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Original Article
Intraoperative neurophysiological monitoring in peripheral nerve surgery: Technical description and experience in a center
Monitorización neurofisiológica intraoperatoria en la cirugía del nervio periférico: descripción técnica y resultados en nuestro centro
M. Herrera-Péreza,b,
Corresponding author
herrera42@gmail.com

Corresponding author.
, A. Oller-Boixa, P.J. Pérez-Lorensuc, J. de Bergua-Domingoa, S. Gonzalez-Casamayora, F. Márquez-Marfila, L. Díaz-Floresd, J.L. Pais-Britoa,b
a Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario de Canarias, La Laguna, Tenerife, Spain
b Facultad de Medicina, Universidad de La Laguna, La Laguna, Tenerife, Spain
c Unidad de Monitorización Neurofisiológica Intraoperatoria, Servicio de Neurofisiología Clínica, Hospital Universitario de Canarias, La Laguna, Tenerife, Spain
d Servicio de Radiodiagnóstico, Hospital Universitario de Canarias, La Laguna, Tenerife, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Microsurgery of the peripheral nerve in the area of Traumatology and Orthopedics is mainly carried out in the treatment of acute neurological lesions or complications thereof &#40;neuromas&#41;&#44; as well as peripheral nerve tumors&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">1</span></a> Traumatic lesions of the peripheral nerve are usually secondary to fractures &#40;open or closed&#41; or to penetrating injuries in the limbs&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">1</span></a> Their diagnosis is mainly clinical&#44; can affect all age groups&#44; and is potentially devastating for patients&#44; as they affect professional and daily life activities&#46; Peripheral nerve tumors are rare lesions developed at the expense of the elements comprising the nerve&#44; with Schwann cells being the main constituent element&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">2&#44;3</span></a> They usually appear as a soft tissue mass in the path of the nerve&#44; which may be painful upon palpation and present positive Tinel sign&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">2&#44;4</span></a> So-called schwannoma or neurilemoma is the most frequent neurogenic tumor in peripheral nerves&#44; accounting for approximately 5&#37; of benign soft tissue neoplasms&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">5&#8211;12</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Both traumatic lesions&#44; particularly secondary ones once the neuroma is constituted&#44; and tumoral lesions&#44; particularly intraneural ones&#44; require advanced anatomical knowledge and extensive experience in microsurgery in order to achieve the desired objectives&#44; which include recovery of the maximum functional capacity possible and elimination of pain&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">1</span></a> Direct nerve repair or through a graft in the first case or exeresis of the lesion respecting the nerve of origin in the second case are the treatments of choice&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">13&#44;14</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Therefore&#44; we can say that an essential goal of this procedure is the preservation of a maximum of the undamaged nerve fascicles&#44; that is&#44; not sacrificing healthy nerves&#44; and it is in this aspect that intraoperative neurophysiological monitoring &#40;INM&#41; studies are of great value&#44; as they provide the surgical team with basic&#44; reliable and real-time information on the functionality of the explored nerve&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">4&#44;5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The main uses of INM of the peripheral nerves and brachial plexus are<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">14&#44;15</span></a>&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0025" class="elsevierStylePara elsevierViewall">Identifying the peripheral nerves&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</span><p id="par0030" class="elsevierStylePara elsevierViewall">Locating preexisting lesions throughout the pathway of the nerve&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#46;</span><p id="par0035" class="elsevierStylePara elsevierViewall">Determining continuity across a nerve lesion&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4&#46;</span><p id="par0040" class="elsevierStylePara elsevierViewall">Determining whether there is root avulsion&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">5&#46;</span><p id="par0045" class="elsevierStylePara elsevierViewall">Identifying the targets for nerve biopsy&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">6&#46;</span><p id="par0050" class="elsevierStylePara elsevierViewall">Monitoring and preventing damage to healthy nerves during the intervention&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">7&#46;</span><p id="par0055" class="elsevierStylePara elsevierViewall">Obtaining an evolutionary prognosis of the neurological lesion&#46;</p></li></ul></p><p id="par0060" class="elsevierStylePara elsevierViewall">The main objective of this study was to describe the technique of intraoperative neurophysiological monitoring conducted at our center and&#44; secondarily&#44; to report the experience of the surgical team in a series of 30 cases&#44; as well as to debate whether these reasons make it a useful technique in peripheral nerve surgery&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Materials and methods</span><p id="par0065" class="elsevierStylePara elsevierViewall">This was a retrospective&#44; descriptive study conducted in January 2014 on 30 patients intervened during the period between January 2009 and September 2013 due to peripheral nerve pathology &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#44; at the same center &#40;Hospital Universitario de Canarias&#44; third level of healthcare&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">A clinical history was obtained from all patients&#44; and all underwent physical exploration&#44; especially focusing on motor and sensory function&#44; before and after the surgery&#44; conducted by the same head surgeon &#40;FMM&#41;&#44; given his knowledge and experience in microsurgery&#46; We followed the criteria described by the British Medical Research Council &#40;BMC&#41; or modified versions classifying sensory recovery between S0 and S5 and motor recovery between M0 and M5&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">1</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">All patients underwent a prior neurophysiological study by the same neurophysiologist in charge of the intraoperative technique &#40;PPL&#41;&#46; The Seddon classification&#44; considered to be the most widely used worldwide&#44; was applied as it provides an understanding of the physiopathology of the lesion&#44; establishes a likely prognosis and&#44; above all&#44; offers an adequate therapeutic approach&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">1</span></a> This classification distinguishes between&#58; <span class="elsevierStyleItalic">neuropraxia</span>&#44; a block in nerve conduction at a local level&#44; without axonal involvement and therefore without distal wallerian degeneration&#44; in which function is recovered rapidly&#44; after a couple weeks at the most&#44; and <span class="elsevierStyleItalic">restitutio ad integrum</span> is the norm&#59; <span class="elsevierStyleItalic">axonotmesis</span>&#44; an axonal lesion associated to distal wallerian degeneration in which the endoneurium and perineurium are intact&#44; thus guaranteeing correct guidance of the axon in regeneration up to the distal end of the lesion site&#44; with fiber displacement speed classically