Neurectomy

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Neurectomy
Specialty Neurology

A neurectomy, or nerve resection is a neurosurgical procedure in which a peripheral nerve is cut or removed to alleviate neuropathic pain or permanently disable some function of a nerve. The nerve is not intended to grow back. For chronic pain it may be an alternative to a failed nerve decompression when the target nerve has no motor function and numbness is acceptable. [1] Neurectomies have also been used to permanently block autonomic function (e.g. excessive sweating in hands [2] or involuntary muscle movement causing cramps [3] ), and special sensory function not related to pain (e.g. vestibular nerve dysfunction causing vertigo [4] ).

Contents

A temporary nerve block with an anesthetic if usually performed before surgery to confirm the diagnosis of neuropathic pain. [1] Risks include numbness, neuroma, and complications due to lack of innervation.

Procedures

Presacral neurectomy

A presacral neurectomy is typically conducted to decrease severe pain and menstrual cramps in the lower abdomen. Pain in this region is difficult to treat with noninvasive treatments. Endometriosis is the most common cause for this severe pain. One solution that doctors often mistakenly recommend as a cure is a hysterectomy, or removal of the uterus. However, this often does not relieve endometriosis pain because the disease is left behind on other organs such as the bladder, bowels, or pelvic side walls, and it can thrive on its own hormone supply. Another is to perform a presacral neurectomy. This is a procedure that interrupts the nerves going towards and/or around the uterus. [5] Pain located on either side of the lower abdomen (but not mid line) should not be treated with a neurectomy. Only individuals with pain that is not relieved by the use of NSAIDs should consider this procedure. Techniques have been developed for this procedure to be performed laparoscopically. [5]

The incision is typically directly under the navel. Normally three small holes are made in the lower abdomen to allow for the instruments and other various surgical tools. Nerve tissue that runs to the uterus is interrupted at the sacral promontory; a point at which spine and tailbones meet. This is the best area to access and obtain a clear view of the nerves in the uterus. Proper precautions must be taken as to avoid unnecessary complications with the major blood vessels surrounding the uterus. Some of the complications post-operation include urinary retention, as well as constipation. Neither has been reported to cause lasting effects. [5]

Recent technological advances have allowed this same procedure to be done robotically, a minimally invasive technique similar to laparoscopy. The outcome of the procedure is identical to an open approach (laparotomy), but the incisions are much smaller allowing for less post-operation pain. Less pain following this surgery allows for a quicker recovery period too; two weeks as opposed to six weeks, on average. [6]

Vestibular neurectomy

A vestibular neurectomy is an operation that severs the vestibular nerve, which contributes to balance, while sparing the cochlear nerve, which contributes to hearing. The procedure has the potential to relieve vertigo, but may preserve the ability to hear. [7] It is important to note that this procedure will not reverse the effects of deafness. The risks include: hearing loss, tinnitus, dizziness, facial weakness, spinal fluid leak, and various infections. [8] There are several different surgical approaches that can be used to complete this procedure: the middle cranial fossa, retrolabrynthine, retrosigmoid, and translabrynthine. [9] The middle cranial fossa approach is one that most often requires neurosurgical expertise. The advantage of this procedure is that the vestibular nerve is clearly visible and can be sectioned without harming the cochlear nerve fibers. [7]

The general procedure begins by positioning the patient supine with the head turned to the side with surgical ear upright. An incision is made at the lower portion of the zygomatic root to the area of the temporal region for roughly seven centimeters. Precautions are taken by clamping flaps of tissue as to not impede further actions. To expose the IAC (Inner Auditory Canal) properly, portions of bone from the metal fundus and also the tegmen tympani must be removed. [8] The SVN (superior vestibular nerve) is then identified and cut at the point furthest from the vestibular crest. Along with the SVN, Scarpa's ganglion is also cut and removed. [8]

In cases of Ménière's disease, a neurectomy may be needed when no other medical treatment is sufficient for over six months. In bilateral Ménière's disease, the procedure is done on the worse-off ear. Some procedures are done on both ears, but the risk of hearing loss then becomes significantly greater. [8]

