Peripheral Nerve Surgery

The nervous system is broadly divided into the central nervous system (which comprises of the brain and the spinal cord) and the peripheral nervous system (all the nerves that exit the brain and the spinal cord). Peripheral nerve surgeries are required in cases of acute nerve injuries, entrapment neuropathies and nerve sheath tumors. The peripheral nerve system is responsible for sensory information (i.e. touch, pressure, temperature, etc) and motor function (i.e. muscular movements both voluntary and involuntary).

A peripheral nerve surgery requires a well experienced and multidisciplinary team (including an orthopedic surgeon, neurosurgeon, plastic and reconstructive surgeon). Very few centres have a well experienced and multi-disciplinary team of medical professionals to cater to the wide ranging medical needs of patients. International destinations which provide a comprehensive set of medical and surgical care for peripheral nerve surgery include South Korea, India, Jordan and Turkey in the Asian continent and Mexico in North America.

Conditions requiring peripheral nerve surgery:

Patients, who have narrowed or blocked femoral or popliteal arteries, which are near the surface of the legs are recommended the fem-pop bypass surgery because that blocked femoral artery may cause significant symptoms or it may threaten the limb (http://www.webmd.com/heart-disease/Femoropopliteal-bypass-fem-pop-bypass-for-peripheral-arterial-disease). The disease of the arteries of the limbs is known as Peripheral Arterial Disease (PAD). PAD can be cured in two ways – the standard procedure is called femoral popliteal bypass surgery and the new intervention called Percutaneous Transluminal Angioplasty (PTA) of the femoral artery.

Percutaneous transluminal angioplasty (PTA) of the femoral arteries

Peripheral Nerve Surgery may be required for a host of medical conditions listed below,

Nerve Compressions

Nerve compression conditions in the Neck, Arm and Hands which include compression of single nerve (Carpel Tunnel Syndrome, Ulnar Nerve Compression at elbow or the wrist, Supinator Syndrome (affecting the finger and wrist extension), Pronator Syndrome (i.e. affects flexion of the fingers and wrist), Greater Occipital Nerve Entrapment, Superficial sensory Radial Nerve entrapment, and Radial tunnel syndrome. Nerve compression condition in the pelvis, leg and feet which includes Peroneal Nerve Entrapment at the Fibular head, Tarsal Tunnel Syndrome, Pudendal Nerve Entrapment, and Neurogenic Pyriformis syndrome.

Nerve Tumors

Nerve surgery is required for benign tumors from the nerve sheath (Schwannomas or Neurofibromas), benign fat tissue tumors (Lipomas), Malignant Nerve Sheath Tumors, Metastasis and infiltrative tumors involving nerves.

Nerve Injuries

Nerve injury causes pain, weakness, and numbness in the part of the body they supply. Although most of the nerve injuries recovery spontaneously, others require surgical intervention and repair

Myopathy and Neuropathy

Nerve surgery is required for some forms of myopathies (muscle weakness) and Neuropathies (nervous weakness) resulting from unexplainable causes.

Peripheral Nerve Surgery: The procedures

The procedure for conducting a peripheral nerve surgery depends upon the underlying medical condition. Different techniques and procedures are used.

Nerve decompression surgery:

External Neurolysis

Nerves in our body tend to cross across muscles and bones and occasionally tend to get trapped due to scarring or fibrosis, causing pain due to nerve irritation, when the limb is moved. The procedure involves the removal of the scar tissue formed around the nerve without entering the nerve.

Internal Neurolysis

The procedure is used when there is internal scarring and swelling in the nerve tissue. In such cases the outer sheath covering the nerve is opened and the scar tissue inside is removed to reduce pain and irritation.

There are the two basic techniques of conducting decompression surgery. The first one is open nerve release, which involves decompressing the nerve tissue through an incision in the skin. The second technique is an endoscopic method, where a tube containing a camera is passed, through a small incision into the affected area and the compression assessed. The procedure of decompression is then conducted. The latter procedure has an advantage of reducing the recovery time and allowing the patient to return back to work at the earliest.

Surgery for Nerve Injuries

Nerve Repair

A procedure that involves re-attaching the two ends of the torn nerve with fine sutures with the help of a microscope. This is possible only when there is no nerve tissue lost as a result of the injury

Nerve Grafting

A procedure, which involves the use of a graft (most often used is the sural nerve from behind the calf). The graft is attached to the injured nerve in the same way as done in the nerve repair procedure. The patient may suffer from temporary numbness in the calf region, which usually resolves after 6-8 months

Conduit Nerve Repair

When the gap is less than 2-3 centimeters, instead of using a nerve grafting procedure, a small absorbable tube is used. As an alternative a vein conduit can also be used, this is equally effective. Conduits may be used to cover or wrap the nerves to protect them from scar tissue in the surrounding area.

Transfer surgery

On few occasions, the above procedures are not adequate to re-instate the normal functioning of the muscle, tendon or the nerve. In such cases transfer of other nerves, muscle or tendons ( which are less frequently used or have multiple controlling nerve supplies) are used

Nerve Transplant

A rarely used procedure which involves transfer of nerve tissue from other patient.

Surgery for Nerve Tumors

Management of nerve tumors involves the excision of the benign or cancerous cells by the oncologist. During the procedure all precautions are taken to ensure minimum damage to the nerve tissue and its functions.

Preoperative Management: Peripheral Nerve Surgery

• A physical evaluation and assessment of the patient is done to verify the urgency and severity of managing the clinical condition. This physical evaluation will include sensory evaluation (which will consist of, the two point discrimination test and light touch test) and Motor assessment (which will include pinch and grip strength measurement and muscle strength measurement).
• Radiological scans like MRI, CT or other studies would be conducted depending upon the condition, to confirm the diagnosis.
• The surgery may be conducted under general anesthesia on IPD basis or under local anesthesia on OPD basis depending upon the severity of the condition and the nerve involved.

Post-operative Care: Peripheral Nerve Surgery

• In a peripheral nerve surgery conducted on OPD basis, the patient is discharged within a couple of hours on the same day.
• For procedures which are conducted on IPD basis, the patient is hospitalized for a few days after the procedure. The dressing is removed 2-3 days after the procedure.
• The patient is recommended several physical exercises to enhance the mobility of the joints. These exercises are aimed at maintaining the functionality of the unaffected muscles at the initial stages after the surgery and subsequently to regain the sensory and motor functions of the affected nerve.

Complications: Peripheral Nerve Surgery

Complications of peripheral nerve surgery are similar to complications associated with similar nature of surgeries which include infection, hematoma, injury to surrounding tissues, etc. There is also a possibility that the surrounding nerves may be injured during the surgical intervention which can further deteriorate the functionality of the affected organ.

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