Peripheral Nerve Surgery Research Articles

Mariano Socolovsky, Lukas Rasulic, Rajiv Midha, and Debora Garozzo (eds): Manual of peripheral nerve surgery: from the basics to complex procedures.

Mariano Socolovsky, Lukas Rasulic, Rajiv Midha, and Debora Garozzo (eds): Manual of peripheral nerve surgery: from the basics to complex procedures.

MANAGEMENT OF BRACHIAL PLEXUS MISSILE INJURIES.

SUMMARY – Missile injuries are among the most devastating injuries in general traumatology. Traumatic brachial plexus injuries are the most difficult injuries in peripheral nerve surgery, and most complicated to be surgically treated. Nevertheless, missile wounding is the second most common mechanism of brachial plexus injury. The aim was to evaluate functional recovery after surgical treatment of these injuries. Our series included 68 patients with 202 nerve lesions treated with 207 surgical procedures. Decision on the treatment modality (exploration, neurolysis, graft repair, or combination) was made upon intraoperative finding. Results were analyzed in 60 (88.2%) patients with 173 (85.6%) nerve lesions followed-up for two years. Functional recovery was evaluated according to functional priorities. Satisfactory functional recovery was achieved in 90.4% of cases with neurolysis and 85.7% of cases with nerve grafting. Insufficient functional recovery was verified in ulnar and radial nerve lesions after neurolysis, and in median and radial nerve lesions when graft repair was done. We conclude that the best time for surgery is between two and four months after injury, except for the gunshot wound associated with injury to the surrounding structures, which requires immediate surgical treatment. The results of neurolysis and nerve grafting were similar.

Introduction: the value of peripheral nerve surgery.

If a single picture is worth a thousand words, then a video, by logical extension, would be priceless. This edition showcases peripheral nerve surgery in all its grandeur and preserves it for posterity. Classic and novel surgical techniques are shown related to tumor biopsy or resection; nerve decompression for entrapment; and nerve reconstruction with direct repair or nerve transfer. Akin to a nautical chart filled with detailed maps for sailors, this Neurosurgical Focus Video Atlas provides navigational tools for neurosurgeons. The shared underlying message is that a sound knowledge of anatomy can lead to innovation (i.e., creative approaches or solutions) and excellence (i.e., improved patient outcomes).

Manual of Peripheral Nerve Surgery

Manual of Peripheral Nerve Surgery

Cerebral plasticity after contralateral cervical nerve transfer in human by longitudinal PET evaluation

ObjectThe treatment of brachial plexus avulsion injury remains a challenging problem. Admittedly, central nervous mechanisms play a significant role in the motor recovery of the paralyzed hand after peripheral nerve surgery. The present study aimed at investigating the relationship between cerebral reorganization and motor recovery after a unique peripheral crossing nerve transfer surgery in brachial plexus injury patients. MethodsIn the present study, two brachial plexus avulsion injury patients with were followed up for 4 years after contralateral C7 nerve transfer surgery. In the surgery, an intact nerve root from the intact limb was transferred to repair the injured nerves. One patient showed a good motor recovery in the paralyzed hand while the other showed relatively poor outcomes. In the longitudinal follow-up, 9 PET scans of the brain were conducted in both patients at regular intervals of every 6 months. A correlation analysis between cerebral glucose metabolism and flexion power of the paralyzed wrists and fingers was performed to investigate the involvement of brain reorganization during the process of motor recovery. ResultsThe cerebral glucose metabolism in the corpus callosum, premotor cortex (Broadmann Area 6) and the precuneus were found positively correlated with the motor recovery of the paralyzed hand in Patient A (P < .01). Positive correlation between the cerebral glucose metabolism and the motor recovery of the paralyze hand was only present in the corpus callosum in Patient B (P < .01). ConclusionCorpus callosum, premotor cortex and precuneus were related with motor recovery after contralateral cervical nerve transfer surgery. The accumulating activation of these cortical regions potentially represented the recovery of high-order motor networks and may have facilitated the motor recovery.

