Peripheral Nerve Surgeons Research Articles

Timing of referral to peripheral nerve specialists in patients with postoperative C5 palsy

The objective of this study was to examine the association between electrophysiology data post-C5-palsy and referral to peripheral nerve surgeons (PNS) using a 15-year cohort of patients who underwent posterior cervical decompression. Endpoints included the associations of postoperative treatments employed with functional recovery and abnormal electrophysiology data. Of 77 included patients (median 64 yr; 68% male), 48% completely recovered. The most common treatments were physical therapy (90%), occupational therapy (34%), oral corticosteroids (18%), and PNS referral (17%). Baseline weakness did not associate with PNS referral or postoperative treatment strategy. None of the treatments predicted recovery, though patients with no [versus complete] recovery were more likely to be recommended for nerve transfers (22.2 vs 0%; p = 0.03). Abnormal electromyography data associated with PNS referral (p < 0.01), nerve transfer recommendation (p < 0.01), occupational therapy referral, and oral corticosteroid therapy. Abnormal findings on EMG obtained between 6-weeks and 6-months post-injury were the most strongly associated with peripheral nerve surgeon referral (p = 0.02) and nerve transfer recommendation (p < 0.01). These data suggest strategies for postoperative C5 palsy management are highly heterogeneous. None of the treatments employed significantly predicted the extent of functional recovery. However, patients with abnormal electrophysiology results were most likely to receive multimodal treatment, suggesting these results may significantly alter medical management of patients with postoperative C5 palsy. Early (6-week to 6-month) electrophysiology data may help to ensure that patients likely to benefit from nerve transfer procedures are referred to a PNS within the 9–12-month time frame associated with the best recovery of function.

Current Concepts Review: Common Peroneal Nerve Palsy After Knee Dislocations

Dislocation of the native knee represents a challenging injury, further complicated by the high rate of concurrent injury to the common peroneal nerve (CPN). Initial management of this injury requires a thorough neurovascular examination, given the prevalence of popliteal artery injury and limb-threatening ischemia. Further management of a knee dislocation with associated CPN palsy requires coordinated care involving the sports surgeon for ligamentous knee reconstruction and the peripheral nerve surgeon for staged or concurrent peroneal nerve decompression and/or reconstruction. Finally, the foot and ankle surgeon is often required to manage a foot drop with a distal tendon transfer to restore foot dorsiflexion. For instance, the Bridle Procedure-a modification of the anterior transfer of the posterior tibialis muscle, under the extensor retinaculum, with tri-tendon anastomosis to the anterior tibial and peroneus longus tendons at the anterior ankle-can successfully return patients to brace-free ambulation and athletic function following CPN palsy. Cross-discipline coordination and collaboration is essential to ensure appropriate timing of operative interventions and ensure maintenance of passive dorsiflexion prior to tendon transfer.

Reverse End-to-Side (Supercharging) Nerve Transfer: Conceptualization, Validation, and Translation.

Partial nerve recovery either after expectant observation following an injury in-continuity or after nerve repair is not an uncommon occurrence. Historically, treatment strategies in these situations-late repair, revision repair, or acceptance of a mediocre result-were unsatisfying. The reverse end-to-side, or supercharging, nerve transfer was conceived to offer a more palatable option. Partially validated primarily through small animal research, supercharging has been rapidly translated to clinical practice. Many have extended the indications beyond the original intent, though the final place of this technique in the peripheral nerve surgeon's armamentarium is still yet to be determined.

What’s New in Hand and Wrist Surgery

What’s New in Hand and Wrist Surgery

How to assess the recovery of muscular function following nerve injury: A view from surgeons and patients

