Nerve Surgeons Research Articles

Intraneural Topography and Branching Patterns of the Common Peroneal Nerve: Studying the Feasibility of Distal Nerve Transfers.

Common peroneal nerve (CPN) disruption is the most common lower extremity nerve injury and results in gait disturbances and sensory paresthesias. The goal of this study is to describe branching patterns and the intraneural topography of the CPN to facilitate operative planning in CPN reconstruction. The CPN and its distal motor and sensory branches were dissected in 6 lower leg cadavers. Branching patterns and distances were recorded with the fibular head as the landmark. Histological review of the nerve cross sections helped characterize the intraneural topography within the fibular tunnel. The CPN distal branching patterns were highly variable. The tibialis anterior motor branch was found on average 9.6 cm distal to the fibular head. Despite the variable branching patterns, the fascicular topography of the CPN within the fibular tunnel was consistent. Proximal to the tunnel, the nerve has 3 major fascicles, which include the superficial peroneal motor, common sensory, and deep peroneal motor (DPN) fascicles from lateral to medial. Within the tunnel, the topography consolidates into the superficial peroneal motor and DPN major divisions-motor axons anteriorly and sensory axons posteriorly. The data presented provide clinically relevant information for the peripheral nerve surgeon where fascicular reconstruction of the nerve and neurolysis should focus on the anterior half of the nerve to restore ankle dorsiflexion. The nerve proximally is divided into 3 major fascicles compared with 2 distally. Surgeons may consider distal nerve transfers from the tibial nerve motor branches to the DPN or tibialis anterior motor branch.

Surgical treatment delay in patients with headache disorders and neuralgia correlates with poor postoperative outcome

Although nerve decompression surgery has proven to be effective in reducing symptoms in patients with head and neck neuralgia and headache disorders, it is currently not part of the treatment algorithms for headache disorders. Therefore, patients wait an average of 20 years from the onset of symptoms to surgery, resulting in high conservative treatment costs ($989,275.65 per patient) and patient morbidity. This study evaluated the clinical impact of treatment delays on surgical outcomes. Overall, 282 patients who underwent nerve decompression surgery at Weill Cornell Medicine and Massachusetts General Hospital between September 2012 and January 2024 were enrolled. Information regarding demographics, onset of symptoms, and headache characteristics was collected using patient surveys. The treatment outcome was evaluated by the percentage of symptom reduction in terms of frequency, duration, and pain intensity. An area under the receiver operating characteristic analysis was performed to determine the optimal timepoint to undergo surgery. Postoperative symptom reduction and time between the onset of symptoms and surgery were negatively correlated (r=-0.22; p<0.001). The most significant difference in outcome was found at 2.9 years from symptom onset; patients who underwent surgery before this timepoint reported an average improvement of 79±23% versus 67±35% in those who were treated after the timepoint (p=0.021). Our results indicate that delays in undergoing nerve decompression surgery beyond 2.9 years from symptom onset leads to less favorable postoperative outcomes, underscoring the need for timely referral to peripheral nerve surgeons when conservative management fails. Nonetheless, even with delays in surgical intervention, patients continued to experience significant symptom reduction.

Optimal Technique for Cutting Peripheral Nerves in Nerve Transfer Surgery: A Survey of Peripheral Nerve Surgeons.

Nerve transfer procedures are performed in patients with proximal nerve injuries to optimize their potential for functional recovery. The study aimed to determine the preferred surgical technique and tool used by peripheral nerve surgeons to transect nerves in nerve transfers. All current members of the American Society of Peripheral Nerve were invited to complete a cross-sectional 10-question survey. Data on practice demographics, nerve-cutting instruments/techniques used, and their belief on whether this impacted patient outcomes were collected. A total of 49 American Society of Peripheral Nerve members participated in the study, the majority of whom were over 10 years into practice (n = 30/49; 61%). The most common response was a scalpel blade (n = 26/49; 53%), with the remaining 47% using iris scissors, micro-serrated scissors, a razor blade, specialized nerve microscissors, or a specialized nerve-cutting device. The number of years in practice (P = 0.0271) and the percentage of practice that involves treating patients with peripheral nerve injuries (P = 0.0054) is significantly associated with the belief that crushing the donor nerves during transection may result in worse outcomes following nerve transfer. Only the latter is significantly associated with this belief in recipient nerves (P = 0.0214). Our findings demonstrate that peripheral nerve surgeons believe that the technique used to transect nerves before coaptation influences outcomes after nerve transfer. Further ex vivo studies are necessary to investigate how different cutting techniques influence nerve morphology and scarring at the coaptation site to optimize outcomes after peripheral nerve surgery.

