Should a neurosurgeon, orthopedic surgeon, plastic surgeon, or hand surgeon perform my peripheral nerve surgery?
It doesn't matter what specialty your surgeon was originally trained in. What matters is their experience, training, and dedication to peripheral nerve surgery. Do they primarily perform nerve surgery, or do they just do the occasional operation when required? Do they offer all available techniques, or only the limited number they are comfortable with? Because so much in peripheral nerve surgery depends on proper diagnosis, it is important they have expertise performing the neuromuscular examination; not just relying on electrodiagnostic testing. When two surgeons appear equally qualified, choose the one you feel most comfortable with.
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What is the difference between endoscopic and open carpal tunnel surgery?
Both techniques are equally efficacious. Open carpal tunnel release is more common. The open technique uses a one-inch or smaller incision on the palm to expose and decompress the carpal tunnel. Although endoscopic techniques vary, they usually involve one or two small incisions on the hand. One common endoscopic technique uses a small metal tube that is placed in the carpal tunnel so that through an opening on its top, the carpal tunnel is released under video observation. A potential advantage of endoscopic carpal tunnel release is an earlier return to work, especially if you perform manual or factory labor.
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What is the difference between a schwannoma and neurofibroma?
Both are benign nerve sheath tumors that originate within a nerve. It is usually not possible to differentiate these tumors on pre-operative MRI. Although neurofibromas are commonly associated with neurofibromatosis, solitary neurofibromas also occur in patients without this genetic disease. Schwannomas are usually easier to remove, considering they often originate from a single, small, nonfunctional nerve fascicle. Neurofibromas tend to be more infiltrative, often involving two or more nerve fascicles that may be functional. Occasionally, a functional fascicle may need to be sacrificed in order to completely remove a neurofibroma. Nevertheless, the risk of weakness, numbness, and pain after surgery is quite low for both types of tumors. (see also nerve tumors section)
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I have a brachial plexus injury. Why are we waiting three months before doing surgery?
Because it is not possible using electrodiagnostic and imaging results to be certain if a stretch injury of the brachial plexus will spontaneously recover, the current standard is to wait about three months before proceeding to surgery. This avoids operating on patients who in the end do not require surgery. Furthermore, if a partial recovery occurs, then the surgeon knows to avoid these recently recovered nerves. Waiting also allows intraoperative nerve action potentials (NAPs) to be performed during surgery. This technique evaluates any functional nerve fascicles across a segment of stretched nerve. A few months are required for these fascicles to regenerate across the injury segment.
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Why does surgical repair of injured nerves not always work?
Despite optimal microscopic nerve repair, recovery does not always occur. The exact reason for this is uncertain, however, the following factors likely contribute: 1. neuron death when the injury is close to the spinal cord, 2. muscle atrophy and fibrosis if reinnervation takes longer than one year, 3. regenerating motor nerves accidentally going to sensory receptors, not muscle, 4. the nerves themselves not being responsive to regeneration, 5. scar tissue, and 6. the disruption of a repaired nerve. For motor function, the ulnar and common peroneal nerves heal the worst, while the radial and tibial nerves do the best. Sensory recovery appears to be about the same for most nerves. Regardless of these limitations, without repair, avulsed or cut nerves have basically no chance of spontaneous recovery.
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How long will it take for my muscles to work after my nerve has been repaired?
Surgery only creates an anatomical situation that allows regeneration to occur. For example, cut nerves are sewn back together, or compressive scar tissue is removed. It is up to the nerves themselves to grow back. Therefore, after nerve suture, graft placement, or nerve transfer, your nerve fascicles need to growth from the point of repair to the muscle itself. This takes about one inch per month. Immediately after surgery your neurological deficit will be unchanged, but in 3-12 months, depending on how far away the muscle is, movement may be seen. During this interim, slowly progressive range-of-motion exercises are important.
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Are there any growth factors or medications available to help my nerve regenerate?
Unfortunately, there are no growth factors or medications currently available to promote nerve regeneration. Research is being conducted to develop such medications, which may become available in the next few years.
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My nerve injury occurred many years ago and never recovered. Are there any surgical options still available?
Nerve repair, nerve grafting, and nerve transfers can work when performed up to one year after injury. However, they work best when performed in less than six months. In select cases, nerve surgery may be indicated for injuries older than one year. Fortunately, there are other options for chronic nerve injuries, including tendon and muscle transfers (see technologies and techniques available), which can work quite well. Common examples include tendon transfers for foot and wrist drop, and muscle transfers for elbow flexion after failed brachial plexus surgery.
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Whether or not I am medical professional, where can I read more about peripheral nerve entrapments, tumors, and injuries?
Medical textbooks on nerve injury include Focal Peripheral Neuropathies by John Stewart and Nerve Injuries by David Kline and Alan Hudson. An introductory text on the examination and diagnosis of focal nerve injuries titled Examination of Peripheral Nerve Injuries by Stephen Russell M.D. is also available. The NIH web site has information on some types of nerve injuries, compressions, and tumors (www.ninds.nih.gov/).
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Over the past years, what have been the major advancements in peripheral nerve surgery?
Widespread introduction of the operating microscope in the late 1960's re-popularized nerve repair and grafting, allowing microsurgical repair to become the standard treatment for a cut or scarred nerve. In the past decade, nerve transfers (see technologies and techniques available) have become increasingly popular because of their efficacy and speed of motor recovery. Future advancements in nerve surgery will likely be in the field of molecular nerve regeneration, using growth factors or medications.
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