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Indocyanine Green Near Infrared Fluorescent Imaging and its Potential Role in Peripheral Nerve Repair
Christopher Kubujak, Rebecca Friedman*, Nikhil Agrawal, Jonathan Bass
Hansjorg Wyss Department of Plastic Surgery, NYU Langone Health, New York City , NY
Background: Upper extremity peripheral nerve injuries result in loss of function, chronic pain, and permanent alterations to daily life. Repair requires tension-free coaptation of healthy, well-vascularized nerve ends to increase likelihood of regeneration. Clinical appearance during debridement is used to confirm viability, however, debridement results in an increased nerve gap, and excessive debridement limits potential for primary repair. Improving objective assessment of perfusion and limiting debridement can invaluably enhance primary nerve repair and regeneration.
Indocyanine green (ICG) is a safe, soluble intravenous dye that emits fluorescence after excitement by near-infrared light sources (NIR). This is detected by digital receiver, allowing for easy and reliable real-time evaluation of tissue. This has a variety of intra-operative uses but has not yet been reported for assessing nerve perfusion before coaptation. We propose its use for enhancing primary peripheral nerve repair.
Methods: Patients with documented peripheral nerve laceration injury were identified. ICG was administered intraoperatively following identification of nerve ends. Debridement was performed using perfusion of nerve ends as a guide, as visualized with ICG fluorescence.
Results: Three patients were selected. Poor perfusion at nerve ends was represented by lack of fluorescence on imaging. Following guided, appropriate debridement, evidence of perfusion was represented by increased fluorescence in the area. On follow up two-four months after nerve repair, patients exhibit satisfactory healing and improved functionality due to appropriate nerve regeneration.
Conclusions: We demonstrate feasibility of ICG and NIR fluorescent imaging for assessment of peripheral nerve perfusion to improve patient outcomes after laceration repair. Improved objective appraisal of nerve ends can reduce length of debridement, increasing likelihood of successful regeneration. Potential implications reach beyond nerve debridement and could represent a viable adjunct to management of peripheral nerve injuries.
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