Upper Extremity Ballistic Nerve Injury

» Gunshot injuries to the upper extremity (UE) have high likelihood for causing peripheral nerve injury secondary to the high density of vital structures. Roughly one-fourth of patients sustaining a gunshot wound (GSW) to the UE incur a nerve injury. Of these nerve injuries, just over half are neurapraxic. In cases of surgical exploration of UE nerve injuries, nearly one-third demonstrate a transected or discontinuous nerve.» Existing literature regarding surgical management of nerve injuries secondary to GSWs comes from both military and civilian injuries. Outcomes are inconsistently reported, and indications are heterogeneous; however, reasonable results can be obtained with nerve reconstruction.» Our proposed management algorithm hinges on 4 treatment questions: if there is a nerve deficit present on examination, if there is a concomitant injury in the extremity (i.e., fracture or vascular insult), whether the injured nerve would be in the operative field of the concomitant injury, and whether there was an identified nerve lesion encountered at the time of surgery by another surgeon?» Early exploration rather than continued expectant management may offer improved recovery from GSW nerve injuries in particular situations. When an UE nerve deficit is present, establishing follow-up after the initial GSW encounter and early referral to a peripheral nerve surgeon are pivotal.

Upper Extremity Nerve Transfers for Treatment of Nerve Injury After Cervical Spine Surgery: A Single-Center Retrospective Review.

Nerve transfers to restore or augment function after spinal cord injury is an expanding field. There is a paucity of information, however, on the use of nerve transfers for patients having undergone spine surgery. The incidence of neurologic deficit after spine surgery is rare but extremely debilitating. The purpose of this study was to describe the functional benefit after upper extremity nerve transfers in the setting of nerve injury after cervical spine surgery. A single-center retrospective review of all patients who underwent nerve transfers after cervical spine surgery was completed. Patient demographics, injury features, spine surgery procedure, nerve conduction and electromyography study results, time to referral to nerve surgeon, time to surgery, surgical technique and number of nerve transfers performed, complications, postoperative muscle testing, and subjective outcomes were reviewed. Fourteen nerve transfers were performed in 6 patients after cervical spine surgery. Nerve transfer procedures consisted of a transfer between a median nerve branch of flexor digitorum superficialis into a biceps nerve branch, an ulnar nerve branch of flexor carpi ulnaris into a brachialis nerve branch, a radial nerve branch of triceps muscle into the axillary nerve, and the anterior interosseous nerve into the ulnar motor nerve. Average patient age was 55 years; all patients were male and underwent surgery on their left upper extremity. Average referral time was 7 months, average time to nerve transfer was 9 months, and average follow-up was 21 months. Average preoperative muscle grading was 0.9 of 5, and average postoperative muscle grading was 4.1 of 5 ( P < 0.00001). Upper extremity peripheral nerve transfers can significantly help patients regain muscle function from deficits secondary to cervical spine procedures. The morbidity of the nerve transfers is minimal with measurable improvements in muscle function.

Current perspectives on peripheral nerve repair and management of the nerve gap.

From the first surgical repair of a nerve in the 6th century, progress in the field of peripheral nerve surgery has marched on; at first slowly but today at great pace. Whether performing primary neurorrhaphy or managing multiple large nerve defects, the modern nerve surgeon has an extensive range of tools, techniques and choices available to them. Continuous innovation in surgical equipment and technique has enabled the maturation of autografting as a gold standard for reconstruction and welcomed the era of nerve transfer techniques all while bioengineers have continued to add to our armamentarium with implantable devices, such as conduits and acellular allografts. We provide the reader a concise and up-to-date summary of the techniques available to them, and the evidence base for their use when managing nerve transection including current use and applicability of nerve transfer procedures.