The effect of topical 5-Fluorouracil application on epineural scar tissue in epineurectomized rat sciatic nevre

Objective: This study investigated the effect of topical 5-Fluorouracil (5-FU) application on the epineural scar tissue, which has a negative impact on the outcome after a peripheral nerve surgery, and whether the application of two doses of 5-FU would change the outcome. Materials and Methods: The study involved 72 3-month-old female Spradue-Dawey rats weighing 250-300 g each. After the experimental animals were observed for a week to make certain that they were healthy, they were randomly divided into 3 main groups; Group A: skin incision + epineurotomy + isotonic (n=24), Group B: skin incision + epineurotomy + single dose of 5-FU (n=24) and Group C: skin incision + epineurotomy + two doses of 5-FU (n=24). Each group was divided into 2 subgroups based on the weeks in which they were examined. The two subgroups in each of the three groups were made subject to a walking test, and macroscopic and histopathological examinations at Week 4 and Week 8. Results: An evaluation of the macroscopic results showed that there was a statistically significant difference between Group A and Group C in sciatic nerve adhesion and severability of its branches. We obtained better results in Group C, when compared with the results obtained in Group A. Conclusion: We demonstrated in our study that 5-FU had a positive effect on the scar tissue developed around the epineurectomized nerve. This positive effect was also reflected in the nerve’s functional capacity, and a second dose of 5-FU application further improved this effect.

Intraoperative Nerve Stimulation During Brachial Plexus Surgery: Comparison Between a Totally Disposable Nerve Stimulator and Nerve Stimulator Normally Used for Nerve Blocks.

Intraoperative nerve stimulation is done routinely in brachial plexus and peripheral nerve surgery as well as in selective neurectomy in spastic patients. The current study compares the use of 2 different devices for nerve stimulation: a totally disposable nerve stimulator and a nerve stimulator used for nerve blocks by anesthetists. A retrospective study of 60 patients who underwent brachial plexus surgery: In 30 patients, we used the totally disposable nerve stimulator (group 1) and in another 30 patients, we used the anesthesia device (group 2). The cost of disposable materials used for nerve stimulation was calculated in each group. The same surgeon performed all operations, and he was asked to give his subjective opinion regarding the convenience and ease of use of the device in each group. The main advantages of the totally disposable device are its placement totally within the sterile field, and it is operated by the surgeon without the need to communicate with the anesthetist. However, the totally disposable device had several major disadvantages when compared to the anesthesia device. Firstly, the disposable stimulator can only deliver 0.5, 1.0, and 2.0 mA stimuli, while the anesthesia device can deliver stimuli of 0.1 to 5 mA (in 0.1 mA increments). Secondly, the disposable stimulator frequently fails to operate during surgery, and this is not experienced with the anesthesia device. Finally, the cost of disposables is less using the anesthesia device. Our center has stopped using the disposable nerve stimulator in favour for the anesthesia device.

Use of human fat grafting in the prevention of perineural adherence: Experimental study in athymic mouse.

Perineural adherences represent a problem after surgery involving peripheral neural system. Fat-grafting with adipose derived stem cells (ASCs) with their pro-regenerative characteristics can be important to prevent the neural damage or to facilitate the neural regeneration. Our idea was to use the fat-grafting as an anti-adherence device and test its efficacy on a postsurgical scar animal model and comparing to an antiadhesive gel. 32 athymic mice were operated under magnification, we exposed both sciatic nerves. We randomly divided all sciatic nerves into four experimental groups: burning (1), burning + carboxy-methylcellulose and poly- ethylene oxide (CMC-PEO) (2) + human adipose fat tissue (3), control group (4). Bio-mechanical evaluation was performed to measure the peak force required to pull out the nerve from the muscular bed. Results: in the CMC-PEO group the peak pull out force was 0.37 Newton. In the fat grafted group we registered a peak pull out force of 0.35 N (t Student 0.913). In burning group the force necessary to tear the nerve apart was markedly superior (0.46 N). In control group, we reported the minimal strength (0.31 N) to slide the nerve from the tissue. Histologically, in the group treated with fat-grating, a thinner scar layer was highlighted. Considering the results of this study we can support the efficacy in animal experimental model of fat graft as an anti-adherence device in peripheral nerve surgery.