described as between 1 and 1&#46;5<span class="elsevierStyleHsp" style=""></span>mm daily&#44; and where functional recovery is also the norm&#44; although with a greater delay than neuropraxia&#44; with up to 6 months&#59; and lastly&#44; <span class="elsevierStyleItalic">neurotmesis</span>&#44; a more severe lesion&#44; with complete section of the nerve&#44; absolute loss of function and absence of any kind of spontaneous recovery&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">1&#44;14</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">All patients with tumoral pathology also underwent a magnetic resonance imaging &#40;MRI&#41; study prior to the surgery&#44; which was interpreted by the same radiologist &#40;LDF&#41;&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Data collection&#44; analysis and interpretation were carried out by the remaining authors of this work &#40;MHP&#44; JPB&#41;&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Al the patients were adequately informed about the necessary procedures&#46; There was no need to obtain approval from the Ethics Committee of our center&#44; as this diagnostic test was accepted for use in daily practice&#46; Moreover&#44; this study did not provide any personal information from patients&#44; thus maintaining their confidentiality&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleItalic">inclusion criteria</span> to participate in the study were the following&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">-</span><p id="par0100" class="elsevierStylePara elsevierViewall">Open traumatic neurological lesions without clinical or neurological recovery after 6 months of evolution since the first intervention&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">-</span><p id="par0105" class="elsevierStylePara elsevierViewall">Closed neurological lesions treated conservatively with worsening of the symptoms and neurophysiology during follow-up&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">-</span><p id="par0110" class="elsevierStylePara elsevierViewall">Neural or extraneural tumoral lesions of the peripheral nerve&#46;</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">-</span><p id="par0115" class="elsevierStylePara elsevierViewall">Existence of a neurophysiological study prior to the surgery&#46;</p></li></ul></p><p id="par0120" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleItalic">exclusion criteria</span> were the following&#58;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">-</span><p id="par0125" class="elsevierStylePara elsevierViewall">Diabetic patients&#46;</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">-</span><p id="par0130" class="elsevierStylePara elsevierViewall">Patients with prior sensory-motor alterations&#46;</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">-</span><p id="par0135" class="elsevierStylePara elsevierViewall">Patients who did not sign the informed consent forms&#46;</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">-</span><p id="par0140" class="elsevierStylePara elsevierViewall">Patients who did not complete the required follow-up&#46;</p></li></ul></p><p id="par0145" class="elsevierStylePara elsevierViewall">Before describing our exploration technique&#44; we should highlight a series of <span class="elsevierStyleItalic">preliminary aspects</span> to be taken into account&#58;<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">&#8226;</span><p id="par0150" class="elsevierStylePara elsevierViewall">A decrease in <span class="elsevierStyleItalic">temperature</span> during the surgical process is difficult to prevent and&#44; therefore&#44; we should bear in mind that this temperature decrease will reduce nerve conduction speeds&#46;</p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">&#8226;</span><p id="par0155" class="elsevierStylePara elsevierViewall">A decrease in <span class="elsevierStyleItalic">arterial tension</span> during surgery reduces the amplitudes of somatosensory evoked potentials &#40;SSEP&#41; and motor evoked potentials &#40;MEP&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">&#8226;</span><p id="par0160" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Peripheral ischemia</span>&#44; caused by the ischemia cuff&#44; affects nerve response by altering the <span class="elsevierStyleItalic">vasa nervorum</span>&#44; and may block nerve response&#46;<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">14&#44;16&#44;17</span></a> If a tourniquet is applied for over 60<span class="elsevierStyleHsp" style=""></span>min&#44; it should be removed at least 20&#8211;30<span class="elsevierStyleHsp" style=""></span>min before starting intraoperative monitoring studies&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">13</span></a></p></li><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">&#8226;</span><p id="par0165" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Anesthesia</span> affects INM studies as it alters cortical excitability&#46; In addition&#44; we should also take into consideration the effect of neuromuscular relaxing agents&#46;</p></li></ul></p><p id="par0170" class="elsevierStylePara elsevierViewall">In our series we did not use peripheral ischemia in any case&#44; the anesthesia used was general with particular precaution regarding the use of neuromuscular relaxing agents which altered intraoperative measurements&#44; and the temperature within operating rooms was maintained at 15<span class="elsevierStyleHsp" style=""></span>&#176;C in all cases&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Methodology&#58; technical description of neurophysiological monitoring</span><p id="par0175" class="elsevierStylePara elsevierViewall">The technique starts once the nerve to be explored has been identified and isolated&#46; Since the main purpose of nerve conduction studies is to assess the integrity of the nerve&#44; its functional continuity or to determine the location of a peripheral nerve lesion&#44; the stimulation and reception electrodes should be placed on either side of the lesion&#46; This is known as <span class="elsevierStyleItalic">bipolar stimulation</span>&#44; and its main advantage is causing less current dispersion&#46; The best alternative when bipolar stimulation is unfeasible&#44; is to conduct monopolar stimulation with the cathode on the nerve and the anode on an inert surface at a certain distance&#46; The <span class="elsevierStyleItalic">bipolar stimulation</span> electrode &#40;preferable hooked electrodes&#41; held by the surgeon is placed on the surface of the nerve&#44; with the active electrode aimed toward the collecting electrodes&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">15</span></a> The distance between the poles of this bipolar electrode is generally of 3&#8211;4<span class="elsevierStyleHsp" style=""></span>mm&#44; although this mainly depends on the size of the nerve&#44; as large nerves may require distances between poles close to 7<span class="elsevierStyleHsp" style=""></span>mm&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">13</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">First&#44; the neural response is evoked in a healthy part of the nerve&#44; placing both the stimulation and reception electrodes proximally or distally to the lesion&#46; Subsequently&#44; the stimulation electrodes are placed proximally and the reception electrodes are placed distally to the lesion to evoke a NAP across it&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">During the stimulation it is advisable to <span class="elsevierStyleItalic">elevate the nerve</span> with respect to the surgical field&#44; in order to avoid contact with any fluids &#40;blood&#44; serum&#8230;&#41; which would reduce the intensity of the stimulus received by