Ivica Ducic

Background: Modern nerve-to-nerve transfers are a significant advancement in peripheral nerve surgery. Nerve transfers involve transferring donor nerves or branches to recipient nerves close to the motor end unit, leading to earlier reinnervation and preservation of the musculotendinous units in proximal nerve injuries. After nerve reinnervation, function may be superior to traditional tendon transfer techniques in terms of strength and independent motion. Nerve transfer surgery has emerged as a promising treatment option for many cases of nerve injury that were previously expected to result in poor outcomes, such as proximal injuries, long nerve gaps, or unavailability of the proximal injured segment. Methods: A review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Publications that focused on upper extremity nerve transfers were included, and functional motor and sensory recovery was analyzed. Technique reports, case reports, brachial plexus injuries, and reports on multiple nerve injuries were excluded. Results: A total of 48 relevant articles were identified with search criteria, and we discuss functional outcomes on nerve transfers for ulnar nerve injury, musculocutaneous nerve injury, median nerve injury, and radial nerve injury that met inclusion criteria. Conclusions: Nerve transfers are an option for restoring hand and forearm function in patients with peripheral nerve injuries adversely affecting their ability to function. The literature demonstrates positive functional outcomes after nerve transfer operations, and thus, the utility and variations have increased. We aim to provide an overview of the outcomes of current nerve transfer techniques for ulnar, radial, median, and musculocutaneous acquired/traumatic mononeuropathies in the hand and upper extremity.

Peripheral nerve injuries (PNIs) often present with variable symptoms, making them difficult to diagnose, treat, and monitor. When neurologic compromise is inadequately assessed, suboptimal treatment decisions can result in lasting functional deficits. There are many available tools for evaluating pain and functional status of peripheral nerves. However, the literature lacks a detailed, comprehensive view of the data comparing the clinical utility of these modalities, and there is no consensus on the optimal algorithm for sensory and pain assessment in PNIs. We performed a systematic review of the literature focused on clinical data, evaluating pain and sensory assessment methods in peripheral nerves. We searched through multiple databases, including PubMed/Medline, Embase, and Google Scholar, to identify studies that assessed assessment tools and explored their advantages and disadvantages. A total of 66 studies were selected that assessed various tools used to assess patient's pain and sensory recovery after a PNI. This review may serve as a guide to select the most appropriate assessment tools for monitoring nerve pain and/or sensory function both pre- and postoperatively. As the surgeons work to improve treatments for PNI and dysfunction, identifying the most appropriate existing measures of success and future directions for improved algorithms could lead to improved patient outcomes.

Introduction: Limited information is available regarding the ability of nerve surgery to affect medication use patterns in patients with chronic pain or neuropathy due to nerve injury. Methods: A retrospective survey was distributed to all operative patients (N = 767) from a single nerve surgeon’s practice between 2014 and 2020. Data collected included demographics, specifics of the injury and symptoms, medication and opioid use before surgery, and medication/opioid use following surgery. Results: Out of the 767 patients, 209 (27.2%) completed the survey. Average age was 48.8 (SD = 19.1) years; 68.9% female and 31.1% male. More than 50% of the patients took at least three medications. More than 50% of the patients after surgery did not need medication or had significant reduction; 54.1% of the patients took opioid medication daily, and 97.3% of patients reported that narcotic medications did not resolve their problem. Patients rated the effectiveness (Likert scale 0–10) of opioid medications in general at an average 3.25 ± 2.03. Of patients who took opioids regularly, 61.6% reported a negative effect of these medications on daily or professional activities. After surgery, more than 50% of the patients did not need opioids or had a significant reduction in opioid usage. Conclusions: Untreated nerve injuries lead to ongoing chronic pain, explaining why medications are mostly ineffective in eliminating symptoms. In this study, nerve surgery targeting the anatomical source of symptoms effectively reduced both opioid and nonopioid medication use.

Introduction: Little emphasis has been paid toward characterizing the socioeconomic burdens experienced by patients seeking treatment for chronic nerve injuries. The aim of this study was to characterize the direct and indirect costs faced by patients with chronic nerve injuries and their attendant health care utilization. Materials and Methods: A cross-sectional survey was distributed to all patients (N = 767) from a single nerve surgeon's practice treated for chronic nerve injuries in the ambulatory setting between 2014 and 2020. Data collected included demographics, etiology, comorbidities, duration and severity of symptoms, history of prior medical and interventional treatments, work or school time lost due to injury or treatment, money spent on treatment, and health care utilization. Results: Of the 767 patients, 209 (27.2%) completed the survey. Average age was 48.8 (SD = 19.1) years, 68.9% female and 31.1% male. Patients with chronic nerve injury reported significant direct costs, indirect costs, and health care utilization associated with their nerve injury symptoms. Direct costs consisted of out-of-pocket spending (68.4% had spent >$1000 per year), physician specialists visits (71.3% had seen at least 4 specialists), and prior interventional procedures intended to address symptoms. Indirect costs included lost time from work or school (24.6% had missed more than 12 months). Health care utilization, represented by annual emergency room visits and hospitalizations related to nerve symptoms, was increased relative to the general population. Detailed statistics are presented in the manuscript. Conclusions: Chronic nerve injuries may be associated with a notable socioeconomic burden to the patient, including missed work or school, frequent physician visits and procedures, hospital visits, and out-of-pocket costs. Interdisciplinary algorithms recognizing a role for surgical evaluation in patients with chronic neuropathic pain due to underlying nerve injuries would facilitate future research into whether timely surgical intervention may reduce this economic burden.

