Surgical Treatment of Upper Extremity Pain

Occurrence and treatment of peripheral nerve injuries after cosmetic surgeries

Although non-invasive and minimally invasive aesthetic procedures increasingly dominate the cosmetic market, traditional plastic surgery remains the most effective improvement method. One of the most common complications in plastic surgery, peripheral nerve injuries, though has a low incidence but intrigued plastic surgeons globally. In this article, a narrative review was conducted using several databases (PubMed, EMBASE, Scopus, and Web of Science) to identify peripheral nerve injuries following cosmetic surgeries such as blepharoplasty, rhinoplasty, rhytidectomy, breast surgeries, and abdominoplasty. Surgery-related nerve injuries were discussed, respectively. Despite the low incidence, cosmetic plastic surgeries can cause iatrogenic peripheral nerve injuries that require special attention. The postoperative algorithm approaches can be effective, but the waiting and treatment processes can be long and painful. Preventive measures are undoubtedly more effective than postoperative remedies. The best means of preventing disease is having a good understanding of anatomy and conducting a careful dissection.

Diagnosis and Outcomes of 225 Consecutive Cases of Complex Regional Pain Syndrome of the Hand

BACKGROUND

The lack of specific tests and potential diagnostic inaccuracy may be behind the stunning figures of complex regional pain syndrome (CRPS) cases. The author tested the hypothesis that patients diagnosed with CRPS at referral could be assigned to recognized conditions and treated accordingly.

METHODS

From January of 2018 to April of 2021, 225 consecutive patients attended the author's office having been diagnosed with and treated for CRPS for an average of 16 ± 26 months. There were 180 women and 45 men; no patient was excluded.

RESULTS

All patients could be allocated in named conditions: 79 had a wrong diagnosis; seven had a true causalgia; 16 were dystonic-psychogenic hands; 20 presented a flare reaction; and 90 had an "irritative" carpal tunnel syndrome. The remaining 13 patients had a miscellany of symptoms within a substandard management setting. Surgery was offered to 175 with a correctable cause; 50 (20 of whom had a tangible cause responsible for their pain) declined, and their outcome is unknown. The remaining 125 were operated on and tracked for an average of 20 ± 9 months. In the operated group, pain dropped 7.5 ± 2.2 points ( P < 0.0001) on a numerical rating scale of 0 to 10. Disabilities of the Arm, Shoulder, and Hand questionnaire scores fell from 80 to 16 ( P < 0.0001). Patients who were operated on rated their satisfaction on a scale of 0 to 10 as 8.9 ± 1.9.

CONCLUSIONS

Unlike with CRPS, all patients in this series had a true, diagnosable condition explaining their clinical picture. Most patients who agreed to be operated on had a favorable outcome.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Outcomes of Carpal Tunnel Release in Complex Regional Pain Syndrome/Reflex Sympathetic Dystrophy/Sudeck Disease Patients

BACKGROUND

The clinical features of classic carpal tunnel syndrome are well known. However, some patients who display atypical symptoms and signs of pain and dysesthesias in the hand, worsening of symptoms at night, and above all, inability to make a full fist, respond equally well to carpal tunnel release. This same clinical picture was shared by some patients labeled as having complex regional pain syndrome. Because of the poor outcome of complex regional pain syndrome patients with current regimens, the authors tested the hypothesis that carpal tunnel release could be effective on them. The purpose of this article is to report the outcome of carpal tunnel release in complex regional pain syndrome patients who presented the above signs and symptoms.

METHODS

Fifty-three patients with an average age of 55 years presenting the above cluster of symptoms were operated on. All were unilateral cases, had sustained trauma, and were treated for complex regional pain syndrome before referral for an average of 16 months. All patients underwent carpal tunnel release.

RESULTS

At a minimum of 6 months' follow-up, pain dropped 7.5 points on a numerical rating scale of 0 to 10 ( p < 0.001). Disabilities of the Arm, Shoulder and Hand scoring fell from 82 to 17 ( p < 0.001). Six patients had an unsatisfactory result.

