Introduction:
Until the late eighteenth century it was believed that the nerves do not regenerate. Throughout the nineteenth century, the debate about regeneration, where Waller defended the fact that after a section of a nerve axons in the proximal segment were connected to the cell body and therefore remained viable, and distal segments degeneraban.1

The technical principles of surgical repair of peripheral nerves, are based on observations of Waller (1851) in respect of the regeneration of the distal end of the projections (Sprouting) axoplasm from the proximal end of sectioned nerves (Terzis, 1979). 2

Since Saliceto William (1210-1277) made the first neurorrhaphy in Poland, in 1977 Daniel and Terzis used microsurgery to attach the ends of severed nerves in various ways (epineural, perineural, interfacicular all, so the term - terminal ) .2

At present up to 1cm nerve regeneration is a reality techniques using biosynthetic materials, biodegradable as collagen mesh-polyglycolic acid, poly-3-hydroxybutyrate (PHB) .3 and the latest in technology, the use of stem cells ( stem cell) of ectodermal (hair follicle), as pioneers in cellular engineering, UEA Japan, Taiwan, France, Brazil, where they run every day new scientific research projects.

History of the End-to-side neurorrhaphy:
The accounts of the termino-lateral neurorrhaphy (NTL) began in the nineteenth century.

In 1876 Depres, story the repair of the median nerve through the distal insertion of the lateral nerve ulnar.3

In 1889 Kennedy story, the treatment of a patient with facial spasm through end-to-side neurorrhaphy, the author performed the facial nerve section and the distal end joined to the lateral aspect of the hypoglossal nerve. This case was published in 1.901.3

In 1895 Ballance also repair facial nerve suturing the distal end after being severed to the lateral accessory nerve palsy treatment facial.3, 4

In 1903 Harris & Low repair an injury to the upper trunk of the brachial plexus through the rehabilitation of injured nerve distal lateral face of the seventh root cervical.3

Several authors used the termino-lateral neurorrhaphy getting good and bad results, for this procedure performed incision in the donor nerve, the epineurium just to keep safe on the opposite side to the neurorrhaphy (Sherr 1906) Figure 1.

 

Figure 1: Diagram of the lateral neurorrhaphy term used in the years 1876 -1927

 

The results were not encouraging neurorrhaphy is leading to Babcock in 1927 to contraindicate its use, due to poor results, due to the large opening in the epineurium of the donor nerve, which caused significant damage to structures is innervated according to the description in 1.906.3,5 Sherrem

This determination led to the abandonment of this technique for several decades until it was revived by Dr. Fausto Viterbo in 1992 in his doctoral thesis known as latero-terminal neurorrhaphy experimental study in mice, developed at the University Estadual Paulista, Botucatu (UNESP) - Brazil 2

Materials and Methods:
Mice were used 40 Wistar, male, weighing between 225-280gramos rough, raised in the Central Vivarium Universidade Estadual Paulista (UNESP) Botucatu campus.
The animals were divided into 3 groups with 20 mice in group A, group B-C with 10 animals each.

Results:
In this first work, Viterbo did not remove the epineurium of the nerve that was obtained with a termino-lateral neurorrhaphy pure. Chart 2.3 axons grow laterally which guarantees maintain tropism muscular.6

 

Graph 2: Diagram of the lateral end neurorrhaphy pure (NTL) used by Viterbo. Figure 3: Diagram of the (NTL) after 6 months showed growth of nerve axons from the donor to the distal end, published by Viterbo in 1992.

 

The animals in group A, showed the fibular nerve sectioned and sutured laterally to the distal tibial nerve without removal of epineuro6 intact, Figure 4.

 

Gráfico4: fibular nerve section, and the distal end is sutured with NTL in the lateral tibial nerve.

 

The test morphological and electrophysiological observations were verified by the presence of regenerated myelinated fibers in most animals.

In other work, using the same experimental model plus the removal of segment-8 Graphic perineuro.7. 5.6

 

Figure 5: Schematic of termino-lateral neurorrhaphy (NTL) with minimal removal of the epineurium, used by Viterbo. Figure 6: Schematic of the (NTL) after 6 months showed growth of nerve axons from the donor to the distal end, published by Viterbo in 1994.

 

Another difference found, both morphologically and electrophysiologically, was the growth of donor nerve axons to the distal fibular nerve, not donor nerve injury present in its territory of innervation, thus becoming, any potential nerve donor nerve. The discovery deep doubts, due to the limited knowledge at that time, the axons could never cross the membranes of tissue involved, namely: endoneurium, perineurium, epineurium. Meanwhile various experimental changed these resistances. Photos 6-8: 6.2.

DISCUSSION:
In the published works of Viterbo, in the NTL without removal and removal of the epineurium were similar in their results, ie found no statistical difference in the size and number of axons, and therefore the removal of the epineurium or not does not imply in the transmission of healthy nerve axons toward the distal end. 2-15.

The indication of the end-to-side neurorrhaphy, occurs when the proximal end of the injured nerve is not available for carrying out the traditional repair-terminal terminal and can use multiple grafts without affecting healthy nerve function.

The author uses this type of neurorrhaphy without removal of the epineurium in all 16,17,18,19,28,29,30 microsurgery.

CONCLUSIONS:
1 .- In this comparative study, Viterbo, carried to term-lateral neurorrhaphy with or without removal of the epi-perineurium. 6-8
2.-The histological results 6 months after surgery, by slitting the site of termino-lateral neurorrhaphy, and nerve cross-receptor, were found lateral sprouting epineurium and perineurium disappearance of the suture site in both groups. Photo 2.6.
3.-They found no differences in morphological and electrophysiological characteristics in the groups studied. 2
4 .- The term-side neurorrhaphy is functional electrical stimulation leads, allows the passage of axons to regenerate the nerve sutured laterally and keeps trophism of muscle. Photo: 7,8,9.
5 .- The presence of the epineurium does not prevent axonal regeneration, or the passage of electrical stimulation. 2-15
6.-These results demonstrate the effectiveness of this type of neurorrhaphy in the recovery of nerve injury when only provides end-distal reinnervation may be obtained from this end (distal) at the expense of compromising functionally integrates nerve.

Clinical Applications:
This technique is being used by Viterbo from año1.993 in the treatment of peripheral nerve disorders like facial paralysis with excellent results, as in paraplegic patients as treatment of pressure ulcers, restoring sensitivity to soft tissue, another applications such as direct muscle neurotization (mioneurotización), which involves implanting one end of the nerve or nerve segment between a paralyzed muscle fibers, being shown to restore muscle function only when the trauma or injury leads to loss of neuromuscular function (Becker et al, 2002) this technique provides good results in brachial plexus injuries. 16-30.

Another application would be looking for penis amputees who performed phalloplasty. This technique opens the possibility of placing a nerve graft at the neo-glans with the hope of restoring sensitivity.

It could also be used in patients with urinary incontinence. This technique would be based on placing a nerve graft at the level of the bladder in order to return the voluntary act of urination.

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