¿Cuál es el mejor momento para intervenir quirúrgicamente una lesión nerviosa traumática primaria? Revisión basada en fisiopatología, clínica y evidencia quirúrgica

Abstract

Introduction: Primary traumatic nerve injuries are a common and disabling consequence of trauma. While the peripheral nervous system retains a notable capacity for regeneration, this process is highly time-dependent. The timing of surgical intervention is a decisive factor in optimizing functional recovery. This narrative review synthesizes current pathophysiological, clinical, and surgical evidence to define the optimal window for nerve repair. Methods: A structured narrative review was conducted, focusing on clinical studies with Level I-II evidence, international consensus statements, and modern surgical textbooks published between 2000 and 2025. Current guidelines from leading scientific societies were included, alongside updated insights into the regenerative microenvironment following nerve injury. Results: There is broad physiological consensus that effective axonal regeneration requires timely surgical repair within a narrow biological window. Key limiting factors include Wallerian degeneration, loss of the Schwann cell reparative phenotype, and Progressive muscle atrophy- together forming a critical regenerative clock. Clinically, repairs performed within the first 3-7 days post-injury yield the best functional outcomes, particularly in open neurotmesis. In closed or uncertain lesions, a 2-4 week delay allows for electrodiagnostic evaluation prior to surgical indication. Beyond 3-6 months, motor recovery potential significantly declines, and nerve transfers may be necessary. Time tolerance varies by nerve type: the facial nerve and brachial plexus demand ultra-early intervention, while sensory nerves exhibit a relatively broader therapeutic window. Conclusión: The optimal surgical timing in primary traumatic nerve injuries must align with the biological principles of peripheral nerve regeneration and the specific characteristics of each nerve. Early repair within the critical regenerative window maximizes functional recovery and minimizes irreversible sequelae. Surgical decision-making should be individualized, integrating injury classification, clinical evolution, available resources, and surgeon expertise.