CONCLUSIONS

Some patients with complex regional pain syndrome may respond successfully to a carpal tunnel release operation. Recognition of this possibility is crucial, as the symptoms and signs might lead the clinician away from the proper diagnosis and treatment.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Traditional Neuroma Management

With the development of newer techniques for symptomatic neuroma treatment, such as regenerative peripheral nerve interface and targeted muscle reinnervation, transposition and coverage techniques often have been referred to as "passive techniques." In spite of its negative connotation, these passive techniques yield positive results in a majority of patients treated. The experienced surgeon has more options than ever before in the prevention and management of problematic neuromas. Critical appraisal of the current literature reveals no single, optimal standard of care. Instead, surgeons have a plethora of useful techniques that can be implemented on a case-by-case basis to optimize outcomes.

Long-term Improvements of Neuroplasty and Scalene Muscle Resection in LTN-injured Winged Scapula Patients

Injuries to the long thoracic nerve, which directly branches off of the C6, C7, and C8 brachial plexus nerve roots, can cause scapular winging and affect shoulder movements. Long thoracic nerve injuries resulting from accidents, violence, or overuse can be severe lesions requiring challenging surgeries. We evaluated the long-term functional outcomes of neuroplasty and the scalene muscle resection procedures in patients with long thoracic nerve injury and winging scapula.

Methods

All 15 patients who underwent scalene muscle resection with decompression and neurolysis of the long thoracic nerve in a single institution to treat winged scapula and limited shoulder movements between March 2007 and May 2020 with follow-up over 2 years were included in the study.

Results

Shoulder abduction and arm flexion improved significantly to 158 ± 52 degrees and 165 ± 53 degrees from a mean of 108 ± 54 degrees and 104 ± 52 degrees (P < 0.02) over 2 years after surgery (mean 3.4 years). Overall, there was a significant reduction in the scapular winging, as assessed by estimating the decrease in the angle between the scapular plane and the posterior chest wall. The extent of the score greatly improved post-surgically from a mean of 1.2 ± 0.4 to 3.5 ± 0.9 (range 1-4; 1-severe, 2-moderate, 3-mild, and 4-minimal) (P < 0.01).

Conclusion

The improvement in shoulder movements and reduced scapular winging was significant and stable over 2 years of surgery in 81% of our study patients.

Regenerative Peripheral Nerve Interfaces for the Management of Symptomatic Hand and Digital Neuromas

Painful neuromas result from traumatic injuries of the hand and digits and cause substantial physical disability, psychological distress, and decreased quality of life among affected patients. The regenerative peripheral nerve interface (RPNI) is a novel surgical technique that involves implanting the divided end of a peripheral nerve into a free muscle graft for the purposes of mitigating neuroma formation and facilitating prosthetic limb control. The RPNI is effective in treating and preventing neuroma pain in major extremity amputations. The purpose of this study was to determine if RPNIs can be used to effectively treat neuroma pain following partial hand and digital amputations. We retrospectively reviewed the use of RPNI to treat symptomatic hand and digital neuromas at our institutions. Between November 2014 and July 2019, we performed 30 therapeutic RPNIs on 14 symptomatic neuroma patients. The average patient follow-up was 37 weeks (6-128 weeks); 85% of patients were pain-free or considerably improved at the last office visit. The RPNI can serve as a safe and effective surgical solution to treat symptomatic neuromas after hand trauma.

A Retrospective Case Series Reporting the Outcomes of Avance Nerve Allografts in the Treatment of Peripheral Nerve Injuries

BACKGROUND

Acellular nerve allografts are a viable treatment modality for bridging nerve gaps. Several small studies have demonstrated results equal to those of autologous grafts; however, there is information lacking with regard to outcomes for wider indications. The authors evaluated the outcomes of patients treated with a nerve allograft in a variety of clinical situations.

METHODS

A retrospective chart analysis was completed between April of 2009 and October of 2017. Inclusion criteria were age 18 years or older at the time of surgery and treatment with a nerve allograft. Patients were excluded if they had not been followed up for a minimum of 6 months. The modified Medical Research Council Classification was used to monitor motor and sensory changes in the postoperative period.

