Nerve injury classification: Difference between revisions

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Nerve injury classification assists in prognosis and determination of treatment strategy for nerve injuries. Classification was described by Seddon in 1943 and by Sunderland in 1951.^[1] In the lowest degree of nerve injury the nerve remains intact, but signaling ability is damaged, termed neurapraxia. In the second degree the axon is damaged, but the surrounding connecting tissue remains intact – axonotmesis. The last degree, in which both the axon and connective tissue are damaged, is called neurotmesis.

Seddon's classification

In 1943, Seddon described three basic types of nerve injury:^[2]

Neurapraxia (Class I)

Neurapraxia is a temporary interruption of conduction without loss of axonal continuity.^[3] Neurapraxia involves a physiologic block of nerve conduction in the affected axons.

Other characteristics:

mildest type of nerve injury
sensory-motor problems present distal to the site of injury
intact endoneurium, perineurium, and the epineurium
wallerian degeneration not present
intact conduction in the distal and proximal segments, but no conduction across the injury^[4]
full nerve conduction recovery, requiring days to weeks
fibrillation potentials (FP) lacking, and positive sharp EMG waves.

Axonotmesis (Class II)

Axonotmesis involves loss of relative axon continuity and myelin covering, but preservation of the connective tissue framework (including encapsulating tissue, the epineurium and perineurium).^[5]

Other characteristics:

distal Wallerian degeneration
distal sensory and motor deficits
nerve conduction distal to the site of injury (3 to 4 days after injury) absent
fibrillation potentials (FP), and positive, sharp EMG waves (2 to 3 weeks post injury).
axonal regeneration and recovery does not typically require surgical treatment, although surgical intervention may be required, due to scar tissue

Neurotmesis (Class III)

Neurotmesis is total severance/disruption of the nerve fiber.^[6] Axon, endo-, peri-, and epineurium transected. Neurotmesis may be partial or complete.

Other characteristics:

distal Wallerian degeneration
partial or complete connective tissue lesion
severe sensory-motor problems and autonomic function defect
nerve conduction distal to the site of injury absent (3 to 4 days after lesion)
no distal conduction (EMG and NCV (nerve conduction velocity)
surgical intervention is necessary to restore function

Sunderland's classification

In 1951, Sunderland expanded Seddon's classification to five degrees. The first two are the same as Seddon's.

Sunderland's third-degree and fourth-degree are included within Seddon's axonotmensis. Sunderland's third-degree is nerve fiber interruption. Includes an endoneurium lesion, with an intact epineurium and perineurium. Recovery from a third-degree injury may require surgical intervention. In fourth-degree injury, only the epineurium remain intact, requiring surgical repair.

Sunderland's fifth-degree is included within Seddon's neurotmesis. Fifth-degree lesion is a complete transection of the nerve, including the epineurium. Recovery requires appropriate surgical treatment.

References

^ "Peripheral Nerve Injuries". 31 October 2022.
^ "Seddon classification of nerve injuries".
^ Otto D.Payton & Richard P.Di Fabio et al. Manual of physical therapy. Churchill Livingstone Inc. ISBN 0-443-08499-8
^ "Electrodiagnostic Studies of the Hand". Archived from the original on 2010-05-27. Retrieved 2010-07-17.
^ "Classification of Nerve Injuries". Archived from the original on 2009-09-25.
^ Otto D.Payton & Richard P.Di Fabio et al. Manual of physical therapy. Churchill Livingstone Inc. Page: 24. ISBN 0-443-08499-8

[1] "Peripheral Nerve Injuries". 31 October 2022.

[2] "Seddon classification of nerve injuries".

[3] Otto D.Payton & Richard P.Di Fabio et al. Manual of physical therapy. Churchill Livingstone Inc. ISBN 0-443-08499-8

[4] "Electrodiagnostic Studies of the Hand". Archived from the original on 2010-05-27. Retrieved 2010-07-17.

[5] "Classification of Nerve Injuries". Archived from the original on 2009-09-25.

[6] Otto D.Payton & Richard P.Di Fabio et al. Manual of physical therapy. Churchill Livingstone Inc. Page: 24. ISBN 0-443-08499-8

