as far as possible, the longitudinal by injection. Those subjected to histology showedhttp://pmj.bmj.com/ system of vessels. The latter procedure, carried that there was invariably degeneration induced out under a dissecting microscope, did not, of within the nerve. The degeneration was never course, affect any vessels running within the massive but it tended to be more extensive in the nerve and could not, therefore, obliterate more more distal parts of the nerve (the segment of the than a proportion of the larger epineural vessels. nerve immediately adjacent to the ligature was The results indicated that on destruction not considered in the assessment of the result). In following those cases which were the nerves were of the epineural vessels there was invariably some injected, on September 23, 2021 by guest. Protected degeneration, varying from case to case, but never subsequently cleared and a comparison made massive, and, in comparison with Adam's results between the injected experimental nerves and (excluding his discrepant findings) the degenera- injected normal nerves. It was found that the tion induced was of a greater order. The escape nerves which had been mobilized and ligatured of the nerve from any obvious degeneration follow- took the injection mass virtually as well as normal ing on the mere ligation of the nutrient vessels nerves except in the lowest segment adjacent to and the invariable production of degeneration on the ligature. These injections were carried out the destruction of epineural vessels, very strongly sufficiently long after the operation, to preclude suggests that the latter are in some way more vital any possibility of leakage from cut vessels, and than the former. It is suggested that by de- suggested strongly that the vascular bed within struction of the epineural vessels some portions of the nerve did not suffer appreciably.
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