Medicine:Neurectomy

From HandWiki
Neurectomy
SpecialtyNeurology

A neurectomy, or nerve resection is a neurosurgical procedure in which a peripheral nerve is cut or removed to alleviate neuropathic pain or permanently disable some function of a nerve. The nerve is not intended to grow back. For chronic pain it may be an alternative to a failed nerve decompression when the target nerve has no motor function and numbness is acceptable.[1] Neurectomies have also been used to permanently block autonomic function (e.g. excessive sweating in hands[2] or involuntary muscle movement causing cramps[3]), and special sensory function not related to pain (e.g. vestibular nerve dysfunction causing vertigo[4]).

A temporary nerve block with an anesthetic if usually performed before surgery to confirm the diagnosis of neuropathic pain.[1] Risks include numbness, neuroma, and complications due to lack of innervation.

Procedures

Presacral neurectomy

A presacral neurectomy is typically conducted to decrease severe pain and menstrual cramps in the lower abdomen. Pain in this region is difficult to treat with noninvasive treatments. Endometriosis is the most common cause for this severe pain. One solution that doctors often mistakenly recommend as a cure is a hysterectomy, or removal of the uterus. However, this often does not relieve endometriosis pain because the disease is left behind on other organs such as the bladder, bowels, or pelvic side walls, and it can thrive on its own hormone supply. Another is to perform a presacral neurectomy. This is a procedure that interrupts the nerves going towards and/or around the uterus.[5] Pain located on either side of the lower abdomen (but not mid line) should not be treated with a neurectomy. Only individuals with pain that is not relieved by the use of NSAIDs should consider this procedure. Techniques have been developed for this procedure to be performed laparoscopically.[5]

The incision is typically directly under the navel. Normally three small holes are made in the lower abdomen to allow for the instruments and other various surgical tools. Nerve tissue that runs to the uterus is interrupted at the sacral promontory; a point at which spine and tailbones meet. This is the best area to access and obtain a clear view of the nerves in the uterus. Proper precautions must be taken as to avoid unnecessary complications with the major blood vessels surrounding the uterus. Some of the complications post-operation include urinary retention, as well as constipation. Neither has been reported to cause lasting effects.[5]

Recent technological advances have allowed this same procedure to be done robotically, a minimally invasive technique similar to laparoscopy. The outcome of the procedure is identical to an open approach (laparotomy), but the incisions are much smaller allowing for less post-operation pain. Less pain following this surgery allows for a quicker recovery period too; two weeks as opposed to six weeks, on average.[6]

Vestibular neurectomy

A vestibular neurectomy is an operation that severs the vestibular nerve, which contributes to balance, while sparing the cochlear nerve, which contributes to hearing. The procedure has the potential to relieve vertigo, but may preserve the ability to hear.[7] It is important to note that this procedure will not reverse the effects of deafness. The risks include: hearing loss, tinnitus, dizziness, facial weakness, spinal fluid leak, and various infections.[8] There are several different surgical approaches that can be used to complete this procedure: the middle cranial fossa, retrolabrynthine, retrosigmoid, and translabrynthine.[9] The middle cranial fossa approach is one that most often requires neurosurgical expertise. The advantage of this procedure is that the vestibular nerve is clearly visible and can be sectioned without harming the cochlear nerve fibers.[7]

The general procedure begins by positioning the patient supine with the head turned to the side with surgical ear upright. An incision is made at the lower portion of the zygomatic root to the area of the temporal region for roughly seven centimeters. Precautions are taken by clamping flaps of tissue as to not impede further actions. To expose the IAC (Inner Auditory Canal) properly, portions of bone from the metal fundus and also the tegmen tympani must be removed.[8] The SVN (superior vestibular nerve) is then identified and cut at the point furthest from the vestibular crest. Along with the SVN, Scarpa's ganglion is also cut and removed.[8]