Which Tests Should Be Routinely Ordered Prior to Brachial Plexus Reconstruction? Results of a Delphi Panel

Background: There are notable differences in how adult patients with traumatic brachial plexus injuries (BPI) are evaluated and treated. Purpose: To better understand existing philosophies, we used the Delphi method to measure and foster consensus on routine use of electrodiagnostic testing, ultrasound, magnetic resonance imaging (MRI), and computed tomography (CT) myelograms prior to surgery. Panelists were 10 peripheral nerve surgeons board certified in their respective specialties at 5 academic medical centers in the United States. Methods: We presented 2 cases (1 complete/pan-BPI and 1 upper trunk BPI) to panelists and asked how often they would order the following preoperative diagnostic tests: electrodiagnostic studies; ultrasound of the brachial plexus; MRI of the brachial plexus; CT myelogram. Our Delphi process included an initial survey with videoconference discussion after the first round. A second survey/videoconference round was conducted to further probe the items that did not reach consensus during the first round. Results: Among the 10 surgeons, there was consensus that prior to brachial plexus surgery electrodiagnostic studies and MRI should be routinely ordered and ultrasound of the brachial plexus should not be routinely ordered. The group did not reach consensus on whether CT myelogram should or should not be routinely ordered. Conclusions: Based on our panel’s discussion, future work should focus on comparing the accuracy of CT myelogram and MRI for evaluation of cervical nerve root presence and viability.

Brachial Gunshot Wounds: Injury Patterns and Considerations for Managing the Abnormal Neurological Examination.

Nerve injuries from gunshot wounds (GSWs) to the upper arm can cause significant morbidity and loss of function. However, indications for surgical exploration and nerve reconstruction remain unclear as both low- and high-grade injuries can present with an abnormal neurological examination. Adult patients presenting with a history of isolated GSW to the upper arm between 2010 and 2019 at a single urban level 1 trauma center were screened for inclusion in this retrospective study. Patient demographics, neurological examination findings, concurrent injuries, and intraoperative findings were gathered. Bivariate analysis was performed to characterize factors associated with nerve injuries. There were 139 adult patients with isolated brachial GSWs, and 49 patients (35%) presented with an abnormal neurological examination and significantly associated with concurrent humerus fractures (39% vs 21%, P = .026) and brachial artery injuries (31% vs 2%, P < .001). Thirty of these 49 patients were operatively explored. Fifteen patients were found to have observed nerve injuries during operative exploration including 8 patients with nerve transections. The radial nerve was the most commonly transected nerve (6), and among the 16 contused nerves, the median (8) was most common. Nerve injury from upper arm GSWs is common with directly traumatized nerves confirmed in at least 39% and nerve transection in at least 16% of patients with an abnormal neurological examination. Timely referral to a hand and/or peripheral nerve surgeon for close clinical follow-up, appropriate diagnosis, and any necessary surgical reconstruction with nerve grafts, tendon transfers, and nerve transfers is recommended.

Educating Future Generations of Surgeons across Borders: Novel Global Linked Hybrid Live Cadaveric Peripheral Nerve Surgical Training Course.

This study aimed to evaluate a novel, multi-site, technology-facilitated education and training course in peripheral nerve surgery. The program was developed to address the training gaps in this specialized field by integrating a structured curriculum, high-fidelity cadaveric dissection, and surgical simulation with real-time expert guidance. A collaboration between the Global Nerve Foundation and Esser Masterclass facilitated the program, which was conducted across three international sites. The curriculum was developed by a panel of experienced peripheral nerve surgeons and included both text-based and multimedia resources. Participants' knowledge and skills were assessed using pre- and postcourse questionnaires. A total of 73 participants from 26 countries enrolled and consented for data usage for research purposes. The professional background was diverse, including hand surgeons, plastic surgeons, orthopedic surgeons, and neurosurgeons. Participants reported significant improvements in knowledge and skills across all covered topics (p < 0.001). The course received a 100% recommendation rate, and 88% confirmed that it met their educational objectives. This study underscores the potential of technology-enabled, collaborative expert-led training programs in overcoming geographical and logistical barriers, setting a new standard for globally accessible, high-quality surgical training. It highlights the practical and logistical challenges of multi-site training, such as time zone differences and participant fatigue. It also provides practical insights for future medical educational endeavors, particularly those that aim to be comprehensive, international, and technologically facilitated.

