Nerve Trauma, Entrapment and RSD
Unique characteristics to these conditions
Nerve trauma and entrapments
Animation: The first actual neurography imaging case — a sciatic nerve injury.
In November 1992, Dr. Aaron Filler conducted the first patient imaging using a an MR Neurography-configured clinical GE Signal MRI scanner.
The patient suffered from a sciatic nerve injury. The first patient image led to the discovery that the fascicle pattern inside the nerve could be seen in an image. This image also proves that the structure imaged is indeed a nerve. The image was published in the British medical journal Lancet in 1993 and received extensive world wide attention.
A) Cross section of the thigh. The arrow indicates the sciatic nerve. This patient had suffered a stab wound to the the thigh which had severed his sciatic nerve.
B) Blow up view of the sciatic nerve revealing the internal fascicle structure.
C) A three dimensional reconstruction of the nerve based on “maximum intensity projection” of the nerve. This image closely matches the shape of the sciatic nerve seen in the photograph (D).
D) Intraoperative photograph taken during surgery. The photo shows the cut sciatic nerve. The arrow indicates the suture line where nerve grafts have been sown into place.
There are many diagnoses and treatments of nerve trauma, entrapment and RSD. Please click on any of the links below to learn more about individualized cases from the files of Dr. Filler.
Repair of Peroneal Nerve Laceration
Repair of Severed Nerve
Animation: Two views of a post-operative neuroma at site of failed nerve repair.
This animation depicts two views of a post-operative neuroma at the site of a failed nerve repair in a lacerated peroneal nerve.
The use of imaging to monitor the progress of a nerve repair may allow time to correct any problems with the initial repair.
Suture repair of nerves often provides an opportunity to recover function after severe trauma. Currently the introduction of nerve tubes for the repair of severed nerves has led to a great reduction in the length of surgical operations for nerve repair and has led to improved resutls for recovery and regrowth of severed nerves.
Obstetrical Brachial Plexus Palsy
Obstetrical Brachial Plexus Palsy from Birth Trauma
Animation: Image diagnosis of nerve disruption in obstetrical brachial plexus palsy.
(A) Three-month-old child with complete flail arm. Image demonstrates absence of plexus elements in area of trunks. A hypointense round (r) abnormality proved to be a mass of disrupted scarred scalene muscle partially incorporating shards of nerve remnants. In this situation, nerve grafts can be used to bridge gaps. In addition, neuroplasty or removal of adhesions helps improve recovery.
(B) Six-month-old child with persistent upper trunk paresis. Imaging confirmed ball neuromas at C5 and C6 demonstrating complete disruption of upper trunk elements. Early demonstration of complete disruption with terminal nerve neuromas can allow for an earlier decision for restorative surgery and hence better outcomes.
Regrowth of Severed Nerves
Regeneration & Regrowth of Nerves After Severe Trauma
Animation: Image diagnosis of eight-year-old boy with partial reinnervation of right leg muscles.
The animation depicts the right-leg muscles of an eight-year-old boy with partial reinnervation eight months after being struck by a motor vehicle. Initially he had flaccid paralysis of the sciatic innervated muscles but by five months began to develop flexion at the knee which was 4/5 strength at the time of the imaging exam.
(A1) – Sagittal image of right thigh showing the femur fracture (fx), damaged sciatic nerve (sc) and patella (pat) for orientation.
(A2) – The sciatic nerve was fully transected by the initial injury and its healed stump is seen with marked nerve injury hyperintensity. Several new growth nerves are seen emerging from the stump to reinnervate the long head of the biceps femoris. (TSN) – truncated sciatic nerve. (NGN) – new growth nerve reinnervating biceps.
(B1) – The semitendinosus and semimembranosus demonstrate muscle denervation hyperintensity (*).
(B2) – The short head of the biceps femoris (**) also continues to demonstrate hyperintensity of denervation.
(C) – Axial image three inches below the level of the sciatic stump (ps(C)) demonstrating the hyperintense semimembranosus and semitendinosus (*) and short head of the biceps femoris (**). There is normal muscle image appearance in the long head of the biceps femoris (***). The femur (fe) is labeled for orientation and the placement of the sagittal image slices for B1 and B2 are also marked ps(B1) and ps(B2).
Lingual Nerve Injury
Lingual Nerve Injury from Dental Extraction
Animation: Injury associated nerve image hyperintensity and swelling at a site of nerve trauma.
This example illustrates an injury associated nerve image hyperintensity and swelling at a site of nerve trauma (*) resulting from an oral surgery procedure.
The lingual and inferior alveolar components of the mandibular nerve (M) are well seen.
The image findings confirm the traumatic origin of the numbness and pain experienced by the patient after the extraction.
Brachial Plexus Trauma
Diagnosis of Traumatic Discontinuities in Brachial Plexus Elements
Animation: Confirmation of total nerve disruption in trauma.