In cases of Ménière's disease, a neurectomy may be needed when no other medical treatment is sufficient for over six months. In bilateral Ménière's disease, the procedure is done on the worse-off ear. Some procedures are done on both ears, but the risk of hearing loss then becomes significantly greater.[8]

Pulsed radiofrequency ablation neurectomy

Some ablations that have been previously performed laparoscopically are also now offered via the pulsed radiofrequency technique. Pulsed radiofrequency ablation relies on delivering an electrical field specifically to neural tissue in order to damage it while minimizing injury to the surrounding area. For example, this technique has been used in patients with chronic shoulder pain as a way to perform a neurectomy of the suprascapular nerve with less risk of damage to nearby muscles within the rotator cuff.[10] There is still a lack of evidence directly comparing the efficacy and safety of this technique compared to the traditional laparoscopic method, but there is evidence that it improves range of motion and pain compared to placebo[10] or sham surgery.[11]

Neurectomy for nerve entrapment

Neurectomy can be an alternative to a nerve decompression for nerve entrapment, such as when the nerves have no motor function and numbness along the dermatome is acceptable. A neurectomy is not a mutually exclusive option to a decompression as a neurectomy can also be used after a failed decompression.[12]

There are many nerves in the human body that are purely sensory such as the cutaneous nerves, which provide innervation to all parts of the skin. The cutaneous nerves are especially susceptible to compression from wearables or injuries due to their superficial location. Some examples of wearable-induced irritation are supraorbital neuralgia from tight goggles,[13] superficial radial neuropathy from handcuffs,[14] and meralgia paresthetica from tight pants.[15] As cutaneous nerves cover all areas of the skin, and any surgery which requires incisions may inadvertently cause injury or scarring, now entrapping a cutaneous nerve.[16]

A common tradeoff when electing to a neurectomy is that numbness along the nerve distribution is expected. Studies that have measured how bothersome numbness is to patients have found that most patients are not bothered at all by the numbness, and the ones that are find the numbness minimally bothering.[17][18]

Intercoastal cutaneous nerve neurectomy

Intercoastal neuralgia is a neuropathic condition that involves the intercoastal nerves. The primary symptom is pain and it may be localized to the distribution of one or more of the intercoastal nerves, manifesting as chest and abdominal pain.[19] No treatment modality prior to neurectomy (e.g. systemic medications, cryoablation, therapeutic nerve blocks, and radioablation) has given effective pain relief and none have been curative.[20]

The success outcome is typically measured as a 50% or more decrease in visual analog scale (VAS) scores, which are numerical pain scores from 0 - 10 or 0-100. Success rates are often reported as 70%.[21][22][23] Studies reporting on intercoastal neurectomy often report cure rates (100% reduction in symptoms), even though it's not the primary success outcome. For example, patients may say they are cured or report pain scores of zero. There is a wide span of the reported cure rates, ranging from 22 - 67%.[21][22][24] A double-blind, randomized, controlled surgery trial found a 22% cure rate for the surgery group and a 4% cure rate for the sham surgery group, suggesting that these cure rates cannot be purely attributable to the natural history of the disease or a placebo effect.[22]

Lateral femoral cutaneous nerve neurectomy

Lateral femoral cutaneous neuralgia, often known as Meralgia Paresthetica, involves neuropathic pain on the outer thigh. The use of a nerve decompression or neurectomy to treat nerve pain along the lateral femoral cutaneous nerve is a firmly established surgical treatment. [25][26] However, the more effective treatment between a decompression and neurectomy is still being researched.

