Nerves run throughout the body, carrying messages for movement and sensation. The nervous system is divided into two parts – the central nervous system and the peripheral nervous system.
The central nervous system lies in the “center” of the body and is made up of the brain and spinal cord. The peripheral nervous system extends out from the central nervous system to the extremities, such as the abdomen, groin, knee hands and feet.
As nerves travel through the body, certain areas along their course are “tighter” than others, causing problems for the nerve and its function. In these areas, nerve compression can result, characterized by numbness, tingling or chronic pain. Areas of tightness can be in the groin, hands, feet or legs. One of the most common types of compression is carpal tunnel syndrome. Factors leading to nerve compression include diabetes, trauma or injury, chemotherapy, toxins or conditions which are unknown. In many diabetics, the nerves supplying the extremities of the body swell and stiffen, leading to the same symptoms as nerve compression. This condition is known as diabetic neuropathy. For some patients the pain and numbness from diabetic neuropathy is treatable, but not every patient is a candidate for surgery.
Some peripheral nerve problems are due to injured nerves, not due to compression. In those cases, a neuroma can result. This is an abnormal swelling of an injured nerve, resulting in pain, paresthesias (zinging sensation), and numbness. In that case, the injured nerve is typically found, trimmed back, and buried in muscle and soft tissue to prevent it from causing further pain.
When a nerve is cut, the piece of nerve that is beyond the cut point eventually dies, however, the cut end of nerve will send out multiple sprouts in the direction of the nerve growth factor in all directions and eventually cluster and form a knot of nerve fibres. This eventually leads to the formation of a neuroma. If it is in a place on your foot where you put a lot of pressure, it will become very painful. Morton’s Neuroma is another type of peripheral nerve problem in the foot. The pain is caused by the repetitive compression of the common plantar digital nerve. This nerve lies between the heads of the metatarsal bones. Consequently, the neuroma that develops is not a true neuroma, but rather a manifestation of chronic nerve compression.
Chronic Headache (Occipital, Frontal or Temporal Neuralgia) Upper & Lower Extremity Neuropathies: Carpal, Cubital, Tarsal Tunnel Diabetic Symptomatic Neuropathy (Extremity Numbness and/or Pain) Groin Pain Following Surgery (Inguinal hernia, Hysterectomy, Abdominoplasty) Knee pain following Knee Replacement Amputation Stump Pain, Foot Drop, Meralgia Paresthetica Peripheral Nerve Tumors, Brachial Plexus Injury, Thoracic Outlet Syndrome Acute Nerve Injury Following Surgery or Trauma
There are several nerve related problems that affect the upper extremities. Carpal Tunnel Syndrome is the most common. Carpal Tunnel Syndrome causes numbness and tingling in the thumb, index and middle fingers. Many times these sensations in the hand awaken patients at night, or their hands may go to sleep during normal activities. This numbness and tingling may come and go, or may be present all the time. Carpal Tunnel Syndrome is caused by the median nerve being pinched or compressed at the wrist in the “Carpal Tunnel”.
Numbness in the little and ring finger may be attributed to Cubital Tunnel Syndrome which causes numbness and tingling in the little finger and the ring finger. Patients may experience weakness in their grip, begin to drop objects, and have trouble opening doors or jars. Also fine motor skills such as buttoning shirts may be difficult. Cubital Tunnel is caused by the ulnar nerve being pinched or compressed at the elbow in the “Cubital Tunnel”.
Radial Tunnel Syndrome causes numbness and tingling in the back of the hand. This is caused by compression of the radial nerve on the forearm in the “Radial Tunnel”.
Many patients have pain in all three nerve distributions referred to as neuropathy. Neuropathy is caused by systemic diseases, the most common of which is diabetes. Patients who are “Pre-diabetic” (those who are overweight with high cholesterol and high blood pressure) exhibit neuropathy symptoms similar to that of diabetic patients. Other causes of neuropathy can include chemotherapy (Vincristine, Thalidomide, Taxol and Cisplatin are common chemotherapy medications that have been proven to cause neuropathy), certain forms of arthritis, thyroid disorders, leprosy, alcoholism, drug use, heavy metal toxicity, and vitamin deficiencies. Still there are many types of neuropathy in which the cause is not known. This is referred to as idiopathic neuropathy.
