Nerve decompression

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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. [1] 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.

Contents

Surgical planning

Surgical planning is distinct from diagnosis of entrapment. Diagnosis will focus on a binary decision: does the patient have entrapment or not? A diagnosis may not be enough information for surgery on its own as the area to explore may be too large. Surgical planning seeks to localize the specific area of entrapment to improve surgical outcomes. Identifying the level of entrapment is an important consideration for surgery as decompressing the wrong area will lead to a failed surgery (e.g. performing back surgery for extra-spinal sciatica), [2] [3] failure to treat nerve entrapment early can lead to permanent nerve injury, [4] and the patient may be unnecessarily exposed to surgical complications.

Diagnostic blocks

Diagnostic nerve blocks can confirm the clinical diagnosis for chronic pain as well as identify the entrapment site. [5] A diagnostic block is like an inverted palpation in the sense that palpation will cause a sensory nerve to send a signal (action potential) and a block will prevent a sensory nerve from sending a signal. By blocking nerve signals, the pain-contributing nerves can be identified or ruled out. Nerves are predisposed to entrapment in certain anatomical regions such as in an osteofibrous tunnels, through a muscle, adjacent to fibrous tissue. [6] Consequently, knowledge of these anatomical regions as well as peripheral nerve anatomy is an essential component to planning successful diagnostic blocks. [5] Ultrasound is a common form of image-guidance to place the needle properly, but it faces limitations visualizing small and deep nerves. [7] CT- or MRI- guidance are better positioned to access deep nerves as well as identify the anatomic level of the needle. [7]

Imaging

MRI may be used to identify certain causes of entrapment such as a structural lesions pressing on a nearby nerve, but is prone to false negatives/positives and has poor correlation with the clinical examination. [8] A major limitation with MRI is that nerve tissue is resistant to imaging. An advancement of MRI that takes advantage of the tissue properties of nerves, called MR neurography (MRN), provides more detail. MR tractography (MRT) can also be of use in surgical planning as it can identify peripheral nerve abnormalities with a high correlation to intraoperative findings and has higher accuracy than MR neurography alone. [9] MRT uses diffusion tensor imaging to visualize the directional movement of water molecules along nerve tracts. Often an abnormality can be identified along tracts of nerve where water is not diffusing normally along the axis. MRT has been used to identify sacral nerve entrapment by the piriformis muscle, which would otherwise only be diagnosable with exploratory surgery. [10]

Surgical outcomes

Nerve decompressions are still a relatively new surgery, however a picture emerges from looking at the outcomes of some of the most studied nerve decompressions: carpal tunnel release, sciatic nerve decompression, and migraine surgery. Even within these commonly performed surgeries, the measurement of outcomes is not always standardized. Common ways of measuring outcomes are syndrome-specific disability questionnaires (e.g. Boston Carpal Tunnel Questionnaire, [11] Oswestry low back disability questionnaire, [12] and the migraine disability assessment [13] ); visual analog scale (VAS); [14] physical examination findings; [15] and subjective patient satisfaction [16]

Carpal tunnel release

Carpal tunnel surgery has a clinical success rate of 75-90%. [17] Success is most frequently measured with the Boston Carpal Tunnel Questionnaire, physical examination (sensory function, motor function, pain, electrodiagnostic, trophic function), and patient self-assessments. One study found that while 86% of patients improved, only 26% had complete recovery of clinical and electrodiagnostic findings. Of the functional assessments, pain showed the greatest improvements following surgery. [18] Another study compared carpal tunnel syndrome patients who elected surgery with those who chose not to. 77% of the surgery group said they were cured compared to 16% who did not elect surgery. [19] While some of the success of surgery may just be due to the natural history of the disease, the surgery groups still have an improvement in outcomes over conservative measures. A systematic review found that surgical treatment outweighed the benefits over conservative treatment overall all outcome measures, however conservative treatment caused fewer complications. [20]