Pulsed radiofrequency ablation neurectomy

Some ablations that have been previously performed laparoscopically are also now offered via the pulsed radiofrequency technique. Pulsed radiofrequency ablation relies on delivering an electrical field specifically to neural tissue in order to damage it while minimizing injury to the surrounding area. For example, this technique has been used in patients with chronic shoulder pain as a way to perform a neurectomy of the suprascapular nerve with less risk of damage to nearby muscles within the rotator cuff. [10] There is still a lack of evidence directly comparing the efficacy and safety of this technique compared to the traditional laparoscopic method, but there is evidence that it improves range of motion and pain compared to placebo [10] or sham surgery. [11]

Neurectomy for nerve entrapment

Neurectomy can be an alternative to a nerve decompression for nerve entrapment, such as when the nerves have no motor function and numbness along the dermatome is acceptable. A neurectomy is not a mutually exclusive option to a decompression as a neurectomy can also be used after a failed decompression. [12]

There are many nerves in the human body that are purely sensory such as the cutaneous nerves, which provide innervation to all parts of the skin. The cutaneous nerves are especially susceptible to compression from wearables or injuries due to their superficial location. Some examples of wearable-induced irritation are supraorbital neuralgia from tight goggles, [13] superficial radial neuropathy from handcuffs, [14] and meralgia paresthetica from tight pants. [15] As cutaneous nerves cover all areas of the skin, and any surgery which requires incisions may inadvertently cause injury or scarring, now entrapping a cutaneous nerve. [16]

A common tradeoff when electing to a neurectomy is that numbness along the nerve distribution is expected. Studies that have measured how bothersome numbness is to patients have found that most patients are not bothered at all by the numbness, and the ones that are find the numbness minimally bothering. [17] [18]

Intercoastal cutaneous nerve neurectomy

Intercoastal neuralgia is a neuropathic condition that involves the intercoastal nerves. The primary symptom is pain and it may be localized to the distribution of one or more of the intercoastal nerves, manifesting as chest and abdominal pain. [19] No treatment modality prior to neurectomy (e.g. systemic medications, cryoablation, therapeutic nerve blocks, and radioablation) has given effective pain relief and none have been curative. [20]

The success outcome is typically measured as a 50% or more decrease in visual analog scale (VAS) scores, which are numerical pain scores from 0 - 10 or 0-100. Success rates are often reported as 70%. [21] [22] [23] Studies reporting on intercoastal neurectomy often report cure rates (100% reduction in symptoms), even though it's not the primary success outcome. For example, patients may say they are cured or report pain scores of zero. There is a wide span of the reported cure rates, ranging from 22 - 67%. [21] [22] [24] A double-blind, randomized, controlled surgery trial found a 22% cure rate for the surgery group and a 4% cure rate for the sham surgery group, suggesting that these cure rates cannot be purely attributable to the natural history of the disease or a placebo effect. [22]

Lateral femoral cutaneous nerve neurectomy

Lateral femoral cutaneous neuralgia, often known as Meralgia Paresthetica, involves neuropathic pain on the outer thigh. The use of a nerve decompression or neurectomy to treat nerve pain along the lateral femoral cutaneous nerve is a firmly established surgical treatment. [25] [26] However, the more effective treatment between a decompression and neurectomy is still being researched.

Between a nerve decompression and a neurectomy, the neurectomy is associated with a higher success rate which has been validated by two Cochrane reviews. The reviews found decompressions beneficial in 88% of cases and neurectomy beneficial in 94% of cases. [27] [28] A German national cohort study found similar results where complete pain relief from decompression was seen in 63% of cases but complete pain relief from neurectomy was seen in 85%. [29]

Use in horses

Neurectomy is also used in equine medicine, primarily for cases of persistent lameness that is non-responsive to other forms of treatment. It is most commonly used for animals with navicular syndrome and suspensory ligament desmitis. [30]

See also

Related Research Articles

<span class="mw-page-title-main">Trigeminal neuralgia</span> Neurological pain disorder

Trigeminal neuralgia, also called Fothergill disease, tic douloureux, trifacial neuralgia, or suicide disease is a long-term pain disorder that affects the trigeminal nerve, the nerve responsible for sensation in the face and motor functions such as biting and chewing. It is a form of neuropathic pain. There are two main types: typical and atypical trigeminal neuralgia. The typical form results in episodes of severe, sudden, shock-like pain in one side of the face that lasts for seconds to a few minutes. Groups of these episodes can occur over a few hours. The atypical form results in a constant burning pain that is less severe. Episodes may be triggered by any touch to the face. Both forms may occur in the same person. It is regarded as one of the most painful disorders known to medicine, and often results in depression and suicide.