There are two main types of neuropathy. The first is when the nerve itself has a problem with the body attacking the lining of the nerves. This is a small fiber neuropathy which cannot be treated with surgery. The second is a “Compressive Neuropathy” which is caused by pressure on the nerve like Carpal Tunnel Syndrome. This type of neuropathy may be treatable by surgically relieving the areas of compression on the nerves caused by the surrounding tissues. Diabetics and “pre-diabetics” often get compression neuropathies. This is because in diabetics the nerves are swollen. When sugar (glucose) from the blood goes into the nerve it changes to sorbitol (another sugar). This chemical reaction causes a greater number of water molecules to enter the nerve causing swelling. The swollen nerves run through tight anatomical tunnels in the body. When swollen nerves are in tight tunnels they get compressed causing pain and numbness. By releasing the areas of compression, (the tight tunnels) sensation can be restored and pain decreased. This is the same operation has been done for carpal tunnel syndrome for many years. The success rate of nerve decompression surgery for diabetic and “pre-diabetic patients is in the eighty-percent range. Decompression of the nerves can reduce or eliminate pain and improve.
Patients usually first try Carpal Tunnel splints at night and during repetitive motions such as typing. Some patients wrap a towel around the elbow to prevent it from being bent at night while sleeping to relieve the pressure in the ulnar nerve. Patients who have neuropathy should first consult their primary care doctor to determine if their type neuropathy is caused by an underlying disease that can be treated, such as a thyroid disorder, vitamin deficiency
Multiple nerve-related problems can affect the lower extremities. Peripheral neuropathy, Morton’s neuromas and nerve injuries/neuromas (due to trauma or surgery) are some of the conditions that respond to surgical treatments, decreasing, and in many cases eliminating, pain.
Many types of neuropathy are caused by chronic diseases, the most common of which is diabetes. Patients who are “Pre-diabetic”, those who are overweight with high cholesterol and high blood pressure exhibit neuropathy symptoms similar to that of diabetic patients. Other causes of neuropathy can include chemotherapy (Vincristine, Thalidomide, Taxol and Cisplatin are common chemotherapy medications that have been proven to cause neuropathy), Lyme’s disease,certain forms of arthritis, thyroid disorders, leprosy, alcoholism, drug use, heavy metal toxicity, and vitamin deficiencies. Still there are many types of neuropathy in which the cause is not known. This is referred to as idiopathic neuropathy.
Compressive neuropathy is caused by pressure on the nerve similar to Carpal Tunnel Syndrome. This type of neuropathy can be corrected by surgically relieving the areas of compression on the nerves caused by the surrounding tissues. Diabetics and “pre-diabetics” most commonly have compression neuropathies. This is because in diabetics the nerves are swollen. When sugar (glucose) from the blood goes into the nerve it changes to sorbitol (another sugar). This chemical reaction causes a greater number of water molecules to enter the nerve causing swelling. The swollen nerves run through tight anatomical tunnels in the body. When swollen nerves are in tight tunnels they get compressed causing pain and numbness. By releasing the areas of compression (the tight tunnels) sensation can be restored and pain decreased. This is the same operation has been done for carpal tunnel syndrome for many years. The success rate of nerve decompression surgery for diabetic and “pre-diabetic” patients is in the eighty-percent range. Decompression of the nerves can reduce or eliminate pain, improve sensation and balance and prevent ulcerations and amputations.
Patients should first consult their primary care doctor to determine if their type neuropathy is caused by an underlying disease that can be treated, such as a thyroid disorder, vitamin deficiency or diabetes. Treatment of the disease can frequently provide relief for the symptoms. Some anesthesia pain management doctors have medical treatment options for those patients who are not healthy enough to undergo surgery or for those who are not good surgical candidates.
Surgery is an option once it is determined that your neuropathy is a “Compression Neuropathy” and that you are a good candidate for surgery. There are different physical examination and neurologic tests that together determine if you are likely to benefit from surgery.
Nerve decompression surgery is an outpatient procedure that takes about two hours. A general anesthetic is administered by an Anesthesiologist and using microsurgical techniques 3-4 incisions are made: one on the top of the foot, one up by the knee on the outside of the leg, one by the calf, and one on the inside of the ankle. Once the nerve is identified, it is followed to the area of compression and the tight band (the top of the tunnel) that is compressing the nerve is released, similar to what is done during carpal tunnel surgery. After the surgery, a simple compressive dressing is placed on the leg and the patient is transferred to the recovery room. There are some patients that notice an immediate difference in there pain as they wake up in the recovery room, others it can take up to several months depending on the amount of compression and the degree of nerve damage from the compression. The patient is sent home and asked to use a walker or crutches for the first week to minimize the amount of pressure placed on the operative leg. After the first week the dressing is removed and the patient may get back into a normal shoe and sock. The final sutures are removed 2-3 weeks after surgery and at this time the patient is released to normal activity. Patients are allowed to immediately walk on the operated leg but we try and limit activity and bending at the ankle to allow proper wound healing.
