Well good evening everybody. I'd like to welcome you to our webinar, Failed Nerve Decompression and Nerve Reconstruction. My name is Jonathan Isaacs and along with my co-chair Amy Moore, we are really looking forward to a great hour and a half of nerve discussion. You can see we've assembled a terrific faculty, Katherine Curran, Christopher Dee, who unfortunately had a family emergency, and will participate in spirit and with his recorded lecture for us, Jamie Bertelli, Kyle Everland, and Glenn Gaston. We have a couple of housekeeping announcements. First of all, your audio will be muted during the presentations. The webinar is being recorded and will be emailed out to all attendees by the end of the week. Please use the Q&A section to submit your questions. We will try to answer as many of them as we can as we go along, and if we start falling behind, we will probably try to answer some of them at the end of the session. In case of technical difficulties, contact webinarsupport at ASSH.org. Additionally, attendees of this virtual webinar can receive up to one and a half hours of CME, which you can claim by logging on to the ASSH website on Monday, February 28th. So the way we're going to work the webinar is we're going to start with case presentations, either by myself or Amy. We'll let these streamline into a didactic presentation and then return back to the case for hopefully a panel discussion. I'm going to lead us off. Here's my disclosures and Amy's disclosures up on the screen. Clearly, I'm doing something wrong with my single one in comparison to you, Jonathan, but that's okay. Thank you. Okay, so our first case, this is a patient of mine, a 34-year-old right-hand dominant female presenting a diffuse weakness and discomfort in her right hand. All of her fingers were numb. She said it started about a year ago, but was initially relieved by a carpal tunnel release, and based on her description, she did quite well until about five or six months postoperatively when she redeveloped tingling, just gradually worsened, and was now very painful, past medical history, some thyroid disease and asthma. This is actually now a couple of years ago. I still remember the visit. She was very upset, very emotional. On exam, she didn't have any swelling or atrophy. She did have a scar that was compatible with the carpal tunnel release. I thought maybe a little distal, but overall in the right place. She had good strength, except for her thumb abduction, which was four out of five. Did have the strong toenails, positive compression tests, phalanx. Finger range of motion was good, but it caused a lot of pain. So the first thing that I thought about was, well, what are my differential diagnoses? C-spine seemed okay. I think a lot of these patients that look like entrapment neuropathy, but don't really have it, actually have fibromyalgia. So I always look for trigger points, no false provocative signs, no proximal compression signs. So now what? I'm going to leave you with the MRI that I obtained, and you can see the image up on there. That is the big, fat, swollen median nerve. She refused an EMG and nerve conduction study. So we don't have that information. And we're going to listen to Christopher's presentation and then come back and talk about what the differential diagnoses are here and how we should approach this patient. Good evening. My name is Christopher Dee. I'm from Washington University in St. Louis. I apologize for not being able to join you live, but thank you to Amy and Jonathan for the opportunity to prerecord. So Jonathan and Amy asked me to talk about failed median nerve decompression, and I think Dr. Tung and McKinnon presented a very nice framework to guide the decision-making and thought process for these patients. The key question is, are these symptoms persistent, recurrent, or new or worsening? And in this context, typically a wrong or inadequate diagnosis is what's driving persistent symptoms, and incomplete decompression is what's driving recurrence, and nerve injury may be driving new or worsening symptoms. When I say wrong or inadequate diagnosis, it doesn't mean that there wasn't carpal tunnel present. It means that there might be other sites of compression of the median nerve, say, for example, in the proximal forearm at the lacertus, the FDS arch, or potentially underneath the pronator. There could be double crush from the cervical spine. It could be C5, C6 radiculopathy. Thoracic outlet syndrome is a possibility, although typically it wouldn't show up with mainly radial-sided paresthesias, and potential compression at the ligament and struthers. While that supracondylar process and the associated ligaments are uncommon in a patient with continued or persistent symptoms after a prior carpal tunnel release, that's one thing that I try to assess on the single AP radiograph of the elbow. There's also a possibility of concomitant ulnar neuropathy. Many of us treat patients that have both carpal and cubital tunnel syndrome, and it's just a question of understanding whether that is something that is at play at the same time. There are some clues that you can have on your physical examination. Classically, what's described for double crush is a tunnel sign over the median nerve and symptoms that not only radiate distally and cause paresthesias in the median distribution, but also radiate proximally towards the elbow along the anterior forearm. I like direct compression over the lacertus as a clue for potential compression, and if that reproduces paresthesias when I'm pushing just on the inside of the flexor pronator mass adjacent to where the biceps tendon is, that's a clue to me. I will also look and see if there is weakness in the FPL and the FTP index on the vast majority of my patients, and this is in addition to the standard cervical spine workup, including things like the Sperling's maneuver and checking for strength in the C5 and C6 distribution innervated muscles. Proximal compression can certainly be a cause for continued symptoms, and in this patient, for example, who had already had a carpal tunnel release, we saw that there was a very tight FDS arch, and releasing this after releasing the lacertus was helpful. I personally don't step lengthen the pronator, although I know that's how it's classically described, and many of you may do that as well. After I've released this FDS arch, I will typically take a blunt instrument and insert it along the course of the median nerve and ensure that it's released all the way down to where I can feel the radius. Recurrent symptoms could be due to incomplete decompression, or if it's after many years, it could be due to reformation of the transverse carpal ligament or scarring of that nerve. Incomplete decompression is a common occurrence, at least among patients who have recurrence of carpal tunnel. This is a series from Germany, from Stutz, that was published in the British Journal in 2006, and of the 200 patients who had recurrent carpal tunnel syndrome that went to the OR, 108 had incomplete release, and of those 108, 65 of them were inadequate distal releases, and 27 were inadequate proximal releases. You can see here just a reflection of the paper that Peter Stern published in JHS in 2009 demonstrating the relative anatomy of the transverse carpal ligament and the sentinel fat that's surrounding the superficial palmar arch. And once you see that fat, it obviously clues you in to protect yourself from the superficial palmar arch, but also tells you that you have about two more millimeters of transverse carpal ligament to release distally. So once you see that fat, pull it back with your ragneller tractor, protect your arch, but then also know you have a little bit left to go in terms of the decompression. So here's an intraoperative picture reflecting, you can see the leading edge of that fat, and then you can see the arch down here, and you can see how much ligament we have then released, ensuring that we are completely released distally. This is a picture that Marty Boyer gave me that demonstrated the patient who had had an incomplete release. So he was revising their carpal tunnel after it had been done elsewhere, and you can see the classic hourglass constriction on that area of the bolar and the brachial fascia that was incompletely released. And that's a good reminder of, you know, many of us use a mini-open technique, making sure that we release these bands that are near the level of the wrist crease under direct visualization, of course, making sure that you're safe, but, you know, knowing that those areas can be quite tight and ensuring that it's completely released. Now, if the patient's symptoms are new or worsening, then I start to get concerned about a nerve injury. So here's an example that David Bergen and I teamed up on. Patient had had a carpal tunnel release done out of state, but had, you know, substantial worsening of her symptoms, zinging, shooting, parasitiasis, and third-web distribution. And upon exploration, you can see that something's not quite right right along here. And you can see there's actually an injury to the median nerve, so a partial median nerve injury, which after excising, you know, the areas that felt scarred and getting back to healthy fascicles through direct