Introduction: Peripheral nerve surgery.

Several mechanisms are involved in peripheral nerve injury including trauma, entrapment syndromes, and tumors. The clinical history and the physical examination are fundamental for the correct diagnosis and for the choice of the best therapy. The indication for surgery will depend on the mechanism of injury and the degree of neurological impairment. For entrapment syndromes, surgery is indicated in the failure of conservative treatment or when there is functional impairment (sensory or motor) related to the affected nerve. Surgery is also indicated for open traumatic injuries of peripheral nerves, and it is generally recommended for patients with intrinsic tumors such as schwannomas. In this chapter we present a review of the main surgical conditions affecting the peripheral nerves.

Current Concept in Adult Peripheral Nerve and Brachial Plexus Surgery.

Peripheral nerve injuries and brachial plexus injuries are relatively frequent. Significance of these injuries lies in the fact that the majority of patients with these types of injuries constitute working population. Since these injuries may create disability, they present substantial socioeconomic problem nowadays. This article will present current state-of-the-art achievements of minimal invasive brachial plexus and peripheral nerve surgery. It is considered that the age of the patient, the mechanism of the injury, and the associated vascular and soft-tissue injuries are factors that primarily influence the extent of recovery of the injured nerve. The majority of patients are treated using classical open surgical approach. However, new minimally invasive open and endoscopic approaches are being developed in recent years—endoscopic carpal and cubital tunnel release, targeted minimally invasive approaches in brachial plexus surgery, endoscopic single-incision sural nerve harvesting, and there were even attempts to perform endoscopic brachial plexus surgery. The use of the commercially available nerve conduits for bridging short nerve gap has shown promising results. Multidisciplinary approach individually designed for every patient is of the utmost importance for the successful treatment of these injuries. In the future, integration of biology and nanotechnology may fabricate a new generation of nerve conduits that will allow nerve regeneration over longer nerve gaps and start new chapter in peripheral nerve surgery.

Novel approach to continuous neurophysiological monitoring during surgery of peripheral nerve tumors.

Background:Intraoperative neurophysiological monitoring (IONM) with nerve action potential (NAP) can be useful during peripheral nerve surgery. However, current methodologies are not optimized for continuous recording of the NAP. The use of newer electrodes may make it possible to more conveniently obtain continuous recordings of the NAP during surgery.Methods:After localizing the nerve of interest and dissecting it from the adjacent soft tissue, two APS® (Automatic Periodic Stimulation) electrodes, originally designed for stimulation of the vagus nerve during thyroid surgery, are placed on the nerve on either sides of the tumor for stimulation and recording using two subdermal electroencephalogram (EEG) needles as anode and reference, respectively. Both monopolar and bipolar recordings can be used as appropriate. Anesthesia regime comprised sevoflurane or total intravenous anesthesia (TIVA). No muscle relaxant after intubation, local anesthesia, or blood pressure cuff is used during the surgery.Results:Twelve patients (6 male, 6 female) with peripheral nerve tumors (motor, sensitive, or mixed nerves) or tumors affecting the peripheral nerves were monitored in our center since 2014 (mean age: 50 years; 28–79). In 10 patients, the NAP was monitored without experiencing any changes from the beginning till the end of the surgery; in these patients, no postoperative deficit was adverted. In the last 2 patients, who departed from a complete neurological deficit, no NAP was recorded at the baseline or during the surgery, and they did not experience any neurological improvement.Conclusion:The vagus nerve stimulation electrodes open new possibilities in peripheral nerve IONM. We have used them for continuous monitoring without additional problems with the traditional probes.