the nerve&#46; We must take into account that an excessive stimulation increases the intensity of the stimulus&#44; which may become a considerable problem if the distances between the stimulation and collection electrodes are small&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Generally the duration of the stimulus is around 0&#46;05&#8211;0&#46;1<span class="elsevierStyleHsp" style=""></span>ms with square pulse&#44;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">7</span></a> and the intensity does not need to be above 1&#8211;5<span class="elsevierStyleHsp" style=""></span>mA to produce a depolarization of the nerve and evoke a supramaximal response&#46; Damaged nerves require stimulation at higher intensities in order to evoke a response &#40;around 20&#8211;25<span class="elsevierStyleHsp" style=""></span>mA or 25&#8211;50<span class="elsevierStyleHsp" style=""></span>V&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">16</span></a> This causes an increase in the stimulation artifact that could interfere with response collection&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleItalic">nerve action potential</span> &#40;<span class="elsevierStyleItalic">NAP</span>&#41; is an electrical potential that is generated and travels through nerve fibers once these have been stimulated above their threshold&#44; physiologically or electrically&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">16</span></a> It can be registered both in the entire nerve and in its various fascicles&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">14</span></a> The presence of NAP is considered to require at least 4000 fibers of over 5<span class="elsevierStyleHsp" style=""></span>&#956; in diameter&#46; When assessing the continuity of the nerve&#44; we must take into account that the presence of a few large-sized myelinated nerve fibers &#40;out of the 4000&#41; can evoke a NAP of normal characteristics&#46; The process of studying a peripheral nerve starts with stimulation and reception of the NAP in a proximal location to the damaged region of the nerve&#44; which allows the technique to be assessed &#40;normal responses should be evoked&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">13</span></a> The electrodes are subsequently placed on both sides of the lesion to assess nerve continuity&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">The distance between the stimulation and collection electrodes should be over 4<span class="elsevierStyleHsp" style=""></span>cm&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">13&#44;16</span></a> The <span class="elsevierStyleItalic">collection electrode</span> should also be bipolar&#44; with a distance of 3&#8211;5<span class="elsevierStyleHsp" style=""></span>mm between the electrodes &#40;with the active electrode placed closer to the cathode of the stimulator&#41;&#44; with a greater separation between them if there is a considerable distance between the stimulator and the receptor&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleItalic">ground</span> electrode can be placed on a surface of the skin of the patient&#44; away from the grounding of the electric scalpel&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">13</span></a></p><p id="par0210" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleItalic">filters</span> required to obtain a NAP response are between 5 and 10<span class="elsevierStyleHsp" style=""></span>Hz for the low frequency and between 2 and 3<span class="elsevierStyleHsp" style=""></span>kHz for the high frequency&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">16</span></a></p><p id="par0215" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleItalic">amplitude</span> of NAP is generally low&#44; about 100<span class="elsevierStyleHsp" style=""></span>&#956;V&#44; so the gain is around 20&#8211;50<span class="elsevierStyleHsp" style=""></span>&#956;V per division&#46; Response averaging is necessary in order to evaluate it &#40;less than 10 stimuli are generally necessary&#41;&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">Naturally&#44; the <span class="elsevierStyleItalic">latency</span> of the response depends on the distance between the stimulation and collection electrodes&#46; Accepting a conduction speed of 50<span class="elsevierStyleHsp" style=""></span>m&#47;s&#44; we can apply 1<span class="elsevierStyleHsp" style=""></span>ms for every 5<span class="elsevierStyleHsp" style=""></span>cm of nerve distance&#44; so the sweep should be around 0&#46;5&#8211;1<span class="elsevierStyleHsp" style=""></span>ms per division and increase to 2<span class="elsevierStyleHsp" style=""></span>ms if the distance between both electrodes is considerable&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Practical implications for intraoperative decision making</span><p id="par0225" class="elsevierStylePara elsevierViewall">The large majority of peripheral nerve lesions do not section the nerves&#44; instead leaving continuity lesions that may not be observed during a visual inspection&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">17</span></a> The presence of structural continuity does not imply nerve functionality&#59; therefore&#44; a simple visual inspection by itself should not be taken into consideration in the surgical process&#44; since electrophysiological studies will be the ones to determine the course of the intervention&#46; Thus&#44; the surgical decision in peripheral nerve lesions is based on the determination of continuity of nerve function through a lesion in the said nerve &#40;ascertaining the presence of continuity&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">17&#44;18</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">How do we know if an explored nerve is functional and therefore viable&#63;</span><p id="par0230" class="elsevierStylePara elsevierViewall">The presence of NAP through a lesion is the gold standard technique and indicates that there is nerve continuity or collateral reinnervation &#40;even though preoperative neurophysiological studies and symptoms may indicate otherwise&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">13&#44;17</span></a> Therefore&#44; surgical procedures should be limited to neurolysis &#40;release of nerve adherences&#41; of the lesion in continuity<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">14</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#44; with this being the crucial point to bear in mind during the decision-making process in peripheral nerve surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">1</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">What to do in case of lack of response to nerve action potential&#63;</span><p id="par0235" class="elsevierStylePara elsevierViewall">In case of a lack of response to NAP&#44; we should carry out the following steps sequentially<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">14&#44;16</span></a>&#58;<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">1&#46;</span><p id="par0240" class="elsevierStylePara elsevierViewall">Verify the presence of hypotension and hypothermia&#46;</p></li><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">2&#46;</span><p id="par0245" class="elsevierStylePara elsevierViewall">Proximal to the lesion or in healthy segments&#44; check the position of the electrodes and ensure that they are not too close&#46;</p></li><li class="elsevierStyleListItem" id="lsti0110"><span class="elsevierStyleLabel">3&#46;</span><p id="par0250" class="elsevierStylePara elsevierViewall">Verify whether the stimulating electrode is producing a stimulus&#46;</p></li><li class="elsevierStyleListItem" id="lsti0115"><span class="elsevierStyleLabel">4&#46;</span><p id="par0255" class="elsevierStylePara elsevierViewall">Make