Updates in peripheral nerve surgery of the upper extremity: diagnosis and treatment options.

The loss of function resulting from peripheral nerve injuries confers a significant burden to the patient and society. The treatment of peripheral nerve injuries requires an accurate diagnosis and formulation of a functional reconstructive plan. Advances in peripheral nerve imaging complement electrodiagnostic studies, and provide us with detailed information regarding the status of nerve injury, repair, and regeneration in order to prognosticate recovery and determine the need for surgical intervention. When direct nerve repair is not possible, the methods for bridging a nerve gap are the nerve autograft, allograft and conduit. While current research supports the use of conduits and nerve allografts for shorter nerve gaps, the nerve autograft still remains the gold standard for bridging a nerve gap. When direct nerve repair or nerve grafting fails, or is anticipated to be insufficient, nerve transfers are an alternative for reconstruction. Knowledge of axonal counts, upper limb innervation patterns, location and clustering of upper limb peripheral nerves allows for the design of new nerve transfers. The options of nerve transfers for radial, ulnar and median nerve injuries are outlined, as well as their outcomes. Nerve transfers are an attractive option for restoring motor and sensory function while minimizing donor site morbidity. However, one must consider their limitations, and preserve donor sites for secondary tendon transfer options. This article presents the latest information regarding the imaging of peripheral nerves, methods to bridge a nerve gap, and nerve transfers to aid the peripheral nerve surgeon in choosing a reconstructive plan.

Shielding the Nerve: A Systematic Review of Nerve Wrapping to Prevent Adhesions in the Rat Sciatic Nerve Model.

Peripheral nerve pathology is frequently encountered in clinical practice among peripheral nerve and extremity surgeons. One major factor limiting nerve regeneration and possibly leading to revision surgeries is the development of traumatic or postoperative adhesions and scarring around nerves. In experimental models, different materials have been studied to limit scar tissue formation when wrapped around nerves. A systematic review of studies describing nerve-wrapping materials in a non-transectional rat sciatic nerve model was performed following the PRISMA guidelines. Literature describing nerve-wrapping methods for the prevention of peripheral nerve scarring in rat sciatic nerve models was identified using PubMed and Web of Science, scanned for relevance and analyzed. A total of 15 original articles describing 23 different materials or material combinations for nerve wrapping were included. The heterogeneity of the methods used did not allow a meta-analysis, thus, a systematic review was performed. Out of 28 intervention groups, 21 demonstrated a preventive effect on scar tissue formation in at least one qualitative or quantitative assessment method. The analyzed literature describes a variety of materials from different origins to limit peripheral nerve scarring and adhesions. Thus, a scar-preventive effect by wrapping peripheral nerves as adhesion prophylaxis seems likely. However, a quantitative comparison of the studies to identify the optimal material or technique is not possible with the diversity of used models and study designs. Therefore, further research needs to be performed to identify the optimal nerve wraps to be used routinely in clinical practice.

A pilot prospective cohort study using experimental quantification of early peripheral nerve regeneration with high-frequency three-dimensional tomographic ultrasound (HFtUS)

Quantification of peripheral nerve regeneration after injury relies upon subjective outcome measures or electrophysiology assessments requiring fully regenerated neurons. Nerve surgeons and researchers lack objective, quantifiable information on the site of surgical repair and regenerative front. To address this need, we developed a quantifiable, visual, clinically available measure of early peripheral nerve regeneration using high-frequency, three-dimensional, tomographic ultrasound (HFtUS). We conducted a prospective, longitudinal study of adult patients with ulnar and/or median nerve injury of the arm undergoing direct epineurial repair within 5 days of injury. Assessment of morphology, volumetric and 3D grey-scale quantification of cross-sectional views were made at baseline up to 15 months post-surgery. Sensory and motor clinical outcome measures and patient reported outcome measures (PROMs) were recorded. Five participants were recruited to the study. Our data demonstrated grey-scale values (an indication of axonal density) increased in distal stumps within 2–4 months after repair, returning to normal as regeneration completed (4–6 months) with concomitant reduction in intraneural volume as surgical oedema resolved. Two patients with abnormal regeneration were characterized by increased intraneural volume and minimal grey-scale change. HFtUS may quantify early peripheral nerve regeneration offering a window of opportunity for surgical intervention where early abnormal regeneration is detected.