Background: Little emphasis has been paid to characterize quality of life (QoL) burdens experienced by patients seeking surgical treatment for nerve injuries and neuropathic pain. Methods: A cross-sectional survey was distributed to all patients (N = 767) from a single nerve surgeon’s practice between 2014 and 2019. Data collected included demographics, specifics of the injury and symptoms, time to referral, and effects of the injury, surgery, and timing of surgery on QoL. Results: Of the 767 patients, 209 (27.2%) completed the survey. Average age was 48.8 years; 68.9% of patients were women and 31.1% men. At presentation, 68% had experienced symptoms for more than 1 year; 86.1% reported severity as being profound; 97.6% reported QoL was at least moderately negatively impacted by nerve injury; 70% felt they should have been referred earlier for surgical evaluation; 51.2% were not told that nerve surgery was an option for their problem; 83.1% felt that earlier referral would have improved their QoL. After surgery, symptoms were significantly mitigated in 55.5% of the patients, moderately mitigated in 21.5%. Patients reported QoL was significantly (59.8%) or at least moderately (76.6%) improved by nerve surgery. Conclusions: The majority of patients reported that nerve injuries imparted a moderate to severe impact on QoL, and that surgical treatment improved QoL. Most patients felt that earlier referral for surgical intervention would have led to better outcome and positively impacted QoL. Interdisciplinary treatment algorithms, including a role for surgical intervention, may be helpful in facilitating timely diagnosis, referral, and thus improved outcomes.

Background: The sural nerve is the most frequently harvested nerve autograft and is most often biopsied in the workup of peripheral neuropathy. While the complication types associated with these two procedures are well known, their clinical significance is poorly understood and there is a paucity of data regarding the complication rates.Methods: Pubmed search identified studies regarding complications after sural nerve harvest and biopsy. The data was grouped into sensory deficits, chronic pain, sensory symptoms, wound infections, wound complications, other postoperative complications, and complications impacting daily life. The incidence of each complication was calculated, and a chi‐square analysis was performed to determine if there were any differences between nerve biopsies and graft harvest with respect to each complication.Results: Twelve studies yielded 478 sural nerve procedures. Sensory deficits occurred at a rate of 92.9%, chronic pain at 19.7%, sensory symptoms at 41.1%, wound infections at 5.7%, noninfectious wound complications at 7.8%, and impact on daily life at 5.0%. The differences in wound infections, sensory symptoms, and impact on daily life between biopsies versus graft excisions were found to reach statistical significance (p < .05).Conclusions: Sural nerve excisions can cause chronic postoperative donor‐site complications. Given these complications, alternative available mediums for nerve reconstruction should be explored and utilized wherever appropriate. If an alternative medium is unavailable and nerve autograft must be harvested for nerve reconstruction, then patients should be counseled about risks for developing donor site complications that may negatively affect quality of life.

Background: Symptomatic neuromas can cause significant chronic pain and negatively impact quality of life. Symptoms often persist despite narcotics and nonoperative interventions, which are largely ineffective. With the opioid crisis, treatments for chronic pain that limit narcotics are needed. Traditional surgical options may result in neuroma recurrence. Autograft reconstruction often results in donor-site morbidity. Processed nerve allografts facilitate axonal growth, nerve regeneration, and eliminate donor-site morbidity. Methods: A literature review was performed to identify studies in which chronic neuroma pain was treated with excision and processed nerve allograft reconstruction. PubMed was queried, and data from the studies were grouped into treatment effective and ineffective groups. Statistical analyses were performed on these groups, and further subgroup analysis was performed on overall change of preoperative and postoperative pain scores using a paired t test. Results: Seven studies fulfilled inclusion criteria yielding 42 patients. Greater than 90% of patients had improvement of pain postoperatively. The preoperative and postoperative pain scores could be determined for 40 patients. The mean preoperative score was 7.9, and the mean postoperative score was 3.54. These results were statistically significant using a paired t test with a P value of <0.001. Conclusions: Chronic pain resulting from symptomatic neuromas can be treated with neuroma excision and nerve stump reconstruction with processed nerve allograft. This obviates autograft-associated donor-site morbidity and provides a platform to potentially restore sensation to the involved nerve whenever a distal nerve end is available. Addressing the root cause is an important paradigm shift for treating symptomatic neuromas.