RESULTS

Two hundred seven nerve allografts were used in 156 patients; of these, 129 patients with 171 nerve allografts fulfilled the inclusion criteria. Seventy-seven percent of patients achieved a sensory outcome score of S3 or above and 36 percent achieved a motor score of M3 or above. All patients with chronic pain had improvement of their symptoms. Graft length and diameter were negatively correlated with reported outcomes. One patient elected to undergo revision surgery, and the original graft was shown histologically to have extensive central necrosis. Anatomically, allografts used for lower limb reconstruction yielded the poorest results. All chronic patients had a significantly lower postoperative requirement for analgesia, and allografts were effective in not only reducing pain but also restoring a functional level of sensation.

CONCLUSIONS

This study supports the wider application of allografts in managing nerve problems. However, caution must be applied to the use of long grafts with larger diameters.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Painful Complications After Cosmetic Surgery: Management of Peripheral Nerve Injury

BACKGROUND

Aesthetic procedures are among the most common surgeries performed by plastic surgeons. The prevalence of persistent pain remains unknown and underappreciated in the plastic surgery literature.

OBJECTIVES

The purpose of this article was to increase awareness of this problem while describing the diagnostic and management strategies for patients with postoperative pain after aesthetic plastic surgery.

METHODS

A literature review was performed utilizing the PubMed database to identify painful complications of brachioplasty, blepharoplasty, rhytidectomy, abdominoplasty, breast augmentation, mastopexy, and breast reduction. A treatment algorithm was described to guide plastic surgeons presented with patients reporting pain after aesthetic surgery.

RESULTS

Title and abstract review followed by application of inclusion and exclusion criteria resulted in 20 clinical studies for this review, including lateral femoral cutaneous nerve, iliohypogastric nerve, and intercostal nerves after abdominoplasty; median antebrachial cutaneous nerve after brachioplasty; supraorbital, supratrochlear, and infratrochlear nerves after blepharoplasty; greater auricular nerve, auriculotemporal nerve, and zygomaticofacial nerve after rhytidectomy; and intercostobrachial nerve after breast surgery.

CONCLUSIONS

Neuromas can be the source of pain following aesthetic surgery. The same clinical and diagnostic approach used for upper and lower extremity neuroma pain can be employed in patients with persistent pain after aesthetic surgery.

LEVEL OF EVIDENCE: 4

Preoperative ultrasound for runoff-venous decompression of peripheral nerves for arteriovenous access-related pain in the upper limb

INTRODUCTION

Arteriovenous access (AVA)-related pain treated successfully with runoff-venous decompression of the causative nerve, following ultrasound (US)-assisted preoperative evaluation, has never been reported.

CASE PRESENTATION

A 57-year-old man suffering from constant exhausting pains along the outflow cephalic vein of the radiocephalic arteriovenous fistula at the wrist and the antecubital fossa, was treated surgically after the diagnosis of AVA-related pain derived from cephalic vein compression on two peripheral cutaneous nerves, the superficial radial nerve (SRN) and the lateral antebrachial cutaneous nerve (LACN).

TECHNIQUE

The SRN and LACN, which ran along and/or provided sensory innervation to the painful regions in the upper limb, were traced using ultrasonography in the short axis and proved to be compressed by and in contact with veins where the pain existed, at the wrist and the antecubital fossa. Once diagnostic US-guided blocks of both were performed and pain disappeared, they were identified as the causative nerves. The cephalic venous decompression surgeries that separated and transposed the veins away from the SRN and the LACN were performed sequentially under pneumatic tourniquet inflation to improve nerve visualization.

RESULTS

The pains disappeared after the operations. An adequate length of the runoff cephalic vein was maintained for needle cannulations during hemodialysis.

CONCLUSIONS

Outflow venous compression to the peripheral nerves may be a cause of AVA-related pain. US-guided assessments of the nerves may improve the safety and efficiency of venous decompression surgeries to treat AVA-related pains.