Sciatic nerve decompression

A systematic review has found that 90% of surgery patients see improved pain scores with scores improving on average from 6.7 preoperatively to 2.1 postoperatively. [21] In the literature, the most common outcome measurement for sciatic nerve decompressions is the visual analog scale, where patients rate their pain on a 100mm horizontal line that gets converted into a numeric score from 0-10 or 0–100. The main disability questionnaires used are the modified Harris Hip score (mHHS) and the Oswestry low back disability questionnaire. One study found that all deep gluteal syndrome surgery patients who were taking narcotics for pre-operative pain (n = 21) no longer needed narcotics for the initial complaint after decompression surgery. [22]

Migraine surgery

A systematic review has found that the improvement is seen in 68-100% of surgery patients and complete migraine elimination is seen in 8-86% of surgery patients. [23] The outcomes are usually measured in migraine intensity, frequency, and duration (an early measurement, the migraine headache index, was just the product of these numerical values). The most common migraine disability questionnaires are the migraine disability assessment (MIDAS), headache impact test (HIT), and migraine specific quality of life questionnaire (MSQ). [24]

One randomized study compared the efficacy of migraine surgery to pharmacologic treatment and found that surgical treatment had a significantly higher success rate than medical treatment. Notably, 36% of patients in the surgical treatment group experienced complete elimination of migraine headaches, compared to and 4% in the medical treatment group. [25] Another randomized study compared surgery to sham surgery. 57% of the surgery group experienced complete elimination of migraine headaches, compared on only 4% of the sham surgery group. [26] A separate study examining outcomes found that there was a bimodal distribution (two main outcomes), where approximately >80% of patients saw either at least an 80% reduction in symptoms or less than 5% reduction. Of the patients seeing significant improvement, the mean improvement was 96%. Of the patients seeing minimal improvement, the average improvement was 0%. [27]

Paying special attention to complete elimination of migraines or measuring outcomes after long follow ups (e.g. years) may be important for assessing the efficacy of migraine surgery because headache research has found a strong placebo effect. [28] A large meta-analysis found that the placebo effect in acute migraine treatments was greatly reduced when the treatment outcome was "pain-free" (9% of patients) compared to "improved" (30% of patients). [29] Studies that have compared migraine surgery to a control group have found similarly low placebo cure rates, both at 4%. [25] [26]

Complications

Complications can be perioperative or postoperative. Among the generic set of surgical complications such as bleeding, infection, scarring, complications from general anesthesia, etc. nerve decompressions come with a risk of nerve injury. A nerve can be directly injured due to transection (cutting), traction (pulling), crush injuries (squeezing), destroying a blood vessel that supplied the nerve, etc. While nerve sparing techniques have been developed to mitigate nerve injury, [30] [31] the radical nature of decompression surgeries cannot eliminate the risk.

In a large national study of carpal tunnel decompression postoperative complications, the serious complications seen were wound dehiscence, wound infection, tendon injury, and neurovascular injury. Serious postoperative complications, defined as requiring re-admittance to a hospital within 90 days, was relatively rare, at 0.1% over approximately 850,000 surgeries. [32]

Endoscopic sciatic nerve decompression has similarly low rates of complication. Two studies with a combined 95 patients found no complications. [33] [22] A systematic review also found a 0% major complication rate and a 1% minor complication rate for the endoscopic approach. [21]

A systematic review on migraine surgeries found a major complication rate of 1% and a liberal estimate on the minor complication rate of approximately 32%. The most common complications were numbness/paresthesia and itching. [23] Another systematic review found the adverse event rate to be 11.6%. [34] One of the challenges in cataloging the complication rate of migraine surgery is that it's a relatively new surgery and so the surgical treatment can be extremely heterogeneous across different surgeons (e.g. remove artery, remove muscle, decompress nerve, remove nerve all across one or more trigger sites). [34]

Other procedures

An alternative to a decompression is a nerve resection. [1] When the nerve does not have any motor fibres and loss of sensation is acceptable, removing the nerve in its entirety may be a more "complete" solution as it will address a much wider dermatome (all distal nerve fibres from the point of excision). Nerve decompressions, in contrast, cannot explore the entire course of a nerve and all its branches and so may potentially miss the true entrapment point. For this reason, a nerve resection may be considered after a failed decompression. Examples of nerves that may be good candidates for resection are lateral femoral cutaneous nerve, [35] zygomaticotemporal branch of the trigeminal nerve, [36] the posterior femoral cutaneous nerve, [37] [38] and the middle/superior cluneal nerves [39]