sure that there should be no fluids in the surgical field and the electrodes should not touch other tissues&#46;</p></li><li class="elsevierStyleListItem" id="lsti0120"><span class="elsevierStyleLabel">5&#46;</span><p id="par0260" class="elsevierStylePara elsevierViewall">There should not be excessive tension in the nerve tissue&#46;</p></li><li class="elsevierStyleListItem" id="lsti0125"><span class="elsevierStyleLabel">6&#46;</span><p id="par0265" class="elsevierStylePara elsevierViewall">If the surgical field has cooled&#44; it should be warmed with warm serum&#46;</p></li><li class="elsevierStyleListItem" id="lsti0130"><span class="elsevierStyleLabel">7&#46;</span><p id="par0270" class="elsevierStylePara elsevierViewall">If the tourniquet is still in place&#44; it should be removed and a period of 20<span class="elsevierStyleHsp" style=""></span>min should be awaited before continuing with INM&#46;</p></li><li class="elsevierStyleListItem" id="lsti0135"><span class="elsevierStyleLabel">8&#46;</span><p id="par0275" class="elsevierStylePara elsevierViewall">No local anesthesia should be used&#46;</p></li><li class="elsevierStyleListItem" id="lsti0140"><span class="elsevierStyleLabel">9&#46;</span><p id="par0280" class="elsevierStylePara elsevierViewall">If a large artifact is observed&#44; about 60<span class="elsevierStyleHsp" style=""></span>Hz &#40;network&#41;&#44; the network filter of the device should be switched off&#44; before checking that there are no other machines&#44; such as X-ray devices in the field&#46;</p></li><li class="elsevierStyleListItem" id="lsti0145"><span class="elsevierStyleLabel">10&#46;</span><p id="par0285" class="elsevierStylePara elsevierViewall">Ensure that the signal obtained does not come from the inadvertent stimulation of other nerves&#46;</p></li></ul></p><p id="par0290" class="elsevierStylePara elsevierViewall">In general&#44; it is accepted that lesions in which NAP is not transmitted after an evolution of 3&#8211;4 months do not have a chance of spontaneous recovery and should be intervened through a graft or nerve transfer&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">13&#44;16</span></a> On the other hand&#44; the presence of NAP points to functional recovery within weeks or months&#46;</p><p id="par0295" class="elsevierStylePara elsevierViewall">Lastly&#44; we must take into account the possibilities for <span class="elsevierStyleItalic">false positive potentials</span><a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">14&#44;16&#44;17</span></a>&#58;<ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0150"><span class="elsevierStyleLabel">1&#46;</span><p id="par0300" class="elsevierStylePara elsevierViewall">Prenodal lesions &#40;plexopathies&#41; may respect the sensory fibers alongside severe damage of the motor fibers and generally the conductions are very high &#40;around 65&#8211;70<span class="elsevierStyleHsp" style=""></span>m&#47;s of the sensory fibers instead of the 50<span class="elsevierStyleHsp" style=""></span>m&#47;s of the motor or mixed&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0155"><span class="elsevierStyleLabel">2&#46;</span><p id="par0305" class="elsevierStylePara elsevierViewall">We may be stimulating and collecting information in a different area from that of the nerve lesion&#46;</p></li><li class="elsevierStyleListItem" id="lsti0160"><span class="elsevierStyleLabel">3&#46;</span><p id="par0310" class="elsevierStylePara elsevierViewall">We may be exploring a different nerve or part of the plexus&#46;</p></li><li class="elsevierStyleListItem" id="lsti0165"><span class="elsevierStyleLabel">4&#46;</span><p id="par0315" class="elsevierStylePara elsevierViewall">Exploring the nerve more than 1 year after the nerve lesion&#46;</p></li><li class="elsevierStyleListItem" id="lsti0170"><span class="elsevierStyleLabel">5&#46;</span><p id="par0320" class="elsevierStylePara elsevierViewall">An excessive averaging may register fine fibers&#46;</p></li><li class="elsevierStyleListItem" id="lsti0175"><span class="elsevierStyleLabel">6&#46;</span><p id="par0325" class="elsevierStylePara elsevierViewall">It is important to be careful with near motor responses&#46;</p></li></ul></p><p id="par0330" class="elsevierStylePara elsevierViewall">In the case of <span class="elsevierStyleItalic">peripheral nerve tumors</span>&#44;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">14</span></a> the use of NAP can detect the peripheral nerve in those locations where the architecture or anatomy is confusing and even identify the functional fascicles &#40;and protect as far as possible&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">13</span></a></p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Results</span><p id="par0335" class="elsevierStylePara elsevierViewall">We registered 12 peripheral nerve schwannomas&#44; 9 in the upper limbs and 3 in the lower limbs &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; In all cases&#44; the surgery was carried out with no incidents and the tumor was resected from the main trunk of the nerve&#44; except for 1 case where we had to sacrifice a only-sensory branch of the posterior tibial nerve after the neurophysiological monitoring showed that it had no motor component&#46; In this case&#44; a residual hypoesthesia was registered in the internal calf region &#40;S2 according to the BMC classification&#41;&#44; which lasted for 3 months &#40;<a class="elsevierStyleCrossRefs" href="#fig0010">Figs&#46; 2 and 3</a>&#41;&#46; As a permanent sequela we report 1 case of schwannoma in the external popliteal nerve which began with sensory and motor involvement &#40;M1 and S1&#41; &#40;<a class="elsevierStyleCrossRefs" href="#fig0020">Figs&#46; 4 and 5</a>&#41;&#44; with a persistent hypoesthesia in the dorsum of the foot &#40;S1 according to the BMC classification&#41;&#44; although without motor involvement&#46; We registered 1 case of fibrolipoma of the median nerve&#44; also known as neural fibrolipomatous hamartoma&#44; perineural lipoma or neural fat infiltration&#44; in a 57-year-old male which started as carpal tunnel syndrome and increased in size in the volar side of the wrist&#46; We were able to treat it through section of the flexor retinaculum of the wrist and endoneurolysis of the median nerve&#46; Therefore&#44; we registered 11 cases with excellent results and 2 with good results&#44; 1 with temporary hypoesthesia and another with almost full motor recovery&#44; although not sensory&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0340" class="elsevierStylePara elsevierViewall">We monitored 17 cases of traumatic lesions &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Ten of these cases were secondary to penetrating wounds&#44; and in 6 of them we conducted direct neurorrhaphy of the damaged nerve&#46; During the revision surgery we verified through INM that in 6 cases the neuroma did not allow distal conduction&#44; so it was necessary to perform grafting with tissue from the sural nerve following the usual technique&#46; In the 4 remaining cases we registered distal conduction so we only carried out neurolysis&#46;</p><p id="par0345" class="elsevierStylePara elsevierViewall">As for the remaining cases&#44; 7 patients had suffered accidental closed trauma or else iatrogenic damage &#40;ulnar nerve damage in surgery for supracondylar fracture&#41;&#46; In this last group&#44; intraoperative neurophysiological monitoring was very useful in 3 children suffering ulnar nerve lesion following incruental reduction and percutaneous fixation of a displaced supracondylar fracture of the humerus&#44; due to a possible lesion whilst introducing the needle from the ulnar side&#46; After being unable to observe functional recovery in the physical exploration or the serial