inspection, we inlaid a CERL, a cabled CERL autograft. That is what our preferred treatment would be, but I know that there are other techniques that some would prefer rather than using this cabled autograft. So to summarize, you know, for patients who have longer, or excuse me, who have persistent symptoms, perhaps look at an alternative diagnosis or something that may be occurring concurrently. For those that have recurrent symptoms, it could be an incomplete decompression or it could be simply recurrence of carpal tunnel if they've had recurrence of their symptoms after many, many years. And that typically can be treated with a revision release without doing much else. And then for the patients with new or worsening symptoms, you clearly want to evaluate for a nerve injury. So I appreciate the time that you've taken to view this, and I'm sorry that I can't join the group live. I'm sure it's going to be a wonderful discussion. And thank you, Amy and Jonathan, and the rest of the Cancer Society staff and faculty for allowing me to join. Thank you very much. So I'm not going to flip to my next slide because I think it shows what I did in this case, but let me start, Catherine, with you. So to jump back to our case, so successful reliefs, patient comes back, very histrionic, which to me is always kind of a little bit, makes me a little nervous about operating on a patient like this. Refused a nerve conduction study, so I'm lacking some objective data from that standpoint. But that MRI, I thought was pretty impressive that I left everybody looking at and thinking about. So first of all, I guess, let me ask you, do you think that the nerve conduction study is essential to making the decision? Or do you think I have enough information now to do something? And if so, what would you do in this situation? Yeah, I don't think nerve conduction studies are going to help that much. But I do wonder if you could do an ultrasound. I really like the dynamic quality of ultrasound. And also it could give you some sense if there's a big change and you have that compression and then that huge swollen nerve distal to an inadequate release. So I might get an ultrasound just to look up and down the nerve because it shouldn't hurt the patient and might give you some information to help guide your treatment. Let me, I'm going to jump back for one second and say this is the MRI. That's the media nerve there. So I agree with the image. I'm not sure. Glenn, let me ask you, do you prefer an MRI in this situation or is the ultrasound your go to also? I usually do MRI just because I'm not good at ultrasound. I'd love to get there. But personally, I'm just, I'm not there yet. But I think in this one, I could probably see it. But I would have gone probably just to get an MRI. But I'm not probably just a nerve study first. And if you refuse to get an MRI like you did, I'm actually unbelievably impressed by the size of that nerve to the point where you only tease us with two images. It, you know, some things that jump into mind, you know, either sometimes if you do have an incomplete release proximate, the nerve will get really swollen like that. But I don't think I've ever seen one quite that swollen. That's to the point where I have seen a couple of cases where someone had a schwannoma of their median nerve and someone did a carpal tunnel release and or I did on one case that I can specifically remember that got temporarily for their symptoms and then it worsened as the schwannoma grew out. It doesn't look like a classic schwannoma from those images, but I'd actually be concerned about intraneural tumor versus just an incomplete release that really swelled up approximately to about the biggest I've ever seen. Oh, and I've seen a neuroma in continuity. That's that's interpreted as a swollen nerve also. And so yeah, the history works against that, though. Those should be instantly right out of the gates be a problem not showing up later. Okay, Kyle more. Do I need more information? Or do you know what to do here? Operate. I personally would do an ultrasound in this patient. I like to do them myself. I think that high frequency ultrasound you can really see quite a bit, including the secular architecture. And I think that honestly would give me some more information. But I think the reality is this patient is likely to get explored. I would do an extended carpal tunnel release and take a look at everything. But the one thing that I still don't fully understand is if this is recurrence of symptoms, it's a bit early for that to happen. Five or six months is is not that typical. So that's the one piece of the puzzle I don't fully understand just yet, but I would explore. Okay, so so as you said, I think I do think Chris didn't talk much about this, but I do think one of the keys when you revise a carpal tunnel is you got to make your incision longer. I think that'll be a recurring theme in the next hour or so. You have to go above and below where you would do your original approach. And to me, one of the things that I'm worried about in this patient from our exam is the the finger motion causing a lot of pain. And that always makes me think of traction neuritis. So all these spot welds of scarring around the median nerve, and then when you move the fingers that the nerve is yanking against these little areas of adhesion. So this is her exploration. I think you could see there is a lot of scar tissue tethering that nerve. Presumably causing compression and causing her symptoms. So I'm going to do a complete release of the scar as you could see there. We talk about epinerectomies and, you know, the literature says, oh, you don't really need an epinerectomy, but in some patients you do. If you have a scarred epineurium, I think you need an epinerectomy. So Jamie, what are you doing after the release here? Are you doing anything to me? I don't want to do the exact same thing the other surgeon did and expect a different result. So... I would just confirm that everything has been released before, but because in general I see the distal part of the capotunnel that has not been adequately released. The scar around the nerve is a problem. If I release, I will move immediately. What I have done in the past that I don't do anymore, because I don't think it's changed, was local flaps of fat tissue, either from the thinner region or from the dorsal side of the hand. I don't think it makes any sense. So I will do what you did and I'm glad when I find some distal compression. When it's just a scar around the nerve, I'm afraid that after some months the neuropathic pain comes back, but we'll do the same thing. Okay, anybody wrapping this? And if so, what are they wrapping it with? Len, what are you wrapping it with? Yeah, I would mainly because you described a lot of posterior adhesions. I think when the adhesions seem to be predominantly on the anterior surface of the nerve and they're more distal, I do still like a hypothenar fat pad for those. When it's on the backside of the nerve by the flexor tendons, you can't really wrap anything else other than a local wrap and I just use one of the manufactured nerve wraps for those. The other thing I'd say is Chris did mention the fact that he considers the inadequate release to be recurrence, which it can be, but I think it can present in all three manners. Inadequate release can be persistent pain. Inadequate release can also be worsening. I've seen plenty of cases where someone has one little band that didn't get released approximately, they come back immediately with decreased two-point, worse than they were pre-op, tons of pain, and it's a tiny little band that needs. So inadequate release, I personally can present all three ways with recurrence, persistence, or worsening. Yeah, so I agree with you completely. So here is the wrap that I put on. This is an SIS material. There's several of them out there. I don't really think the data supports one over another and she actually did great. She is complete relief. I was worried because she was so emotional and I'm high-fiving everybody out the door and then 18 months, which I think is a long time, but as Jamie now has appropriately predicted, she returns very similar to her initial presentation, positive tunnels, lots of pain, lots of pain. So we went ahead and this time she did agree to a nerve conduction study, which was normal. This time I did get an ultrasound. The images were not good, so I didn't include them in the talk, but it shows enlargement. Hey, Jonathan, can I ask you a question? You betcha. Did you move the wrist after your carpal tunnel release or did you immobilize? I know I can't remember, but I typically would move it. I don't typically immobilize after a nerve release for scarring, but would you have done something different? No, well, I wouldn't have wrapped it, but that's just my bias. But I think the reality of it is a lot of times I think people who scar and we know are bad scar formers, then if we don't move them and get them gliding, they stick back down. And so that's part of very much early on, within five days they're in therapy and doing those glides. And I've also become a big fan of the Amnion products to help with just decreasing the potential for the scar tissue, but I love early