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Recovery early after surgery is needed to confirm it. The article expands nerve injury classification, introduces Sunderland Zero/ischemic neurapraxia, and proposes a Nerve Injury Calculator to estimate axonal loss, demyelination, and ischemic injury and to guide prognosis timing via three 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postoperative recovery used for confirmation.",{"name":70,"@type":61,"acceptedAnswer":71},"What is the Nerve Injury Calculator (NIC) used for?",{"text":72,"@type":64},"The NIC estimates the percent of axonal loss, demyelinating loss, and ischemic axons to predict both timing and quality of recovery, and its clinical utility is demonstrated through three cases.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},434483,1790794521,{"code":4,"msg":82,"data":83},"success",[84,88,92,96,101,106,109,114,119,122,126],{"id":22,"doc_module":4,"doc_module_name":25,"category_name":85,"show_sort_weight":86,"slug":87},"Story & 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[homepage:](homepage: www.elsevier.com/locate/jpra)[ www.elsevier.com/locate/jpra](homepage: www.elsevier.com/locate/jpra)  \nOriginal Article  \nSurgeons, physiatrists and neurologists speaking“EDX and nerve surgery”: A paradigm shift for nerve injured patients  \nDeng Pana,\\#, Aneri U. Patel a,\\#, J. Megan Patterson b,  \nAnna Rose Johnsona, Travis Gordon a, Susan E. Mackinnona,∗ a Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, 660 S. Euclid Ave, St. Louis, MO, USA  \nb Department of Orthopedic Surgery, University of North Carolina, Chapel Hill, 102 Mason Farm Road, NC, USA  \na r t i c l e i n f o  \nArticle history:  \nReceived 14 October 2025  \nAccepted 2 November 2025  \nAvailable online 12 November 2025  \nKeywords: nerve surgery  \nnerve injury classification  \nEDX studies Sunderland Zero nerve recovery  \na b s t r a c t  \nSurgeons’ ability to interpret electrodiagnostic (EDX) studies has greatly enhanced patient selection and outcome for nerve surgeries as it has informed our understanding of the classification of nerve injury. EDX measures axons present, lost, or demyelinated. It does not measure an area where axons experience chronic ischemia, making a Sunderland Zero nerve injury a clinical diagnosis that should be suspected when patients have normal EDX, decreased recruitment on electromyography (EMG), and no atrophy. Only observation of recovery in the earliest postoperative period would confirm a Sunderland Zero. In this article, we present an expanded classification of nerve injury, highlighting Sunderland Zero or ischemic neurapraxia, and provide a historical and pathophysiological overview of how it came to be recognized. We also offer a user-friendly classification and an equation we call the Nerve Injury Calculator (NIC) that calculates the percent axonal loss, demyelinating loss, and ischemic axons to predict timing and quality of recovery. The clinical utility of the NIC is exemplified with three cases. With the development and introduction of the NIC, there is  \n∗ Corresponding author.  \n\\# Deng Pan and Aneri U. Patel are co-first authors and contributed equally to this work.  \n[https://doi.org/10.1016/j.jpra.2025.11.004](https://doi.org/10.1016/j.jpra.2025.11.004)  \n2352-5878/Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. This isan open access article under the CC BY-NC-ND license ([http://creativecommons.org/licenses/by-nc-nd/4.0/](http://creativecommons.org/licenses/by-nc-nd/4.0/))  \nD. Pan, A. U. Patel, J.M. Patterson et al. JPRAS Open 47 (2025) 3–20  \na paradigm shift amongst surgeons, physiatrists, and neurologists that allows us all to speak the same language of EDX and nerve surgery, enabling improved patient education, prediction of prognosis and timing of recovery, and efficient follow up with respect to patients’ postoperative period.  \nPublished by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. This is an open access article under the CC BY-NC-ND license  \n([http://creativecommons.org/licenses/by-nc-nd/4.0/](http://creativecommons.org/licenses/by-nc-nd/4.0/))  \nIntroduction  \nIndications for nerve surgery expand as new innovations drive new techniques. Management strategies have progressed significantly due to a combination of a new awareness of neural fascicular anatomy, basic science research, and clinical experience. By bringing axons closer to their targets nerve transfers have increased the likelihood of functional recovery as the most important factor influencing recovery has been identified as the time to reinnervation of the distal motor end plate and sensory receptors.1 However, appropriate patient selection remains critical for the success of all nerve surgeries. In recent years, there has been increased awareness on the importance of sur","cbCaidFQt0TSsXBa","https://ap.wps.com/l/cbCaidFQt0TSsXBa","pdf",4992743,18,"English","# Introduction\n# Seddon and Sunderland’s original classification system\n## Expanded classification emphasizing Sunderland Zero or ischemic neurapraxia\n## Nerve Injury Calculator (NIC) and user-friendly tools","[{\"question\":\"Why is EDX interpretation central to nerve surgery outcomes?\",\"answer\":\"EDX interpretation helps surgeons select appropriate patients and better predict the degree and pattern of injury, recovery likelihood, and timing, which also supports choosing suitable surgical options and improving outcomes.\"},{\"question\":\"What makes Sunderland Zero different from other nerve injuries on EDX?\",\"answer\":\"Sunderland Zero is associated with chronic ischemia that EDX cannot directly measure, so it is suspected clinically using normal EDX, decreased EMG recruitment, and no atrophy, with early postoperative recovery used for confirmation.\"},{\"question\":\"What is the Nerve Injury Calculator (NIC) used for?\",\"answer\":\"The NIC estimates the percent of axonal loss, demyelinating loss, and ischemic axons to predict both timing and quality of recovery, and its clinical utility is demonstrated through three cases.\"}]","Surgeons, physiatrists and neurologists speaking“EDX and nerve surgery”: A paradigm shift for nerve injured patients | PDF",1790669498,45]