US can accurately diagnose transected nerves, but is limited by large hematomas, skin lacerations and soft tissue edema. In contrast to PNS, Microglia play a vital role in CNS wallerian degeneration. . They occur as isolated neurological conditions or, more commonly, in association with. There is significant room for improvement in the development of more formal diagnostic tools, aiding prognostication for these difficult and sometimes severe injuries. Wilcox M, Brown H, Johnson K, Sinisi M, Quick TJ. Soluble factors produced by Schwann cells and injured axons activate resident macrophages and lead to recruitment of hematogenous macrophages. Nerve Structure: https://commons.wikimedia.org/w/index.php?curid=1298429. Recovery by regeneration depends on the cellular and molecular events of Wallerian degeneration that injury induces distal to the lesion site, the domain through which severed axons regenerate back to their target tissues. 3. David Haustein, MD; Mariko Kubinec, MD; Douglas Stevens, MD; and Clinton Johnson, DO. Pierpaoli C, Barnett A, Pajevic S et-al. [9] A brief latency phase occurs in the distal segment during which it remains electrically excitable and structurally intact. While Schwann cells mediate the initial stage of myelin debris clean up, macrophages come in to finish the job. axon enter cell cycle thus leading to proliferation. | Find, read and cite all the research you . Mild to moderate autotomy, guarding, excessive licking, limping of the ipsilateral hind paw, and avoidance of placing weight on the injured side were noticed aer the procedure. Motor symptoms, which include any changes related to movement, are frequently present with mononeuropathies. soft tissue. The activity of SARM1 helps to explain the protective nature of the survival factor NMNAT2, as NMNAT enzymes have been shown to prevent SARM1-mediated depletion of NAD+. Those microglia that do transform, clear out the debris effectively. endstream endobj 386 0 obj <>/Metadata 13 0 R/PageLayout/OneColumn/Pages 383 0 R/StructTreeRoot 17 0 R/Type/Catalog>> endobj 387 0 obj <>/Font<>>>/Rotate 0/StructParents 0/Type/Page>> endobj 388 0 obj <>stream Epidemiology. Sensory symptoms of VIPN start in the fingertips and toes and often persist after discontinuation of vincristine (Boyette-Davis et al., 2013). However, immunodeficient animal models are regularly used in transplantation . This occurs by the 7th day when macrophages are signaled by the Schwann cells to clean up axonal and myelin debris. Open injuries with complete nerve transection are repaired based on the laceration type. 75 (4): 38-43. wherein a chronic central nervous system disorder is selected from Alzheimer's disease, Parkinson's disease, amyotrophic lateral sclerosis (ALS, Lou Gehrig's disease), multiple sc Transient detection of early wallerian degeneration on diffusion-weighted MRI after an acute cerebrovascular accident. 1989;172 (1): 179-82. Prior to degeneration, the distal section of the axon tends to remain electrically excitable. [48][49] One explanation for the protective effect of the WldS mutation is that the NMNAT1 region, which is normally localized to the soma, substitutes for the labile survival factor NMNAT2 to prevent SARM1 activation when the N-terminal Ube4 region of the WldS protein localizes it to the axon. The authors conclude that MR imaging provides a sensitive method of evaluating wallerian degeneration in the living human brain. When the regenerating axon reaches the end organ, the axon matures and becomes myelinated. The recruitment of macrophages helps improve the clearing rate of myelin debris. If a sprout reaches the tube, it grows into it and advances about 1mm per day, eventually reaching and reinnervating the target tissue. Delayed macrophage recruitment was observed in B-cell deficient mice lacking serum antibodies. Conclusions. . Get Top Tips Tuesday and The Latest Physiopedia updates, The content on or accessible through Physiopedia is for informational purposes only. [21] Grafts may also be needed to allow for appropriate reinnervation. Gaudet AD, PopovichPG &Ramer MS. Wallerian degeneration: Gaining perspective on inflammatory events after peripheral nerve injury.Journal of Neuroinflammation.2011 Available from. yet to be fully understood. However, the reinnervation is not necessarily perfect, as possible misleading occurs during reinnervation of the proximal axons to target cells. Another key aspect is the change in permeability of the blood-tissue barrier in the two systems. No matter which surgery, postoperative nerve repairs should be immobilized for 10 days to 6 weeks depending on the injury severity. Diffusiontensorimaging(DTI), a type of MR, can quantify axon density and myelin thickness. The primary cause for this could be the delay in clearing up myelin debris. 