Patient experience of motor recovery from denervation paralysis is complex and textured. The Medical Research Council (MRC) system of grading muscle peak volitional force is widely used as a single measure of assessment. However, it is becoming clear that current motor function assessments are not reflecting the patient lived experience of muscle reinnervation. Therefore, this study aimed to engage international expert nerve surgeons in a classical Delphi process to achieve a consensus of opinion on the ideal clinical assessment of motor function. This was compared with patient-reported impairments of reinnervated muscle. Invitations to engage in the Delphi process were extended to expert peripheral nerve surgeons across two international specialist meetings. For comparison, patients who attended a "Nerve Injury Community Day" were invited to complete a questionnaire on patient-reported impairments of reinnervated muscle. Questions were designed on the basis of a literature review and the clinical experiences of a specialist nerve injury unit. A combination of direct yes/no, multiple choice, open-ended and Likert questions were employed throughout the questionnaires. Eighteen surgeons engaged with the Delphi process; 18 and 11 responded to the first and second rounds respectively. Thirty-one patients responded to the questionnaire. It was found that clinicians were strongly biased towards efferent assessments of muscular function, while patients strongly favoured muscular fatigue, co-contraction and pain when monitoring their own recovery. The findings suggest that current clinical assessments of muscular function are inadequate and should embody measurements of afferent muscular function to better reflect the lived experience of muscle reinnervation.

Letter: The Impact of the Coronavirus (COVID-19) Pandemic on Neurosurgeons Worldwide.

Letter: The Impact of the Coronavirus (COVID-19) Pandemic on Neurosurgeons Worldwide.

Mechanisms and outcomes of the supercharged end-to-side nerve transfer: a review of preclinical and clinical studies.

Proximal peripheral nerve injuries often result in poor functional outcomes, chiefly because of the long time period between injury and the reinnervation of distal targets, which leads to muscle and Schwann cell atrophy. The supercharged end-to-side (SETS) nerve transfer is a recent technical innovation that introduces donor axons distally into the side of an injured nerve to rapidly innervate and support end organs while allowing for additional reinnervation after a proximal repair at the injury site. However, the mechanisms by which donor axons grow within the recipient nerve, contribute to muscle function, and impact the regeneration of native recipient axons are poorly understood. This uncertainty has slowed the transfer's clinical adoption. The primary objective of this article is to comprehensively review the mechanisms underpinning axonal regeneration and functional recovery after a SETS nerve transfer. A secondary objective is to report current clinical applications in the upper limb and their functional outcomes. The authors also propose directions for future research with the aim of maximizing the clinical utility of the SETS transfer for peripheral nerve surgeons and their patients.

Characteristics of Iatrogenic Nerve Injury from Orthopedic Surgery Correlate with Time to Subspecialty Presentation.

Background:There is no current literature examining iatrogenic nerve injury resulting from orthopedic procedures across subspecialties and anatomic areas. This study uses a single peripheral nerve surgeon’s experience to investigate the variable time to presentation of adult patients with iatrogenic nerve injury after orthopedic surgery.Methods:A retrospective review of patients examined in Peripheral Nerve Clinic (PNC) from January 1, 2012, to April 1, 2018, at a single, private, university hospital was performed. Fifty-eight adult patients met inclusion criteria. Charts were reviewed to determine the index orthopedic procedure, peripheral nerve affected, clinical deficits, patient demographics, and time from injury to PNC presentation.Results:The average patient age was 51.2 years, and the average time to PNC referral was 10.9 months after the procedure that resulted in nerve injury. The orthopedic procedures included fracture fixation (13), joint arthroplasty (10) knee arthroscopy and ligament reconstruction (9), mass excision (9), shoulder arthroscopy (7), irrigation and debridement (2), removal of deep hardware (2), tendon procedures (2), trigger digit release (2), nerve decompression (1), and release of exertional compartment syndrome (1). Time from injury to PNC presentation was substantially shorter for patients with upper extremity versus lower extremity deficits (5.9 months vs 19.8 months; P = 0.0173) and for patients with motor nerve involvement versus those with isolated sensory nerve injury (4.5 months vs 24.3 months; P = 0.0164).Conclusions:Iatrogenic nerve injury is a risk across orthopedic subspecialties. Nerve injuries in the lower extremity and those with isolated sensory deficits have significantly delayed time to subspecialty presentation.

