The Role of the Peripheral Nerve Surgeon in the Treatment of Pain

Abstract

Pain is a frequent cause of physician visits. Many physicians find these patients challenging because they often have complicated histories, emotional comorbidities, confusing examinations, difficult problems to fix, and the possibility of factitious complaints for attention or narcotic pain medications. As a result, many patients are lumped into the category of chronic, centralized pain and relegated to pain management. However, recent literature suggests that surgical management of carefully diagnosed generators of pain can greatly reduce patients' pain and narcotic requirements. This article reviews recent literature on surgical management of pain and four specific sources of chronic pain amenable to surgical treatment: painful neuroma, nerve compression, myofascial/musculoskeletal pain, and complex regional pain syndrome type II.

Keywords: Causalgia; Chronic pain; Complex regional pain syndromes; Hyperalgesia; Myofascial pain syndromes; Nerve compression; Neuralgia; Neuroma; Neurosurgery; Orthopedic surgery; Peripheral nerve injury; Plastic surgery; Reflex sympathetic dystrophy; Surgery.

Fig. 1

This patient demonstrates the typical guarded posture of complex regional pain syndrome (CRPS). Note that the shoulder is adducted and forward flexed causing muscle imbalance, shoulder pain, and traction on the brachial plexus at the middle scalene and axillary at the quadrangular space. The elbow is flexed compressing the ulnar nerve at the cubital tunnel. The forearm is pronated compressing the radial and median nerves at the supinator and pronator. The wrist is also flexed compressing the median nerve. Also note that the metacarpal–phalangeal joints are extended, not flexed in a clenched fist position. The authors thank Dr. Catherine Curtin, MD for allowing us to use this photograph.

Fig. 2

Our preferred pain evaluation form includes multiple visual analogue scales of pain, depression, anxiety, and anger. It also includes an avatar for patients to mark their pain location(s) and numerous questions about relevant comorbidities

Fig. 2

Our preferred pain evaluation form includes multiple visual analogue scales of pain, depression, anxiety, and anger. It also includes an avatar for patients to mark their pain location(s) and numerous questions about relevant comorbidities

Fig. 2

Our preferred pain evaluation form includes multiple visual analogue scales of pain, depression, anxiety, and anger. It also includes an avatar for patients to mark their pain location(s) and numerous questions about relevant comorbidities

Fig. 3

Diagrams of patients’ pain can help understand pain’s source. a Patients with neuroma will often describe an initial injury accompanied by pain with certain descriptive adjectives. They will then have a surgery and immediately develop much worse pain with new, different, often neuropathic-associated adjectives. Their pain level is often near 10 out of 10. b Patients with pain relating to compression neuropathy, muscle imbalance, or myofascial pain will describe a gradual worsening of their symptoms without a major change in pain adjectives. Giving patients colored pencils and asking them to draw their pain in this way, with different colors representing different pain, can be very informative