1. American Academy of Physical Medicine and Rehabilitation, Neurological recovery and neuromuscular physiology, Physiology, biomechanics, kinesiology, and analysis, Normal development and Models of learning and behavioral modification. [40], The Wallerian degeneration pathway has been further illuminated by the discovery that sterile alpha and TIR motif containing 1 (SARM1) protein plays a central role in the Wallerian degeneration pathway. It occurs between 7 to 21 days after the lesion occurs. Bamba R, Waitayawinyu T, Nookala R et al. Left column is proximal to the injury, right is distal. Forty-three patients with wallerian degeneration seen on MR images after cerebral infarction were studied. Subclavian steal syndrome is the medical term for a group of signs and symptoms that indicate retrograde blood flow in an artery. Within a nerve, each axon is surrounded by a layer of connective tissue . The axon then undergoes a degeneration process that can be anterograde or orthograde (Wallerian) [1] or retrograde. Degeneration usually proceeds proximally up one to several nodes of Ranvier. Wallerian degeneration is named after Augustus Volney Waller. Coleman MP, Conforti L, Buckmaster EA, Tarlton A, Ewing RM, Brown MC, Lyon MF, Perry VH (August 1998). Peripheral nerve repair with cultured schwann cells: getting closer to the clinics. De simone T, Regna-gladin C, Carriero MR et-al. This page was last edited on 30 January 2023, at 02:58. Anterograde volume loss after stroke can occur through either "wallerian" degeneration of the lesioned neurons or transsynaptic degeneration. [29][30] The gene mutation is an 85-kb tandem triplication, occurring naturally. In cases of cerebral infarction, Wallerian . CNS regeneration is much slower, and is almost absent in most vertebrate species. Also in the CNS, oligodendrocytes inhibit regeneration. Rosemont, IL 60018, PM&R KnowledgeNow. 2023 ICD-10-CM Range G00-G99. The effect of cooling on the rate of Wallerian degeneration. Myelin debris, present in CNS or PNS, contains several inhibitory factors. Wallerian Degeneration: Read more about Symptoms, Diagnosis, Treatment, Complications, Causes and Prognosis. A novel therapy to promote axonal fusion in human digital nerves. Entry was based on first occurrence of an isolated neurologic syndrome . US National Library of Medicine.National Institutes of Health.2015; 51(2): 268275. Fig 1. After injury, the axonal skeleton disintegrates, and the axonal membrane breaks apart. Peripheral nerve reconstruction after injury: a review of clinical and experimental therapies. endstream endobj startxref Innate-immunity is central to Wallerian degeneration since innate-immune cells, functions and . PDF | Background Elevated serum creatine kinase (CK) levels have been reported in patients with Guillain-Barr syndrome (GBS), more frequently in. Willand MP, Nguyen MA, Borschel GH, Gordon T. Electrical Stimulation to Promote Peripheral Nerve Regeneration. MeSH information . Neurapraxia is a disorder of the peripheral nervous system in which there is a temporary loss of motor and sensory function due to blockage of nerve conduction, usually lasting an average of six to eight weeks before full recovery. Axon degeneration is a prominent early feature of most neurodegenerative disorders and can also be induced directly by nerve injury in a process known as Wallerian degeneration. By using our website, you agree to our use of cookies. Rodrigues MC, Rodrigues AA, Jr., Glover LE, Voltarelli J, Borlongan CV. The rate of degradation is dependent on the type of injury and is also slower in the CNS than in the PNS. In the cord, Wallerian degeneration can occur both rostrally (involving the dorsal columns above the injury) and caudally (involving the lateral corticospinal tracts below the injury) 8. Perry, V. H., Lunn, E. R., Brown, M. C., Cahusac, S. and Gordon, S. (1990), Evidence that the Rate of Wallerian Degeneration is Controlled by a Single Autosomal Dominant Gene. This table lists general electrodiagnostic findings. We report a 54 year old male patient, referred to our hospital for sudden-onset left hemiparesis. The Wlds mutation is an autosomal-dominant mutation occurring in the mouse chromosome 4. MR imaging of Wallerian degeneration in the brainstem: temporal relationships. . 