Classification of Nerve Injuries

There is no single classification system that can describe all the many variations of nerve injury.
Most systems attempt to correlate the degree of injury with symptoms, pathology and prognosis.
In 1943, Seddon introduced a classification of nerve injuries based on three main types of nerve
fiber injury and whether there is continuity of the nerve ( Table 1 ).
The three types are : axonotmesis, neuropraxia and neurotmesis.
Axonotmesis: It involves loss of the relative continuity of the axon and its covering of myelin,
but preservation of the connective tissue framework of the nerve ( the encapsulating tissue, the
epineurium and perineurium, are preserved ). Because axonal continuity is lost, wallerian
degeneration occurs. Electromyography ( EMG ) performed 2 to 3 weeks later shows fibrillations
and denervation potentials in musculature distal to the injury site. Loss in both motor and sensory
spleens is more complete with axonotmesis than with neuropraxia, and recovery occurs only
through regenerations of the axons, a process requiring time. Axonotmesis is usually the result of
a more severe crush or contusion than neuropraxia. There is usually an element of retrograde
proximal degeneration of the axon, and for regeneration to occur, this loss must first be
overcome. The regeneration fibers must cross the injury site and regeneration through the
proximal or retrograde area of degeneration may require several weeks. Then the neuritis tip
progresses down the distal site, such as the wrist or hand. Proximal lesion may grow distally as
fast as 2 to 3 mm per day and distal lesion as slowly as 1.5 mm per day. For regeneration requires
a number of weeks.
Neuropraxia: In this case there is an interruption in conduction of the impulse down the nerve
fiber, and recovery takes place without wallerian degeneration. This is the mildest for of nerve
injury. This is probably a biochemical lesion caused by concussiom or shock-like injuries to the
fiber. In the case of the role nerve, neuropraxia is brought about by compression or relatively
mind, blunt blows, including some low-velocity missile injuries close to the nerve. There is a
temporary loss of function which is reversible within hours to months of the injury ( the average
is 6-8 weeks ). There is frequently greater involvement of motor than sensory function with
autonomic function being retained.
Neurotmesis: Its the more severe lesion with potential of recovering. Occurs on severe
contusion, stretch, lacerations. Not only the axon, but the encapsulating connective tissue lose
their continuity. The last (extreme) degree of neurotmesis is transsection, but most neurotmetic
injuries do not produce gross loss of continuity of the nerve but rather than internal disruption of
the architecture of the nerve sufficient to involve perineurium and endoneuruim as well as axons
and their covering. Denevertion changes recorded by EMG are the same as those seen with
axonotmetic injury. There is a complete loss of motor, sensory and autonomic function. If the
nerve loss has been completely divided, axonal regeneration causes a neuroma to form in the
proximal stump. For neurotmesis is better to use a new classification, more complete, called
Sunderland System ( see table 2 ).

Table 1 : Seddons classification (1).

Table 2 : Sunderland System (2)

________________________________________________________________________
First-degree: "Seddons neuropraxia": nerve in continuity, compression or
ischemia - local conduction block, focal demyelinization may occur, recovery
is usually complete in 2-3 weeks ( not the 1mm/day rule ).
Second-degree: "Seddons axonotmesis": injury to axon, supporting structures
( including endoneurium ) intact; wallerian degeneration occurs; recovery at
1mm/day as axon follow tubule, sometimes most only be diagnosed
retrospectively, recovery is poor in lesions requiring >18 months to reach
the target muscle.
Third-degree: endoneurium disruptured, epineurium & perineurium intact:
recovery may range from poor to complete and depends on degree of
intrafascicular fibrosis; nerve may not appear seriously damaged on gross
inspection.
Fourth-degree: interruption of all neural and supporting elements; epineurium
intact; the nerve is usually enlarged.
Fifth-degree: complete transection with loss of continuity.
__________________________________________________________________________

References

(1) Andrew Kaye. " Classification of Nerve Injuries "; in Essential Neurosurgery. Churchill
Livingstone. 1991; pages 333-334.
(2) Mark S. Greenberg, MD. " Injury Classification System "; in Handbook of Neurosurgery.
Third edition. 1994; pages 411- 412.