Pudendal nerve entrapment (PNE), also known as Alcock canal syndrome, is an uncommon source of chronic pain in which the pudendal nerve is entrapped or compressed in Alcock's canal. There are several different types of PNE based on the site of entrapment anatomically. Pain is positional and is worsened by sitting. Other symptoms include genital numbness, fecal incontinence and urinary incontinence.

Neuralgia is pain in the distribution of a nerve or nerves, as in intercostal neuralgia, trigeminal neuralgia, and glossopharyngeal neuralgia.

Occipital neuralgia (ON) is a painful condition affecting the posterior head in the distributions of the greater occipital nerve (GON), lesser occipital nerve (LON), third occipital nerve (TON), or a combination of the three. It is paroxysmal, lasting from seconds to minutes, and often consists of lancinating pain that directly results from the pathology of one of these nerves. It is paramount that physicians understand the differential diagnosis for this condition and specific diagnostic criteria. There are multiple treatment modalities, several of which have well-established efficacy in treating this condition.

<span class="mw-page-title-main">Nerve block</span> Deliberate inhibition of nerve impulses

Nerve block or regional nerve blockade is any deliberate interruption of signals traveling along a nerve, often for the purpose of pain relief. Local anesthetic nerve block is a short-term block, usually lasting hours or days, involving the injection of an anesthetic, a corticosteroid, and other agents onto or near a nerve. Neurolytic block, the deliberate temporary degeneration of nerve fibers through the application of chemicals, heat, or freezing, produces a block that may persist for weeks, months, or indefinitely. Neurectomy, the cutting through or removal of a nerve or a section of a nerve, usually produces a permanent block. Because neurectomy of a sensory nerve is often followed, months later, by the emergence of new, more intense pain, sensory nerve neurectomy is rarely performed.

Meralgia paresthetica or meralgia paraesthetica is numbness or pain in the outer thigh not caused by injury to the thigh, but by injury to a nerve that extends from the spinal column to the thigh.

<span class="mw-page-title-main">Morton's neuroma</span> Benign neuroma of an intermetatarsal plantar nerve

Morton's neuroma is a benign neuroma of an intermetatarsal plantar nerve, most commonly of the second and third intermetatarsal spaces, which results in the entrapment of the affected nerve. The main symptoms are pain and/or numbness, sometimes relieved by ceasing to wear footwear with tight toe boxes and high heels. The condition is named after Thomas George Morton, though it was first correctly described by a chiropodist named Durlacher.

<span class="mw-page-title-main">Lateral cutaneous nerve of thigh</span> Nerve of the thigh

The lateral cutaneous nerve of the thigh is a cutaneous nerve of the thigh. It originates from the dorsal divisions of the second and third lumbar nerves from the lumbar plexus. It passes under the inguinal ligament to reach the thigh. It supplies sensation to the skin on the lateral part of the thigh by an anterior branch and a posterior branch.

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<span class="mw-page-title-main">Superior hypogastric plexus</span>

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Post herniorrhaphy pain syndrome, or inguinodynia is pain or discomfort lasting greater than 3 months after surgery of inguinal hernia. Randomized trials of laparoscopic vs open inguinal hernia repair have demonstrated similar recurrence rates with the use of mesh and have identified that chronic groin pain (>10%) surpasses recurrence (<2%) and is an important measure of success.

<span class="mw-page-title-main">Superior cluneal nerves</span>

The superior cluneal nerves are pure sensory nerves that innervate the skin of the upper part of the buttocks. They are the terminal ends of the L1-L3 spinal nerve dorsal rami lateral branches. They are one of three different types of cluneal nerves. They travel inferiorly through multiple layers of muscles, then traverse osteofibrous tunnels between the thoracolumbar fascia and iliac crest.

Migraine surgery is a surgical operation undertaken with the goal of reducing or preventing migraines. Migraine surgery most often refers to surgical nerve decompression of one or several nerves in the head and neck which have been shown to trigger migraine symptoms in many migraine sufferers. Following the development of nerve decompression techniques for the relief of migraine pain in the year 2000, these procedures have been extensively studied and shown to be effective in appropriate candidates. The nerves that are most often addressed in migraine surgery are found outside of the skull, in the face and neck, and include the supra-orbital and supra-trochlear nerves in the forehead, the zygomaticotemporal nerve and auriculotemporal nerves in the temple region, and the greater occipital, lesser occipital, and third occipital nerves in the back of the neck. Nerve impingement in the nasal cavity has additionally been shown to be a trigger of migraine symptoms.