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 {{Short description|Scheme developed by Seddon and Sunderland}}
+[[File:Sedon's classification of nerve injuries.jpg|thumb|Seddon's classification of nerve injuries|300px]]
-{{Underlinked|date=February 2024}}
+'''Nerve injury classification''' assists in [[prognosis]] and determination of treatment strategy for [[Nerve injury|nerve injuries]]. Classification was described by Seddon in 1943 and by Sunderland in 1951.<ref>{{cite web| title = Peripheral Nerve Injuries | date = 31 October 2022| url = http://emedicine.medscape.com/article/1270360-overview}}</ref> In the lowest degree of nerve injury the nerve remains intact, but signaling ability is damaged, termed [[neurapraxia]]. In the second degree the [[axon]] is damaged, but the surrounding [[Connective tissue|connecting tissue]] remains intact – [[axonotmesis]]. The last degree, in which both the axon and connective tissue are damaged, is called [[neurotmesis]].
-[[File:Sedon's classification of nerve injuries.jpg|thumb|400px]]
-Classification of [[nerve injury]] assists in [[prognosis]] and determination of treatment strategy. Classification of nerve injury was described by Seddon in 1943 and by Sunderland in 1951.<ref>{{cite web| title = Peripheral Nerve Injuries | url = http://emedicine.medscape.com/article/1270360-overview}}</ref> The lowest degree of nerve injury in which the nerve remains intact but signaling ability is damaged is called [[neurapraxia]]. The second degree in which the axon is damaged but the surrounding connecting tissue remains intact is called [[axonotmesis]]. The last degree in which both the axon and connective tissue are damaged is called [[neurotmesis]].
 ==Seddon's classification==
-In 1943, Seddon described three basic types of nerve injury<ref>{{cite web| title = Seddon classification of nerve injuries | url = http://www.gpnotebook.co.uk/simplepage.cfm?ID=x20091231010118724280&linkID=72782&cook=no&mentor=1}}</ref> that include:
+In 1943, Seddon described three basic types of nerve injury:<ref>{{cite web| title = Seddon classification of nerve injuries | url = http://www.gpnotebook.co.uk/simplepage.cfm?ID=x20091231010118724280&linkID=72782&cook=no&mentor=1}}</ref>
 ===Neurapraxia (Class I)===
 {{main|Neurapraxia}}
-It is a temporary interruption of conduction without loss of axonal continuity.<ref>Otto D.Payton & Richard P.Di Fabio et al. Manual of physical therapy. Churchill Livingstone Inc. {{ISBN|0-443-08499-8}}</ref> In neurapraxia, there is a physiologic block of nerve conduction in the affected axons.
+Neurapraxia is a temporary interruption of conduction without loss of axonal continuity.<ref>Otto D.Payton & Richard P.Di Fabio et al. Manual of physical therapy. Churchill Livingstone Inc. {{ISBN|0-443-08499-8}}</ref> Neurapraxia involves a physiologic block of nerve conduction in the affected axons.
 Other characteristics:
-*It is the mildest type of nerve injury.
+*mildest type of nerve injury
-*There are sensory-motor problems [[distal]] to the site of injury.
+*sensory-motor problems present [[distal]] to the site of injury
-*The [[endoneurium]], [[perineurium]], and the [[epineurium]] are intact.
+*intact [[endoneurium]], [[perineurium]], and the [[epineurium]]
-*There is no [[wallerian degeneration]].
+*[[wallerian degeneration]] not present
-*Conduction is intact in the distal segment and proximal segment, but no conduction occurs across the area of injury.<ref>{{cite web| title = Electrodiagnostic Studies of the Hand| url = http://www.cmki.org/LMHS/Chapters/33-electrophysiological.htm| access-date = 2010-07-17| archive-url = https://web.archive.org/web/20100527213521/http://www.cmki.org/LMHS/Chapters/33-electrophysiological.htm| archive-date = 2010-05-27| url-status = dead}}</ref>
+*intact conduction in the distal and proximal segments, but no conduction across the injury<ref>{{cite web| title = Electrodiagnostic Studies of the Hand| url = http://www.cmki.org/LMHS/Chapters/33-electrophysiological.htm| access-date = 2010-07-17| archive-url = https://web.archive.org/web/20100527213521/http://www.cmki.org/LMHS/Chapters/33-electrophysiological.htm| archive-date = 2010-05-27| url-status = dead}}</ref>
-* Recovery of nerve conduction deficit is full, and requires days to weeks.
+* full nerve conduction recovery, requiring days to weeks
-*EMG shows lack of [[fibrillation]] potentials (FP) and positive sharp waves.
+*[[fibrillation]] potentials (FP) lacking, and positive sharp [[Electromyography|EMG]] waves.
 ===Axonotmesis (Class II)===
 {{main|Axonotmesis}}
-It involves loss of the relative continuity of the axon and its covering of myelin, but preservation of the connective tissue framework of the nerve (the encapsulating tissue, the epineurium and perineurium, are preserved).<ref>{{cite web| title = Classification of Nerve Injuries| url = http://www.medstudents.com.br/neuroc/neuroc4.htm| url-status = dead| archiveurl = https://web.archive.org/web/20090925104719/http://www.medstudents.com.br/neuroc/neuroc4.htm| archivedate = 2009-09-25}}</ref>