Traumatic peripheral nerve lesions : Diagnosis and treatment

Traumatic peripheral nerve lesions affect patients of all age groups. They are associated with functional deficits that have severe consequences for affected patients and prolonged or permanent inability to work has socioeconomic relevance. In order to improve prognoses and achieve the best possible outcome an early diagnosis and competent knowledge of the correct approach and treatment strategies are essential. Unfortunately, nerve lesions are often not detected in time, so that surgical treatment can only be initiated after a delay. Because of the relatively high proportion of iatrogenic nerve lesions, aprofound knowledge of the optimal care of patients with peripheral nerve lesions is compulsory for every doctor who works in the operative field. Surgical treatment of peripheral nerve lesions should remain in the hands of experienced peripheral nerve surgeons. The foundation of successful treatment, however, begins earlier at the initial referral when the patient receives the correct diagnostics and treatment.

3451 Pain, Quality of Life, and Emotional Measures as Predictors for Outcomes following Surgery for Nerve Injuries

OBJECTIVES/SPECIFIC AIMS: Examine data from PNID patients to evaluation the strength of associations between pre-operative and post-operative levels of pain, quality of life, and emotional reactions to pain to determine if one or more can serve as better predictors of surgical success than pain. METHODS/STUDY POPULATION: In our preliminary study, we gathered data from a pre-existing database of 464 PNID patients that contains self-reported visual analog scale scores (VAS) of pain intensity, QoL, and depression. We measured these variables at three time points: pre-operatively, post-operatively, and at the final visit. We used the Wilcoxon signed rank test to determine if each of these three variables differed significantly between the pre-operative visit and the post-operative visit period and from the pre-operative visit to the final visit. RESULTS/ANTICIPATED RESULTS: Median time from the pre-operative visit to surgery was 9 weeks; median time from surgery to the post-operative visit was 4 weeks; and median time from the post-operative visit to the final visit was 23.5 weeks. There was a clinically meaningful difference in pain scores between the pre-operative and post-operative visits (median difference 1.15; 95% CI 0.75-1.55). In the period between the post-operative visit and the final visit there was also a decrease in pain (0.90; 95% CI 0.55-1.30). The magnitude of change in median difference of 1.85 (95% CI 1.50-2.20) between the pre-operative visit and the final visit was larger than the change in median difference of 0.90 (95% CI 0.55-1.30) between the post-operative visit and the final visit. The pre-operative visit median QoL score was higher than the median score at the post-operative visit (1.65; 95% CI 1.25-2.10). The smallest median difference in QoL of occurred between the post-operative and the final visit (1.10; 95% CI 0.60-1.45). As seen with the pain scores, the magnitude of change in median difference of 2.50 (95% CI 2.20-2.85) for QoL was greatest between the pre-operative and the final visit. Depression scores showed the least amount of change amongst all the variables, between the pre-operative and the post-operative visit (1.00; 95% CI (0.70-1.40), and similarly between the post-operative visit and the final visit (0.15; 95% CI (0-.40). The median differences between the pre-operative and final visit were greatest in QoL (2.50; 95% CI 2.20-2.85), followed by pain scores (1.85; 95% CI 1.50-2.20), and finally, depression (1.05; 95% CI 0.70-1.40). DISCUSSION/SIGNIFICANCE OF IMPACT: Our results show that all three variables measured improve with surgery and continue to improve over the post-operative course to the final visit. This suggest that the relationships between pain, QoL, and depression should be further investigated. We are hopeful that elucidating how these variables interact in the PNID patient population, will encourage peripheral nerve surgeons to use these parameters in conjunction with pain intensity to measure outcomes. A follow-up study expanding on these results and including measures of anger and frustration in a larger sample is underway.

The surgical management of traumatic neuromas

Following injury to a peripheral nerve, a neuroma may form and cause severe debilitating neuropathic pain. End neuromas are the result of an amputation or are found at the proximal stump in a complete nerve transection or rupture. Neuromas-in-continuity follows traction or compression injury and may complicate repair of a nerve transection or rupture. Symptomatic neuromas should be assessed and treated by a peripheral nerve surgeon working within a multi-professional team. The objectives of the initial treatment should encompass pain management, psychological support and physical therapies with the aim of restoration of normal nerve response thresholds to afferent stimuli and optimisation of the perineuroma environment. Surgical intervention should be reserved for non-responders and in cases where reconstruction of nerve function is deemed essential for useful functional recovery and pain resolution.

