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Three Part Question

In [a patient with a clean recent nerve transaction] does [immediate repair of the nerve] give [better functional outcome]?

Clinical Scenario

A 30 year old lady who has cut her wrist with a clean blade. On exploring the wound and controlling the bleeding you discover she has cleanly transected her median nerve. When referring this to the local Plastic surgery centre they suggest that they will not repair this for a few days. From previous teaching you think that immediate repair is indicated. The following three part question formulates in your mind;

Search Strategy

Using ATHENS to perform a search on EMBASE 1974-Dec 07, MEDLINE (OVID) 1950-Dec 07 and CINAHL 1982 – Dec 07, the following stratagy is entered ; [peripheral nerve map- peripheral nerve injury, nerve regeneration, facial nerve, leg, arm, hand,] AND [cut OR trans$ OR injur$] AND [timing OR delay OR immediate OR early} AND repair.mp]

Search Outcome

Medline this gave 203 results of which on review of abstracts 3 were relevant. The same search was repeated on EMBASE 1974 onwards which gave 287 results of which 5 were retrieved and 2 were relevant. CINAHL produced 140 results but identified the same papers as previously found.
Of those that the articles were found two referenced the same textbook source for their information and this was also found but had no further references.

Comment(s)

There appears to be a lack of evidence relating to timing of nerve repair in peripheral nerves. Textbooks, quoted in the review articles, cite world war two researches that advocates delayed repair in war and immediate repair in clean civilian injuries. Consensus from review articles appears to be that outcome is favourable if repaired within the first 7 days of injury

Clinical Bottom Line

There appears to be no clear evidence of difference in outcome from immediate repair to early repair of the median nerve.

Level of Evidence

Level 3 - Small numbers of small studies or great heterogeneity or very different population.