Why neurosurgeons should do peripheral nerve surgery
Debora Garozzo
Mediclinic Parkview Hospital Dubai, UAE
Neurosurgeons are reluctant to embrace peripheral nerve surgery (PNS) and often dismiss it as a subspecialty for plastic, orthopedic or hand surgeons. In many countries, PNS is not even included in the neurosurgical curriculum. There are however many reasons for this fascinating subspecialty to be an integral part of neurosurgery - the first and most obvious one being that peripheral nerves are part of the nervous system!
Peripheral nerve injury (PNI) can have a direct impact on the brain, as we can see in both children and adults who sustain a brachial plexus injury (BPI). Babies with a right obstetrical brachial plexus palsy usually shift their hand dominance and may present complications like speech delay or developmental apraxia (1, 2). In adults with BPI, functional MRI has shown dynamic changes within the brain's resting-state networks - not only the obvious sensory motor network, but also the higher cognitive networks such as the salience network and default mode network (3, 4). We have learned that the successful outcome of our reconstructive procedures depends partly on this brain plasticity (5). Research has demonstrated that cortical changes may even be triggered by nerve entrapment (6).
This evidence highlights the importance of having a thorough neurological background, which is unusual in non-neurosurgeons. When treating patients with neurological symptoms, thorough knowledge of peripheral nerve anatomy and pathology is crucial for differential diagnosis; inappropriate surgery and unsuccessful outcome are frequently caused by misdiagnosis.
PNS overlaps with many other neurosurgical subspecialties, the most obvious being functional neurosurgery, as a significant percentage of patients present with neuropathic pain (7).
Peripheral nerve injury is a very important component of Neurotrauma. The current epidemiological data related to peripheral nerve injuries (especially BPI) are inaccurate or incomplete (8, 9,10) and underestimate its true incidence; over the last decade, we have observed a significant escalation of PNI worldwide. In low- and middle-income countries (LMICs), this is led by the explosion in affordable two-wheeled motor vehicles; sadly, the ongoing warfare that currently plagues many areas of the world is another factor significantly fueling the increased incidence of PNI, as was recently reported in conferences by neurosurgeons practicing in Ukraine, Tigray, Sudan, and Gaza. Neurotrauma should therefore always include PNI.
This surgical discipline focuses on the prevention of disability, which is a major cause of poverty in developing countries (11); individuals who are unable to earn a living represent an additional burden for a family already struggling with financial challenges. Moreover, the diagnostic workup in PNS is mainly based on electrodiagnostic studies and ultrasound, which are fairly cheap and readily available, and surgery does not require fancy equipment or postop ICU. Patient turnover is high due to short hospitalization and a low rate of complications.
PNS provides excellent opportunities for training and should be included in the neurosurgical curriculum; young neurosurgeons should be encouraged to practise PNS even if they prefer to focus their energies mainly on brain and/or spine surgery.
Unfortunately, part of the reluctance that neurosurgeons show for PNS is due to misconceptions that are rooted in our professional community.
Many still believe that outcome from PNS is poor, despite evidence that over the last decades new techniques have successfully restored full function in injuries deemed irreversible in the past. Although surgery for total brachial plexus palsy is still a salvage procedure, in partial injuries nowadays surgery can fully restore useful function and rescue these patients (both adults and children) from invalidity (12).
PNS has conquered new frontiers and is expanding its fields of application; for instance, nerve transfers, having revolutionised brachial plexus surgery, have recently been applied in tetraplegia following spinal cord injury. Although surgical series are still limited, results are extremely promising (13, 14, 15) with significant functional improvement especially when neurotizations were associated with tendon transfers (16).
Another remarkable application of peripheral nerve surgery is in the treatment of spasticity; already since the 60’s in last century, selective neurotomies and rhizotomies have proved useful in improving function in patients (17, 18). Recently, contralateral C7 transfers have started to gain popularity for the treatment of cerebral spasticity (19).
PNS is an intellectually challenging subspecialty that should be no longer considered the “ugly duckling” of neurosurgery; young surgeons especially should embrace this surgical discipline with interest and enthusiasm. Promoting PNS in our professional community is a mission for the WFNS peripheral nerve surgery committee and we have picked up the challenge!
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