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Nerve Compression Injury and Increased Endoneurial Fluid Pressure: a "Miniature Compartment Syndrome"

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Nerve Compression Injury and Increased Endoneurial Fluid Pressure: a J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.46.12.1119 on 1 December 1983. Downloaded from Journal of Neurology, Neurosurgery, and Psychiatry 1983;46:1119-1124 Nerve compression injury and increased endoneurial fluid pressure: a "miniature compartment syndrome" GORAN LUNDBORG, ROBERT MYERS, HENRY POWELL From the Division for Hand Surgery, Department of Orthopedics, University of Lund, Departments of Orthopedics and Rehabilitation and ofNeurosciences, Anesthesiology and Pathology (Neuropathology), University of California, San Diego, School ofMedicine, La Jolla, CA., and the Veterans Administration Medical Center, San Diego, CA, USA SUMMARY An inflatable miniature cuff was used to apply local compression of 80 mm Hg or 30 mm Hg to a segment of rat sciatic nerve for time periods varying from two to eight hours. The endoneurial fluid pressure was measured by direct micropipette measurement techniques at one or 24 hours after removal of the cuff, and the nerves were subjected to histological analysis. Endoneurial oedema, associated with a four-fold increase in endoneurial fluid pressure, was observed after compression at 80 mm Hg for four hours, and a three-fold increase was found after compression at 30 or 80 mm Hg for eight hours. Such an increase in endoneurial fluid pressure may interfere with intrafascicular capillary flow, and thereby constitute an important nerve pathophysiological mechanism in compression injuries. Protected by copyright. The pathophysiological mechanisms of acute and Chronic nerve compressions may be more compli- chronic nerve compression injuries are not com- cated in their general pathophysiology, since the pletely understood, although considerable know- local anatomy at different common entrapment ledge has accumulated during recent years. In acute levels of the extremities may vary with respect to compression lesions, for example tourniquet palsy size and shape of extraneural tissue compartments, and other conditions where pressure of high mag- muscles and fascia edges, as well as the force applied nitude has been directly applied to a nerve trunk, to the nerve (stretch-bending-compression). It has the resulting disturbances in nerve function are also been suggested that in these cases the symptoms based mainly upon local myelin changes under the presented are based exclusively on local myelin edge of the cuff. The redistribution of tissue from changes in the affected nerve segment.6 However, it compressed to non-compressed levels of the nerve is is a common clinical experience, that even chronic associated with invagination of the myelin sheaths at entrapments with longstanding muscle weakness the nodes of Ranvier.' 2 The resulting myelin dam- and sensory disturbances sometimes show a very age is associated with partial or complete local con- rapid reversibility of some or all of the symptoms duction block, usually reversible within weeks or after surgical decompression of the nerve. These http://jnnp.bmj.com/ months. Also a possible microvascular factor has findings suggest the existence of a local metabolic been considered as irrelevant by Williams et al3 and block in the compressed segment of the nerve. The we have demonstrated the occurrence of endo- rapid reversibility indicates that such a disturbance neurial oedema in the transitional zones of a nerve may be based upon temporary microvascular disor- segment, subjected to higher pressure.4 During der in the compressed part of the nerve in addition certain circumstances this oedema may to local myelin changes.79 be associated with a no-reflow phenomenon in the In recent investigations we have studied the affected nerve segment.5 effects of compression on intraneural microvascular on September 26, 2021 by guest. flow.5 The present study was concerned with the microvascular factors in experimental nerve com- Address for reprint requests: Goran Lundborg, MD. Div for Hand pression injuries, this time with special reference to Surgery, Lunds University Hospital, S-221 85 Lund, Sweden. the occurrence of an intrafascicular oedema with cor- Received 1 February 1983 and in revised form 7 May 1983. responding increase in endoneurial fluid pressure at Accepted 28 June 1983. the site of injury. The study was- made possible by 1119 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.46.12.1119 on 1 December 1983. Downloaded from 1120 Lundborg, Myers, Powell the use of micropipette techniques for direct meas- bicarbonate-buffered and temperature controlled. All urements of the endoneurial fluid pressure.'" endoneurial fluid pressure measurements were referenced to atmospheric pressure by establishing a baseline pressure Material and methods from the fluid bath surrounding the nerve. Adult Sprague-Dawley rats weighing 250-300 grams were Histological analysis anaesthetised by intraperitoneal injection of a solution After measurement of endoneurial fluid pressure, the scia- composed of Nembutal (50 