Delayed motor nerve transfer reconstruction for C5 and C6 resection during tumour surgery

We present a case of a delayed motor nerve reconstruction following resection of the C5 nerve root due to a recurrent aneurysmal bone cyst. Our patient, a 17-year-old male, presented with a major motor radiculopathy of C5 and revision surgery requiring resection of the C5 root. Four peripheral nerve transfers were undertaken to successfully reconstruct the functional loss at more than 14 months from the paralysis onset. Nerve transfer is usually considered only when the target muscles can be reinnervated within 9 months after lower motor neurone loss. The strategies for reducing reinnervation time and the differences in nerve transfer surgery for traumatic lesions will be discussed. Tumour surgeons should consider early involvement of a peripheral nerve surgeon when nerve must be sacrificed during tumour clearance. This allows the option of early targeted reconstruction and provides guidance to the patient on anticipated outcomes after surgery.

The Role of the Peripheral Nerve Surgeon in the Treatment of Pain.

Pain is a frequent cause of physician visits. Many physicians find these patients challenging because they often have complicated histories, emotional comorbidities, confusing examinations, difficult problems to fix, and the possibility of factitious complaints for attention or narcotic pain medications. As a result, many patients are lumped into the category of chronic, centralized pain and relegated to pain management. However, recent literature suggests that surgical management of carefully diagnosed generators of pain can greatly reduce patients' pain and narcotic requirements. This article reviews recent literature on surgical management of pain and four specific sources of chronic pain amenable to surgical treatment: painful neuroma, nerve compression, myofascial/musculoskeletal pain, and complex regional pain syndrome type II.

Peripheral nerve injury with Nexplanon removal: case report and review of the literature

BackgroundImplantable devices offer convenient, long-acting, and reversible contraception. Injury to the peripheral nerves and blood vessels have been reported as rare complications of implantation and extraction.Case presentationWe present a case of ulnar nerve injury in a 21-year-old woman from attempted in-office removal of a deeply implanted Nexplanon® device. The injury resulted in an ulnar nerve palsy requiring surgical exploration, neuroma excision, and sural nerve cable grafting.ConclusionsIn-office attempts to remove contraceptive implants that are deep or have migrated can cause iatrogenic nerve injury. Devices that are non-palpable, deep, or migrated should be imaged before formal surgical exploration and removal. Any patient with neurologic symptoms after placement or after attempted removal requires prompt diagnosis and referral to a peripheral nerve surgeon.

The Assessment and Management of Peripheral Nerve Trauma.

The purpose of this review is to discuss the therapeutic options available in the treatment of traumatic injuries involving peripheral nerves. For nerve gap repair, synthetic nerve tubes are limited to gaps below 3cm in length and to small-diameter nerve repairs, whereas the dependency on proliferating host Schwann cell limits the size of acellularized autografts. Thus, in most situations, nerve autografts remain superior for nerve gap correction. When conservative treatment is either not indicated or ineffective, surgical intervention may be employed. The ideal timing of surgical intervention is often unclear and determined by a number of factors, including the circumstances surrounding the injury, the timing of the symptoms, the type and severity of the injury, the completeness of the lesion, the required regenerative distance, the degree of fascicular disruption, and the degree of concomitant tissue trauma and contamination, as well as the morbidity and mortality of the procedure, and the age and comorbidities of the patient. The most common nonsurgical error is unnecessary surgical delay. To avoid losing the opportunity to achieve successful motor recovery, it is important to involve a peripheral nerve surgeon early.

Nerve Repair with Nerve Conduits: Problems, Solutions, and Future Directions.

Nerve conduits are becoming increasingly popular for the repair of peripheral nerve injuries. Their ease of application and lack of donor site morbidity make them an attractive option for nerve repair in many situations. Today, there are many different conduits to choose in different sizes and materials, giving the reconstructive surgeon many options for any given clinical problem. However, to properly utilize these unique reconstructive tools, the peripheral nerve surgeon must be familiar not only with their standard indications but also with their functional limitations. In this review, the authors identify the common applications of nerve conduits, expected results, and shortcomings of current techniques. Furthermore, future directions for nerve conduit use are identified.

Elective amputation of the upper limb is an option in the treatment of traumatic injuries of the brachial plexus?