<span class="mw-page-title-main">Nerve compression syndrome</span> Human disease

Nerve compression syndrome, or compression neuropathy, or nerve entrapment syndrome, is a medical condition caused by chronic, direct pressure on a peripheral nerve. It is known colloquially as a trapped nerve, though this may also refer to nerve root compression. Its symptoms include pain, tingling, numbness and muscle weakness. The symptoms affect just one particular part of the body, depending on which nerve is affected. The diagnosis is largely clinical and can be confirmed with diagnostic nerve blocks. Occasionally imaging and electrophysiology studies aid in the diagnosis. Timely diagnosis is important as untreated chronic nerve compression may cause permanent damage. A surgical nerve decompression can relieve pressure on the nerve but cannot always reverse the physiological changes that occurred before treatment. Nerve injury by a single episode of physical trauma is in one sense an acute compression neuropathy but is not usually included under this heading, as chronic compression takes a unique pathophysiological course.

<span class="mw-page-title-main">Spinal stenosis</span> Disease of the bony spine that results in narrowing of the spinal canal

Spinal stenosis is an abnormal narrowing of the spinal canal or neural foramen that results in pressure on the spinal cord or nerve roots. Symptoms may include pain, numbness, or weakness in the arms or legs. Symptoms are typically gradual in onset and improve with leaning forward. Severe symptoms may include loss of bladder control, loss of bowel control, or sexual dysfunction.

Occipital nerve stimulation (ONS), also called peripheral nerve stimulation (PNS) of the occipital nerves, is used to treat chronic migraine patients who have failed to respond to pharmaceutical treatments.

Anterior cutaneous nerve entrapment syndrome (ACNES) is a nerve entrapment condition that causes chronic pain of the abdominal wall. It occurs when nerve endings of the lower thoracic intercostal nerves (7–12) are 'entrapped' in abdominal muscles, causing a severe localized nerve (neuropathic) pain that is usually experienced at the front of the abdomen.

<span class="mw-page-title-main">Presacral neurectomy</span>

Presacral neurectomy is one of the treatments for chronic pelvic pain and dysmenorrhea. Lapraroscopic presacral neurectomy is an initial surgical intervention for chronic pelvic pain when medical therapy fails.

A nerve decompression is a neurosurgical procedure to relieve chronic, direct pressure on a nerve to treat nerve entrapment, a pain syndrome characterized by severe chronic pain and muscle weakness. In this way a nerve decompression targets the underlying pathophysiology of the syndrome and is considered a first-line surgical treatment option for peripheral nerve pain. Despite treating the underlying cause of the disease, the symptoms may not be fully reversible as delays in diagnosis can allow permanent damage to occur to the nerve and surrounding microvasculature. Traditionally only nerves accessible with open surgery have been good candidates, however innovations in laparoscopy and nerve-sparing techniques made nearly all nerves in the body good candidates, as surgical access is no longer a barrier.

<span class="mw-page-title-main">Deep gluteal syndrome</span> Medical condition

Deep gluteal syndrome describes the non-discogenic extrapelvic entrapment of the sciatic nerve in the deep gluteal space. It is an extension of non-discogenic sciatic nerve entrapment beyond the traditional model of piriformis syndrome. Symptoms are pain or dysthesias the buttocks, hip, and posterior thigh with or without radiating leg pain. Patients often report pain when sitting. The two most common causes are piriformis syndrome and fibrovascular bands, but many other causes exist. Diagnosis is usually done through physical examination, magnetic resonance imaging, magnetic resonance neurography, and diagnostic nerve blocks. Surgical treatment is an endoscopic sciatic nerve decompression.