mg/ml), saline and diazepam tic nerve was removed and processed for light microscopy (5 mg/ml) in volume proportions of 1:1:2. by fixation in 2-5% phosphate-buffered glutaraldehyde, post-fixation in osmium tetroxide, dehydration in serial Compression procedure alcohols and embedded in araldite. One-micron-thick sec- The sciatic nerve of the left midthigh was exposed by a tions were stained with paraphenylenediamine for light lateral incision. The nerve was compressed by a special microscopic analysis. compression chamber constituting a smaller modification of the chamber described in detail by Rydevik and Lund- Results borg.4 This compression device consists of two symmetrical halves of plexi-glass into which thin rubber membranes are Endoneurial fluid pressure glued. The two halves were placed around the nerve trunk are and joined by four small screws. The chamber was con- The results from the pressure measurements nected to a servo pressure system (AB Stille-Werner, presented in fig 1. Stockholm) allowing inflation of the rubber cuffs in the chamber to a desired pressure. The system automatically 80 mm Hg compensated for any leakage of air, thus maintaining the After compression periods up to 4 hours there was a pressure of the system at a constant level. The length of the continuous increase in endoneurial fluid pressure as compressed nerve segment was approximately 3 mm. revealed by measurements one hour as well as 24 After the compression chamber was secure, the skin was hours after release of the compression. The maximal to sutured, thereby allowing only the connecting tubes endoneurial fluid pressure was recorded 24 hours Protected by copyright. penetrate the skin into the wound. after compression for 4 hours when the endoneurial Animal experiments fluid pressure was 8-5 cm H2O, that is more than In one series of animals (n = 4), a pressure of 30 mm Hg four times the normal pressure. Extending the was applied to the nerves for 2, 4, 6 and 8 hours. In period of compression more than 4 hours did not another series (n = 4), a pressure of 80 mm Hg was increase the endoneurial fluid pressure; on the con- applied for the same time periods. In four animals, sham Vary, there was a tendency to decrease endoneurial experiments were performed so that only the chamber was fluid pressure with longer periods of compression. applied around the nerve for 2, 4, 6 and 8 hours without Following 8 hours compression, endoneurial fluid being inflated. The pressure levels of 30 and 80 mm Hg pressure was 5*8 cm H2O, at one-hour as well as 24 were chosen because it is known from previous experi- hours after release of the compression cuff. ments- that these pressures will interfere with intraneural venular flow (30 mm Hg) or cause a circulatory arrest in the nerve (80 mm Hg). 80mmHg After the compression periods, the skin was opened and - 30 mmHg the compression device removed. One hour or 24 hours O 1 h atteroperation later a direct measurement of the endoneurial fluid pres- 10- * 24 h after operation sure was performed as described below. The animal was 0-- then killed by an overdose of Nembutal, and the nerve was I http://jnnp.bmj.com/ removed for histological analysis. E c_ 6 Measurement of endoneurial fluid pressure IL w Endoneurial fluid pressure was measured directly with a .. servo-null micropipette system by inserting the tip of a *..-...........a glass micropipette (4 microns diameter) through the perineurial membrane into the endoneurium, a method Normal EFP which has been described in detail elsewhere by Myers et al.'0 The measurements were made in the transitional zone between compressed and non-compressed parts of the 2 4. 6 8 on September 26, 2021 by guest. nerve, under the edge of the cuff, since we know from Duration of compression ( hours) previous experiments4 '° that the maximal structural and Fig 1 Graphical results ofchanges in endoneurial fluid functional injury is induced in the nerve at this level. For pressure associated with nerve compression at different each animal, three or more recordings were taken and pressure levels for various periods oftime. Normal averaged together. The nerve was surrounded and irri- endoneurial fluidpressure is 2-0 + 1 0 cm H,O; elevation of gated with a physiological salt solution which was endoneurial fluid pressure beyond normal levels is plotted. J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.46.12.1119 on 1 December 1983. Downloaded from Nerve compression injury and increased endoneurial fluid pressure 1121 30 mm Hg Two hours of compression was not followed by a detectable increase in endoneurial fluid pressure, while longer periods of compression induced a con- tinuous increase in endoneurial fluid pressure lasting at least 24 hours. The maximal increase of endoneurial fluid pressure was observed following 8 hours compression. Endoneurial fluid pressure was found to be approximately 6-0 cm H2O, that is nearly the same as after compression at 80 mm Hg for 8 hours. Sham experiments Application of the chamber around the nerve for 2-8 hours without inflating it did not result in any increase of endoneurial fluid pressure above normal values (2.0 + 1-0 cm H20).
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