Between a nerve decompression and a neurectomy, the neurectomy is associated with a higher success rate which has been validated by two Cochrane reviews. The reviews found decompressions beneficial in 88% of cases and neurectomy beneficial in 94% of cases.[27][28] A German national cohort study found similar results where complete pain relief from decompression was seen in 63% of cases but complete pain relief from neurectomy was seen in 85%.[29]

Use in horses

Neurectomy is also used in equine medicine, primarily for cases of persistent lameness that is non-responsive to other forms of treatment. It is most commonly used for animals with navicular syndrome and suspensory ligament desmitis.[30]

See also

References

  1. ↑ 1.0 1.1 Lipinski LJ, Spinner RJ. Neurolysis, neurectomy, and nerve repair/reconstruction for chronic pain. Neurosurg Clin N Am. 2014 Oct;25(4):777-87. doi: 10.1016/j.nec.2014.07.002. Epub 2014 Aug 14. PMID: 25240664.
  2. ↑ Vannucci F, Araújo JA. Thoracic sympathectomy for hyperhidrosis: from surgical indications to clinical results. J Thorac Dis. 2017 Apr;9(Suppl 3):S178-S192. doi: 10.21037/jtd.2017.04.04. PMID: 28446983; PMCID: PMC5392541.
  3. ↑ Miller LE, Bhattacharyya R, Miller VM. Clinical Utility of Presacral Neurectomy as an Adjunct to Conservative Endometriosis Surgery: Systematic Review and Meta-Analysis of Controlled Studies. Sci Rep. 2020 Apr 23;10(1):6901. doi: 10.1038/s41598-020-63966-w. PMID: 32327689; PMCID: PMC7181806.
  4. ↑ Alarcón AV, Hidalgo LO, Arévalo RJ, Diaz MP. Labyrinthectomy and Vestibular Neurectomy for Intractable Vertiginous Symptoms. Int Arch Otorhinolaryngol. 2017 Apr;21(2):184-190. doi: 10.1055/s-0037-1599242. PMID: 28382129; PMCID: PMC5375706.
  5. ↑ 5.0 5.1 5.2 "Presacral Neurectomy". http://www.womensdoctor.com/site/presacral-neurectomy. [unreliable medical source?]
  6. ↑ "Robotic Presacral Neurectomy". The Robotic Surgery Center, NYU Langone Medical Center. Archived from the original on August 1, 2013. https://web.archive.org/web/20130801041656/http://www.robotic-surgery.med.nyu.edu/for-patients/our-departments/gynecology/procedures/presacral-neurectomy. Retrieved December 15, 2013. 
  7. ↑ 7.0 7.1 Vestibular Neurectomy at eMedicine
  8. ↑ 8.0 8.1 8.2 8.3 "Vestibular Neurectomy (Balance Nerve section)". Dallas Ear Institute. http://www.dallasear.com/services-vestibular-neurectomy.html. 
  9. ↑ Silverstein, Herbert; Norrell, Horace; Haberkamp, Thomas (1987). "A comparison of retrosigmoid iac, retrolabyrinthine, and middle fossa vestibular neurectomy for treatment of vertigo" (in en). The Laryngoscope 97 (2): 165–173. doi:10.1288/00005537-198702000-00007. ISSN 1531-4995. PMID 3807619. 
  10. ↑ 10.0 10.1 Liu, An; Zhang, Wei; Sun, Miao; Ma, Chiyuan; Yan, Shigui (April 2016). "Evidence-based Status of Pulsed Radiofrequency Treatment for Patients with Shoulder Pain: A Systematic Review of Randomized Controlled Trials" (in en). Pain Practice 16 (4): 518–525. doi:10.1111/papr.12310. PMID 25990576. 
  11. ↑ Gofeld, Michael; Restrepo-Garces, Carlos E.; Theodore, Brian R.; Faclier, Gil (February 2013). "Pulsed Radiofrequency of Suprascapular Nerve for Chronic Shoulder Pain: A Randomized Double-Blind Active Placebo-Controlled Study: Pulsed Radiofrequency of Suprascapular Nerve" (in en). Pain Practice 13 (2): 96–103. doi:10.1111/j.1533-2500.2012.00560.x. PMID 22554345. 
  12. ↑ Lipinski LJ, Spinner RJ. Neurolysis, neurectomy, and nerve repair/reconstruction for chronic pain. Neurosurg Clin N Am. 2014 Oct;25(4):777-87. doi: 10.1016/j.nec.2014.07.002. Epub 2014 Aug 14. PMID: 25240664.
  13. ↑ O'Brien JC Jr. Swimmer's headache, or supraorbital neuralgia. Proc (Bayl Univ Med Cent). 2004 Oct;17(4):418-9. doi: 10.1080/08998280.2004.11928006. PMID: 16200130; PMCID: PMC1200682.
  14. ↑ Grant AC, Cook AA. A prospective study of handcuff neuropathies. Muscle Nerve. 2000 Jun;23(6):933-8. doi: 10.1002/(sici)1097-4598(200006)23:6<933::aid-mus14>3.0.co;2-g. PMID: 10842271.