neurophysiological studies after 9&#44; 10 and 11 months&#44; respectively&#44; we decided to perform exploration and direct monitoring &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; In the 3 cases we were unable to observe evident macroscopic lesions and registered that the nerve did conduct at a distal level&#44; so we simply performed neurolysis&#46; Function was recovered 3&#44; 4 and 4&#46;5 months after the surgery&#44; respectively&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Discussion</span><p id="par0350" class="elsevierStylePara elsevierViewall">Peripheral nerve surgery is a very demanding type of surgery&#44; requiring advanced technical and anatomical knowledge in order to obtain good functional results&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">1&#44;14</span></a> The decision to repair a damaged nerve should take into account both the condition of the nerve and the capacity of the surgical team and the hospital&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">18</span></a> One of the most important factors to obtain these results is the moment when the surgical reconstruction is carried out&#44; that is&#44; surgical timing&#46; Given that&#44; very often&#44; the lost nerve function returns spontaneously&#44; performing surgery too early would be therapeutically rash&#44; as the patient would undergo an unnecessary surgical intervention&#46; On the other hand&#44; acting too late would reduce the chances of recovery&#44; because muscles which do not receive innervation inevitably tend to become atrophied&#44; so the longer the period elapsed between the lesion and its repair&#44; the greater the atrophy and the smaller the chances of success&#46; In general practice&#44; the second scenario &#40;patients referred belatedly&#41; is much more common than the first&#46; Two main groups can be established&#58; closed and open lesions&#46; The first are those that generally require an expectant initial approach and deferred surgery&#44; not before 3 months since the trauma&#46; On the other hand&#44; open lesions should be explored rapidly in order to carry out direct neurorrhaphy whenever feasible&#44; or else cleaning and repair of the ends of the sectioned nerve&#44; in order to conduct a repair with an interposed graft&#46; Other nerve exploration indications include&#58; nerve lesions with arterial damage&#44; lesions caused by traction on the brachial plexus&#44; decrease of nerve functionality after an initially expectant approach&#44; lack of neurological improvement following a closed lesion&#44; lack of improvement following a conduction block within 6 weeks after the lesion&#44; persistent pain and suspected formation of a neuroma&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">1&#44;18</span></a></p><p id="par0355" class="elsevierStylePara elsevierViewall">Following a nerve lesion&#44; a neurophysiological study helps to determine the severity of the nerve involvement&#44; as well as detect signs of functional recovery before these are reflected by the symptoms&#46; Currently&#44; decision-making in peripheral nerve pathologies is still the result of a combination of neurophysiological studies and serial physical examinations&#46; However&#44; the use of INM has sparked a considerable and increasing interest&#44; as it provides real-time information&#44; by stimulating neural structures directly&#44; about the functionality of the main affected nerve branches and the presence or absence of an action potential in the distal nerve to the lesion&#44; particularly when the nerve is not completely sectioned and a neuroma has formed&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">13&#44;14&#44;16&#44;17</span></a> This technique can even distinguish between an intact fascicle and a neuroma&#46; Clinically&#44; the size and hardness of the neuroma is a negative factor for recovery&#44; but good amplitude signals distal to the nerve lesion indicate a better prognosis because they point to the existence of intact fascicles crossing the damaged area&#46;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">15&#44;18</span></a> We find this technique particularly interesting in cases of posttraumatic closed lesions or after surgery in specific locations&#44; as in the case of the ulnar nerve at the level of the elbow in supracondylar humeral fractures in children&#44; as in 3 cases in our series&#46; With this technique we were able to determine whether the nerve was functional or required a nerve graft&#44; as in one of the cases described&#46; Lastly&#44; and although not part of the objective of this work&#44; INM has also been used experimentally in animals in the implementation of biological techniques for nerve repair that will serve as coadjutants in nerve regeneration in the near future&#46;<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">19&#8211;24</span></a></p><p id="par0360" class="elsevierStylePara elsevierViewall">In the case of tumors settled on the peripheral nerve&#44; the goal of treatment is complete exeresis with minimal damage to the nerve&#46; Within these tumors we must distinguish resectable nerve tumors from unresectable cases&#46; The former avoid fascicular groups without penetrating them&#44; that is&#44; they are extraneural&#44; so they can be enucleated without having to break nerve continuity&#44; such as schwannomas&#44; for example&#44; with an excellent functional prognosis&#46; There are no studies proving that optimal results would not be achieved without using INM&#46;</p><p id="par0365" class="elsevierStylePara elsevierViewall">On the other hand&#44; it is in unresectable tumors &#40;solitary neurofibroma&#44; hemangioma of the Schwann sheath&#44; neural fibrolipoma&#41; that INM is most useful&#46; These tumors infiltrate all the elements that constitute the nerve and it is impossible to excise them completely without altering the nerve fibers&#44; as in the case of fibrolipoma of the median nerve reported in our series&#46; Therefore&#44; they are intraneural and it would be important to know which fascicles are functionally viable in order to preserve them&#44; even though in many cases this will not be possible and we will need to resort to nerve grafts or nerve conduits&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">18</span></a></p><p id="par0370" class="elsevierStylePara elsevierViewall">In the literature review we found very few specific references to the use of this technique in peripheral nerve tumoral surgery related to the field of Orthopedics&#44; not being able to support its generalized use in our field&#44; although we found numerous studies reporting excellent results in cases suffering traumatic lesions of the peripheral nerve and brachial plexus&#44; as well as in facial nerve surgery&#46;<a class="elsevierStyleCrossRefs" href="#bib0295"><span class="elsevierStyleSup">23&#8211;25</span></a> The majority of articles dealing with this technique refer to the fields of Otolaryngology and Neurosurgery&#44; particularly surgery of the skull base&#44; and are usually reviews of case series or isolated case reports&#46;<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">25&#8211;28</span></a> It is worth highlighting the extensive experience existing in the case of schwannomas of the vestibulocochlear nerve &#40;eighth cranial nerve&#41;&#44;<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">25&#8211;30</span></a> including the article by Oh et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">28</span></a> who perfectly described the monitoring technique for neurinomas in this location&#44; very similar to that used at our center&#46; Kwok et al&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">31</span></a> reported excellent results in the case of benign tumors