Selective Tibial Neurotomy for Spastic Equinovarus Foot: Operative Technique.

Spastic equinovarus foot (SEF) is a common complication of stroke and other upper motor neuron injuries. It is characterized by a plantigrade and inverted foot, often with toe curling, causing significant disability from pain, gait, and balance difficulties. Management includes physical therapy, antispasticity drugs, orthoses, chemical neurolysis, or botulinum toxin, all of which may be insufficient, sedating, or transient. Selective tibial neurotomy (STN) provides a surgical option that is effective and long-lasting. Our goal is to provide a concise description of our technique for performing the STN for treatment of SEF. We discuss the standard posterior approach with surgical variations used by other groups and a medial approach, should the posterior approach be insufficient. A posterior leg approach allows access to the tibial nerve and its branches to the bilateral gastrocnemius muscles, soleus, posterior tibialis, and extrinsic toe flexors. A medial approach is used if the toe flexors cannot be accessed sufficiently from the posterior approach. Nerve branch targets identified by preoperative functional assessment are carefully exposed and fully neurolysed distally to identify all terminal branches to each muscle of interest before neurotomy. The STN is a powerful tool for treating SEF, with an immediate and lasting effect. Approximately 80% of the target muscle should be denervated to ensure long-term efficacy while maintaining adequate function of the muscle through collateral innervation. The STN is a safe and effective outpatient procedure that can be performed by an experienced nerve surgeon to improve balance and ambulation and reduce pain for patients with SEF. Large clinical trials are necessary to further establish this underutilized procedure in the United States.

The emerging role of MRI neurography in the diagnosis of chronic inguinal pain.

Chronic pain is a frequent and notable complication after inguinal hernia repair, it has been extensively studied, butits management and diagnosis are still difficult. The cause of chronic pain following inguinal hernia surgery isusually multifactorial. This case series highlights the utility of MRI neurography (MRN) in evaluating the damage toinguinal nerves after a hernia repair, with surgical confirmation of the preoperative imaging findings. A retrospective review was performed on patients who underwent inguinal mesh removal and triple denervation of the groin. Inclusion criteria included MRI neurography. All patients underwent surgical exploration of the inguinal canal for partial or complete mesh removal and triple denervation of the groin by the same senior surgeon. A total of nine patients who underwent triple denervation were included in this case series. MRN was then performed on 100% of patients. The postoperative mean VAS score adjusted for all patients was 1.6 (SD p), resulting in a 7.5 score difference compared to the preoperative VAS score (p). Since chronic groin pain can be a severely debilitating condition, diagnosis, and treatment become imperative. MRN can detect direct and indirect signs of neuropathy even in the absence of a detectable compressive causeaids in management and diagnosis by finding the precise site of injury, and grading nerve injury to aid pre-operativeassessment for the nerve surgeon. Thus, it is a valuable diagnostic tool to help with the diagnosis of nerve injuriesin the setting of post-inguinal hernia groin pain.

Ten steps for proper peripheral nerve handling during inguinal hernia surgery.

Post-inguinal pain after a hernia surgery is prevalent and can be quite frustrating for the surgeon and patient alike. There are several sources for possible post-operative inguinal pain after a successful hernia repair; however, in the setting where a recurrent inguinal hernia is not present, it is likely related to the nerves in the inguinal canal or pelvis. Chronic inguinal groin pain after hernia repairs have been reported in a high percentage of patients following inguinal hernia surgery despite being one of the most common procedures performed annually in the USA and worldwide. We present ten of the basic concepts utilized by peripheral nerve surgeons to limit nerve injury, which can easily be applied to open inguinal hernia surgery with or without mesh, starting with the firm understanding of the inguinal anatomy to addressing the nerves, meticulous placement of the mesh and the active revision of the surrounding structures and nerve position before closure. Understanding the proper handling of the inguinal nerves during hernia surgery can decrease the incidence of post-operative chronic pain by employing microsurgical concepts to day-to-day surgical procedures and prevent complications in an extensive set of patients.