movement. So you would wrap, but you'd use an Amnion product? I lay it on top. I don't wrap it around. I've been using Amnion a little bit too. It has some nice handling characteristics. It's a little easier to wrap. The data is compelling, but again, there's nothing definitive on any of these products. I think that says that they definitely work. So, anybody do anything with her now? Is it, well, I did the best I could. I mean, that was a good release. I mean, have I done the best I could? Are we done with her? Kathleen, do you do anything else with this person? Is this somebody for pain management? Well, yeah, we could always do pain management. I think I would just take a pause to make sure we haven't missed some proximal entrapments. One more time to look again, proximal forearm, C5, C6, something else that we are missing and before I would go to nerve pain management where you could maybe consider a nerve stimulator. So, would you say the nerve conduction study rules out proximal compression or not really? No, I think that the nerve, electrodiagnostics for proximal median nerve entrapments are difficult. And so, I wouldn't be certain that they would be able to catch something that's not causing an axonal injury. So, I was impressed enough with her. I kind of, you know, I use these off-the-shelf wraps. I'm not positive they work and she sure looks like she has recurrent scar to me. So, I did re-explore her. You could see there's a ton of scar tissue around there. Now, interestingly, you can't really see it, but I've noticed this with the off-the-shelf wraps before that there is a plane there. You can easily develop a plane between the wrap and the underlying nerve, but does the scar that's still surrounding the whole structure, does that make a difference? And the reason why I showed this case is because to me, the ultimate scar barrier is autologous vein. And so, I've completely freed up the scar again. And I'm going to take a vein. Obviously, it's a different patient. You can see a different skin color. You need about three to four times the length of vein as the nerve you're trying to wrap. You split it longitudinally like you see on the screen there. And this is, again, a different nerve, but I just wanted to show how it's wrapped, like a candy cane, or you spiral it around. The intimal side is down against the nerve. And this is her, back to her wrist with a vein wrap around the nerve. And you pay a price because you take it from the leg. They do get some swelling. They do have some problems, potentially, with the donor site, but I have found that that absolutely works the best, and it really seemed to work for her. She got significant improvement, and I've not seen her since, which may mean she's doing great, or it may mean that she showed up at Glenn's Clinic in North Carolina. So with that, there's one other quick question from the audience is, is there a role for a lay-on nerve stimulator in this situation? I think that maybe they're thinking about the Sprint nerve stimulator, which is the one that you can put in interoperatively. It's a temporary one, and then it's pulled out at 60 or 90 days. You know, I like that for people I'm really worried about because it's not a permanent thing. Sometimes hard to get insurance to pay for it, though. And I'm gonna finish with one last question from the audience, can you use allograft vein? And there is data that says that that's okay. Some of the older data implied that some of the preservatives they put around the allograft vein cause some reaction. So I don't typically do that. There are people that do it. Anybody have any experience with allograft vein in these situations? All right, well, let me move on to the next case. Amy's gonna take over and I'll be quiet for a little bit. All right, I'm going to click to gain control. Hi, everyone. And let's go backwards. So this is, we're gonna move on to the ulnar nerve. This is a 52-year-old who was, you know, taken care of in an outside hospital, had an ulnar nerve transposition with a wrap. And then she woke up with pain, was her biggest complaint, numbness and tingling, and increased loss of dexterity. So again, when we think about it on her exam, mild clawing, definitely a change in the worse for her sensation and very hyper, you know, tingling up in her elbow, which I always get worried about. And then weakness. So this is somebody I don't want to sit on. And I go back and I love the Christy WashU world because in the head, I think about any nerve that's compressed, is it persistent, is it recurrent, and is it new? And with the ulnar nerve, it is, you know, the same kind of thing. Is it the wrong diagnosis? Is it recurrent because of, you know, the kinking? And is it new, meaning there's now injury there? And so I love that continued using it again, that saying, is it persistent? Is it new? Is it recurrent? And then, so I sent her for EMG nerve conduction studies. She did not refuse it. And it was confirmed against with my exam that she has axonal injury, which was not present preoperatively. So with that, I'm going to turn it over to Dr. Gaston to take over. Thanks, Amy. Trying to click and take it, there it goes. So we didn't plan this either. None of us have seen each other's slides, but exactly as Amy just said, I think one of the things we have to do is decide, is this recurrent, persistent, or a new issue? And the line always gives, I had surgery nine months ago, but after so-and-so, and I'm no better, and in fact, I may be worse. So that's what we got to figure out. So recurrent, as has been mentioned, that means they got better for a period of time, and then they got worse again. And with cubital tunnel, there's some studies that would show up to almost 32%, others down to about 10%, but right around that range of true, quote, recurrent. And recurrent cubital tunnel, in my experience, is usually due to scar. And there's a lot of factors that could conceivably contribute to increased scar formation, prolonged immobilization, hematoma, like this patient of mine, return to certain occupational hazards, and sometimes I think it's just bad luck, quite frankly. And extra neural scarring, I think, can manifest in three ways, and Jonathan alluded to some of these, and so did Amy, that sometimes you just get recurrent compressive neuropathy. It's just scar-mediated, scars around the nerve, and it's just recompressed due to the scar tissue. Other times with ulnar nerve, particularly if it's transposed, you can develop an ischemic neuritis, and I think these are actually the worst cases where you go back in and look at them, and the nerve literally looks dead through a segment. Those, in my experience, do really poorly if they're bad epineurial blood flow, status post-transposition. And the third is traction neuritis, and I think this is the trickiest one to pick up, because sometimes they can just have scar around the nerve, and these are the ones that'll have a normal nerve study. So you're inclined to say there's nothing wrong, but their symptoms are dynamic. Every time they flex their elbow, the nerve can't glide properly, and they develop traction neuritis symptoms. Next is persistent, as was mentioned, and persistent can be due to several different things, I think, with cubital tunnel. One is a failure of the actual surgery. That can be several different factors that I'll run through coming up. The other, as has been mentioned, is the wrong diagnosis. And the third is just severity of the initial disease. If it's really, really bad cubital tunnel to start, sometimes it's just not going to get better. So from a surgical failure technique-mediated problem, I think you can have incomplete releases proximally and distally. I'll say, personally, I see way more distal problems than I do proximal. Archaea of Struthers, pretty rare. B-elunar muscular septum not being excised sometimes, but usually it's really kinking distally. At the FCU, or even more commonly, beyond the FCU fascia is that FDS to the ring finger fascia, and that's usually where it's taking a powerful kink distally. And here's an example of that. You can see here, really tight down there distally. And that's been described by several different authors in the past. I love this little picture of the nerve stain by Gary Lurie's group. You can really see it compress there distally. And they have a little sign Gary describes calling an FDS resisted ring finger test that has supposedly about a 75% sensitivity for picking up persistent distal entrapment of the ulnar nerve. And other causes, medial head of the triceps. This one has surprised me. I've gone in on a couple of cases I thought was nerve subluxation, but it really wasn't. It was just the medial head of the triceps subluxating and literally causing like a tenels against an ulnar nerve that was actually well located after an incisor decompression. So don't forget about your medial head triceps. You can have loose bodies from osteoarthritis that come through the floor of the cubital tunnel and impinged on the backside. And then tight fascial slings, particularly with non-absorbable sutures. Here's the most extreme version I've ever seen of an awfully tight fascial sling. And then wrong diagnosis. Amy alluded to several of these. Cervical