Peripheral Retrograde Nerve Regeneration After Sciatic Nerve Injury in a Rat Model: A New Concept in Peripheral Nerve Surgery

Background: Neuroregeneration after nerve injury occurs via anterograde (proximal in the distal) regrowth. The purpose of this study was to demonstrate that nerve regeneration occurs not only proximally to distally as classically described, but also distally to proximally using a rat model with a left sciatic nerve injury, with or without repair, compared to a healthy uninjured control group. Methods: Fifteen rats were divided into 3 groups; a healthy control (Group 1, n=5), left sciatic nerve injury (Group 2, n=5), and left sciatic nerve injury and surgical retrograde nerve repair (Group 3, n=5). In Groups 2 and 3, complete surgical resection of the left sciatic nerve was performed and retrograde reconstruction of the nerve was done in Group 3 using an original, unique technique. Neuroconductive and histological variables were analyzed and compared between groups. Results: After 15 weeks, Groups 1 (control) and 3 (retrograde reinnervation) behaved similarly, with no significant differences (p<0.05) in the proportion of Schwann cells and axons, amplitude waves, nerve conduction velocity, and latency response time (p<0.05), whereas Group 2 (injured unrepaired nerve) was significantly different from Groups 1 and 3 (p<0.05). The reconstruction of injured sciatic nerves showed histopathological and neuroconductive characteristics similar to that of the healthy control group 15 weeks after the reinnervation process. Conclusion: This preclinical study demonstrates that retrograde nerve regeneration after sciatic nerve injury is feasible in a rat model 15 weeks after reconstructive nerve surgery. These results indicate that neuroregeneration is possible in a caudo-cephalic direction.

Comparison of Peripheral Nerve Regeneration with Side-to-side, End-to-side, and End-to-end Repairs: An Experimental Study.

Background:The present study was conducted to find out a tool to enable improved functional recovery with proximal nerve injury. In this experimental study, nerve regeneration was compared between side-to-side (STS), end-to-side (ETS), and end-to-end repairs.Methods:The walk track analysis was used as an outcome of functional recovery. Nerve regeneration was studied with morphometry and histology 6 or 26 weeks postoperatively.Results:All 3 repair techniques showed regeneration of the nerve. From 12 weeks onward, the functional results of the 3 intervention groups were significantly better compared with the unrepaired control group. End-to-end repair was significantly better when compared with the STS and ETS groups. At 26 weeks, the functional and morphometric results and histologic findings did not differ between the STS and ETS groups. The functional results correlated with the morphometric findings in all groups.Conclusions:STS neurorrhaphy showed nerve regeneration, and the end results did not differ from clinically widely used ETS repair. Further studies are warranted to optimize the neurorrhaphy technique and examine possible applications of STS repair in peripheral nerve surgery.

The reduction of extraneural scarring with buccal mucosa graft wrapping around the sciatic nerve: an experimental study in a rat model

Background: The postoperative development of epineural and extraneural scar tissue adversely affects peripheral nerve surgery outcomes. Although several surgical methods, pharmacological agents, and chemical materials have been used to prevent epineural scar formation in both clinical and experimental models, the results are still unsatisfactory. The purpose of this study was to investigate the efficacy of buccal mucosa graft (BMG) wrapping on epineural scarring in an adult rat model.Methods: Bilateral sciatic nerves were carefully exposed in 24 adult Sprague-Dawley rats, and a circumferential segment of epineurium (0.5 cm) was excised from both nerves. The epineurectomised left nerve segment was wrapped with a BMG (experimental side), while the right nerve segment did not receive any surgical procedure other than the epineurectomy, and served as the control side. To perform gross and histopathological examinations, 12 randomly selected rats were euthanised at 4 weeks postoperatively, and the remaining rats were euthanised at 8 weeks.Results: The left sciatic nerve that was wrapped with a BMG following epineurectomy showed significantly less nerve adhesion at 8 weeks (p = .018), and less epineural scar tissue at both 4 (p = .014) and 8 weeks (p = .025). Inflammation of the BMG-wrapped nerves was increased at 4 weeks (p = .029), but not at 8 weeks.Conclusion: BMG wrapping decreases postoperative adhesion and scar tissue formation of epineurectomised healthy nerves, despite the presence of increased inflammation in the early postoperative period.