0 It is seen as a contiguous tract of gliosis leading from a region of cortical or subcortical neuronal injury towards the deep cerebral structures, along the expected topographical course of the involved white matter tract. However, their recruitment is slower in comparison to macrophage recruitment in PNS by approximately 3 days. It is noteworthy that these TAD-like lesions do not come with classic Wallerian-type axonal degeneration and evolve through a dose limiting manner [12,13,14]. Sensory symptoms often precede motor weakness. The fact that the enhanced survival of WldS axons is due to the slower turnover of WldS compared to NMNAT2 also helps explain why SARM1 knockout confers longer protection, as SARM1 will be completely inactive regardless of inhibitor activity whereas WldS will eventually be degraded. If the sprouts cannot reach the tube, for instance because the gap is too wide or scar tissue has formed, surgery can help to guide the sprouts into the tubes. Neuregulins are believed to be responsible for the rapid activation. The process takes roughly 24hours in the PNS, and longer in the CNS. They finally align in tubes (Bngner bands) and express surface molecules that guide regenerating fibers. The following code (s) above G31.9 contain annotation back-references that may be applicable to G31.9 : G00-G99. It may result following neuronal loss due to cerebral infarction, trauma, necrosis, focal demyelination, or hemorrhage. Open injuries with nerve in-continuity (epineurium intact), and all closed-injuries, initially are managed conservatively, with nerve function evaluation at 3 weeks via nerve conduction study and electromyography (NCS/EMG). In the first weeks to months, re-innervation by collaterals may result in polyphasic MUAPs and/or satellite potentials, while the slower axonal re-growth will eventually result in larger amplitude, longer duration potentials. Severity is classified by pathologic findings: neurapraxia, axonotmesis, and neurotmesis, also known as Seddon Classification. This type of degeneration is known as Wallerian degeneration and involves disintegration of the axoplasm and axolemma over the course of 1-12 weeks and degradation of the surrounding myelin. Sullivan R, Dailey T, Duncan K, Abel N, Borlongan CV. [6] The protective effect of the WldS protein has been shown to be due to the NMNAT1 region's NAD+ synthesizing active site. Schwann cells and endoneural fibroblasts in PNS. MRI demonstrating promise in both diagnosing and monitoring injury, especially in the surgical setting. Boyer RB, Kelm ND, Riley DC et al. Patients treated with vincristine predictably develop neuropathic symptoms and signs, the most prominent of which are distal-extremity paresthesias, sensory loss, . In addition, recovery of injury is highly dependent on the severity of injury. After this, full passive and active range of motion may be introduced for rehabilitation. Acute crush nerve injuries and traction injuries can be detected. Nerve entrapment syndromes (meaning a common group of signs and symptoms), occurs in individuals as a result of swelling of the surrounding tissues, or anatomical abnormalities. When refering to evidence in academic writing, you should always try to reference the primary (original) source. This will produce a situation called Wallerian Degeneration. European Journal of Neuroscience, 2: 408-413. glial cell line-derived neurotrophic factor, nicotinamide mononucleotide adenylyltransferase 1, Connective tissue in the peripheral nervous system, "Wallerian degeneration, wld(s), and nmnat", "Endogenous Nmnat2 is an essential survival factor for maintenance of healthy axons", "NMNAT: It's an NAD + Synthase It's a Chaperone It's a Neuroprotector", Current Opinion in Genetics & Development, "Experiments on the Section of the Glossopharyngeal and Hypoglossal Nerves of the Frog, and Observations of the Alterations Produced Thereby in the Structure of Their Primitive Fibres", "An 85-kb tandem triplication in the slow Wallerian degeneration (Wlds) mouse", "Nerve injury, axonal degeneration and neural regeneration: basic insights", "Endocytotic formation of vesicles and other membranous structures induced by Ca2+ and axolemmal injury", "Axon degeneration: molecular mechanisms of a self-destruction pathway", "Multiple forms of Ca-activated protease from rat brain and muscle", "Microanatomy of axon/glial signaling during Wallerian degeneration", "Complement depletion reduces macrophage infiltration and ctivation during Wallerian degeneration and axonal regeneration", "Degeneration of myelinated efferent fibers prompts mitosis in Remak Schwann cells of uninjured C-fiber afferents", "Delayed macrophage responses and myelin clearance during Wallerian degeneration in the central nervous system: the dorsal radiculotomy model", "Changes of nerve growth factor synthesis in nonneuronal cells in response to sciatic nerve