radiculopathy, thoracic outlet brachial plexopathy, peripheral nerve sheet tumors, as you see there, Guillain's canal entrapment. Some are subtle, some are more obvious. This case probably was not just a cubital tunnel problem. And then persistent, again, as I said, initial severity. If they've got really bad cubital tunnel, I do like nerve studies in advance and I do like repeat nerve studies as the group was just discussing to compare. Because if their nerve study improves slightly, but not significantly, sometimes it's just that it was just too bad. Patient age, comorbidities can contribute to that. And previous number of surgeries. For anybody that tries to take on a like fourth time revision cubital tunnel, I will tell you the success rate is very, very low. And don't think that you're that much better than everybody else before you, unless you have a really compelling reason to go in for multiple revisions. And the new onset of pain, as was mentioned. Neuromas, medial anabrachial cutaneous is the big one in this area. These are the people that come in with their arm on a pillow, their olecranon's numb, they don't want you to touch them. And then CRPS would be in the differential, although admittedly, I don't see as much of that as I do, MABCN neuromas. So when we're doing revisions, we want to remove scar tissue, cushion the nerve, improve gliding, revascularize maybe, prevent adhesions to the surrounding soft tissue. And then I think other people on this panel will discuss the role potentially of adding downstream axons with nerve transfers, which I personally don't use much for cubital tunnel itself, but I know other people are. Jonathan mentioned the exact thing I feel, which is when you're doing revision surgery, your incision starts proximal and it ends distal to the old scar. So these are big incisions. I find a nerve simulator actually really helpful. Sometimes it gets real tough in some of these to figure out what's nerve and what's scar. And it's just one more tool you can add, but obviously whenever you're in doubt, leave a little tissue around the nerve rather than risking injury. And then explore all sides of compression, again, particularly distal. In terms of wrapping, this was just mentioned. For cubital tunnel, I really personally like an autologous fat wrap. It's readily available and you can do it about throughout almost the entire length of the nerve. Other synthetics, muscles and veins are described, I think are very reasonable. And just don't forget to check for myone or brachial cutaneous nerve neuromas on your revision. And then once you decided which of those three, is it persistent, recurrent or new onset, there's other factors you still have to think about. Like, why did it fail? Is it subluxation? Is it just persistent or recurrent? How bad was it initially? So most nerve subluxations I treat with just a transposition. If it's persistent or recurrent, it's gonna be a better decompression plus minus a transposition or a wrap, depending. And then initial severity. Sometimes it's just so bad to begin with that the best treatment is just simple observation. And then it also depends on what surgery do they have first. If they had an in situ and they've got subluxation or an inadequate release, basically if they fail an in situ for me, they're gonna get transposed the next time around in my hands. Typically a subcutaneous transposition. If they fail a sub-Q transposition, a little depends for me. Sometimes I'll just re-neuralize it, particularly if the nerve looks scarred or kinked in one particular area and then free it up in that spot and plus minus that fat wrap. If it's that the whole bed looks terrible, that's the rare time I'll consider a submuscular or an intramuscular transposition, which I don't personally do routinely. And then what if they fail a submuscular? I think these are some of the hardest ones. They're oftentimes kinked. The other time, this is the cases where I see nerve dysvascularity the most and they're just plastered to like the capsule of the elbow joint. And those for me, I pull back out and revise them to a sub-Q with an autologous fat wrap. Thanks a bunch. Yeah, great. Okay, so I'm gonna try to take over control again and we're gonna go backwards. It doesn't actually really matter, but that was great, Glenn. So thank you. I have a question for you before I start on this. When you have that medial head of the triceps snapping, how do you fix it? What do you do for those patients? I just excise all of that tendon and you can take a ton of it out because most of the triceps inserts laterally anyway, so you're not gonna have any issue with that. And I just keep resecting until I flex the elbow and there's nothing touching the nerve. So I'll resect as much as I need to to the triceps portion of the fascia there and the tendon itself. Love it. Jonathan, do you have to do anything different for triceps? No, I've seen that also. Generally, when I focus on the triceps, it's actually when I've done a in situ release and I don't wanna transpose and the medial head of the triceps keeps pushing it up over the medial epicondyle. So that's usually when I'm more aggressively take out some of the muscle there and that can help. The only thing I might add is that to me, a warning sign when a patient comes in with a very small incision and an op report that says they had an anterior transposition, I think to properly do an anterior transposition, you need about a 12 to 15 centimeter incision. And if it's done through a five centimeter incision that I all but guarantee they have, I don't think I coined this term, but I call it the omega sign because the nerve is kinked on one side, loops around and then kinked distally. So. Yeah, that's great. I totally agree. And I think some of the patients that have made me go with the dynamic ultrasound are those that I've transposed and then they can complain of it snapping, doesn't have this nerve symptoms, but it's the triceps. And I'm like, oh, what do I do then? Do I, I know it's not my nerve because the nerve has gotten better, but they still have this triceps part. So now I'm much more keen to resect even when I transpose because I think like it, I have this fear of those patients that keep coming in. All right, so back to this case. So we have the patient who has worsening symptoms and has denervation seen on the EMG, which showed us as fibrillations and the owner innervated muscles. So I clearly went back to the OR. Would anyone add those distal nerve transfers? Kyle, what would you do? Would you plan to re-explore and then do anything distal? No, I wouldn't probably do anything distally, although the only thing I would consider would maybe a Guion's canal decompression, but I don't think that's indicated here necessarily. Her problems at the elbow, I think that she probably had an ineffective or inadequate transposition and I would try to remedy that bubble. Okay, yeah, well, we'll see, because clearly I found. So every patient that I go to the operating room, I look for where there are 10 L's. And so this arrow is marked on the skin preoperatively. And I think that has become a really important thing to do with most of my patients who have nerve pain after previous surgeries, even if it's not a decompression surgery. And that MABC, just as Glenn had shown, is quite the bad actor. I think also here, going long on these incisions, I think that is a good theme for anybody with failed surgeries. You got to get outside that zone of injury. And this is a perfect example of why. When I see this amount of scarring, I'm like, oh man. And that just sort of keeps the sphincter tone pretty tight. And so for this patient, as they got in closer and closer, where the wrap was, was where this inflammation was. I don't think that's because of the wrap. I think it's just that it tends to be just a scarred bed. And then releasing the entrapment points that we discussed. So I don't want to rebuild labor and I don't really have many questions to ask the group, except that here we have this scar and worried about that dysvascular spot. So Glenn, when you see a nerve feel like that, that just looks dead, what do you do? Yeah, I don't think there is a right answer. That's why I've kind of moved towards those autologous fat wraps. I feel like it's the best I have to offer it. I would neuralyze it through that area as best I could. And then I would take that fat that's between your sin retractor and the deeper subcute and then just take a layer of that and wrap it around the nerve at that level. It's the best I personally have. Would you ever consider resecting it? I've never resected, I would not in this case. Because they've still got something coming through. You know, they've still got some sensation. They've still got some, I would not resect it. Yeah, I saw one patient who they resected because they said it looked so bad and they woke up with much worsening symptoms. So I think you can have a very ugly looking nerve and it recover. You providing that fat pad or a better environment for that nerve, that vascularity, I think is key. And I too would agree without resecting it. Jamie, would you resect a dead nerve or what nerve that looks bad after just a decompression surgery? In patients like that, first I will