+Axonotmesis involves loss of relative axon continuity and [[myelin]] covering, but preservation of the connective tissue framework (including encapsulating tissue, the [[epineurium]] and [[perineurium]]).<ref>{{cite web| title = Classification of Nerve Injuries| url = http://www.medstudents.com.br/neuroc/neuroc4.htm| url-status = dead| archiveurl = https://web.archive.org/web/20090925104719/http://www.medstudents.com.br/neuroc/neuroc4.htm| archivedate = 2009-09-25}}</ref>
 Other characteristics:
-*[[Wallerian degeneration]] occurs distal to the site of injury.
+*distal [[Wallerian degeneration]]
-*There are sensory and motor deficits distal to the site of lesion.
+*distal sensory and motor deficits
-*There is no nerve conduction distal to the site of injury (3 to 4 days after injury).
+*nerve conduction distal to the site of injury (3 to 4 days after injury) absent
-*EMG shows  fibrillation potentials (FP), and positive sharp waves (2 to 3 weeks postinjury).
+*fibrillation potentials (FP), and positive, sharp EMG waves (2 to 3 weeks post injury).
-*Axonal regeneration occurs and recovery is possible without surgical treatment. Sometimes surgical intervention is required, due to [[scar|scar tissue]] formation.
+*axonal regeneration and recovery does not typically require surgical treatment, although surgical intervention may be required, due to [[scar|scar tissue]]
 ===Neurotmesis (Class III)===
 {{main|Neurotmesis}}
-It is a total severance or disruption of the entire nerve fiber.<ref>Otto D.Payton & Richard P.Di Fabio et al. Manual of physical therapy. Churchill Livingstone Inc. Page: 24. {{ISBN|0-443-08499-8}}</ref> This includes transection of the axon, endo-, peri-, and epineurium. Neurotmesis may be partial or complete.
+Neurotmesis is total severance/disruption of the nerve fiber.<ref>Otto D.Payton & Richard P.Di Fabio et al. Manual of physical therapy. Churchill Livingstone Inc. Page: 24. {{ISBN|0-443-08499-8}}</ref> Axon, endo-, peri-, and epineurium transected. Neurotmesis may be partial or complete.
 Other characteristics:
-*Wallerian degeneration occurs distal to the site of injury.
+*distal Wallerian degeneration
-*There is connective tissue lesion that may be partial or complete.
+*partial or complete connective tissue lesion
-*Sensory-motor problems and autonomic function defect are severe.
+*severe sensory-motor problems and autonomic function defect
-*There is no nerve conduction distal to the site of injury (3 to 4 days after lesion).
+*nerve conduction distal to the site of injury absent (3 to 4 days after lesion)
-*EMG and NCV findings show no distal conduction.
+*no distal conduction (EMG and NCV (nerve conduction velocity)
-*Because of complete transection, surgical intervention is necessary to restore function.
+*surgical intervention is necessary to restore function
 ==Sunderland's classification==
-In 1951, Sunderland expanded Seddon's classification to five degrees of nerve injury:
+In 1951, Sunderland expanded Seddon's classification to five degrees. The first two are the same as Seddon's.
+Sunderland's third-degree and fourth-degree are included within Seddon's axonotmensis. Sunderland's third-degree is [[nerve fiber]] interruption. Includes an endoneurium lesion, with an intact epineurium and perineurium. Recovery from a third-degree injury may require surgical intervention. In fourth-degree injury, only the epineurium remain intact, requiring surgical repair.
-;'''First-degree''' (Class I)
-Seddon's neurapraxia and first-degree are the same.
+Sunderland's fifth-degree is included within Seddon's neurotmesis. Fifth-degree lesion is a complete transection of the nerve, including the epineurium. Recovery requires appropriate surgical treatment.
-;'''Second-degree''' (Class II)
-Seddon's axonotmesis and second-degree are the same. Only the axon is disrupted, with endoneurium intact.
-;'''Third-degree''' (Class II)
-Third-degree is included within Seddon's axonotmensis
-Sunderland's third-degree is a [[nerve fiber]] interruption. In third-degree injury, there is a lesion of the endoneurium, but the epineurium and perineurium remain intact. Recovery from a third-degree injury is possible, but surgical intervention may be required.
-;'''Fourth-degree''' (Class II)
-Fourth-degree is included within Seddon's axonotmensis
-In fourth-degree injury, only the epineurium remain intact. In this case, surgical repair is required.
-;'''Fifth-degree''' (Class III)
-Fifth-degree is included within Seddon's neurotmesis.
-Fifth-degree lesion is a complete transection of the nerve, including the epineurium. Recovery is not possible without an appropriate surgical treatment.
 ==See also==

v t e Neurotrauma
Traumatic brain injury	Intracranial hemorrhage Intra-axial Intraparenchymal hemorrhage Intraventricular hemorrhage Extra-axial Subdural hematoma Epidural hematoma Subarachnoid hemorrhage Brain herniation Cerebral contusion Cerebral laceration Concussion Post-concussion syndrome Second-impact syndrome Dementia pugilistica Chronic traumatic encephalopathy Diffuse axonal injury Abusive head trauma Penetrating head injury
Spinal cord injury	Anterior spinal artery syndrome Brown-Séquard syndrome Cauda equina syndrome Central cord syndrome Paraplegia Posterior cord syndrome Spinal cord injury without radiographic abnormality Tetraplegia (Quadriplegia)
Peripheral nerves	Nerve injury Peripheral nerve injury classification Wallerian degeneration Injury of accessory nerve Brachial plexus injury Traumatic neuroma