Reconstructive Nerve Surgery

The peripheral nervous system is defined as the nerves outside the spinal canal. Among their many functions, nerves allow us to move, allow us to sense our environment (touch), and give us the useful protective element of pain. A problem with the peripheral nervous system, therefore, can cause difficulties with movement, can decrease feeling in our hands and legs, and can cause pain.

Dr. Dumanian is an expert in brachial plexus reconstruction, removal of nerve tumors, repair of cut nerves, and he has special expertise in treating patients with painful neuromas. His new investigations include the treatment of painful conditions for patients who have suffered from major limb amputations.

Nerves within the spine and spinal canal are treated by orthopedic surgeons and neurosurgeons. Unfortunately, some nerve conditions consist of problems of the nerves both as they exit the spine and also in the periphery. You may need for than one type of physician to evaluate your nerve problem.

Painful Foot Nerves

It is not uncommon for patients to have injured nerves around the foot and ankle. The nerves can be compressed around the ankle (tarsal tunnel syndrome) or on the top of the foot by tight shoes. Nerves can be injured during surgery when foot and ankle surgeons approach the bones of the foot. Finally, even some severe ankle twists can injure nerves. Dr. Dumanian treats painful nerves of the feet. A common procedure is to remove the injured nerve, and to splice in a replacement using a nerve substitute. He will publish his results on 26 patients with painful foot nerves soon.

Carpal Tunnel

Carpal tunnel syndrome is a due to a pinched nerve at the wrist (the median nerve). The pinched nerve causes pain on the inner part of the forearm up to the elbow, but usually not past the elbow. There is decreased feeling with pins and needles in the thumb, index, middle and ring fingers. A classic association of carpal tunnel syndrome is waking up at night and shaking your hand to make it feel better.

Conditions associated with carpal tunnel syndrome include diabetes, renal failure, trauma to the wrist including broken wrists, obesity, arthritis in the neck, and pregnancy.

Carpal tunnel is typically graded as mild, moderate, and severe by your surgeon. In moderately severe carpal tunnel syndrome, there is weakness of the muscles of the thumb, and in severe cases, there is atrophy or thinning of the muscles of the thumb. The suspicion for carpal tunnel syndrome will often cause your surgeon to order nerve tests to confirm the diagnosis.

Patients with mild carpal tunnel syndrome wear nighttime splints to lower the pressure on the nerve. The splints prevent bending of the wrist at night, and so the median nerve is not in a bent and compressed position. Patients with longstanding symptoms not responsive to splinting or with thumb weakness are candidates for surgery. A cortisone shot in the wrist is sometimes used to delay the need for surgery (such as for women who are pregnant), or to help diagnose patients with carpal tunnel syndrome who have normal nerve studies.

At Northwestern Plastic Surgery, both open and endoscopic (using a telescope and a smaller incision) carpal tunnel releases are performed.

Pain After Groin Hernia Repair

One patient out of 20 will experience chronic groin pain after the treatment of an inguinal hernia. Dr. Dumanian performs the “triple neurectomy” procedure to treat chronic localized pain after inguinal hernia repair. In the office, Dr. Dumanian will often inject local anesthesia to numb the area as a test to see if you are a good candidate for surgery.

Nerves are like electrical wires than conduct electricity and information in two directions from the brain out to the periphery, and simultaneously from the periphery back to the brain. Injuries to the peripheral nerves can occur in many different situations, with trauma being a leading cause of cut or injured peripheral nerves. Surgery for other conditions can lead to cut nerve endings as well. There are situations when injured peripheral nerves can be repaired to help restore function. Within 3 weeks of injury, a cut nerve can often be primarily repaired to partly restore function. After 3 weeks from the injury, nerve grafting with nerves taken from the back of the leg, or even synthetic tubes, can be used to help repair the injured nerve. This is a complex topic, and every patient is different. Ask your doctor if something can be done to help your injured nerve.

Cubital Tunnel Syndrome

Cubital tunnel syndrome is due to a pinched nerve at the elbow (the ulnar nerve). The pinched nerve causes pins and needles to be felt in the fifth finger and part of the fourth finger. In moderately severe cases, there can be weakness in the small muscles of the hand, clumsiness, and even decreased gripping strength. In severe cases of a pinched nerve of the elbow, there is atrophy or thinning of the muscles of the hand and/or forearm. This is easiest to see if one compares the size of the muscles on the back of the hand between the thumb and the index finger.