The Chang Gung Memorial Hospital Microsurgery Fellowship: A Review of 1 Year of Experience.

Sir: The microsurgery fellowship at the Chang Gung Memorial Hospital in Taiwan was founded in 1984 by Professor Fu Chan Wei.1 The Department of Plastic and Reconstructive Surgery offers a 1-year fellowship in microsurgery. The fellowship setup, diversity and number of cases, and high success rate make it a sought target for training. In this article, I share my personal experience from a 1-year fellowship as a guide tool for those considering microsurgery training at this prestigious institution. FELLOWSHIP SETUP This fellowship is provided by the Division of Microsurgery at the Department of Plastic and Reconstructive Surgery. In total, 6 to 8 fellows are selected annually for duration of 1 year. Different areas of reconstruction are covered during the fellowship, and rotations can be customized based on the need and interest of the fellows, and these areas include head and neck reconstruction, breast reconstruction and lymphedema surgery, upper limb reconstruction, lower limb and trauma reconstruction, peripheral nerve, and facial reanimation. The fellowship is based on the principle of mentorship, and the year is composed of six 2-month rotations, where in each rotation, the team is composed of the professor, the fellow, and 1 resident. The fellow is engaged actively in the clinical and operative activity including the preoperative planning and postoperative care. There is no assigned on-call schedule for the fellow; however, he/she is expected to be in any flap takeback for the team as part of the learning experience. Table 1 summarizes the structure of the fellowship.Table 1.: Fellowship StructureEDUCATION Activities that emphasize educational value to enrich the theoretical knowledge and surgical judgment skills are as follows: Biweekly plastic surgery grand rounds: Valuable review of topics in plastic surgery, updates, and new researches are discussed. Weekly microsurgery teaching rounds: During this meeting, a review of scientific microsurgery articles, book chapters, and all cases mandates exploration during that week. Thirty-four scientific articles and 8 book chapters were reviewed this year. Operative education: Formal teaching about surgical cases is done at the day of surgery where there will be a full presentation of the cases followed by relevant literature review. SURGICAL CASES AND WORKLOAD There was an average of 3 operative days, with 2 rooms running simultaneously, and 1½ clinic days each week. The cases included microsurgical cases (free flaps, peripheral nerve surgery, and lymphatic surgery), pedicle flap, and secondary revision for all procedures. I was involved in a total of 164 cases: 101 microsurgical cases, 4 pedicled flaps, and 59 nonmicrosurgical cases. Table 2 summarizes the areas and flaps for reconstruction.Table 2.: Area of Reconstruction and Types of Free FlapRESEARCH OPPORTUNITY AND FUNDING There are ample opportunities for research in different aspects of reconstructive microsurgery. Funding is not promised for the fellow during this year. CONCLUSIONS The microsurgery fellowship at the Chang Gung Memorial Hospital provides an unparalleled opportunity to learn, understand, and practice microsurgery. I personally liked the fellowship setup, diversity and surgical loads, and the advanced techniques used here, which I think are reproducible and essential to achieve competency in microsurgery. ACKNOWLEDGMENTS The author would like to acknowledge all the professors at the Department of Plastic Surgery and the Ministry of Foreign Affairs of Taiwan (MOFA).

