Bridging the neural gap

The gold standard for bridging a nerve gap remains a nerve autograft. Since the first implementation of a nerve allograft in 1870 by Philipeaux and Vulpian, significant contributions to suturing technique, neural topography, and the biology of nerve regeneration have transformed the way we approach nerve gaps. Although primary neurorrhaphy and autografts are the most common methods of repair, several newer options are at our disposal. Nerve transfers have revolutionized our approach to nerve gaps, from devastating brachial plexus injuries to highly selected upper and lower motor and sensory nerve injuries. Nerve allografts, bioengineered nerve conduits, and therapies to augment the regenerative properties of the peripheral nerve are the current objects of investigation in academic laboratories and industry. Breaking these barriers of nerve regeneration limitation will push peripheral nerve surgery to the next level. Nerve allografts have the advantage of being closest to an autologous nerve. When the morbidity associated with even temporary immunosuppression becomes negligible, allografts may have a prominent role in grafting in cases of larger nerve volume loss. Industry-driven tissue engineering is already being implemented in bioengineered nerve conduits. The future of bioengineered grafts may entail a combination of tissue typing, trophic factors, and perhaps the use of embryonic stem cells to create effective nerve substitutes.