The treatment of complete post-traumatic brachial plexus palsy resulting in a flail shoulder and upper extremity remains a challenge to peripheral nerve surgeons. The option of upper limb amputation is controversial and scarcely discussed in the literature. We believe that elective amputation still has a role in the treatment of select cases. The pros and cons of the procedure should be intensely discussed with the patient by a multidisciplinary team. Better outcomes are usually achieved in active patients who strongly advocate for the procedure.

Difficult removal of subdermal contraceptive implants: a multidisciplinary approach involving a peripheral nerve expert

ObjectivesWe aim to describe our experiences and identify patients who may benefit from referral to a peripheral nerve surgeon for removal of contraceptive subdermal implants in which neurovascular injury may occur, and describe a treatment pathway for optimal care. Study designWe reviewed the charts of 22 patients who were referred to the Division of Family Planning for difficult removal of etonogestrel contraceptive implants between January 1, 2014, and April, 1 2016. Of these, five were referred to a peripheral nerve surgeon due to pain or location of the implant. We evaluated and described these cases and, from our findings, developed recommendations for care in a multidisciplinary team approach. ResultsTwo patients reported pain, including one with four previous failed removal attempts. In the two patients with pain, the implants were adherent to a sensory nerve. In another, the implant was within the biceps muscle and difficult to locate. In all cases, ultrasound imaging, general anesthesia and a wide exposure allowed for safe removal and good outcomes. Our multidisciplinary care approach has elucidated important referral and technical considerations that improve patient care and safety. ConclusionWhen necessary, multidisciplinary care with a Family Planning expert and possibly a peripheral nerve surgeon may be beneficial in safely removing etonogestrel contraceptive implants that would be difficult or risky to remove in an ambulatory setting.

Muscle Response to Complete Peripheral Nerve Injury: Changes of Acetylcholine Receptor and Creatine Kinase Activity over Time.

Background This study was designed to assess the changes of acetylcholine receptor (AChR) and creatine kinase (CK) levels, which are important biochemical markers for muscle viability in cases of long-term muscle denervation. Scientists and peripheral nerve surgeons may find these data important regarding maximal range of muscle viability applicable for timing of effective peripheral nerve reconstructive surgery. Methods The study was conducted on 48 rats (96 gastrocnemius muscles), whose right legs were denervated by removing a 10-mm segment of sciatic nerve, while their left legs remained intact. Under general anesthesia, the rats were euthanized at seven points in time, on days 7, 14, 21, 30, 60, 120, and 210. In both legs, AChR was quantified by 125I-α-bungarotoxin, whereas CK activity was measured using a spectrophotometric method. Results CK levels in the denervated limb reached a minimal level of 34% on day 30 in comparison to the intact limb and remained at this level up to 210 days after operation. AChR levels in the denervated limb reached a minimal level of 38% on day 120 in comparison to the intact limb and remained at this level up to 210 days after operation. Conclusion The present study shows that AChR and CK levels in rat denervated muscles remain constant at about third of its intact condition for a period of at least a third of rat's lifetime postinjury.

Protocol for a Randomised Controlled Trial Investigating Decompression for Leprous Neuropathy (The DELN Protocol)

An expert group of peripheral nerve surgeons, reconstructive surgeons, and immunologists who have extensive experience with Hansen’s Disease convened to discuss the status of nerve decompression as a treatment for leprous neuropathy. The expert group recommended an international, multi-center randomised controlled trial (RCT). Subsequently, a study protocol called Decompression for Leprous Neuropathy (DELN) was designed and further refined by multiple investigators worldwide. The DELN RCT seeks to determine the long-term effect of nerve decompression on sensibility, motor function, neuropathic pain, disability, and quality of life. The RCT would enroll patients with clinically diagnosed leprous neuropathy and positive Tinel signs in the upper and lower extremities. Patients would then be randomized to receive nerve decompression or not. Outcomes of interest include sensory function, motor function, pain, disability, and quality of life. The development of ulcers or amputations after surgery and the influence of corticosteroid therapy are also important outcomes that DELN seeks to determine. The study Decompression for Leprous Neuropathy (DELN) is an international, multi-center RCT with the potential to produce high quality data to address whether nerve decompression for leprous neuropathy can conclusively improve patient outcomes. We invite discussion from all those involved in the peripheral nerve and leprosy communities.