It's not clear whether a nerve resection is superior to a nerve decompression when both treatments may be suitable. A study on occiptal neuralgia in 2017 found that there was not enough data to make a determination. [40] A study on Meralgia Paraesthetica found higher success rates for nerve resection and that most patients were not bothered by numbness following the procedure. [41]

See also

Related Research Articles

<span class="mw-page-title-main">Carpal tunnel syndrome</span> Medical condition

Carpal tunnel syndrome (CTS) is the collection of symptoms and signs associated with median neuropathy at the carpal tunnel. Most CTS is related to idiopathic compression of the median nerve as it travels through the wrist at the carpal tunnel (IMNCT). Idiopathic means that there is no other disease process contributing to pressure on the nerve. As with most structural issues, it occurs in both hands, and the strongest risk factor is genetics.

<span class="mw-page-title-main">Sciatic nerve</span> Large nerve in humans and other animals

The sciatic nerve, also called the ischiadic nerve, is a large nerve in humans and other vertebrate animals which is the largest branch of the sacral plexus and runs alongside the hip joint and down the lower limb. It is the longest and widest single nerve in the human body, going from the top of the leg to the foot on the posterior aspect. The sciatic nerve has no cutaneous branches for the thigh. This nerve provides the connection to the nervous system for the skin of the lateral leg and the whole foot, the muscles of the back of the thigh, and those of the leg and foot. It is derived from spinal nerves L4 to S3. It contains fibers from both the anterior and posterior divisions of the lumbosacral plexus.

<span class="mw-page-title-main">Sciatica</span> Lower back pain that extends down leg

Sciatica is pain going down the leg from the lower back. This pain may go down the back, outside, or front of the leg. Onset is often sudden following activities like heavy lifting, though gradual onset may also occur. The pain is often described as shooting. Typically, symptoms are only on one side of the body. Certain causes, however, may result in pain on both sides. Lower back pain is sometimes present. Weakness or numbness may occur in various parts of the affected leg and foot.

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.

<span class="mw-page-title-main">Tarsal tunnel syndrome</span> Medical condition

Tarsal tunnel syndrome (TTS) is a nerve entrapment syndrome causing a painful foot condition in which the tibial nerve is compressed as it travels through the tarsal tunnel. This tunnel is found along the inner leg behind the medial malleolus. The posterior tibial artery, tibial nerve, and tendons of the tibialis posterior, flexor digitorum longus, and flexor hallucis longus muscles travel in a bundle through the tarsal tunnel. Inside the tunnel, the nerve splits into three segments. One nerve (calcaneal) continues to the heel, the other two continue on to the bottom of the foot. The tarsal tunnel is delineated by bone on the inside and the flexor retinaculum on the outside.

<span class="mw-page-title-main">Flexor retinaculum of the hand</span> Thickened fascia over the carpal tunnel

The flexor retinaculum is a fibrous band on the palmar side of the hand near the wrist. It arches over the carpal bones of the hands, covering them and forming the carpal tunnel.

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. Neurectomies have also been used to permanently block autonomic function, and special sensory function not related to pain.

<span class="mw-page-title-main">Spinal disc herniation</span> Injury to the connective tissue between spinal vertebrae

A spinal disc herniation is an injury to the cushioning and connective tissue between vertebrae, usually caused by excessive strain or trauma to the spine. It may result in back pain, pain or sensation in different parts of the body, and physical disability. The most conclusive diagnostic tool for disc herniation is MRI, and treatment may range from painkillers to surgery. Protection from disc herniation is best provided by core strength and an awareness of body mechanics including posture.

<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.