  15. ↑ Moucharafieh R, Wehbe J, Maalouf G. Meralgia paresthetica: a result of tight new trendy low cut trousers ('taille basse'). Int J Surg. 2008 Apr;6(2):164-8. doi: 10.1016/j.ijsu.2007.04.003. Epub 2007 Apr 14. PMID: 17521975.
  16. ↑ Charipova K, Gress K, Berger AA, Kassem H, Schwartz R, Herman J, Miriyala S, Paladini A, Varrassi G, Kaye AD, Urits I. A Comprehensive Review and Update of Post-surgical Cutaneous Nerve Entrapment. Curr Pain Headache Rep. 2021 Feb 5;25(2):11. doi: 10.1007/s11916-020-00924-1. PMID: 33547511.
  17. ↑ de Ruiter GC, Kloet A. Comparison of effectiveness of different surgical treatments for meralgia paresthetica: Results of a prospective observational study and protocol for a randomized controlled trial. Clin Neurol Neurosurg. 2015 Jul;134:7-11. doi: 10.1016/j.clineuro.2015.04.007. Epub 2015 Apr 11. PMID: 25911497.
  18. ↑ de Ruiter, G.C.W., Wurzer, J.A.L. & Kloet, A. Decision making in the surgical treatment of meralgia paresthetica: neurolysis versus neurectomy. Acta Neurochir 154, 1765–1772 (2012). https://doi.org/10.1007/s00701-012-1431-0
  19. ↑ Hsu, E., Argoff, C., Galluzzi, K., Leo, R., & Dubin, A. (2013). Intercostal neuralgia. In Problem-Based Pain Management (pp. 114-119). Cambridge: Cambridge University Press. doi:10.1017/CBO9781139135054.025
  20. ↑ Williams EH, Williams CG, Rosson GD, Heitmiller RF, Dellon AL. Neurectomy for treatment of intercostal neuralgia. Ann Thorac Surg. 2008 May;85(5):1766-70. doi: 10.1016/j.athoracsur.2007.11.058. PMID: 18442581.
  21. ↑ 21.0 21.1 Ducic I, Larson EE. Outcomes of surgical treatment for chronic postoperative breast and abdominal pain attributed to the intercostal nerve. J Am Coll Surg. 2006 Sep;203(3):304-10. doi: 10.1016/j.jamcollsurg.2006.05.018. Epub 2006 Jul 11. PMID: 16931302.
  22. ↑ 22.0 22.1 22.2 Boelens OB, van Assen T, Houterman S, Scheltinga MR, Roumen RM. A double-blind, randomized, controlled trial on surgery for chronic abdominal pain due to anterior cutaneous nerve entrapment syndrome. Ann Surg. 2013 May;257(5):845-9. doi: 10.1097/SLA.0b013e318285f930. PMID: 23470571.
  23. ↑ Maatman, R.C., Steegers, M.A.H., Boelens, O.B.A. et al. Pulsed radiofrequency or anterior neurectomy for anterior cutaneous nerve entrapment syndrome (ACNES) (the PULSE trial): study protocol of a randomized controlled trial. Trials 18, 362 (2017). https://doi.org/10.1186/s13063-017-2110-5
  24. ↑ Armstrong LB, Dinakar P, Mooney DP. Neurectomy for anterior cutaneous nerve entrapment syndrome in children. J Pediatr Surg. 2018 Aug;53(8):1547-1549. doi: 10.1016/j.jpedsurg.2017.11.062. Epub 2017 Dec 8. PMID: 29321104.
  25. ↑ Coffey R, Gupta V. Meralgia Paresthetica. [Updated 2023 May 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK557735/
  26. ↑ Lu VM, Burks SS, Heath RN, Wolde T, Spinner RJ, Levi AD. Meralgia paresthetica treated by injection, decompression, and neurectomy: a systematic review and meta-analysis of pain and operative outcomes. J Neurosurg. 2021 Jan 15;135(3):912-922. doi: 10.3171/2020.7.JNS202191. PMID: 33450741.
  27. ↑ Khalil N, Nicotra A, Rakowicz W. Treatment for meralgia paraesthetica. Cochrane Database of Systematic Reviews 2012, Issue 12. Art. No.: CD004159. DOI: 10.1002/14651858.CD004159.pub3. Accessed 16 September 2023.
  28. ↑ Khalil N, Nicotra A, Rakowicz W. Treatment for meralgia paraesthetica. Cochrane Database of Systematic Reviews 2008, Issue 3. Art. No.: CD004159. DOI: 10.1002/14651858.CD004159.pub2. Accessed 16 September 2023.
  29. ↑ Schönberg, B., Pigorsch, M., Huscher, D. et al. Diagnosis and treatment of meralgia paresthetica between 2005 and 2018: a national cohort study. Neurosurg Rev 46, 54 (2023). https://doi.org/10.1007/s10143-023-01962-0
  30. ↑ Jackman, Bradley R.; Baxter, Gary M.; Doran, Richard E.; Allen, Douglas; Parks, Andrew H. (1993). "Palmar Digital Neurectomy in Horses 57 Cases (1984–1990)" (in en). Veterinary Surgery 22 (4): 285–288. doi:10.1111/j.1532-950X.1993.tb00399.x. ISSN 1532-950X. PMID 8351810. 