of the brachial plexus&#44; and maintained that its generalized use has minimized intraoperative complications&#46;</p><p id="par0375" class="elsevierStylePara elsevierViewall">We found up to 3 reports of the application of this technique in the case of schwannomas of the posterior tibial nerve as a cause of tarsal tunnel syndrome&#44; a pathology which is included in the differential diagnosis of atypical talalgias&#46;<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">32&#8211;35</span></a> Two of these publications included recommendations for the systematic use of this technique to avoid iatrogenic lesions deriving from the surgical intervention&#46;<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">32&#44;33</span></a> In our series&#44; we reported 3 schwannomas of the posterior tibial nerve&#44; with complete recovery and intact functionality in all cases &#40;<a class="elsevierStyleCrossRefs" href="#fig0010">Figs&#46; 2 and 3</a>&#41;&#46;</p><p id="par0380" class="elsevierStylePara elsevierViewall">Following the considerations described by Mohler and Hanel<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">36</span></a> in his article&#44; there is a discrepancy between the previous neurophysiological condition and the symptoms&#44; in the case of closed lesions of peripheral nerves&#44; and the final functional results&#44; with considerable variability between the different peripheral nerves and between one patient and another&#46; For this reason&#44; we need more precise tools that can determine if it is possible to perform conservative surgery of the affected nerve during the intervention&#46;</p><p id="par0385" class="elsevierStylePara elsevierViewall">Lastly&#44; the authors believe that&#44; as is already occurring in neurosurgery and spinal surgery&#44; the advent and development of these monitoring techniques mean we are not far from the need&#44; not only from a therapeutic standpoint but also from the medical-legal&#44; to make these diagnostic tools available to our patients in order to achieve a better functional result&#44; which is the ultimate goal of our treatment&#46; Our results are excellent from the functional standpoint&#44; with only 2 patients with schwannoma suffering a partial sensory deficit&#44; and with this deficit persisting in only 1 of the patients after 3 years of monitoring&#46; The best results in traumatic cases were obtained with median nerve grafts&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Study limitations</span><p id="par0390" class="elsevierStylePara elsevierViewall">The main limitations of our study came from its methodology&#44; as it was a retrospective descriptive study&#46; We have not compared our results with those of interventions performed without monitoring&#44; although it is worth mentioning that this kind of surgery is not carried out without INM at our center since 2009&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conclusions</span><p id="par0395" class="elsevierStylePara elsevierViewall">Our results indicate that the use of INM in peripheral nerve surgery is a useful technique&#44; especially indicated in secondary surgery of traumatic lesions in which the conventional neurophysiology and symptoms point to an irreversible neurological lesion&#46; It would be necessary to conduct comparative prospective studies to ensure that the technique is essential and indispensable in all peripheral nerve interventions&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Level of evidence</span><p id="par0400" class="elsevierStylePara elsevierViewall">Level of evidence <span class="elsevierStyleSmallCaps">IV</span>&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Ethical disclosures</span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Protection of people and animals</span><p id="par0405" class="elsevierStylePara elsevierViewall">The authors declare that this investigation adhered to the ethical guidelines of the Committee on Responsible Human Experimentation&#44; as well as the World Medical Association and the Declaration of Helsinki&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Confidentiality of data</span><p id="par0410" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their workplace on the publication of patient data&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Right to privacy and informed consent</span><p id="par0415" class="elsevierStylePara elsevierViewall">The authors declare having obtained written informed consent from patients and&#47;or subjects referred to in the work&#46; This document is held by the corresponding author&#46;</p></span></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Conflict of interests</span><p id="par0420" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare&#46;</p></span></span>"
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            1 => "Nervio perif&#233;rico"
            2 => "Neuromas traum&#225;ticos"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Intraoperative neurophysiological monitoring has experienced a spectacular development in the past 20 years&#44; particularly in the fields of neurosurgery and spine surgery&#46; It has become a useful&#44; almost indispensable tool in preventing nerve damage during surgery&#46; The aim of this article is to describe the intraoperative technique and analyze its results in the field of peripheral nerve surgery&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objective</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">To describe the usefulness of a technique in peripheral nerve surgery&#44; the technique used and the experience in a center&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Patients and methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A retrospective study was conducted on 30 cases of peripheral nerve surgery performed in this center from 2009 to 2013&#44; using the intraoperative monitoring technique&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Of the total of 13 peripheral nerve tumors recorded&#44; there were 11 excellent results and 2 good results&#44; one temporary hypoesthesia and one with almost complete sensory&#44; except for motor recovery&#46; Traumatic injury was recorded in 17 cases&#44; of which 6 required performing a graft&#44; and the remaining 11 cases only neurolysis was performed&#44; with complete motor and sensory recovery&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Intraoperative neurophysiological monitoring is a useful tool in the secondary surgery of peripheral nerve injury and the intraneural tumor pathology&#46;</p></span>"
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introducci&#243;n</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La monitorizaci&#243;n neurofisiol&#243;gica intraoperatoria ha experimentado un espectacular desarrollo en los &#250;ltimos 20 a&#241;os&#44; particularmente en campos como la neurocirug&#237;a y la cirug&#237;a de raquis&#46; Se ha constituido en una herramienta muy &#250;til en la prevenci&#243;n de da&#241;o neurol&#243;gico durante la cirug&#237;a&#44; si bien su utilidad en la cirug&#237;a del nervio perif&#233;rico en el &#225;rea de traumatolog&#237;a y ortopedia no ha sido constatada&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Objetivo</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Describir exhaustivamente la t&#233;cnica de monitorizaci&#243;n neurofisiol&#243;gica intraoperatoria y secundariamente comunicar la experiencia de nuestro centro&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Pacientes y m&#233;todo</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Estudio descriptivo retrospectivo de 30 casos de cirug&#237;a de nervio perif&#233;rico realizadas en nuestro centro en el per&#237;odo 2009&#8211;2013&#46; Descripci&#243;n pormenorizada de la t&#233;cnica de monitorizaci&#243;n neurofisiol&#243;gica intraoperatoria utilizada&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Registramos 13 tumores del nervio perif&#233;rico&#44; de estos&#44; obtuvimos 11 resultados excelentes y 2 buenos&#44; uno con hipoestesia temporal y otro con recuperaci&#243;n motora casi completa aunque no sensitiva&#46; Registramos 17 casos de lesiones traum&#225;ticas&#44; en 6 casos fue necesaria la realizaci&#243;n de injerto&#44; en los 11 restantes solo realizamos neurolisis&#44; con recuperaci&#243;n sensitiva y motora completa&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusiones</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">La monitorizaci&#243;n neurofisiol&#243;gica intraoperatoria supone una herramienta &#250;til en la cirug&#237;a secundaria de las lesiones del nervio perif&#233;rico y en la enfermedad tumoral intraneural de dicho nervio&#46;</p></span>"
