complications in nerve surgery
DESCRIPTION
nerve surgery and complications, hand surgery, nerves, complications, nerve surgery,TRANSCRIPT
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