transection", "Interleukin 1 increases stability and transcription of mRNA encoding nerve growth factor in cultured rat fibroblasts", "Ninjurin, a novel adhesion molecule, is induced by nerve injury and promotes axonal growth", https://doi.org/10.1111/j.1460-9568.1990.tb00433.x, "A gene affecting Wallerian nerve degeneration maps distally on mouse chromosome 4", "Non-nuclear Wld(S) determines its neuroprotective efficacy for axons and synapses in vivo", "A local mechanism mediates NAD-dependent protection of axon degeneration", "NAD(+) and axon degeneration revisited: Nmnat1 cannot substitute for Wld(S) to delay Wallerian degeneration", "Targeting NMNAT1 to axons and synapses transforms its neuroprotective potency in vivo", 10.1002/(SICI)1096-9861(19960729)371:3<469::AID-CNE9>3.0.CO;2-0, "dSarm/Sarm1 is required for activation of an injury-induced axon death pathway", "Sarm1-mediated axon degeneration requires both SAM and TIR interactions", "Resolving the topological enigma in Ca 2+ signaling by cyclic ADP-ribose and NAADP", "SARM1 activation triggers axon degeneration locally via NAD destruction", "+ Cleavage Activity that Promotes Pathological Axonal Degeneration", "S, Confers Lifelong Rescue in a Mouse Model of Severe Axonopathy", "Pathological axonal death through a MAPK cascade that triggers a local energy deficit", "MAPK signaling promotes axonal degeneration by speeding the turnover of the axonal maintenance factor NMNAT2", "Attenuated traumatic axonal injury and improved functional outcome after traumatic brain injury in mice lacking Sarm1", https://en.wikipedia.org/w/index.php?title=Wallerian_degeneration&oldid=1136392406. hmk6^`=K Iz Medical & Exercise Physiology School.Wallerian degeneration/ regeneration process of nerve fiber/axon cut and progressive response. According to the FA AH/UH, patients were also classified into groups with minimal or extensive Wallerian degeneration (WD). EMG can demonstrate reinnervation via collateral sprouting and axonal regrowth. Wallerian degeneration ensues. DTI was used to monitor the time course of Wallerian degeneration of the . Available from. [26] Schwann cells upregulate the production of cell surface adhesion molecule ninjurin further promoting growth. Schwann cells continue to clear up the myelin debris by degrading their own myelin, phagocytose extracellular myelin and attract macrophages to myelin debris for further phagocytosis. Sunderland grades 1-3 are treated with conservative measures while grades 4-5 usually require surgical repair. [27] These lines of cell guide the axon regeneration in proper direction. We therefore asked whether genetic deletion of SARM1 also protects from myelinated axon loss in the toes. [39] However, once the axonal degradation has begun, degeneration takes its normal course, and, respective of the nervous system, degradation follows at the above-described rates. 4.7-T diffusion tensor imaging of acute traumatic peripheral nerve injury. Uchino A, Sawada A, Takase Y et-al. For example, bilateral cerebral infarction can produce atrophy of the intervening corpus callosum due to Wallerian degeneration of the commissural fibers. The term "Wallerian degeneration" is best reserved to describe axonopathy in peripheral nerve; however, similar changes can be seen in spinal cord and brain. Wallerian degeneration is an active process of retrograde degeneration of the distal end of an axon that is a result of a nerve lesion. 2. Generally, the axon re-grows at the rate of 1 mm/day (i.e. These include: Select ALL that apply. Schwann cell activation should therefore be delayed, as they would not detect axonal degradation signals from ErbB2 receptors. [11] Apart from growth factors, Schwann cells also provide structural guidance to further enhance regeneration. It occurs in the section of the axon distal to the site of injury and usually begins within 2436hours of a lesion. 5-7 In either case, the volume loss does not become visible until at least several months poststroke. Axonal degeneration is followed by degradation of the myelin sheath and infiltration by macrophages. The mutated region contains two associated genes: nicotinamide mononucleotide adenylyltransferase 1 (NMNAT1) and ubiquitination factor e4b (UBE4B). major peripheral nerve injury sustained in 2% of patients with extremity trauma. The time period of response is estimated to be prior to the onset of axonal degeneration. Presentations of nerve damage may include: Depends on various criteria including pain and psychosocial skills but could include: Wallerian Degeneration can instigate a nerve repair mechanism. Requires an intact endoneurial tube to re-establish continuity between the cell