Minimally Invasive Surgery for Chronic Pain Management: An Evidence-Based Approach

This book presents the essential steps involved in diagnosing and treating pain due to peripheral nerve injury and compression. In the first chapter, the relevant anatomy and diagnostic tools to identify peripheral-nerve-related issues are described. The main part of the book, however, deals with the surgical techniques to address specific types of peripheral nerve pain, e.g. neuroma, thoracic outlet or migraine. A step-by-step, practical approach is provided, including important aspects to consider both       pre- and post-op. The procedures presented are minimally-invasive and maximally effective. Each chapter features detailed surgical illustrations and anatomical images.

Chronic pain control is a growing need and minimally invasive yet effective surgical techniques, combining the competences of neurosurgery, plastic surgery, orthopedics, general surgery, pain management and neurology are in high demand. The increasing demand on the part of patients suffering from neuropathic pain is to date not matched by adequate practical training in peripheral nerve surgery to control pain. The authors are experts in this discipline “from head to toe” and present a valuable guide that provides medical students and experienced clinicians alike with useful information for their daily practice.

• Language: English
• Publisher: Springer
• Release date: Oct 5, 2020
• ISBN: 9783030501884

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© Springer Nature Switzerland AG 2020

G. Pietramaggiori, S. Scherer (eds.)Minimally Invasive Surgery for Chronic Pain Managementhttps://doi.org/10.1007/978-3-030-50188-4_1

Surgical Anatomy and Diagnosis of Peripheral Nerve Compression and Injury

Giorgio Pietramaggiori¹  , Laurent Thierrin²   and Saja Scherer¹  

(1)

Plastic and Reconstructive Surgery, Global Medical Institute, Lausanne, Switzerland

(2)

Anesthesia, Clinique de La Source Lausanne, Lausanne, Switzerland

Giorgio Pietramaggiori (Corresponding author)

Email: [e-mail]

Laurent Thierrin

Email: [e-mail]

Saja Scherer

Email: [e-mail]

Keywords

NeuropathyNeuralgiaNerve blockUltrasonographyChronic pain managementNeurolysisAnatomyPeripheral nervesLocal anesthesiaCortisoneNeuroma

1 Introduction

The symptoms of neuropathy include continuous or paroxysmal dysesthesia (abnormal or unpleasant sensation), hyperesthesia (excessive sensitivity of the skin), cold intolerance, and allodynia (pain from stimuli that normally are not painful). Often patients have trouble sleeping and develop anxiety and depression with long term persisting neuropathic pain. Neuropathic pain is suspected when symptoms arise from a known anatomic compression point or scar tissue (Fig. 1) along the somatic territory of a nerve. In the point of compression or injury, a Tinel sign will be classically positive, manifesting as tingling (or pins and needles) in the distribution of the nerve by lightly tapping over it.

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Fig. 1

Main nerve targets for pain management

To confirm the hypothesis that a dysfunctional nerve is the cause of pain, a targeted nerve block with a small volume (1–5 cc) of local anesthesia (typically lidocaine with epinephrine) should be performed under ultrasound guidance proximal to the site of suspected compression or injury. The anesthesia should alleviate almost immediately at least 50% of the pain (possibly close to 100%), while resting and moving, in order to be considered positive.

Immediately after the nerve block, patients are asked to touch the sensitive area and make movements that were not possible or limited by pain.

Only the patient is considered accountable for estimating the relative reduction of pain and we recommend asking some questions while still under the effects of the nerve block, such as:

1.

If surgery could achieve half of this improvement, would you be satisfied?

2.

Would you be able to go back to work/perform better in your daily activities?

3.

Would you be ready to risk a worsening of the pain to achieve this state?

Knowing that anesthetic blocks often achieve more dramatic results (but only temporary) and that pain rarely worsen after nerve preserving surgery, strongly positive blocks (achieving nearly 100% pain relief) often correlate with satisfactory outcome. In our practice, we repeat nerve blocks at least twice before considering a patient eligible for surgery.

We systematically use in our practice a high-frequency ultrasound probe for nerve blocks. We highly recommend to implement ultrasound in the peripheral nerve surgery practice for quicker and more reliable diagnosis. Ultrasound-guided nerve blocks can be adopted fairly quickly by surgeons as they already master surgical anatomy. When this is not possible, patients can be referred to a pain specialist for a specific nerve block. Novel technologies allow for relatively affordable, small probes that can be connected to a tablet or smartphone (for example, Philips Lumify, Philips Andover, MA, USA). We recommend using non-echogenic blunt needles (for example, Stimuplex, B. Braun, Bethlehem, PA, USA) for peripheral blocks for better visualization and to limit the risk of iatrogenic nerve injury. Small volumes of local anesthetic (1–5 cc maximum) are delivered to target possibly only one nerve at the time. Cortisone can be added to the mixture to obtain extended relief in some cases (some days to some