stimulate the nerve in top. If there is any sort of contractions on the first dose of enterosis or do anything, just neutralize it and breathe. I'm afraid not of the motor recovery. I'm afraid of pain. Pain. I see a lot of recurrence on pain on this case of nerves. I'm not that sure that it's only about compression or decompression. I think after the first surgery, there is some sort of injury to the nerve in their bottom, and this is why there is persistent pain. But being direct to your question, if there is a contraction, I do nothing, and if there is no contraction upon stimulation, I'm worried not about cloning, I'm worrying on the first dose of enterocleotis mass, I mean, I would do a distal nerve transfer. And what I observed that in patients with compression, you can do, I saw 16 months, 18 months with a waist-first space, and they can recover after distal nerve transfer. It seems that it's not a dead nerve, there is some support to the dead muscles, yeah, so. Totally. Not cutting, not cutting. Yeah, no, I think it's really important comment to make. And so for this individual, I took it from the subcutaneous and then dropped it into the intramuscular, and making sure through full range of motion that that nerve is lying in a straight line. Peeling off the wrap was the hardest part of the case in getting to it. And then I, unlike some of the counterparts on the panel, I definitely, with any axonal injury that still has motor units, I do an AI and supercharge. And then every once in a while, depending on the severity of their symptoms and how irritated and hypersensitive, I will do the cross-cross bridge gaffes. Dr. Curtin, how about you? Would you proceed with anything distal on somebody who has this horrible response to their first surgery? Yeah, I don't think I would have. I was wondering though about, with all of the information on electrical stimulation intraoperatively and that paper where they took that severe cubital tunnel, did you think about doing intraoperative nerve stim to try and improve this or not? Yeah, so it's not FDA approved, but I stim with a handheld stim device, two milliamps, 100 Hertz for 10 minutes with the tourniquet down at the end of the case. I stim every nerve that I either reconstruct or decompress because of the regenerative potential that we found in all of our animal studies. As for the MABC, what did I do with it? So I think that the MABC is not usually a bad actor. I think if the neuroma results because it's been injured and not dealt with, I don't think that it has that same reactivity. And so oftentimes I will do a crush cut. So crush proximally, cut out the neuroma, and then I flip it into the triceps muscle. I haven't been having to go aggressive and do TMR on the MABC. I use MABC as a donor for nerve grafting often without any trouble with this nerve. So I am definitely less aggressive with the MABC, but I look for those neuromas. Glenn, what do you do with them? No, that's why I was curious. That's why I was asking you what you do with it too, because you put the X right where that was, and clearly that was part of their symptoms. I think it's a problem when it's right around the medial epicondyle itself. I do think it's an issue there if it's where their elbow rests down. I agree with you. I think when you take it for a graft, the difference is you're taking it higher and it's in an area that very rarely contacts things. So it's not as big of a deal. I personally probably would have just done an RPNI for that, cut it back and taken a free muscle graft and wrapped it around it. But that would have been my play. Kyle, I don't want to push you on it because I don't want to like show your cards before your final case. But what would you do with that MABC? Yeah, I think there's lots of options. I probably would either do RPNI or what you did. I think it's reasonable. There's not a lot of great TMR targets here and it probably more than is necessary. Jonathan, would you do anything different? I'm not a big believer in the bridge crafts. I don't, I think it's too few axons make it out the side and then supercharge into the next thing. I just can't conceptualize how there would be enough axons to make a difference, but I certainly would have supercharged there also. And I think like you, I've seen it work well sometimes and I've seen it not work. And I struggle a little bit with knowing whether if I had not done it, if the person would have still done well, but certainly conceptually, as you and I are both big believers, at least conceptually in it, I certainly would have done the same thing. Yeah, great. Thank you. All right, I'm gonna take over and we're gonna move on now to failed nerve repairs. This is a patient who had one of those handheld like Dremel saws and it hit a hard spot in the floor and jumped up and you could see really did a number on his wrist. So there you could see that the muscles and tendons are really torn apart. This is the median nerve that I thought was so torn up that I didn't fix it at the initial presentation. Again, you can see the extensive damage going on to all the tissue, but there's his ulnar nerve. You can see there's a little yellow clip in the background. So we had to revascularize the hand. Again, a legitimate significant injury. But I thought, well, the median nerve had a big defect and I wanted to let that demarcate similar to how I might approach a open fracture or a gunshot wound. The ulnar nerve looked to me like, that's not such a big gap. I probably could address that primarily without getting into right now a big debate about allograft versus autograft. In that situation, it's certainly very appealing to use allograft and that's how I fixed it. You can see the repair there. Very straightforward, nothing too exciting about it. And there's one more picture of it. And then four weeks later, I came back. Now I know he's gonna have a big defect in his median nerve because I had measured it. So actually I started with him prone so I could get his sore ulnar very efficiently. Take it out, put it on ice, close that up, and then flip them over to get into the wrist. And you could see big zone of injury, big cable autograft reconstruction. As you see up there, you could see I've got fiber and glue around the ends of it. That's the snotty looking stuff there. And then six months later, he's got no intrinsic function, no sensation. And we're looking at him and thinking, well, what are we gonna do? Is it what it is or do we have options? And I think with that, I'm gonna turn it over to Jamie to talk about how he approaches these problems. And then we'll jump back to my case in just a minute. Let me put in the beginning. Can you put at the beginning? If you click on, before you hit the button, just click on your picture there, Jamie, with your mouse. Yes, uh-huh, I did it, okay. Okay, good evening, everybody. My topic now is the failed nerve repair. It's very difficult to consider when a nerve repair has been failed. Just put the number, I would say two years. But if it takes two years for you to decide that this nerve transfer is not working, then maybe it's too late for any other nerve surgery. Let me talk about a few exceptions. For instance, medial nerve repair in emergency and direct suture. Patients arrive and then what I do, if some of those patients, they have thinner muscle functioning, but very poor sensation. So I do a reopen, I do a neuralysis, I do a neuroma debulking, which I consider removing all the scar around the neuroma. It's like some sort of onion you remove. And then when I see the micro sutures, I remove all the micro suture, I do a decompression, and some cases I do a distal nerve transfer. What I observed, I mean, in general, the distal nerve transfer I do is radial, those radial nerve branches to the pulmonocollaterals. I do this nerve transfer, but what I observe in general is that two or three weeks later, those patients get better. And for sure it's not my nerve transfer, it's just something that was compressed around the neuroma zone. But sometimes we face this sort of injury. Six-year-old boy, this kind of injury, someone told the boy that he could not find the sural nerve and then put a silicone tube as a conduit, 10 centimeters long. So I saw the patient three years later, I'd say I tried to do something and then I did a nerve graft, didn't work. So sometimes it's very difficult to abandon those patients because of age or any other particular characteristics that you think that can be improved. So the only way sometimes to discover that it doesn't work or didn't work because you have done the alternative, or in this case, the tendon transfer. This is a brachial plexus injury, step one. It was repaired in urgency by directly suture. And then I saw the patient 18 months later. She had, she recovered the elbow flexion but not function around the shoulder. She had 30 degrees of abduction and no external rotation. So I said, why not a distal nerve transfer? 