Patient Perspectives on Interdisciplinary Peripheral Nerve Trauma Care

Introduction: Peripheral nerve injury (PNI) is a complex, debilitating condition that is increasingly being treated in interdisciplinary clinics. Patients see peripheral nerve surgeons, neurologists, physiatrists, and electrodiagnostic technicians in a single encounter. No studies have evaluated patient experience within this unique interdisciplinary care model. This study aims to assess patients’ perceptions of the effectiveness of delivery of care and health care information in an interdisciplinary PNI clinic. Methods: A cross-sectional mixed-methods study was conducted using a 23-question survey that was by a lived-experience partner (an individual who had a brachial plexus injury) in research who helped design the survey. Participants attended an interdisciplinary clinic for PNI 1-2 days prior to taking the survey. The survey included 5-point Likert scales for measuring patient understanding and qualitative questions that were categorized into themes, using conventional content analysis. Results: Of the 20 participants, 65% were male, 35% were female and the mean age was 42.6 ± 17.8. Median scores of 4 were obtained for the patient understanding of the testing purposes, test results, nerve recovery after PNI, and surgical decision-making (full understanding = 5). On improving the clinical experience, 58% indicated no improvements were necessary, while 17% indicated the clinic felt rushed or overwhelming. When asked about positive aspects of their clinical experience, 64% appreciated the team approach to care, 27% valued the informative nature of the clinic, and 27% appreciated the progress they felt when providers at the clinic performed nerve testing. Conclusions: The results demonstrate that patients with PNI have overall positive perceptions of the delivery of care and information in an interdisciplinary PNI clinic. These results provide new insight into how interdisciplinary care may be beneficial to PNI patients based on the perceived effectiveness of knowledge translation.

(278) Neurosensory Re-Education Following Gender-Affirming Phalloplasty: A Novel Treatment Protocol

Abstract Introduction Sensory nerve transfers are performed as a routine part of phalloplasty surgery. It is well documented that nerve transfers are dependent on therapy and rehabilitation in order to optimize outcomes. Despite this, targeted sensory re-education to rehabilitate the nerve transfers in phalloplasty has yet to be employed in this clinical setting. Additionally, little attention has been paid to the role of the central nervous system in experienced sensation following surgery. Addressing these contributions to sensation may represent a step forward in optimizing sensory outcomes in phalloplasty. Objective The purpose of this paper is to report on the development and implementation of a targeted rehabilitation protocol to integrate and optimize peripheral and central contributions to sensation following phalloplasty. Methods This Neurosensory Re-Education protocol was constructed over four phases by a multi-disciplinary team (phalloplasty and peripheral nerve surgeon, reconstructive urologist, pelvic floor physiotherapists, peripheral nerve therapist, sex therapist, specialist in sexual medicine) and individuals with lived phalloplasty experience. The final protocol was approved by all members of the team and is supported here by qualitative narratives from people with lived phalloplasty experience now using the protocol. Results In each stage of the protocol, exercises were grouped into three core themes: visualization, tactile stimulation and sexual/erogenous stimulation. Visualization exercises progress from static to dynamic. Tactile exercises progress from simple touch towards targeted sensory stimulation. Sexual exercises focus on developing erogenous sensation in the phallus that is separate from erogenous sensation in the natal clitoral tissue. Overall individuals who underwent phalloplasty felt the protocol was a valuable and helpful resource. It was felt that the protocol provided a meaningful way to connect with the phallus and process ongoing dysphoria while working towards the next stages of surgery. The protocol helped individuals stay excited about new sensation entering the phallus and encouraged additional interaction with their penis. For individuals highly focused on sensation, the protocol provided peace of mind that everything was being done to optimize sensation and strengthen the mind-body connection By recommendation of phalloplasty patients, the protocol is now integrated into our centers phalloplasty care pathway for all individuals undergoing phalloplasty surgery. Conclusions This protocol is the first instrument available to support and engage phalloplasty patients in their sensory rehabilitation and sexual recovery following surgery. It was constructed by a robust multi-disciplinary team and individuals undergoing phalloplasty. We introduce this novel protocol targeting peripheral and central contributions to sensation to provide a tool for patients and care teams to best optimize experienced sensation for transmasculine individuals following phalloplasty surgery. Disclosure No

Following a Surgical Paradigm Shift Through the Adoption of Nerve Transfers Among Board-Eligible and Practicing Plastic Surgeons.