Further reading

  • Surgical treatment of Ménière's disease.
  • Candiani, Giovanni Battista; Fedele, Luigi; Vercellini, Paolo; Bianchi, Stefano; Nola, Giuliana Di (1992). "Presacral neurectomy for the treatment of pelvic pain associated with endometriosis: A controlled study". American Journal of Obstetrics and Gynecology 167 (1): 100–3. doi:10.1016/S0002-9378(11)91636-6. PMID 1442906. 
  • Castro-Lopes, Josém.; Tavares, Isaura; Coimbra, Antonio (1993). "GABA decreases in the spinal cord dorsal horn after peripheral neurectomy". Brain Research 620 (2): 287–91. doi:10.1016/0006-8993(93)90167-L. PMID 8369960. 
  • Tjaden, B; Schlaff, W. D.; Kimball, A; Rock, J. A. (1990). "The efficacy of presacral neurectomy for the relief of midline dysmenorrhea". Obstetrics and Gynecology 76 (1): 89–91. PMID 2193272. 
  • Perez, J. J. (1990). "Laparoscopic presacral neurectomy. Results of the first 25 cases". The Journal of Reproductive Medicine 35 (6): 625–30. PMID 2141645. 
  • Halmagyi, G. M.; Curthoys, I. S.; Cremer, P. D.; Henderson, C. J.; Todd, M. J.; Staples, M. J.; d'Cruz, D. M. (1990). "The human horizontal vestibulo-ocular reflex in response to high-acceleration stimulation before and after unilateral vestibular neurectomy". Experimental Brain Research 81 (3): 479–90. doi:10.1007/BF02423496. PMID 2226683. 



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