body and the distal terminal nerve segment. approximately one inch per month), but individual nerves may have different speeds (ulnar, 1.5 mm/day; median, 2-4.5 mm/day; and radial, 4-5 mm/day). One study found that during a surgical repair of a sharp, complete resection, the application of PEG for 2 minutes after surgical connection of the injured ends, helps to decrease inappropriate calcium-mediated vesicle formation, promote fusion, enhance axonal continuity with nerve healing, and improve sensory recovery, based on static two-point discrimination. Wallerian degeneration is an active process of retrograde degeneration of the distal end of an axon that is a result of a nerve lesion. Degeneration usually proceeds proximally up one to several nodes of Ranvier. Wallerian degeneration (the clearing process of the distal stump), axonal regeneration, and end-organ reinnervation. Begins within hours of injury and takes months to years to complete. The type of surgery can be guided by the size of the gap of injury: Autologous graft to provide a conduit for axonal regrowth. [32][33] The protection provided by the WldS protein is intrinsic to the neurons and not surrounding support cells, and is only locally protective of the axon, indicating an intracellular pathway is responsible for mediating Wallerian degeneration. No change in signal characteristics was seen with time (six cases) or following contrast material administration (two cases). In most cases Physiopedia articles are a secondary source and so should not be used as references. For instance, the less severe injuries (i.e. 8@ .QqB[@Up20i_V, i" i. While Alzheimer's disease (AD) is the most common neurodegenerative disease that causes it, more than 50 "Experiments on the section of the glossopharyngeal and hypoglossal nerves of the frog, and observations of the alterations produced thereby in the structure of their primitive fibres." Wallerian degeneration is the simplest and most thoroughly studied model of axonal degeneration. Bassilios HS, Bond G, Jing XL, Kostopoulos E, Wallace RD, Konofaos P. The Surgical Management of Nerve Gaps: Present and Future. Patients with more extensive WD had poorer grip strength, dexterity, and range of movement. Time: provider may be able to have study done sooner if a timely EMG isdifficultto obtain. 16 (1): 125-33. Wallerian degeneration. In neurapraxia, diminished muscle strength and/or sensation develop acutely, but because of axon continuity, nerve conduction of the distal segment remains intact regardless of the length of time following injury. In many . Sequential electrodiagnostic examinations may help predict recovery: As noted above, reinnervation by collaterals may result in polyphasic MUAPs and/or satellite potentials, while the slower axonal re-growth will eventually result in larger amplitude, longer duration potentials. . In the three decades since the discovery of the Wallerian degeneration slow (WldS) mouse, research has generated . Reference article, Radiopaedia.org (Accessed on 04 Mar 2023) https://doi.org/10.53347/rID-18998, {"containerId":"expandableQuestionsContainer","displayRelatedArticles":true,"displayNextQuestion":true,"displaySkipQuestion":true,"articleId":18998,"questionManager":null,"mcqUrl":"https://radiopaedia.org/articles/wallerian-degeneration/questions/1308?lang=us"}, View Maxime St-Amant's current disclosures, see full revision history and disclosures, stage 1: degeneration of the axons and myelin sheaths with mild chemical changes (0-4 weeks), stage 2: rapid destruction of myelin protein fragments that were already degenerated, lipids remain intact (4-14 weeks), stage 4: atrophy of the white matter tracts (months to years), brainstem atrophy with or without hypointensity. MAPK signaling has been shown to promote the loss of NMNAT2, thereby promoting SARM1 activation, although SARM1 activation also triggers the MAP kinase cascade, indicating some form of feedback loop exists. If gliosis and Wallerian degeneration are present . Endoplasmic reticulum degrades and mitochondria swell up and eventually disintegrate. When an axon is transected (axected), it causes the Wallerian degeneration. Oligodendrocytes fail to recruit macrophages for debris removal. If any of your symptoms worsen or change after your physical exam, it is important to follow-up with your health care provider. The typical example is Wallerian degeneration (WD), which results from traumatic or ischemic injuries that disconnect the neuronal cell body from the distal segment of the axon. However, if the injury is at the end of the axon, at a growth of 1mm per day, the distal segment undergoes granular disintegration over several days to weeks and cytoplasmic elements begin to accumulate.