Thirty-Day Perioperative Adverse Outcomes After Peripheral Nerve Surgery: An Analysis of 2351 Patients in the American College of Surgeons National Surgical Quality Improvement Program Database

Because peripheral nerve surgery has become more common in recent years, the pressure to increase this procedure's health care safety and cost-effectiveness has increased. Given our limited understanding, we evaluated prospectively identified and randomly sampled patients who underwent peripheral nerve surgery from 2005 to 2014 through the American College of Surgeons National Surgical Quality Improvement Program database. We used bivariate testing and multivariate logistic regression analysis to identify patient- and surgery-related risk factors for postoperative complications and unplanned readmission in peripheral nerve surgery patients, and especially to estimate the impact of the nerve grafting procedure. Overall, 2351 patients underwent peripheral nerve surgery, 120 complications were identified in 100 patients (4.25%), and 103 patients (4.38%) received nerve grafting. Thirty-one of the 1593 patients (1.95%) underwent unplanned readmission. Nerve grafting procedures had noassociation with postoperative complications and unplanned readmission rates. Patients who experienced an inpatient procedure (odds ratio [OR], 2.54; P < 0.001), a longer operative time (OR, 1.00; P < 0.001), and worse wound classifications (OR, 1.83; P < 0.001) all had increased odds of postoperative complications. An inpatient procedure (OR, 2.74; P= 0.014) and any complications (OR, 24.43; P < 0.001) were significantly associated with unplanned readmission. Our study confirms that peripheral nerve surgery and nerve graft procedures can be safely performed with low complication risks and low unplanned readmission rates. We also identified the risks associated with perioperative adverse outcomes, and these data may be used as an adjunct for risk stratification for patients under consideration for peripheral nerve surgery. This approach may enable the improved targeting of the most costly and harmful complications of preventive measures.

Use of Posterior Root-Muscle Reflexes in Peripheral Nerve Surgery: A Case Report

ABSTRACTIt is well established that a mixed-agent general anesthetic regimen of volatile gas and intravenous anesthetic or total intravenous anesthetic (TIVA) is required to obtain adequate transcranial motor-evoked potentials (TcMEPs) to detect and hopefully prevent injury during brain, spinal cord, and peripheral nerve surgery. But even under ideal general anesthetic conditions, TcMEPs are not always detectable in every muscle monitored, and are prone to anesthetic fade, especially when neuropathic or injured tissue is monitored. TcMEP sensitivity to general anesthesia can be especially problematic during peripheral nerve surgery where there is often only one or a few essential muscles required to provide adequate monitoring; thus, maximum fidelity is essential. However, there is an anesthetic-resistant high-fidelity modality available to successfully monitor the motor component of distant peripheral nerves originating from the cauda equina. Percutaneus transabdominal electrical stimulation elicits a relatively anesthetic-resistant, robust motor response in muscles innervated by cauda equina nerve roots. We report the successful use of posterior root-muscle (PRM) reflex to monitor the decompression of the sciatic nerve at its bifurcation in a 22-year-old female with a history of severe sciatic nerve neuropathic pain and muscle weakness following benign thigh tumor resection.

C.05 Canadian neurosurgery operative landscape

Background: The Canadian Neurosurgery Research Collaborative (CNRC) is a trainee-led multi-centre collaboration made up of representatives from 12 of 14 neurosurgical centres with residency programs. To demonstrate the potential of this collaborative network, we gathered administrative operative data from each centre in order to provide a snapshot of the operative landscape in Canadian neurosurgery. Methods: Residents from each training program provided adult neurosurgical operative data for the 2014 calendar year, including the number of surgeries in the subcategories cranial, spinal, and peripheral nerve. Because some residency programs have surgeries distributed among more than one hospital, we calculated mean case load per residency program and per hospital. Results: Interim results from 6 neurosurgery residency programs are presented (with data from other programs forthcoming). Overall, there were on average 2,352 operative cases per residency program (n=6) and 1,176 operative cases per adult hospital (n=12). Among 5 programs with more detailed operative data, the mean numbers of cranial, spinal, peripheral nerve, and miscellaneous surgeries per residency program were 757 (47%), 487 (30%), 47 (3%), and 319 (20%) respectively. Conclusions: We show as a proof-of-concept that a trainee-led nation-wide research collaborative can generate meaningful data in a Canadian context.

