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Sunderland classification of nerve injuries

Last reviewed dd mmm yyyy. Last edited dd mmm yyyy

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Sunderland described a classification of nerve injuries in 1951 that correlates pathological changes with prognosis. The grades are:

  • first degree injury:
    • demyelinated nerve
    • a physiological local conduction block
    • neuropraxia in the Seddon scheme
    • conservative management
    • recovery expected over weeks to months
  • second-degree injury:
    • some axons disrupted
    • endoneurial sheaths and surrounding connective tissue layers remain intact
    • Wallerian degeneraiton distally
    • equivalent to axonotmesis in Seddon scheme
    • treatment is conservative
    • regeneration of axons can be followed clinically by an advancing Tinel's sign
    • complete recovery can be expected over months
  • third-degree injury:
    • axons and endoneurial sheaths disrupted
    • scarring replaces existing structures
    • perineurium and connective tissue layers outside of this remains
    • most of these injuries will recover spontaneously but partially
  • fourth-degree injury:
    • axon, endoneurium and perineurium disrupted
    • scarring replaces existing structures
    • epineurium remains
    • scar blocks all neuronal regeneration
    • no recovery likely without operative management
  • fifth-degree injury:
    • nerve transection
    • all structures including epineurium divided
    • no recovery expected without operative management

Sixth-degree injury was subsequently added to the scheme by Susan Mackinnon. This describes a nerve injury with features of two or more of the above categories.

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