18 months after the initial lesion, I said, maybe I can improve the result. What happened is that two years after my initial repair, I have the same results I had preoperatively. So I got re-innovation because after cutting the nerves, I had it paralyzed, I mean all the muscles and then they recover. So now I think that in chronic lesions, if I do a new nerve repair, I will only get a re-innovation of the previous innovated fibers. I mean, on my thoughts, I cannot get anything more, just what I get at the beginning because of the problems of the aging nerves and muscle. But then there are some cases that arrived to me around 12 months of lesion. Some patients, it's very difficult to see or to demonstrate there are some kind of recovery. For instance, in this aulana, and then something that I think very useful is anesthetic block before any surgery. Then you anesthetize the patient, you block the nerve and you re-examine the patient again and you ask if there is some function that was lost after the anesthetic block. So if there is no function, then you can go ahead and you can do your, in this case, nerve grafting. And I see if at 12 months, some patients get improvement at least on correcting the claw or in the sensation of the ulnar side of the hand. This is another kind of patient that arrived 12 months. I'm dealing in those patients that they are limited. Brachial plexus exploration, and then they said they did neuralysis 12 months. So I think no recovery, then this is a good option to do a distal nerve transfer. And then in that case, you should be very proximal to the muscle and do the accessory to suprascapular nerve transfer, just distal to the transverse superior scapular ligament from the anterior approach. So this, I think it's valid. So a new nerve repair, even by a very distal nerve transfer, cannot restore additional function after 18 months of lesion. Functional recovery is time dependent regardless of the interval between injury and the old nerve repair, maybe because of aging pathways and muscle atrophy. In 2006, we published a paper that was about the concepts on nerve regeneration. And one of my thoughts, it's why some axons fail to regenerate. So I have the story of pruning trees. And I imagine that this is what happened. We see that after one axon is lesioned, there is a production of an arborization of several of new axons. And it's very, I mean, on my thoughts, I think it's very heavy for these neurons in terms of energy to support all these branchings. And sometimes how this nerve, this axon, this motor neuron dies. So we did some experiments a long time ago in rats, and we discovered that there was some functional improvement after aberrant corrections or wrong projections were trimming. So I did my retrograde label studies on the median nerve. So this is the motor branch of the median nerve, and this is the sensory branch. The sensory branch in the rat has very few motor axons. And after retrograde labeling, this is what we observed. So just three months after our nerve grafting to the median nerve, we used predegenerated and conventional nerve graft just to see if there was any difference. Observe that the number of motor axons in the sensory branch was three times bigger, higher than the controls. But there was a decrease in the number of these motor axons and also an improvement of grasping strength. So the organism was correcting wrong projections, sensory motor axons that went to the sensory, the motor axons that went to the sensory branches. I think the motor axons, they really like the sensory branches. And then I found this case, and I just brought this case today just to give you some thoughts and maybe to provoke some sort of a discussion or at least something for you to think about. I saw this patient, radial nerve lesion, 12 months after a pneumatofracture, he was operated, but he had some finger extension, but 12 months, no wrist extension. And I say, why not operate on him and do a distal nerve transfer? I didn't want to cut the radial nerve because he had some function. So I did a pronator teres motor branch of the ECRB and concomitantly, I crushed the superficial branch of the radial nerve. And then I thought I will do some sort of surgical trimming of wrong projections. And this is the guy 15 days after surgery. This is just the recovery of wrist extension by improving finger extension. So this is what we are working in our lab now and try to understand if the recovery was because I just touched the nerve or because I did some crushing. Okay, thank you. Thank you, Gianmarco. You got pretty deep there. That's some really interesting ways to look at the physiology of what's going on. I thought you said a couple of things that were particularly interesting to me. One is you pointed out, and I've stated this before, I say that there's no babysitting effect. Partial reinnervation does not seem to preserve the rest of the muscle. So that if enough time has passed and you redo the repair, yeah, the best you could do is probably what you achieved the first time, if there's some recovery. Now, if you have no recovery at all, that becomes a much easier decision. But I do think that partial recovery situations makes the decision tree very, very difficult. The other point that a clinical maybe point to make is I think you should be able to think of something different to do. If you've done a really good repair and you really are comfortable with it, especially if you've done it, and yes, I mean you, Jamie, but also to all of the competent nerve surgeons out there, you've done it yourself and you're confident that you did a good job. You have to, doing the exact same repair again, it's hard to see why that would make it better. And I think that that's an important way to think about it. So you can see I'm exploring my wrist again here. I wish I had a empty slide so we could talk about whether or not I should be exploring it again at this point. But the rationale, now, first of all, six months, his median nerve may not have recovered yet. I think everybody saw how long that gap was and it may not have recovered. But his ulnar nerve, I should have been seeing something at that point at six months out. And so to me, kind of some of the points that you made, Jamie, was that, you know, you can't wait these out forever. If you wait too long, you miss your window. So I explored this and that's the ulnar nerve repair. So looking at that, let me, Glenn, I'll jump up to you. I know you do some allograft repairs. What's your thoughts on seeing that? You saw my repair early on. It was a good looking repair. What are your thoughts looking at that, a good looking ulnar nerve allograft? Yeah, not as good looking. I think I'm as depressed as you were when you opened up and saw it. And not, it's easy to play Monday morning quarterback. The only thing on that case, round one, I probably would have been thinking is if I'm already going back and doing a serral nerve graft for the median nerve, I don't know that I would have chosen an allograft for the ulnar nerve. I personally would have said, I'm already going to get serral nerve. I'll just use some of the serral nerve excess to do both. Would have probably been my play, but I guess wrong on plenty of these as well. And so at this point, at six months, I would be looking at resetting back to healthy nerve and serral nerve grafting from the other leg now. It's probably where I would personally be going with this because you don't have a lot of great distal nerve transfer options since the median's already out as well. But I also think, as Jamie alluded to earlier, and I think you were pushing as well, that none of the revision nerve repair, which are never repair, it's always a revision nerve grafting, none of those do great. I mean, really and truly, none of them. So I think anytime there's a distal nerve transfer option, I'm always choosing that preferentially over a excise and graft in a revision setting. This time, your hands are kind of tied. Kyle, would you fix an ulnar nerve with an allograft initially? Well, I think it depends on the size of the gap, but I agree with what Glenn said. I think that the challenges I look at this case is, I wonder if you had an intact median nerve, whether you would have re-explored this at six months, if there was some sensory function in the hand, that I just wonder what your threshold was to say I'm going back at exactly six months. But in this case, I think I would excise it and do an autologous serral nerve graft repair, but ulnar nerve repair or ulnar nerve reconstruction do not do very well. They do far less well than the median nerve does. So I wouldn't be hoping for much. So I did do interoperative nerve testing. This does not look good. So, but as routine, I'll do this. And I did it for the median nerve also. The median nerve does seem like it's recovering at this point, though I was primarily exploring because I was worried about the ulnar nerve. And then here's my resection. And going proximal to my graft, I still have a bad looking nerve. Jamie, do you think that that means that I never got out of my zone of injury or does having a failed nerve repair with an allograft, does that make the nerve degenerate proximally as well? Well, to decide the good zone of injury, it's sometimes, I mean, the good, the healthy zone for putting a graft is something. But I mean, I don't use allografts. I think that even with autograft, I can't get good results with nerve grafting around the wrist. So I prefer, I don't use allografts, no. I mean, I would do the same thing