Background: Breast numbness is a recognized problem following mastectomy and subsequent reconstruction. Contemporary literature acknowledges the positive role of breast neurotization, but it is characterized by a variety of technical approaches and substantial heterogeneity with respect to the degree of recovered sensibility that remains suboptimal in comparison with other sensory nerve reconstructions. This study’s purpose was to provide an anatomical basis for observed inconsistencies and therein provide a principle that can be used to develop a technical approach that will optimize sensory recovery. Methods: Anatomical dissections on 6 fresh cadavers, that is, 12 hemi-abdominal flaps and 12 hemi-chest dissections, were performed. The technical aspects of harvesting the abdominal flap with a nerve target, that is, inclusion of a sensory nerve branch only, recipient nerves in the chest, and the applications of allograft for acquired nerve gap reconstruction were investigated. Results: Abdominal flaps that include sensory-only intercostal nerve 10–12 segments and identification of recipient chest wall intercostal nerves 2–4 could be consistently performed. The dissection and extraction of the donor sensory nerve target allowed preservation of the motor rectus innervation. The acquired nerve gap was easily bridged by an interposing allograft, allowing free arch of rotation for flap inset, suitable for either single or dual neurotization. Conclusions: We provide a likely anatomical explanation for suboptimal sensory recovery after deep inferior epigastric perforator (DIEP) flap breast neurotization, as mixed intercostal autograft is prohibitive to maximal sensory recovery. Breast neurotization with allograft that bridges sensory donor intercostal nerves to sensory recipient intercostal nerves should anatomically optimize restoration of breast sensibility.

Peripheral nerve repair can be very rewarding for both surgeon and patient when expected outcomes are achieved. In many cases, however, the results are suboptimal due to number of possible objective and technical reasons. Although we cannot influence patent's comorbidities, the extent or mechanism of the nerve injury, we may help optimize technical details when aiming towards improved outcomes. While the suture coaptation for primary nerve repair or nerve reconstruction with grafting served as the reconstructive standard for many decades, technical imperfections remain threats to reconstructive goals. Tension, fascicular misalignment generated by over tightening suture coaptation, deeply placed sutures, reactive scarring to foreign material at anastomosis site, may all negatively affect axonal regeneration. As the goal of every nerve repair is to have ideally opposed tension free nerve fascicles, protected from the deleterious effects of the wound bed. The utilization of coaptation aids to overcome the challenges of nerve repair has been suggested as an alternative to the classical suture repair. A review of clinical literature was performed to assess the evidence for this technique and the critical success factors to consider when implementing this technique. Twelve clinical studies met criteria, majority suggesting improved outcomes by the utilization of a coaptation aid. Most commonly reported improvements were improved sensory outcomes, reduced tenderness or pain at the coaptation site and reduced operative time. The current clinical evidence data suggests that utilization of a coaptation aid is a technical innovation to help provide better nerve repair and reconstructive functional outcomes.

Introduction: Chronic headaches following concussion are debilitating and difficult to treat. Commonly employed initial therapeutic modalities include pharmacologic, physical, and psychological interventions. Despite these efforts, a subset of patients with chronic pain remains. Peripheral nerve surgery has never before been reported as an effective treatment for the management of post‐concussion headaches. In this study, we report on our early outcomes following peripheral nerve surgery for this novel indication.Methods: A retrospective review of 28 consecutive patients with post‐concussion headaches who underwent occipital nerve surgery was performed. Preoperative and postoperative headache pain was evaluated on visual analog scale (VAS) in 24 patients with at least 6 months follow‐up.Results: The average VAS headache pain reduced from 6.4 preoperatively, to 1.4 (P < 0.0001). Twenty‐one patients (88%) had a successful outcome of at least a 50% reduction in their VAS following peripheral nerve surgery. Additionally, twelve patients (50%) were pain free at time of final follow‐up. There were no surgical complications.Conclusions: Early results indicate peripheral nerve surgery is a safe and effective new therapy for post‐concussion headaches in the properly selected patients, whose chronic pain persists despite initial treatments by a neurologist, specialized in headache management. Future studies should focus on larger patient populations, and examine the long‐term durability of outcome. In the meantime, an interdisciplinary approach involving neurologists and a peripheral nerve surgeon is suggested for the care of patients with refractory chronic post‐concussion occipital neuralgia and other post‐traumatic chronic headaches. © 2015 Wiley Periodicals, Inc. Microsurgery 35:603–607, 2015.