Nerve Pain Surgery Special Issue
With a rapid expansion of ideas, techniques, and products available for surgical treatments of nerve pain problems, it is data, rigorous investigation, and honest reporting that are critical to ensuring high-quality care. In this special issue we take a broad approach, delving into various aspects of how surgeons manage nerve pain, focusing on harder-to-tell and less-often discussed pieces of this growing puzzle.
Nerve Pain SurgeryNerve pain has plagued humanity, in some form, for millennia. Whether due to trauma, post-traumatic changes, compression, metabolic abnormalities, infections, inflammatory pathologies, or another neuropathic etiology, consistent and reliable treatments for these nerve pain issues are still needed. Throughout history, as science and technology have changed, so have the proposed treatments. Yet one of the main limitations to overall progress is that we still do not truly understand the nature of many nerve pain problems, making finding a proper treatment even more difficult.
Multiple Concurrent Decompressions for the Treatment of Upper Extremity PainNeuropathic pain can be life altering and difficult to treat. Nerves can be compressed along their path in the upper extremities, resulting in chronic neuropathic pain. This study was performed to evaluate the effectiveness and safety of multiple concomitant distal nerve decompressions for the treatment of upper extremity nerve pain.
High-Transhumeral Amputation: Targeted Muscle Reinnervation and Soft Tissue Coverage With Pedicled Latissimus Dorsi FlapThe introduction of targeted muscle reinnervation has improved amputation pain outcomes and the control of upper-extremity myoelectric prostheses. However, patients with proximal transhumeral amputation levels and soft tissue deficits present a unique challenge. Existing described targeted muscle reinnervation techniques in transhumeral amputees rely on recipient motor nerves from the biceps and triceps; however, these may be absent in patients with more proximal injuries. Here, we describe the use of the pedicled latissimus dorsi flap for both soft tissue coverage and additional motor targets in patients with high-transhumeral amputation with complex soft tissue deficits.
Use of Vascularized, Denervated Muscle Targets for Prevention and Treatment of Upper-Extremity NeuromasNeuroma formation following upper-extremity peripheral nerve injury often results in persistent, debilitating neuropathic pain with a limited response to medical management. Vascularized, denervated muscle targets (VDMTs) offer a newly described surgical approach to address this challenging problem. Like targeted muscle reinnervation and regenerative peripheral nerve targets, VDMTs are used to redirect regenerating axons from an injured nerve into denervated muscle to prevent neuroma formation. By providing a vascularized muscle target that is reinnervated via direct neurotization, VDMTs offer some theoretical advantages in comparison with the other contemporary surgical options.
Changes in Patient-Reported Pain Interference After Surgical Treatment of Painful Lower Extremity NeuromasPainful neuromas commonly cause neuropathic pain, in up to 1 in 20 cases of traumatic or iatrogenic nerve injury. Despite the multiple surgical treatment types that reduce pain, no type has been universally accepted.
Selective Thumb Carpometacarpal Joint Denervation for Painful Arthritis: Follow-Up of Long-Term Clinical OutcomesThumb carpometacarpal (CMC) joint osteoarthritis is a common problem affecting up to 85% of patients over the age of 70. The most common presenting symptom for patients with CMC arthritis is pain with joint loading. Loss of function due to subluxation or joint destruction is comparatively rare. Carpometacarpal joint denervation is a relatively novel method for managing CMC arthritis, treating the most impactful symptom: pain.
Diagnostic Biomarkers for Upper Extremity Chronic Pain ConditionsHand surgery patients often experience chronic pain conditions. However, there are few reliable ways to measure pain, making diagnosis and subsequent management of these conditions notably challenging for the hand surgeon. Various diagnostic biomarkers have been actively studied in the chronic pain management field with promising results. This review discusses the development of diagnostic biomarkers for chronic pain conditions of the upper extremity, including complex regional pain syndrome, osteoarthritis, and neuropathic pain.
Treatment of Refractory Radial Sensory Neuroma With Function-Sparing Targeted Muscle Reinnervation to the Extensor Carpi Radialis BrevisThe radial sensory nerve can be injured during many common procedures, including intravenous cannulation, first extensor compartment release, and radial-sided wrist surgery. Injury to the nerve may result in neuroma formation that can lead to chronic and debilitating pain. Nonsurgical treatments and surgical interventions, including excision of the neuroma and burying the nerve into local muscle, are frequently ineffective. Here, we present a technique for treating recalcitrant neuromas of the radial sensory nerve with targeted muscle reinnervation to a redundant motor nerve branch of the extensor carpi radialis brevis.
Upper-Extremity Peripheral Nerve StimulatorsChronic pain conditions are some of the most challenging problems upper-extremity surgeons face and often require a multimodal approach including neuromodulation. Peripheral nerve stimulation (PNS) is one of these modalities, delivering electrical stimulation to peripheral axons to modulate the spinal cord and block out nociceptive signals from the extremity. This blockade leads to long-lasting effects in both the peripheral and central nervous systems. Not only does PNS decrease peripheral pain signals but it also decreases the peripheral inflammatory response and assists with central nervous system plasticity for long-term pain control.
What is Operative? Conceptualizing Neuralgia: Neuroma, Compression Neuropathy, Painful Hyperalgesia, and Phantom Nerve PainNeuralgia, or nerve pain, is a common presenting complaint for the hand surgeon. When the nerve at play is easily localized, and the cause of the pain is clear (eg, carpal tunnel syndrome), the patient may be easily treated with excellent results. However, in more complex cases, the underlying pathophysiology and cause of neuralgia can be more difficult to interpret; if incorrectly managed, this leads to frustration for both the patient and surgeon. Here we offer a way to conceptualize neuralgia into 4 categories—compression neuropathy, neuroma, painful hyperalgesia, and phantom nerve pain—and offer an illustrative clinical vignette and strategies for optimal management of each.