        "secciones" => array:5 [
          0 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Introducci&#243;n"
          ]
          1 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Objetivo"
          ]
          2 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Pacientes y m&#233;todo"
          ]
          3 => array:2 [
            "identificador" => "abst0045"
            "titulo" => "Resultados"
          ]
          4 => array:2 [
            "identificador" => "abst0050"
            "titulo" => "Conclusiones"
          ]
        ]
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Herrera-P&#233;rez M&#44; Oller-Boix A&#44; P&#233;rez-Lorensu PJ&#44; de Bergua-Domingo J&#44; Gonzalez-Casamayor S&#44; M&#225;rquez-Marfil F&#44; et al&#46; Monitorizaci&#243;n neurofisiol&#243;gica intraoperatoria en la cirug&#237;a del nervio perif&#233;rico&#58; descripci&#243;n t&#233;cnica y resultados en nuestro centro&#46; Rev Esp Cir Ortop Traumatol&#46; 2015&#59;59&#58;266&#8211;274&#46;</p>"
      ]
    ]
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      0 => array:7 [
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Placement of electrodes in the ulnar nerve in a case of axonotmesis following a supracondylar humerus fracture treated by closed reduction and fixation with Kirschner wires&#46;</p>"
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">MRI scan showing a round lesion close to the posterior tibial nerve&#46;</p>"
        ]
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      2 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Figure 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Identification of the posterior tibial nerve and common fibular nerve &#40;vessel-loop&#41; and a well-defined schwannoma in the sensory superficial branches stemming from the posterior tibial nerve&#46;</p>"
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      3 => array:7 [
        "identificador" => "fig0020"
        "etiqueta" => "Figure 4"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
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          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Neurinoma of the common fibular nerve before the intervention&#46;</p>"
        ]
      ]
      4 => array:7 [
        "identificador" => "fig0025"
        "etiqueta" => "Figure 5"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
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          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Neurinoma of the common fibular nerve after the intervention&#46;</p>"
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      5 => array:6 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">CFN&#58; common fibular nerve&#59; ENG&#58; electroneurogram&#59; INM&#58; intraoperative neurophysiological monitoring&#59; NAP&#58; nerve action potential&#59; Schw&#46;&#58; schwannoma&#46;</p>"
          "tablatextoimagen" => array:1 [
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              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Gender&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Diagnosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Prior ENG &#40;SEDDON&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Drugs used in anesthesia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Type of INM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Previous surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Female&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">37&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Schw&#46; median&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sevoflurane&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NAP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Exeresis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Schw&#46; median&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Propofol<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>remifentanil&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NAP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Exeresis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Female&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Section median&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neurotmesis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sevoflurane&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NAP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neurorrhaphy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sural graft&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Female&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">42&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Schw&#46; posterior tibial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Propofol<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>remifentanil&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NAP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Exeresis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Female&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">51&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Section ulnar&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neurotmesis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sevoflurane&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NAP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neurorrhaphy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neurolysis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Paralysis ulnar&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neuropraxia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sevoflurane&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NAP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neurolysis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Female&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">72&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Schw&#46; ulnar&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sevoflurane&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NAP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Exeresis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">41&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Paralysis radial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neurotmesis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sevoflurane&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NAP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neurolysis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Schw&#46; tibial posterior&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Propofol<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>remifentanil&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NAP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Exeresis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Paralysis