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How can peripheral nerve surgery impact patient care for the primary care physician?

Gaining a working knowledge of the role and limitations of peripheral nerve surgery can exponentially improve your ability to correctly diagnose and refer patients with peripheral nerve pain for evaluation and treatment.

Currently, patients with chronic neurogenic pain will inevitably be consigned to the pain management realm. Being able to recognize peripheral nerve problems and have them treated appropriately can spare your patients a lifetime of narcotic use along with the associated side effects. Ironically, a common bond these patients share is that despite being on high doses of narcotics, they usually experience surprisingly poor pain control.

The more confusing a patient’s pain problem seems, the more diagnostic testing seems to be unable to identify the source of the pain, and the more all the usual treatment modalities fail to provide your patient with pain relief, the more likely it is that they are dealing with some type of peripheral nerve pathology.

One of the most common reasons patients seek medical care is to address some kind of pain problem.

For patient’s who go on to develop severe chronic pain, often defined as pain lasting more than 6 months, the consequences can be life shattering. This relatively new field of peripheral nerve surgery that Dr. Tollestrup has introduced to the state of Nevada is arguably the most exciting advancement in the treatment of many forms of chronic since the domestication of the opium poppy by the Egyptians over 5000 years ago. As odd as it may sound in the age of the internet, for the majority of chronic pain patients the mainstay of pain management, narcotic pain medication, has varied little in over 5 millennia.

While incredible advances have been commonplace throughout almost all other branches of medicine over the last 200 years, many types of debilitating chronic pain problems have resisted any and all attempts at a solution. Many types of these chronic pain problems share a common thread that is poorly understood by physicians across the medical spectrum – the root cause of the pain involves peripheral nerve pathology. As an anatomical system, peripheral nerves are essentially the re-headed stepchild of the bunch, largely ignored while other surgical subspecialties rapidly developed to treat pathology involving all the other anatomic systems in the body. The important role that peripheral nerves play in many types of chronic pain that have heretofore been considered “untreatable,” as well as the development of a new field of surgery which is providing exciting, revolutionary solutions for patients suffering with this kind of pain, is without a doubt the “best kept secret” in medicine.

The reason for this has to do with a combination of the complexity of peripheral nerve anatomy, the complete lack of meaningful instruction regarding recognition and diagnosis of peripheral nerve pathology across physicians of all stripes during their training years, and the heavy historical reliance on narcotic pain medication for the treatment of chronic pain. As a result, with a few exceptions, the approach to treating chronic pain has evolved into a “one size fits all” approach. Chronic pain is more or less viewed as a homogenous disease and pain medication the cure. The dirty little secret that no one really wants to acknowledge, however, is that for many chronic pain patients, this approach produces consistently horrible results. For too many patients with chronic pain problems, all the bells and whistles that the field of modern pain management has to offer them notwithstanding, gnawing, soul-shattering pain is a constant companion.

Underlying much of this refractory chronic pain is some type of damage involving peripheral nerves.

This usually takes the form of nerve compression, stretch-traction injury, nerve entrapment in scar tissue, or physical damage (laceration, or crush injury) to the nerve resulting in a neuroma. Fundamentally, these types of pathologies all represent a mechanical problem with the nerve. This is also the reason why even high doses of narcotic pain medication as well as medications like Gabapentin and Lyrica are typically ineffective at treating nerve pain of peripheral origin. For this type of nerve pathology, only surgical intervention, with its ability to physically change or eradicate the root cause of the problem by decompressing a compressed nerve or excising a painful neuroma, has the ability to eliminate the pain generating source permanently. To treat peripheral nerve problems pharmacologically makes about as much sense as treating a displaced femur fracture with ibuprofen in hopes that the pain will simply go away.

So, in practical terms, how can a primary care physician tell if the patient sitting in front of them is suffering from pain stemming from peripheral nerve pathology vs some other source.

Although the majority of peripheral nerve-related chronic pain problems fall into one of these categories, unique patients are common and often a particular surgical procedure or approach has to be developed or tailored to meet the requirements of a particular problem.

Anytime patients complain of the following symptoms, there is a high likelihood that a peripheral nerve is involved:

Pain which is often seems out of proportion with the inciting event or the patient’s current appearance. Often patients suffering with severe peripheral nerve pain appear otherwise normal. While nerve pain can assume virtually any description, it is often characterized as having a burning/freezing or electrical quality to it. The pain will often start in one location and then radiate or “shoot” to another location, often up or down the course of the affected limb for example. Cramping or “charlie horse” pain is common. The patient’s pain level frequently increases with increased activity level or use of the affected body part.

Sensory alterations such as loss of sensation, dulling of sensation, numbness, tingling, pins/needles, etc. Pressure or the sensation of a part of the body being squeezed is also a common feature. Another hallmark is patient’s describing the phenomenon of dropping items from their grasp unintentionally which stems from loss of tactile sensation in the hand. In the feet, loss of sensation due to peripheral nerve pathology often manifests as loss of balance.

Muscle weakness. This can manifest as true motor weakness or as merely a sensation of weakness that is not present when the affected muscle group is actually motor tested. Patients with “meralgia paresthetica” (compression or injury to the lateral femoral cutaneous nerve which innervates the skin over the anterolateral thigh) often complain of a subjective feeling of quadriceps weakness and sensation that the leg is imminently going to “give out” on them. The patient usually never gives a history of actually falling, however. Deterioration in grip strength and fine motor coordination in the upper extremity is a hallmark of ongoing peripheral nerve pathology.

Here’s a few simple principles that, if kept in mind, can make you look like a diagnostic genius:

If a patient has trouble verbally describing the character or location of their pain due to the fact that they just can’t find the right words to articulate the “strangeness” of what they are experiencing they probably have a peripheral nerve problem.

Patients who develop chronic pain after some type of traumatic injury or “new” or “different” pain after a surgical procedure should be considered to be suffering from a peripheral nerve injury until proven otherwise.

Patients with pain problems that no one else seems to be able to “figure out” or diagnose correctly are very likely to be suffering from a peripheral nerve problem. These patients have tried everything under the sun for relief including pain management, physical therapy, chiropractic, acupuncture, dry needling, cupping,…the list can be endless. Often they have seen doctor after doctor without result. Many patients with serious peripheral nerve problems have seen at least 10 different physicians for the problem.

Patients who undergo multiple surgical procedures trying to get rid of pain with no improvement or worsening of their symptoms probably have a peripheral nerve problem. Classic examples of this are the patient who undergoes multiple knee surgeries to try and get rid of neuropathic knee pain without success, or the patient who has multiple spine surgeries to try and resolve the “sciatica” in a particular leg.

Patients with severe pain in a specific location with stone cold normal imaging studies of the affected body part probably have a peripheral nerve problem. This often includes normal or nonspecific EMG/NCV studies as well.

One common characteristic of pain stemming from peripheral nerve pathology is that the patient will often report that the pain is at its worst in the evening or during the night. These patients typically wake up multiple times a night due to the pain and tend to be chronically fatigued as a result.

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