I did with my case of the silicone tube. I would do a pseudograft. Okay. But I would, in this case, I mean, I would do distal nerve transfer for at least sensory reconstruction. Distal nerve transfer of what? Sorry, what would you do? The dorsal radial nerve, the dorsal radial nerve to the palmar branch of the tongue and index. Well, his medial nerve ended up recovering, which is kind of the crazy thing with that long graft. But with the sural nerve, his medial nerve ended up recovering. Well, I looked at this and I said, it wasn't the tool that I didn't get out of the zone of injury. And so I actually, I put another allograft in him. The patient and I discussed the pros and cons of this quite a bit. And this is what he was in favor of. So I ended up with a five centimeter allograft as opposed to a two and a half centimeter was the initial one. And it didn't work. Now we're stuck though with a situation that now I've had two out of the four panelists say, yeah, good luck, no matter what you do. And I used allograft and it didn't work. And now I still feel a little bit stuck with the question, did it not work because it was allograft or did it not work because I was screwed as soon as I was in that situation. I'm gonna throw out one question from the audience real quick. Would anybody consider using a vascularized sterile nerve graft in that initial gap that we saw there, a gap greater than five centimeters? I don't think it's necessary. I've done nerve grafts, 20 centimeters in length. And I don't think that's the case if you have good proximal and distal coaptations that allow the blood to flow and reestablish very quickly through an autograft. So I don't think the vascular nature is necessary. And I do think, who was saying it, Glenda, you were saying around the wrist or Kyle, that I do think that grafts in general around the wrist don't quite do as well as they do in other areas. And that kind of makes sense when you think about it from a vascularization standpoint that there's not as good a vascularized tissue, certainly in the carpal canal compared to other areas. Okay, we could probably talk about this a lot and I could really, I know if I open myself up to criticism on using this allograft, I know that this is all we'll talk about for the rest of the session. So I'm gonna show what I did and explain why I did it, what my rationale was, let people reflect on that, and I'm gonna let us move on to Amy's next case. Yes, we will let that be your confessional. We all have them. So let's see, I'm taking control and I'm gonna go back. All right, so we have 30 minutes left of our webinar and I just wanna thank the panelists and Jonathan for the discussion because I think this is when we dive into what makes nerve surgery so awesome, but so hard, right? Is that we don't have the right answer. We can do everything perfectly with expertise and still not get a great outcome. And so I think I appreciate the sharing of the cases because I think we all learn and elevate nerve surgery by discussing it. And so I appreciate everybody who's here at the webinar tonight, as well as our panelists. And so we're moving now, we're gonna take two, we have two more didactic talks. So we have 30 minutes, we're gonna try to keep it within 15 minutes. We have a multiple question in the queue. So we're gonna try to answer those by typing because we may run out of time at the end to discuss, but let's start case four. So case four, this is with regards to pain. So here's a 25 year old laborer who's eight months after a wrist laceration, after punching a window. He was treated outside hospital, had that primary nerve repaired, no really discussion of what they used. And I always think it's interesting when patients come, it's never like at three months, it's always this like window of time where I don't really know, okay, what's going on. He had some swelling at the wrist. And if you look at his muscle, his thenars, he's not atrophied, right? So he still has some bulk. And so the question is, is, you know, what's going on here for this patient? But his complaint, he could care less about his sensation that he didn't have. It was his pain. And so I have every patient fill out a patient questionnaire and how much it affects their quality of life. He had a wrist laceration, but what you can see is that his pain involved his entire extremity, right? And so these are the patients where it's no longer focused on, can I give you great function? I'm focused on, can I control your pain? And so here it is on, you know, he had some thenar, probably a Martin Gruber, but our options. And so we're thinking of pain and I'm sort of teeing up Dr. Curtin. But, you know, what are our options now? Like, okay, he has, did he maximize his therapy? Does he do this GMI? Does he have desensitization? He, you know, I sent him for all of those things to see if that could help his pain, to calm him before we proceed with any operative intervention, but he failed that. So now he's at eight weeks and, you know, what would we do? And so I would go back and excise this neuroma, but let's see what Dr. Curtin has to say to help us handle these patients with pain. Okay, terrific. So I'm gonna click on there and there we go. So I just, when I thought about pain after failed surgery, I wanted just to focus on two things, sort of how you kind of diagnose where your targets are and then what are the treatment options? And I won't spend a lot of time on the surgical components. I know Kyle's gonna talk a little bit about neuromas, so I'll let him do that. And so I think that, again, diagnosis is the key to find out, Amy's case is pretty straightforward, but sometimes you have patients like our ulnar nerve patient with still pain and you really wanna make sure you confirm your diagnosis. And so for this, I find that the sensory exam is incredibly helpful. I use the 10 test where you have them grade their sensation from zero to 10. It's very fast and efficient, and you can go through your anatomy following your nerve distributions to help you localize. So if we were talking about like a failed cubital tunnel, still pain, if they have numbness on their medial arm, then maybe you might look for more proximal entrapment. Or if you have a failed, you know, someone with carpal tunnel and they're numb on their palmar cutaneous, it could be injured by the surgery, or it could be that they have a proximal median nerve entrapment. So sensory exam, I think is very helpful. The next is a motor exam. You can look for subtle weakness in, again, looking at your nerve trees and helping you localize. If you have your ulnar nerve patient who has still pain and they're weak in FTP index, then maybe again, you are looking more proximal at a thoracic outlet or something like that that could be the problem. Palpation, Amy showed that she put an X where pain marks the spot. That can actually be really helpful. If you can push and it's a painful place, then what is that, what's there, could be contributing to the pain. And then we all have our provocative tests, NELs, valence, things like this that can help you localize. So the diagnosis and keeping a good physical exam is where you start. I also really like a diagnostic block. We've talked about electrodiagnostics. I think that they can be hard sometimes, especially in people who've already had surgery, but the diagnostic block where you have them get a little bit of numbing medicine above where you think the nerve is, and then seeing if they have benefit can help you localize. I actually have my pain colleagues do this under ultrasound guidance. And my only sort of wisdom would be make sure the patient understands that you're really looking for that first hour or so after the block to see if they had relief because they'll come back and say it didn't work at all because it's not a long lasting treatment, it's a diagnosis. Also, I do think that ultrasound can be helpful. It's dynamic. And so as the person is placing the probe, they can say, well, that's really the sore spot. And you can see changes in the nerve diameter that might be helpful and help guide you. And as we saw, MRI can be helpful. You can show a bright nerve, a swollen nerve with increased fascicles to help guide you. All right, and just always remember that the nerves are all part of a tree and that you can have some other nerve that is crushed or compressed that is contributing to the pain. And so just, again, I just harp on that. Good physical exam and just thinking of the whole tree that might be contributing to your pain that you're seeing. So as far as treatments, I'll spend a little time on medications and then therapy and nerve stimulation and leave surgery for the next talk. So for the medications that do have some evidence to be beneficial, NSAIDs, some, not so much for a painful nerve. There is some evidence that steroids in the acute setting can be helpful. So when you have that patient who comes in and is hot and bothered in that first month, the steroids can be beneficial. Our pain doctors recommend actually starting at 30 and tapering down over a three-week period, 30 milligrams of prednisone. So higher than your sort of steroid dose pack that you do over five. The gabapentinoids, the evidence is mixed. It seems to