Resident Exposure to Peripheral Nerve Surgical Procedures During Residency Training.

Background Variability in case exposures has been identified for orthopaedic surgery residents. It is not known if this variability exists for peripheral nerve procedures. Objective The objective of this study was to assess ACGME case log data for graduating orthopaedic surgery, plastic surgery, general surgery, and neurological surgery residents for peripheral nerve surgical procedures and to evaluate intraspecialty and interspecialty variability in case volume. Methods Surgical case logs from 2009 to 2014 for the 4 specialties were compared for peripheral nerve surgery experience. Peripheral nerve case volume between specialties was performed utilizing a paired t test, 95% confidence intervals were calculated, and linear regression was calculated to assess the trends. Results The average number of peripheral nerve procedures performed per graduating resident was 54.2 for orthopaedic surgery residents, 62.8 for independent plastic surgery residents, 84.6 for integrated plastic surgery residents, 22.4 for neurological surgery residents, and 0.4 for surgery residents. Intraspecialty comparison of the 10th and 90th percentile peripheral nerve case volume in 2012 revealed remarkable variability in training. There was a 3.9-fold difference within orthopaedic surgery, a 5.0-fold difference within independent plastic surgery residents, an 8.8-fold difference for residents from integrated plastic surgery programs, and a 7.0-fold difference within the neurological surgery group. Conclusions There is interspecialty and intraspecialty variability in peripheral nerve surgery volume for orthopaedic, plastic, neurological, and general surgery residents. Caseload is not the sole determinant of training quality as mentorship, didactics, case breadth, and complexity play an important role in training.

Medical Student and Primary Care Physician Perception of the Surgical Management of Upper- and Lower-Extremity Peripheral Nerve Entrapment.

Upper- and lower-extremity peripheral neuropathies are commonly encountered in the primary care setting and account for 14.3 million specialist referrals in the United States annually. Despite the integral role of plastic surgeons in the development of the field of peripheral nerve surgery, plastic surgeons are not commonly recognized as peripheral nerve specialists. The purpose of this study was to investigate the pattern of diagnosis, treatment, and referral of upper- and lower-extremity peripheral nerve entrapment syndromes by both medical students and primary care providers. An online survey including 5 peripheral nerve entrapment clinical scenarios (2 upper extremity and 3 lower extremity) was administered to medical students and primary care providers at a large academic medical center. Respondents were surveyed for level of training, prior clinical exposure, initial diagnostic studies of choice, initial therapeutic modalities of choice, need for subspecialty referral, and appropriate surgical subspecialists for management of the peripheral nerve entrapment. Overall, 248 medical students (38.3% response rate) and 54 primary care providers (13.5% response rate) completed the study. The majority of medical students and primary care providers indicated prior clinical experience with upper-extremity peripheral nerve entrapment in contrast to lower-extremity peripheral nerve entrapment with 26.2% and 39.9% of medical students and primary care physicians reporting prior clinical exposure, respectively. Medical students and primary care providers identified orthopedic surgery as the preferred choice for subspecialty referral for both upper- and lower-extremity peripheral nerve entrapment. Primary care physicians are more inclined to initially manage upper-extremity nerve entrapment without referral to other specialties than for the management of lower-extremity nerve entrapment; 38.0% and 61.1% of the primary care physicians surveyed would refer to another specialty for the initial management of carpal tunnel and cubital tunnel syndromes, in contrast to 83.0%, 90.0%, and 88.2% for the management of common peroneal nerve compression, sural nerve compression, and deep peroneal nerve compression, respectively. We contend that early education of medical students and primary care providers regarding the role of plastic surgeons as peripheral nerve specialists may improve future referral patterns.