We Work with Orthopedic Surgeons
How can peripheral nerve surgery benefit the orthopedic surgeon? – By providing effective solutions for:
- Chronic pain after total joint arthroplasty
- Chronic pain after nonsurgical orthopedic trauma
- Chronic pain after orthopedic trauma requiring surgical intervention
- Chronic pain after elective orthopedic surgery
- Many types of chronic pain which may resemble a specific orthopedic problem but for which no “orthopedic etiology” can be identified
- Persistent weakness after orthopedic trauma or surgery – foot drop, wrist drop, sciatic or femoral nerve palsy, neurogenic thoracic outlet syndrome, etc.)
Bottom Line – patients who continue to experience persistent pain, paresthesias, or weakness after orthopedic trauma or surgery should be considered to have an undiagnosed peripheral nerve injury until proven otherwise.
The subspecialty field of peripheral nerve surgery geared towards eliminating pain of nerve origin is without a doubt the most significant advancement in treating chronic pain since the discovery of the opium poppy. Despite the advances of modern medicine, patients who continue to experience debilitating pain after surgery or traumatic injury are still often left with treatment options that would have been familiar to the ancient Egyptians more than 5 millennia ago – opium based pain medication. In the 21st century, we can now replace painful arthritic knee joints with engineering marvels made of metal alloys, plastic, and ceramic components. Ironically, if the patient still experiences chronic debilitating “knee pain” after a total knee arthroplasty, they invariably end up being treated with technology that’s essentially 5,000 years old.
This relatively new field of peripheral nerve surgery represents a “hand in glove” symbiosis which can provide solutions for some of the most difficult problems the orthopedic surgeon faces in trying to diagnosis and treat disorders of the musculoskeletal system.
One important concept to understand is that the type of injury mechanisms that produces orthopedic injuries, as well as the type of surgery that is often required to address orthopedic pathology puts patients at significant risk of sustaining concomitant injuries to the peripheral nervous system. Peripheral nerves are the musculoskeletal systems’ “silent partner,” if you will. In the setting of acute trauma, injuries to bones, ligaments and tendons are readily diagnosed with the latest imaging techniques. These serious injuries can then be addressed in the appropriate manner, sometimes with conservative treatment, but very frequently requiring surgical intervention.
Unless a peripheral nerve injury involves major damage to an important motor nerve, the pain and weakness that accompanies peripheral nerve pathology will usually be “masked” or “blend in” with the rest of the pain generated by the orthopedic trauma. This is equally applicable to nerve damage resulting from elective orthopedic procedures. In the case of nerve compression, it may takes weeks or months for the patient to even start to experience pain.
Because peripheral nerves are not imaged well with CT scans or MRIs, and because orthopedic physical examination is not designed to pick up most peripheral nerve injuries, they will often be missed in the acute setting and remain undiagnosed over the long term.
For most orthopedic procedures, wether it be an IM nail for a long bone fracture or a total joint arthroplasty, the surgeon usually has a fairly good idea of the timeframe required for recovery. So what does an orthopedic surgeon do when the patient starts to fall off the “recovery curve,” due to acute pain or weakness that persists long enough to become “chronic?” There are the usual steps of ruling out infection, hardware or implant defects, and making sure that the procedure was performed correctly, but when all those boxes have been checked what options are left? Returning to the knee replacement example above, what is an orthopedic surgeon to do in the case of the patient with a “perfect” total knee arthroplasty (TKA) and no post-operative complications, who continues to complain about debilitating knee pain? In an article published in the journal “Pain” in 2011, 15% of patients reported experiencing “severe-extreme” persistent pain 3 to 4 years following a total knee arthroplasty. Approximately 700,000 total knee arthroplasties are performed annually in the US. Using the “15%” figure, this translates to over 100,000 people a year continuing to experience debilitating knee pain even after the pathologic joint has been completely removed! This is a problem that is widely recognized in the orthopedic community, but for which no one has any diagnosis or solution.
The answer to the scenario of the TKA patient with no post-operative complications but continued, debilitating knee pain is that the orthopedic surgeon is no longer dealing with an orthopedic problem. He is now trying to solve a peripheral nerve puzzle. It’s like expecting the carpenter to fix an electrical issue!
The reason patients have persistent knee pain after TKA is that in most cases, the original sensory nerves to the knee joint, as well as the sensory nerves innervating the soft tissue envelope around the knee have all be left behind. Due to damage or entrapment in scar tissue, these nerves are now simply serving as chronic pain generators, sending constant pain signals to the brain. In these situations, it doesn’t matter how many additional orthopedic procedures the patient undergoes, the pain will never get better. In fact, at this stage, additional surgery aimed at solving a nonexistent orthopedic problem will often compound the situation leading to even more morbidity for the patient. Post-TKA neurogenic pain is often misdiagnosed as some type of “unrecognized or under treated” preexisting pathology, a problem with the implant itself, or “chronic infection,” often leading to additional, unnecessary surgery for the patient.
From the orthopedic surgeon’s perspective, peripheral nerve surgery provides an excellent alternative to consigning their “chronic pain” patients to languish forever in the pain management setting, by offering definitive, permanent relief of chronic neurogenic pain in most cases. Remember, for patients who develop chronic pain following trauma or surgery, and especially for patients with pain for which imaging provides no clear orthopedic etiology, keep the possibility of a peripheral nerve problem near the top of your differential diagnosis list.
Patient Success Stories
We enjoy sharing patient success stories to show those that are looking for help that people with similar circumstances were able to get help and that help made a difference. The following are instances where we were able to make a difference in a patient’s life:
The Tollestrup Team Can Help
If you’re a patient or an Orthopedic Surgeon, reach out to Dr. Tollestrup’s office today to see how we can help. Call us at 702-666-0463 or fill out an an interest form on this page. If you’re interested in learning more about how well we collaborate with other medical disciplines, please visit our physician portal.