[3]. All agents have been tested only in cell-culture or animal models. QUESTION 1. In cases of cerebral infarction, Wallerian degeneration appears in the chronic phase (>30 days). This condition has two main causes: 1) degenerative diseases affecting nerve cells, such as Friedreich's disease, and 2) traumatic injury to the peripheral nerves. Given that proteasome in- portant for the DNA damage response, and Axonal degeneration (termed Wallerian hibitors block Wallerian degeneration both degeneration) often precedes the death of in vitro and in vivo (5), the Ufd2a protein neuronal cell bodies in neurodegenerative fragment (a component of the ubiquitin A. Bedalov is in the Clinical . Various possibilities have been studied to improve/accelerate nerve repair/regeneration via neuronal-death reduction and axonal-growth enhancement. 398 0 obj <>/Filter/FlateDecode/ID[<54E57DDCE89C43429F18A19BD223772B><90A4F5B4A330934DA644DDE1010DB79E>]/Index[385 24]/Info 384 0 R/Length 72/Prev 35308/Root 386 0 R/Size 409/Type/XRef/W[1 2 1]>>stream Myelin clearance is the next step in Wallerian degeneration following axonal degeneration. Affected axons may . Treatment can involve observation, repair, tendon transfers or nerve grafting depending on the acuity, degree of injury, and mechanism of injury. Y]GnC.m{Zu[X'.a~>-. (2010) Polish journal of radiology. Physiopedia articles are best used to find the original sources of information (see the references list at the bottom of the article). Peripheral nerve injury results in orchestrated changes similar to the Wallerian degeneration leading to structural and functional alterations which affect the whole peripheral nervous system including peripheral nerve endings, afferent fibers, dorsal root ganglion (DRG) and also central afferent terminals in the spinal cord (Austin et al., 2012). Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. Reinnervated fibers have been shown to fatigue earlier compared to non-injured fibers, especially during isometric repetitive actions. 5. The macrophages, accompanied by Schwann cells, serve to clear the debris from the degeneration.[5][6]. The type of symptoms to manifest largely rely upon the area of the brain affected and the functions for which the affected region of the brain is responsible. [ 1, 2] The term brachial may be a misnomer, as electrodiagnostic and radiologic evidence often . It occurs between 7 to 21 days after the lesion occurs. [45] The SARM1 protein has four domains, a mitochondrial localization signal, an auto-inhibitory N-terminus region consisting of armadillo/HEAT motifs, two sterile alpha motifs responsible for multimerization, and a C-terminus Toll/Interleukin-1 receptor that possesses enzymatic activity. Although most injury responses include a calcium influx signaling to promote resealing of severed parts, axonal injuries initially lead to acute axonal degeneration (AAD), which is rapid separation of the proximal (the part nearer the cell body) and distal ends within 30 minutes of injury. Open injuries with sharp laceration are managed with immediate repair within 3-7 days. Practice Essentials. 2001; Rotshenker 2007)] could all be factors affecting the visual white matter depending on . Wallerian degeneration is an active process of degeneration that results when a nerve fiber is cut or crushed and the part of the axon distal to the injury (which in most cases is farther from the neuron's cell body) degenerates. , autoimmune disease) or localized damage (e.g., trauma, compression, tumors) and manifest with neurological deficits distal to the level of the lesion. Macrophage entry in general into CNS site of injury is very slow. PERIPHERAL NEUROPATHIES Caused by injury to peripheral axons Classification: generalized symmetrical polyneuropathies, generalized neuropathies and focal or multifocal neuropathies Pathophysiology Wallerian generation - traumatic injury leading to severed nerve. Visalli C, Cavallaro M, Concerto A et al. After the 21st day, acute nerve degeneration will show on the electromyograph. The degenerating axons formed droplets that could be stained, thus allowing for studies of the course of individual nerve fibres. Ultrasonography of traumatic injuries to limb peripheral nerves: technical aspects and spectrum of features. Question: QUESTION 1 Carpal tunnel and tarsal tunnel syndrome cause nerve degeneration resulting in specific symptoms and changes in the nerves. Peripheral neurological recovery and regeneration. Becerra JL, Puckett WR, Hiester ED, Quencer RM, Marcillo AE, Post MJ, Bunge RP.
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