(A) The right brachial plexus of a 15-year-old with flail arm – lacking any movement or sensation, two months after a motorcycle accident. The image demonstrates gross discontinuities ro disruptions in the upper plexus elements (ue), meningocoeles proximally (me), and bright swollen nerve trunks (st).
(B) Disconnected and retracted lower trunk (lt) in traumatic injury of brachial plexus.
Information on Nerve Entrapment
RSD from Nerve Entrapment
Complex Regional Nerve Pain After Trauma
Animation: Sciatic nerve hyperintensity associated with adhesion to a site of pelvic fracture.
(A) Sciatic nerve hyperintensity associated with adhesion to a site of pelvic fracture in a patient with new onset reflex sympathetic dystrophy (RSD). The RSD symptoms resolved after nerve release surgery.
(B) Deformation in the shape of the sciatic nerve at a site of prior trauma and failed surgical exploration.
(B1) This reconstruction in the sagittal plane shows a flattened sciatic nerve with an irregular course instead of the expected straight smooth course.
(B2) In the coronal view the sciatic nerve is broad and flat. The two images together show the severe mechanical distortion of the nerve at this site of adhesion. After four years of failed intensive pain management, the symptoms were relieved by nerve release surgery.
Normal Mobility of Median Nerve
Movement of Nerves Across Joints Can Become Impaired
Animation: Joint nerve movement.
(A) The median nerve (mn) at the wrist located near the palmar aspect of the carpal tunnel with the tendons (te) posterior to it.
(B) The median nerve is posterior to the tendon in this image. A & B are images of the same individual at the same location in the hand but, image A is obtained with the wrist in flexion and image B is obtained in extension.
Diagnosis of Unusual Entrapments
Imaging for Diagnosis of Unusual Entrapments
Animation: Marked hyperintensity of the recurrent branch.
This animation depicts severe impingement syndrome affecting the recurrent branch of the median nerve in the wrist.
A 62-year-old woman suffered severe denervation of thenar muscles with no other symptoms of carpal tunnel syndrome after casting for a wrist fracture.
The image demonstrates marked hyperintensity of the recurrent branch as it separates from the median nerve.
Repair of Peroneal Nerve Laceration
Repair of Severed Nerve
Animation: Two views of a post-operative neuroma at site of failed nerve repair.
This animation depicts two views of a post-operative neuroma at the site of a failed nerve repair in a lacerated peroneal nerve.
The use of imaging to monitor the progress of a nerve repair may allow time to correct any problems with the initial repair.
Suture repair of nerves often provides an opportunity to recover function after severe trauma. Currently the introduction of nerve tubes for the repair of severed nerves has led to a great reduction in the length of surgical operations for nerve repair and has led to improved resutls for recovery and regrowth of severed nerves.
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Meet Dr. Filler
A globally recognized expert in the treatment of peripheral nerve disorders and the development of nerve imaging technology, Dr. Aaron Filler is the world’s leading expert in treatment of nerve pain. He has revolutionized nerve-pain treatment by inventing several new technologies. One such technology, MR Neurography, enables doctors to use an MRI scanner to examine nerves, previously a difficult-to-impossible tissue to visualize with MR imaging.
Dr. Filler’s research in axonal transport is leading to a whole new generation of advanced pain medications. He has developed many new “minimal access” surgery methods that allow him to treat complex nerve problems with small outpatient surgeries. He has also pioneered the use of the Open MRI scanner to do surgeries and other therapies with the ultra-high precision and safety of the magnetic resonance imaging.
At Dr. Filler’s Neurological Injury Specialists Management Group in Santa Monica, California, the key to success remains a very traditional endeavor: listening to the patient and doing a thorough and expert neurological examination. Dr. Filler typically spends more than an hour with each new patient. The results of the initial examination are then strengthened and perfected with application of advanced technology available nowhere else in the world.
Dr. Aaron Filler combines three key components in his treatment of each patient:
- Compassionate personal attention,
- Expert medical skills, and
- The best technology in the world
He combines these components to turn insoluble pain problems into specific treatable diagnoses. Prior to coming to the Institute for Nerve Medicine, many of Dr. Filler’s patients have seen a dozen doctors (or more), experienced failed surgeries, and have even had their very pain questioned. Time and again, Dr. Filler demonstrates that in many of these cases the problem is the doctor and not the patient. A cure is in reach when the best available medical care is brought to bear.
Dr. Filler has an MD from the University of Chicago, a PhD from Harvard University, and is also a Fellow of the Royal College of Surgeons in England. His medical training included four years of medical school, eight years of neurosurgical training at one of the leading neurosurgery programs in the US, an additional one-year fellowship in neuroimaging at the University of London, another year of training in complex spinal surgery at UCLA, and a fellowship in peripheral nerve surgery with Dr. David Kline in New Orleans.
He is the inventor on ten major patents, has published more than twenty prominent scientific publications, and has done more than a hundred presentations at scientific and medical meetings. He is also the author of Do You Really Need Back Surgery? from Oxford University Press, a well-received 300-page book for the general public. He enjoys medical staff privileges at Cedars-Sinai Medical Center in Los Angeles.