The elbow is most pinched when the elbow is bent, and so keeping the elbow straight at night helps to relieve pressure on the nerve. A “Heilbo” splint is often prescribed, and the padded part of the splint is worn on the inside of the elbow to keep the arm straight.

A combination of a failure to improve, weakness, and confirmatory nerve studies are elements that would lead to a surgical release or unpinching of the nerve. There are several techniques by which the nerve can be released, and the physicians at Northwestern perform all of these procedures. What is “best” for you would be discussed at the time of your office appointment.

    The following sites offer more information on Cubital Tunnel Syndrome:

  • eMedicine

Radial Tunnel Sydrome

Radial tunnel syndrome is the least well recognized of the nerve compression syndromes of the arm. Pinching of the radial nerve in the forearm causes pain to radiate up and down the mid-portion of the outer aspect of the arm, and centered around the elbow. The syndrome causes pain predominantly, and sometimes weakness of extension of the fingers. It can occur with the very common condition called “lateral epicondylitis” or “tennis elbow”. Some cases of tennis elbow that don’t respond to regular treatment are actually patients with radial tunnel syndrome.

The majority of patients improve with rest, physical therapy, and occasionally a cortisone shot in the forearm. Nerve tests are often normal, and though nerve tests are often ordered, a normal study does not mean you do not have radial tunnel syndrome. Patients with well diagnosed radial tunnel syndrome that is not responsive to conservative treatment are often helped with an unpinching or release of the radial nerve. This is a 30-45 minute procedure, done in the operating room as an outpatient.

Neuromas / Cut Nerve Endings

The ends of cut nerves can become painful when tapped. Some cut nerve endings are painful all of the time. General strategies for treatment of painful cut nerve endings are to either move the neuroma to a deeper more remote spot where it will not be tapped, or else to give the neuroma somewhere to go with a nerve graft or a nerve transfer. This is a complex topic, and every patient is different. Ask your doctor if something can be done to help your injured nerve.

Nerve Tumors

Tumors can form on nerves, just as they can involve other types of tissue in the body. The most common type of nerve tumor is the “Schwannoma” or “neurolemmoma”. These tumors feel like small marbles under the skin, and tapping them causes pins, needles, or “shooters” to go down the limb in the distribution of that nerve. They tend to be straightforward to remove, and their removal does not tend to cause any nerve injury, as they push normal nerve out of the way as they grow. They should be removed in the operating room.

Neurofibromas are nerve tumors that can infiltrate the nerve. Removal of a neurofibroma, in contradistinction to the schwannoma, can result in partial or total loss of the function of the nerve. Some patients can have numerous neurofibromas, and that syndrome is called von Recklinghausen’s disease. Rarely, a neurofibroma can become painful at rest—in these situations the neurofibroma can be degenerating into a cancer, and it must be removed.

Speak with your doctor about the evaluation of your nerve tumor, if an MRI should be done, and what are the chances for a loss of function from removal of the tumor.

Leg Nerves: Tarsal Tunnel Syndrome and Peroneal Nerve Compression

Nerves of the lower extremity can be affected in the same way as upper extremity nerves. Nerves can be injured in trauma, they can be injured during surgery for other indications, they can be involved with tumors, and they can be compressed. Injured nerves can be painful, cause a lack of feeling, or muscle weakness.

Injured lower leg nerves can be due to problems at the spine, or metabolic conditions such as diabetes. Nerves within the spine and spinal canal are treated by orthopedic surgeons and neurosurgeons. Some nerve conditions consist of problems of the nerves both as they exit the spine and also in the periphery. You may need for than one type of physician to evaluate your nerve problem, including a plastic surgeon, a neurologist, a spine physician, and your internist to address all of the potential problems.

Facial Nerve Injuries

The Facial nerve controls all Facial expressions, including the important function of smiling. Injury to the Facial nerve can occur after surgeries to remove tumors, after some illnesses such as Bell’s palsy, from birth trauma or congenital deficits, or from trauma to the area near the cheek. Some Facial nerve injuries can be repaired by finding the cut nerve ends and using nerve grafts to restore the lost function. Nerve injuries over 9-12 months in age are more difficult to repair. In order to restore a smile, both new nerves and muscles must be transferred to the cheek in a delicate 6-hour procedure. Ask you physician if you are a candidate for a procedure to restore Facial nerve function.

More about Dr. Dumanian

Dr. Dumanian has more than 20 years of experience performing reconstructive and cosmetic surgery. In addition to performing reconstructive nerve surgery, he is a well-known breast reconstruction, abdominal hernia repair and reconstructive hand surgery provider.