References

  1. 1 2 Lipinski LJ, Spinner RJ. Neurolysis, neurectomy, and nerve repair/reconstruction for chronic pain. Neurosurg Clin N Am. 2014 Oct;25(4):777-87. doi : 10.1016/j.nec.2014.07.002 Epub 2014 Aug 14. PMID: 25240664.
  2. ↑ Vannucci F, Araújo JA. Thoracic sympathectomy for hyperhidrosis: from surgical indications to clinical results. J Thorac Dis. 2017 Apr;9(Suppl 3):S178-S192. doi : 10.21037/jtd.2017.04.04 PMID: 28446983; PMCID: PMC5392541.
  3. ↑ Miller LE, Bhattacharyya R, Miller VM. Clinical Utility of Presacral Neurectomy as an Adjunct to Conservative Endometriosis Surgery: Systematic Review and Meta-Analysis of Controlled Studies. Sci Rep. 2020 Apr 23;10(1):6901. doi : 10.1038/s41598-020-63966-w PMID: 32327689; PMCID: PMC7181806.
  4. ↑ Alarcón AV, Hidalgo LO, Arévalo RJ, Diaz MP. Labyrinthectomy and Vestibular Neurectomy for Intractable Vertiginous Symptoms. Int Arch Otorhinolaryngol. 2017 Apr;21(2):184-190. doi : 10.1055/s-0037-1599242 PMID: 28382129; PMCID: PMC5375706.
  5. 1 2 3 "Presacral Neurectomy". Archived from the original on 2013-12-15. Retrieved 2013-12-15.[ unreliable medical source? ]
  6. ↑ "Robotic Presacral Neurectomy". The Robotic Surgery Center, NYU Langone Medical Center. Archived from the original on August 1, 2013. Retrieved December 15, 2013.
  7. 1 2 Vestibular Neurectomy at eMedicine
  8. 1 2 3 4 "Vestibular Neurectomy (Balance Nerve section)". Dallas Ear Institute.
  9. ↑ Silverstein, Herbert; Norrell, Horace; Haberkamp, Thomas (1987). "A comparison of retrosigmoid iac, retrolabyrinthine, and middle fossa vestibular neurectomy for treatment of vertigo". The Laryngoscope. 97 (2): 165–173. doi:10.1288/00005537-198702000-00007. ISSN   1531-4995. PMID   3807619. S2CID   46147336.
  10. 1 2 Liu, An; Zhang, Wei; Sun, Miao; Ma, Chiyuan; Yan, Shigui (April 2016). "Evidence-based Status of Pulsed Radiofrequency Treatment for Patients with Shoulder Pain: A Systematic Review of Randomized Controlled Trials". Pain Practice. 16 (4): 518–525. doi:10.1111/papr.12310. PMID   25990576. S2CID   28437179.
  11. ↑ Gofeld, Michael; Restrepo-Garces, Carlos E.; Theodore, Brian R.; Faclier, Gil (February 2013). "Pulsed Radiofrequency of Suprascapular Nerve for Chronic Shoulder Pain: A Randomized Double-Blind Active Placebo-Controlled Study: Pulsed Radiofrequency of Suprascapular Nerve". Pain Practice. 13 (2): 96–103. doi: 10.1111/j.1533-2500.2012.00560.x . PMID   22554345. S2CID   6824776.
  12. ↑ Lipinski LJ, Spinner RJ. Neurolysis, neurectomy, and nerve repair/reconstruction for chronic pain. Neurosurg Clin N Am. 2014 Oct;25(4):777-87. doi : 10.1016/j.nec.2014.07.002 Epub 2014 Aug 14. PMID: 25240664.
  13. ↑ O'Brien JC Jr. Swimmer's headache, or supraorbital neuralgia. Proc (Bayl Univ Med Cent). 2004 Oct;17(4):418-9. doi : 10.1080/08998280.2004.11928006 PMID: 16200130; PMCID: PMC1200682.
  14. ↑ Grant AC, Cook AA. A prospective study of handcuff neuropathies. Muscle Nerve. 2000 Jun;23(6):933-8. doi : 10.1002/(sici)1097-4598(200006)23:6<933::aid-mus14>3.0.co;2-g. PMID: 10842271.
  15. ↑ Moucharafieh R, Wehbe J, Maalouf G. Meralgia paresthetica: a result of tight new trendy low cut trousers ('taille basse'). Int J Surg. 2008 Apr;6(2):164-8. doi : 10.1016/j.ijsu.2007.04.003 Epub 2007 Apr 14. PMID: 17521975.
  16. ↑ Charipova K, Gress K, Berger AA, Kassem H, Schwartz R, Herman J, Miriyala S, Paladini A, Varrassi G, Kaye AD, Urits I. A Comprehensive Review and Update of Post-surgical Cutaneous Nerve Entrapment. Curr Pain Headache Rep. 2021 Feb 5;25(2):11. doi : 10.1007/s11916-020-00924-1 PMID: 33547511.
