PERIPHERAL NERVE SURGERY: A LESSER-KNOWN OPTION FOR INTRACTABLE NEUROPATHIC PAIN

When people living with neuropathic pain are referred to Kyle Eberlin, MD, they sometimes wonder if they are in the correct office. They have nerve pain, and he’s a … plastic surgeon?

He shares, “I have patients all the time come in to see me; they often say, ‘Am I in the right place?’” Eberlin does not perform cosmetic surgery or breast reconstruction. Instead, he performs peripheral nerve surgery and extremity reconstruction at Massachusetts General Hospital. He completed a fellowship in hand and microsurgery and since then has dedicated his practice to extremity reconstruction.

“The reason I became interested in treating patients with painful conditions is that many patients with extremity injuries develop neuropathic pain,” he says. “We can do things to fix fractures or provide new skin coverage, but one of the most impactful issues with which we can help patients is improving their pain.”

How repairing nerves can lessen pain

Robert Hagan, MD, is a peripheral nerve surgery specialist in Saint Louis, Missouri, practicing at Neuropax Clinic (neuropaxclinic.com). He was also trained as a plastic surgeon, and is very familiar with repairing and reconstructing nerves damaged by trauma or irritated during other surgeries.

“It became more and more apparent that [certain chronic pain conditions] were kind of being overlooked from a surgical perspective; [nerve] problems were being labeled as chronic pain but not being stratified into the care model,” Hagan says.

He highlights carpal tunnel as a common compression neuropathy, but this type of compression can happen at approximately 20 sites on each side of the body other than the hand and forearm.

“Many times if a nerve is irritated, there’s pain associated with it,” explains Hagan. A pinched nerve in the neck, for example, can trigger migraine attacks for some patients, resulting in days of excruciating head pain. “[By decompressing the nerve], we’re not curing migraine disease,” he says. “We’re just deactivating a trigger that’s activating migraine.”

Hagan also frequently treats individuals living with diabetic neuropathy. As people with diabetic neuropathy lose sensation in their feet, they become more prone to falls—Hagan compares it to trying to walk on water balloons. Decompressing the swollen nerves restores sensation in the feet and decreases pain for those with diabetic neuropathy. “This is really important, because the predominant reason people [with diabetic neuropathy] get ulcers on the bottom of the foot is that they don’t feel it,” states Hagan. “There’s already studies out there showing that restoring sensation decreases ulcers, which decreases amputations.”

Types of peripheral nerve surgery

Peripheral nerve surgery can take many forms. Nerve decompression can treat pinched or swollen nerves such as with carpal tunnel or diabetic neuropathy. Targeted muscle reinnervation is used to treat neuromas—and involves connecting a cut major nerve to a smaller nerve to innervate surrounding muscle, which can be helpful in cases of amputations and phantom limb pain. Nerve allografts can be used to connect severed nerves without sacrificing another nerve from the body.

Peripheral nerve surgery is often an outpatient procedure done under general anesthesia, although it varies by case. “The good news is that from a recovery standpoint, much of the initial recovery is ensuring adequate wound healing, which only takes a couple of weeks,” says Eberlin.

His patients vary on how quickly the nerve pain dissipates. “In some patients, it’s relatively immediate,” Eberlin says. “There’s nothing more impactful to me as a peripheral nerve surgeon than a patient showing up at the first visit [after a surgery] and saying, ‘I’m totally better.’ But while that does happen frequently, it’s not always the case. Most of the time, it’s a longer recovery than that.”

In some cases, it can take up to one or two years.

“Imagine someone who has had nerve pain for, let’s say, five or 10 years—even if we are able to make that pain better surgically, the brain has been wired to perceive those painful signals, and it takes a little while for the system to figure out that things are different,” Eberlin says.

Is this option right for you?

Not all people with nerve pain are good candidates for peripheral nerve surgery. Surgeons will evaluate a patient with an examination, followed frequently by local anesthetic nerve blocks (numbing medication). Eberlin looks for people with localized pain instead of general pain. “Nerve surgery most often works best if there’s one focal nerve involved,” he says.

Hagan works with pain management doctors to evaluate patients and potential candidates for nerve surgery. “Can we [help] with medications alone or with other conservative modalities? Does this person need an injection?” he says. “If none of those have worked or it’s so severe, we need to consider surgery. There’s an algorithm to determine who is a candidate and who isn’t right.”

Both doctors admit peripheral nerve surgery has been slow to gain traction in the medical community. Many people do not expect, or realize, a plastic surgeon can help with pain.

“The biggest impact [in neuropathic pain] is gaining a greater awareness of all the techniques available, not just pain management with opioids,” says Hagan.

He recommends people with nerve pain seek out a peripheral nerve surgeon specializing in nerve pain, many of whom may offer initial screenings via telehealth.

“Even 15 years ago, it was more acceptable to see a [general surgeon],” he says, noting several of his patients had previously sought surgery to correct nerve pain, but it never addressed the nerve in question. “There is a group of surgeons that are focusing on [peripheral nerve surgery], and it’s developed as its own subspecialty. That’s important. I think it’s meaningful to outcomes; it’s meaningful to being diagnosed correctly.” 

“We can do things to fix fractures or provide new skin coverage, but one of the most impactful issues with which we can help patients is improving their pain.”.”