Complications in nerve surgery

At the end of the lecture the participant will be able to:

• 1. List the possible complications and describe their prevention and management

• 2. Understand and manage complex regional pain syndrome

Complications

• Immediate – as result of surgery• Early – immediate post op period• Late – secondary to nerve regeneration• Secondary effects

Immediate• Non diagnosis – early/partial• Pain – CRPS• During surgery – iatrogenic injury of nerves and

vessels, nerve transfer/graft deficit of donor

Intermediate• tender neuroma • paralysis, and • incomplete sensory

recovery. • degree of cold intolerance• Decreasing functional

recovery• Non progressing Tinel

Late• Dysesthesia and disuse• Surgical failure - tension,

technique, poor vascular bed

• Contractures• Deformities – claw, Simian

hand• Atrophic changes

5219 procedures on 1819 patients total complication rate was 2.91%

Perioperative complications in patients undergoing peripheral nerve surgery.Ducic I, Hill L, Maher P, Al-Attar A. Ann Plast Surg. 2011 Jan;66(1):69-72.

Consenting

Complex regional pain syndrome CRPS

• Type I - without a nerve lesion (commonest)• type II – post nerve• Increased sweating, trophic changes, and

vasoconstriction• related coldness of the affected limb• long been considered as results of autonomic

(sympathetic) hyperactivity• 10% of patients report minor trauma

Pain Pract. 2009 Mar-Apr;9(2):86-99 Current understandings on complex regional pain syndrome.de Mos M, Sturkenboom MC, Huygen FJ.

Budapest Diagnostic Criteria

CRPS

1. an inflammatory process2. sympathetically mediated disorder3. Central sensitization4. autoimmune condition5. limb ischaemia /reperfusion injury6. Cortical reorganization7. nerve damage8. Neurogenic inflammation

6 years after disease onset

• 30% completely recovered, and • 54% of patients consider their disease as

stable• 15% of patients no improvement, • 30% unable to work

Outcome of the complex regional pain syndrome. Clin J Pain 2009;25:590 -7de Mos M, et al

Recommendations for the treatment

• Educated and self management• specialized physio /occupational therapy• Multidisciplinary pain management• drug or interventional treatments ( SCS etc)• Perioperative care• Long-term care

SCS is the application of an electrical current to the spinal cord dorsal column through a catheter inserted into the epidural space

ReferencesRheumatology (Oxford). 2011 Oct;50(10):1739-50. Complex regional pain syndrome in adults.Goebel A

Harden RN, Bruehl S, Stanton-Hicks M, Wilson PR.Proposed new diagnostic criteria for complex regional pain syndrome. Pain Med 2007;8:32631

Kemler MA, Barendse GA, van Kleef M et al.Spinal cord stimulation in patients with chronicreflex sympathetic dystrophy. N Engl J Med 2000;343:61824.

Kingery WS. Role of neuropeptide, cytokine, and growth factor signaling in complex regional pain syndrome. Pain Med 2010;11:123950

Latremoliere A, Woolf CJ. Central sensitization: a generator of pain hypersensitivity by central neural plasticity J Pain 2009;10:895926