  17. ↑ de Ruiter GC, Kloet A. Comparison of effectiveness of different surgical treatments for meralgia paresthetica: Results of a prospective observational study and protocol for a randomized controlled trial. Clin Neurol Neurosurg. 2015 Jul;134:7-11. doi : 10.1016/j.clineuro.2015.04.007 Epub 2015 Apr 11. PMID: 25911497.
  18. ↑ de Ruiter, G.C.W., Wurzer, J.A.L. & Kloet, A. Decision making in the surgical treatment of meralgia paresthetica: neurolysis versus neurectomy. Acta Neurochir154, 1765–1772 (2012). doi : 10.1007/s00701-012-1431-0
  19. ↑ Hsu, E., Argoff, C., Galluzzi, K., Leo, R., & Dubin, A. (2013). Intercostal neuralgia. In Problem-Based Pain Management (pp. 114-119). Cambridge: Cambridge University Press. doi : 10.1017/CBO9781139135054.025
  20. ↑ Williams EH, Williams CG, Rosson GD, Heitmiller RF, Dellon AL. Neurectomy for treatment of intercostal neuralgia. Ann Thorac Surg. 2008 May;85(5):1766-70. doi : 10.1016/j.athoracsur.2007.11.058 PMID: 18442581.
  21. 1 2 Ducic I, Larson EE. Outcomes of surgical treatment for chronic postoperative breast and abdominal pain attributed to the intercostal nerve. J Am Coll Surg. 2006 Sep;203(3):304-10. doi : 10.1016/j.jamcollsurg.2006.05.018 Epub 2006 Jul 11. PMID: 16931302.
  22. 1 2 3 Boelens OB, van Assen T, Houterman S, Scheltinga MR, Roumen RM. A double-blind, randomized, controlled trial on surgery for chronic abdominal pain due to anterior cutaneous nerve entrapment syndrome. Ann Surg. 2013 May;257(5):845-9. doi : 10.1097/SLA.0b013e318285f930 PMID: 23470571.
  23. ↑ Maatman, R.C., Steegers, M.A.H., Boelens, O.B.A. et al. Pulsed radiofrequency or anterior neurectomy for anterior cutaneous nerve entrapment syndrome (ACNES) (the PULSE trial): study protocol of a randomized controlled trial. Trials18, 362 (2017). doi : 10.1186/s13063-017-2110-5
  24. ↑ Armstrong LB, Dinakar P, Mooney DP. Neurectomy for anterior cutaneous nerve entrapment syndrome in children. J Pediatr Surg. 2018 Aug;53(8):1547-1549. doi : 10.1016/j.jpedsurg.2017.11.062 Epub 2017 Dec 8. PMID: 29321104.
  25. ↑ Coffey R, Gupta V. Meralgia Paresthetica. [Updated 2023 May 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK557735/
  26. ↑ Lu VM, Burks SS, Heath RN, Wolde T, Spinner RJ, Levi AD. Meralgia paresthetica treated by injection, decompression, and neurectomy: a systematic review and meta-analysis of pain and operative outcomes. J Neurosurg. 2021 Jan 15;135(3):912-922. doi : 10.3171/2020.7.JNS202191 PMID: 33450741.
  27. ↑ Khalil N, Nicotra A, Rakowicz W. Treatment for meralgia paraesthetica. Cochrane Database of Systematic Reviews 2012, Issue 12. Art. No.: CD004159. doi : 10.1002/14651858.CD004159.pub3 Accessed 16 September 2023.
  28. ↑ Khalil N, Nicotra A, Rakowicz W. Treatment for meralgia paraesthetica. Cochrane Database of Systematic Reviews 2008, Issue 3. Art. No.: CD004159. doi : 10.1002/14651858.CD004159.pub2 Accessed 16 September 2023.
  29. ↑ Schönberg, B., Pigorsch, M., Huscher, D. et al. Diagnosis and treatment of meralgia paresthetica between 2005 and 2018: a national cohort study. Neurosurg Rev46, 54 (2023). doi : 10.1007/s10143-023-01962-0
  30. ↑ Jackman, Bradley R.; Baxter, Gary M.; Doran, Richard E.; Allen, Douglas; Parks, Andrew H. (1993). "Palmar Digital Neurectomy in Horses 57 Cases (1984–1990)". Veterinary Surgery. 22 (4): 285–288. doi:10.1111/j.1532-950X.1993.tb00399.x. ISSN   1532-950X. PMID   8351810.

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