ulnar&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neuropraxia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sevoflurane&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NAP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sural graft&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Female&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Section median&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neurotmesis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sevoflurane&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NAP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neurorrhaphy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neurolysis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Female&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">44&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Section ulnar&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neurotmesis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sevoflurane&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NAP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neurorrhaphy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neurolysis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Schw&#46; median&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sevoflurane&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NAP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Exeresis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Female&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Schw&#46; median&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Propofol<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>remifentanil&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NAP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Exeresis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">43&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Section ulnar&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neurotmesis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sevoflurane&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NAP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sural graft&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">71&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Section radial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neurotmesis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sevoflurane&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NAP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neurorrhaphy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sural graft&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Section deep fibular&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neurotmesis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sevoflurane&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NAP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neurorrhaphy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sural graft&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Schw&#46; radial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sevoflurane&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NAP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Exeresis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">55&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Section radial sensory&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neuropraxia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sevoflurane&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NAP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neurolysis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">63&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Paralysis radial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neurotmesis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sevoflurane&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NAP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neurolysis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Schw&#46; median&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sevoflurane&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NAP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Exeresis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Female&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">41&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Section posterior tibial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neurotmesis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sevoflurane&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NAP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sural graft&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">71&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Paralysis sciatic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neuropraxia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sevoflurane&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NAP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neurolysis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Schw&#46; CFN&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sevoflurane&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NAP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Exeresis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">57&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Fibrolipoma median&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neuropraxia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sevoflurane&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NAP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neurolysis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Female&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">46&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Section median&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neurotmesis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sevoflurane&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NAP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neurorrhaphy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Paralysis ulnar&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neuropraxia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sevoflurane&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NAP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neurolysis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">28&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Paralysis ulnar&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neuropraxia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Propofol<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>remifentanil&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NAP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neurolysis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">29&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Female&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Schw&#46; radial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sevoflurane&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NAP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Exeresis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Schw&#46; median&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sevoflurane&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NAP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Exeresis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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Article information
ISSN: 19888856
Original language: English
DOI:10.1016/j.recote.2015.04.005
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