<span class="mw-page-title-main">Ulnar nerve entrapment</span> Medical condition

Ulnar nerve entrapment is a condition where pressure on the ulnar nerve as it passes through the cubital tunnel causes nerve dysfunction (neuropathy). The symptoms of neuropathy are paresthesia (tingling) and numbness primarily affecting the little finger and ring finger of the hand. Ulnar neuropathy can progress to weakness and atrophy of the muscles in the hand. Symptoms can be alleviated by attempts to keep the elbow from flexing while sleeping, such as sticking one’s arm in the pillow case, so the pillow restricts flexion.

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">Magnetic resonance neurography</span>

Magnetic resonance neurography (MRN) is the direct imaging of nerves in the body by optimizing selectivity for unique MRI water properties of nerves. It is a modification of magnetic resonance imaging. This technique yields a detailed image of a nerve from the resonance signal that arises from in the nerve itself rather than from surrounding tissues or from fat in the nerve lining. Because of the intraneural source of the image signal, the image provides a medically useful set of information about the internal state of the nerve such as the presence of irritation, nerve swelling (edema), compression, pinch or injury. Standard magnetic resonance images can show the outline of some nerves in portions of their courses but do not show the intrinsic signal from nerve water. Magnetic resonance neurography is used to evaluate major nerve compressions such as those affecting the sciatic nerve (e.g. piriformis syndrome), the brachial plexus nerves (e.g. thoracic outlet syndrome), the pudendal nerve, or virtually any named nerve in the body. A related technique for imaging neural tracts in the brain and spinal cord is called magnetic resonance tractography or diffusion tensor imaging.

Anterior interosseous syndrome is a medical condition in which damage to the anterior interosseous nerve (AIN), a distal motor and sensory branch of the median nerve, classically with severe weakness of the pincer movement of the thumb and index finger, and can cause transient pain in the wrist.

<span class="mw-page-title-main">Pronator teres syndrome</span> Medical condition

Pronator teres syndrome is a compression neuropathy of the median nerve at the elbow. It is rare compared to compression at the wrist or isolated injury of the anterior interosseous branch of the median nerve.

<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.

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.

<span class="mw-page-title-main">Carpal tunnel surgery</span>

Carpal tunnel surgery, also called carpal tunnel release (CTR) and carpal tunnel decompression surgery, is a nerve decompression in which the transverse carpal ligament is divided. It is a surgical treatment for carpal tunnel syndrome (CTS) and recommended when there is constant (not just intermittent) numbness, muscle weakness, or atrophy, and when night-splinting no longer controls intermittent symptoms of pain in the carpal tunnel. In general, milder cases can be controlled for months to years, but severe cases are unrelenting symptomatically and are likely to result in surgical treatment. Approximately 500,000 surgical procedures are performed each year, and the economic impact of this condition is estimated to exceed $2 billion annually.

<span class="mw-page-title-main">Osborne's ligament</span> Connective tissue in the body

Osborne's ligament, also Osborne's band, Osborne's fascia, Osborne's arcade, arcuate ligament of Osborne, or the cubital tunnel retinaculum, refers to either the connective tissue which spans the humeral and ulnar heads of the flexor carpi ulnaris (FCU) or another distinct tissue located between the olecranon process of the ulna and the medial epicondyle of the humerus. It is named after Geoffrey Vaughan Osborne, a British orthopedic surgeon, who described the eponymous tissue in 1957.

Nerve glide, also known as nerve flossing or nerve stretching, is an exercise that stretches nerves. It facilitates the smooth and regular movement of peripheral nerves in the body. It allows the nerve to glide freely along with the movement of the joint and relax the nerve from compression. Nerve gliding cannot proceed with injuries or inflammations as the nerve is trapped by the tissue surrounding the nerve near the joint. Thus, nerve gliding exercise is widely used in rehabilitation programs and during the post-surgical period.

<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

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  34. 1 2 Wormald JCR; Luck, J.; Athwal, B.; Muelhberger, T.; Mosahebi, A. (2019). "Surgical intervention for chronic migraine headache: A systematic review". Jpras Open. 20: 1–18. doi:10.1016/j.jpra.2019.01.002. PMC   7061614 . PMID   32158867.
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