A Brief Update in Peripheral Nerve Surgery: Reflecting on the Current Literature
In our experience, pursuing a fellowship specializing in orthoplastic techniques and peripheral nerve surgery is a privilege. Reading current literature is imperative to understand and stay updated on the most recent evidence-based treatments. The peripheral nerve surgeon should have a high suspicion for a nerve injury if the patient presents with a history of trauma, sprain, fall, fracture, or prior surgery. It is important to note, patients may present with orthopedic and neurologic symptoms related to the etiology of their pain. However, when the physician recognizes a concomitant peripheral nerve injury, the treatment plan can be tailored to help provide the patient relief.
Our current management in our service focuses on reconstructive procedures of peripheral nerve injuries. More specifically, when referring to the Seddon classification, we typically pursue decompression and fasciectomy for a Type I nerve injury and resection of neuroma with interpositional conduit-allograft or conduit-autograft repair for a Type II nerve injury. Targeted muscle reinnervation and regenerative peripheral nerve interface are the among most recently published reconstructive procedures in the plastic reconstructive literature for a Type III nerve injury and residual pain.1,2,3 The Sunderland classification4 of nerve injuries expands upon the anatomy of nerve injuries.4 Chhabra and colleagues5 devised a treatment algorithm table for nerve injuries grading the injuries I-VI.5 This same paper suggests no surgical intervention for Grades I-II, either no surgical intervention or neurolysis for Grade III, nerve repair, nerve grafting, or nerve transfer for Grades IV-V, and neurolysis, nerve repair, grafting, or nerve transfer for a Grade VI injury.5
Before considering which techniques are appropriate, a patient must undergo a neurophysiology exam involving nerve conduction studies and electromyographic studies prior to intervention.1 It is imperative that a nerve study evaluates the nerve along its entire course to identify possible proximal and distal zones of injury. When the diagnostic studies reveal the extent of the injury and location, the proper protocol should be followed according to the type of nerve injury as discussed by Ward and Rodriguez1 or Chhabra.5 Occasionally, patients that present with neuropathic symptoms of tingling, burning, and shooting pains have an inciting event of neuropathic pain and respond well to diagnostic ultrasound-guided nerve blocks. However, the neurophysiology exam results do not reveal an identifiable zone of injury or neuroma. The question is raised, “What option is now available to the patient if they failed conservative measures?” “The Reset Neurectomy for Cutaneous Nerve Injuries,” published in Plastic and Reconstructive Surgery by Eberlin and team in early 2021 is an option for patients with diffuse pain along a nerve trajectory with no identifiable neuroma on the nerve conduction studies.6
Understanding Another Potential Option for Neuropathic Pain
The reset neurectomy is utilized in cutaneous nerve injuries within patients having neuropathic pain symptoms. Its purpose is to remove the painful afferent stimuli and promote regeneration into the distal nerve segment.6 The neurectomy takes place proximal to the zone of injury, at the location of the clinically performed ultrasound-guided nerve block, that provided significant relief, and is immediately coapted. The surgeon places the surgical incision within a well-vascularized area. This nerve block in the office during the preoperative work-up is imperative for identifying if this patient is a candidate for a reset neurectomy and where to place the surgical incision. Placing the surgical incision proximal to the zone of injury is ideal for accessibility and reconstruction. The use of an allograft and conduits is an option with this procedure. One can perform a segmental neurectomy when using the allograft-conduit repair. The article advocates that if performing segmental neurectomy, it should measure between 5 and 50mm.6 An allograft should not be utilized in a segmental neurectomy exceeding 70mm for optimal results and axonal regeneration. If the segmental neurectomy exceeds 70mm, one must use an autograft.1
Final Thoughts
As discussed within the article, the reset neurectomy is an option in patients with diffuse nerve injuries without an identifiable neuroma, for sensory nerve injuries and nerve injuries Grade II-IV as described by Eberlin and colleagues, giving the patient and surgeon another option for pain relief.6 As stated in this article, the proximal nerve segment resection removes the noxious afferent signal once produced by the injured nerve. Once removing the nerve segment, the proximal and distal neurectomy sites are immediately coapted with a conduit-assisted repair, if the neurectomy is less than 5 mm, or the repair is made with an allograft-conduit, depending on the size of the defect.6 If using an allograft or autograft in the nerve repair, it is the authors’ opinion that this helps alleviate the central pain component while axonal regeneration occurs within the graft.
Peripheral nerve pain can be debilitating. Often, patients are searching for an answer with no results. If the podiatrist, even if not specializing in peripheral nerve surgery, can recognize and know the signs and symptoms of nerve pathology, the patient will be that much closer to finding pain relief.
Dr. Schnack is the Fellow at the AMITA Health Saint Joseph Hospital Chicago Fellowship in Complex Deformity Correction and Limb Reconstruction. She is board certified by the American Board of Podiatric Medicine and board qualified by the American Board of Foot & Ankle Surgery in Foot and Reconstructive Rearfoot and Ankle Surgery.
Dr. Oexeman is a Fellowship-trained foot and ankle surgeon at Oexeman Foot and Ankle, PLLC. She is affiliated with AMITA Health Saint Joseph Hospital Chicago. She is board certified by the American Board of Podiatric Medicine and board qualified by the American Board of Foot & Ankle Surgery in Foot and Reconstructive Rearfoot and Ankle Surgery.
Dr. Rodriguez-Collazo is the Fellowship Director of the AMITA Health Saint Joseph Hospital Chicago Fellowship in Complex Deformity Correction and Limb Reconstruction.
References
1. Ward KL, Rodriguez-Collazo ER. Surgical Treatment Protocol for Peripheral Nerve Dysfunction of the Lower Extremity: A Systematic Approach. Orthoplastic techniques for lower extremity reconstruction–Part II, An Issue of Clinics in Podiatric Medicine and Surgery, E-Book. 2020;38(1):73-82.
2. Schnack LL, Oexeman S, Ward KL, Rodriguez-Collazo E. Microneurosurgery: A Guide For Diagnosing Nerve Pathology And Treatment Options In The Lower Extremity. Podiatry Today. October 2021.
3. Seddon H. Three types of nerve injury. Brain. 1943;66(4):237-88.
4. Sunderland S. A classification of peripheral nerve injuries producing loss of function. Brain. 1951;74:491-516.
5. Chhabra A, Ahlawat S, Belzberg A, Andreseik G. Peripheral nerve injury grading simplified on MR neurography: as referenced to Seddon and Sunderland classifications. Ind J Radiol Imaging. 2014;24(3):217-224.
6. Eberlin KR, Pickrell BB, Hamaguchi R, Hagan RR. Reset Neurectomy for Cutaneous Nerve Injuries. Plast Reconst Surg Global Open. 2021 Feb;9(2).
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