As the nerves regenerate and grow some patients may experience neuro-regenerative sensations such as shooting, stabbing or electrical types of pain. This is a good sign showing the nerve is growing. As the nerve continues to grow, the numbness the patient had before surgery will improve and the neuro-regenerative pain will improve.
The biggest risk with this operation is that patients may still be left with areas of pain or numbness or there might be no change at all in the amount of numbness and/or pain. The most common risks associated with any type of surgical procedure include minor infections and scaring. Certain medical conditions, such as diabetes, may slow the healing process increasing the risk of infection. Other risks include an increase in pain (which is usually the progression of the neuropathy and not an operative complication) or DVT which are very uncommon.
Morton’s Neuroma is another type of peripheral nerve problem in the foot caused by the repetitive compression of the common plantar digital nerve. This nerve lies between the heads of the metatarsal bones. Consequently, the neuroma that develops is not a true neuroma, but rather chronic nerve compression. Tight shoes and high heels can intensify this type of pain. If the Morton’s Neuroma has already been operated on by another physician and he/she cut the nerve, then the Morton’s Neuroma is a true neuroma and the nerve needs to be resected. For this type of Morton’s Neuroma see the next section on nerve injuries.
Morton’s Neuroma symptoms can often be alleviated by wearing flat, wide-toe shoes or Orthotic devices made by a podiatrist. Other treatments include the use of arch supports or custom-fitted shoes to redistribute weight away from the area.
Patients who are under the age of 75 that are in good health with abnormal physical and neurologic tests are typically good surgical candidates.
Morton’s Neuroma surgery is an outpatient procedure taking about and hour. A general anesthetic is used in most cases though in rare instances a spinal block may be used. Once the nerve is identified, the area of compression is released. A dressing is placed and the patient is transferred to the recovery room. There are some patients that notice an immediate difference in there pain as they wake up in the recovery room, others it can take up to several months depending on the amount of compression and the amount of time since the compression presented. The patient is sent home and asked to use a walker or crutches for the first week to minimize the amount of pressure placed on the operative foot. After the first week the dressing is removed and the patient may put on a shoe and sock. The final sutures are removed three weeks after surgery and at this time the patient is released to normal activity.
The biggest risk with this operation is that patients may still be left with areas of pain or there is no change in the amount of pain. The most common risks associated with any type of surgical procedure include bleeding, infection and scaring. Other risks include an increase in pain (which is usually the progression of the neuropathy not an operative complication) or DVT which are very uncommon.
When a nerve gets injured due to a traumatic injury or surgery the damaged portion of the nerve, the neuroma, causes shooting, stabbing and/ or throbbing pain. There are operations for some of these nerve injuries that can decrease and in most cases eliminate the pain.
Patients should first consult their primary care doctor to determine if the cause of the pain is nerve related. Also there are pain management specialists that may be able to help to diagnose and sometimes manage the pain especially for patients that are not good surgical candidates.
Surgery is an option once it is determined that the pain is from a neuroma and that you are a good candidate for surgery. Nerve blocks are used to determine which nerve is causing the pain. This is done by injecting the area surrounding the nerve with a local anesthesia similar to what a dentist would use on a patient undergoing dental work. The nerve block should last several hours and will allow the patient to see how the involved are will feel after surgery. After several hours the pain that existed before the block will return.
Patients that are in good health and have appropriate responses to the local anesthesia block may be good candidates for surgery.
Neuroma surgery is an outpatient procedure taking about and hour. A general anesthetic is administered by an Anesthesiologist. Using microsurgical techniques the damaged nerve is identified, and the neuroma is cut out and the nerve is buried into muscle. A dressing is placed and the patient is transferred to the recovery room. There are some patients that notice an immediate difference in there pain as they wake up in the recovery room, others it can take up to several months. The patient is sent home and asked to use a walker or crutches for the first week to minimize the amount of pressure placed on the operative foot. After the first week the dressing is removed and the patient may put on a shoe and sock. The final sutures are removed three weeks after surgery and at this time the patient is released to normal activity.
The biggest risk with this operation is that patients may still be left with areas of pain or there is no change in the amount of pain. The most common risks associated with any type of surgical procedure include bleeding, infection and scaring. Other risks include an increase in pain or DVT which are very uncommon. Unfortunately some patients may continue to have pain and their body never responds to removing the nerve. These patients are often thought to have “centralized pain” which means their pain will not respond to procedures done on the nerve itself and instead need these patients need the expertise of a pain management specialist.
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