Nerve transfers represent a new paradigm in the treatment of nerve injuries. Their current level of adoption among surgeons is unknown. This study evaluates the incidence of nerve transfers on case logs of board-eligible plastic surgeons over the past 14 years and surveys practicing nerve surgeons regarding their use of this technique. We queried the American Board of Plastic Surgery case log database for all nerve reconstruction Current Procedural Terminology codes from 2008 to 2021 and assessed trends and relationships between geographic region, examination year, and nerve transfer use. We surveyed nerve surgery professional societies to assess trends in practice, compared with a 2017 survey. A total of 1959 nerve reconstruction cases were logged by 738 candidates from 2008 to 2021. Twelve percent of cases included nerve transfers. The proportion of nerve transfer codes (Z = -11.57; P < .0001) and the proportion of candidates performing nerve transfers (Z = -9.21, P < .0001) increased over the study period. Nerve transfers were associated with geographic region (χ2 = 25.826, P = .0002), with most cases performed in the Midwest (26.4%). A higher proportion of practicing nerve surgeons reported performing nerve transfers in this survey than in our 2017 survey (χ2 = 16.7, P < .001). There has been an increase in nerve transfers logged in the past 14 years by board-eligible plastic surgeons, as well as increased use among currently practicing nerve surgeons. Although nerve transfer use is increasing among both plastic and orthopedic surgeons, a greater proportion of nerve reconstructions include nerve transfers in the plastic surgery cohort.

The Peripheral Nerve Surgeon’s Role in the Management of Neuropathic Pain

Summary: Neuropathic pain (NP) underlies significant morbidity and disability worldwide. Although pharmacologic and functional therapies attempt to address this issue, they remain incompletely effective for many patients. Peripheral nerve surgeons have a range of techniques for intervening on NP. The aim of this review is to enable practitioners to identify patients with NP who might benefit from surgical intervention. The workup for NP includes patient history and specific physical examination maneuvers, as well as imaging and diagnostic nerve blocks. Once diagnosed, there is a range of options surgeons can utilize based on specific causes of NP. These techniques include nerve decompression, nerve reconstruction, nerve ablative techniques, and implantable nerve-modulating devices. In addition, there is an emerging role for preoperative involvement of peripheral nerve surgeons for cases known to carry a high risk of inducing postoperative NP. Lastly, we describe the ongoing work that will enable surgeons to expand their armamentarium to better serve patients with NP.

Treatment of C5 Palsy: An International Survey of Peripheral Nerve Surgeons.

International survey. C5 palsy (C5P) is a neurological complication affecting 5-10% of patients after cervical decompression surgery. Most cases improve with conservative treatment; however, nearly 20% of patients may be left with residual deficits. Guidelines are lacking on C5P management and timing of surgical intervention. Therefore, we sought to survey peripheral nerve surgeons on their management of C5P. An online survey was distributed centered around a patient with C5P after posterior cervical decompression and fusion. Questions included surgeon demographics, diagnostic modalities, and timing and choice of operation. Responses were summarized and the chi-squared and Kruskal-Wallis H tests were used to examine differences across specialties. A total of 154 surgeons responded to the survey, of which 59 (38%) indicated that they manage C5P cases. Average time prior to operating was 4.5 ± 2.2months for complete injuries and 6.6 ± 3.2months for partial injuries, with neurosurgeons significantly more likely to wait longer periods for complete (P = .01) and partial injuries (P = .03). Foraminotomies were selected by 19% of surgeons, while 92% selected nerve transfers. Transfer of the ulnar nerve to the musculocutaneous nerve was the most common choice (81%), followed by transfer of the radial nerve to the axillary nerve (58%). Consensus exists among peripheral nerve surgeons on the use of nerve transfers for surgical treatment in cases with severe motor weakness failing to improve. Most surgeons advocate for early intervention in complete injuries. Disagreement concerns the type of nerve transfer employed, timing of surgery, and efficacy of foraminotomy.