help, especially with people who are opioid dependent. So this is your gabapentin, your Lyrica, and it can help with some of the neuropathic pain. It can also help with sleeping, which can be beneficial for these folks. The antidepressants, there's pretty good evidence, again, that these can be helpful. Duloxetine, Cymbalta, seems to be one that's being quite effective, at least in my own patient population. And it also is antidepressant, which sort of gets you at two for. So those are the medications that are out there for just pain that have some evidence to suggest they're beneficial. As far as therapy, Amy alluded to this, but you definitely can have the benefit of our hand therapy colleagues. Scar management, gliding, we spoke about that early, early motion, no splinting. I think posture can be very important to help with other compressions when you have that patient with that sort of injured arm, with their shoulder tucked at their side, their wrist flexed, that can help perpetuate the pain process. Graded motor imagery is a mirror therapy in that retraining of the brain, and that can be beneficial. And there are some free apps that I like to mention, which is the Orientate app, where people look at their, it's just a quick seeing, is this right or it's left? Is it right or it's left? And for whatever reason, that does seem to help train the brain, especially for painful processes. And then finally, nerve stimulation, which I think has been a real value add for the patient with a painful nerve that might not have a very good surgical treatment. This is based on the gait theory, where the brain can only process so much stimuli. And so if you have some non-painful stimuli that the brain is processing, then it won't be able to process the painful stimuli. And so we've done spinal cord stimulation has been around for a long time, but with advances in technology, we can now use these in the peripheral nervous system and be quite targeted. So here's sort of what one of these nerve stimulators look like. The leads are soft and flexible. They can be placed under ultrasound guidance next to the nerve, and it gives the patient control. So they're able to turn it on or turn it off, which I think also helps with the pain. There are surgeries, make the nerves happy, decompress them, neuralyze them, put them in a happy place, treat the painful neuromas. And so those are also things that can be beneficial. Thank you. Awesome. Thank you, Catherine. I think the reality of it is, every patient who has a nerve injury, you have to ask about pain, and then you have to have your algorithm. So I just wanted to ask the panelists, do you guys have your go-to medication that you use? I love Cymbalta, the duloxetine. It has been my now go-to. It has minimal side effects, and it adds elevation of mood versus some of the depressant qualities that can come from gabapentin and sedative qualities. I'm a big fan. Are the other panelists, do they have a good drug of choice that they try to talk about fixing the brain pain as then you also have better effect by using the peripheral pain? I like amitriptyline. I think patients who have trouble sleeping and have a lot of neuropathic pain, it can kind of kill two birds with one stone there. And it does make them quite sleepy the following day, so they need to be aware of that. But I've found that helpful for nighttime symptoms and neuropathic pain. Okay, is that your first choice, Kyle? Or do you, are they already on gabapentin or something? It's not my first choice. I usually will start with gabapentin or Lyrica. And I like to keep some bullets in my gun in case one of them doesn't work. So I try not to start Cymbalta, Lyrica, or gabapentin and a tricyclic antidepressant at the same time. But it just depends on the patient, I think. Yeah, I did that once early in my practice, just loaded all these meds and the patient had a psychotic episode. And so I admitted them to my service. I took it, then I worked with psych, I learned. So please don't do that. It does not make sense. There's a reason why you shouldn't prescribe all those at the same time. And they work at the brain level, so be mindful. It's not wrong to get your primary care doctors involved or the pain management physicians. Glenn, Jonathan, or Jamie, you guys want to pipe up like what your drug of choice is treating these patients with pain? I like this. I usually start with Elavil. I think it's well-tolerated. I agree with Kyle that the sleep becomes very important and people lose their coping skills when they don't sleep. So I think that's really important. I will often do Elavil and Neurontin together. When that fails, I like Cymbalta, but I go to a second line because many of my patients seem to not be able to tolerate the side effects of it. Really? Okay, good. Glenn? You know, it's interesting. We really use more of a multidisciplinary approach in that we're not primary on most of these. We'll start them on low-dose gabapentin, go up a little bit. And once it moves into Cymbalta and the rest of the world, typically we involve our colleagues on that one. We step out, truthfully. Yeah, that's probably smart. Jamie? Same thing. I begin with gabapentin and tryptalin, and then I can add something else. If I send my patients to the pain practice nurse, they are going to give morphine and a derivate. So, and I try to do without them because I know how it will end. And two comments, if the nerve has been cut accidentally, you have a good choice to operate, good chance to operate and get it better. If the nerve has been operated before, then things change. You have bad prognosis in your neurosurgery. In this symptomatic patients with hand pain, I like to do a radiofrequency at the T2 and T3 level. This is sympathetic. And I see some cases that is good, they do fine and others, the pain come back. But what is amazing that you can control the pain at the sympathetic level. I mean, not doing thoracic sympathectomy, just radiofrequency and the CT scan. So just as an option to not operate your patients that have been multiple operated. Yeah, great. Love it. Okay, so then I won't belabor this because we've talked about these principles. I explored for this gentleman's pain after he failed his therapy, get outside the zone of injury like we've seen with the cases from Jonathan and I used autographed using MABC. And by seven months, wasn't quick, but at seven months or so, we started seeing the pain improve. Quality of life improves before you get the actual pain improving. And so that's where we go. The last case is about how do we treat neuromas? And I saw another patient today with a similar issue. So I'm really hopeful for help from the panelists. So here's a 21 year old. She was on a golf scholarship, had some first dorsal compartment pain, outside surgeon goes in and releases it and has this debilitating pain in the superficial branch of the radial nerve. That is our nightmare from this simple surgery, one centimeter incision. And so multiple surgeons saw this patient, they neuralized it, they wrapped it. And then she created more and more burning pain, 100 pounds of weight gain, lost her scholarship, comes to be miserable. And I'm asked by the head of my hospital to help. So there was a little bit of pressure in this. And so here is her exploration. We can see that beautiful wrap that's present over the nerve and it could dissect the wrap off of the soft tissue, but peeling the wrap off of the nerve was a nightmare. And you can see the nerve was nodular along that wrap. And so here's what I'm going to say about wraps. I am biased because I see these types of patients and if you've noticed every one of my cases I've had, oh, there was a wrap. So I'm biased, I don't see the successes, but I do think if you put on that wrap and you put it too tight and that nerve swells, you strangulate your nerve. And so I will tell you, if you use as a connector, proximal and distal, please put it on loose and expect the swelling. Otherwise you will kill your nerve. And so here she was, she had this nodular, you feel it awful. And I'm like, oh great, I'm going to help this woman. I'm going to do this great thing. I used a five centimeter allograft because I said, okay, if she doesn't get sensation, that's okay, but maybe it'll dwindle its way across. And great, okay, we did it. So post-op, three months later, no change. Okay, I'm like, all right, well, it's going to take a little bit of time because that's what these patients do in five months. No difference. Maybe she can touch her hand a little bit more, but it was not great. So she had irritation of the LAVC. So now I'm thinking, oh, okay, so really do I fix the SBNRN? And now it's just the LAVC. So she convinces me that, okay, I'm going to go to the OR. LAVC only becomes a problem if it's, you know, like again, I use that as a donor. So why would it give me, so I crush, cut and burn and flip it into the muscle. And one year later, she's having awful pain. If you notice, I changed my pain diagram. You can't really see it, but if like, I'm like having to look like this, but still awful pain. And so she now finds a PMR doctor who does an ultrasound and shows, oh, well, there's an neuroma at the wrist. So here it is. I have another neuroma and that's my pain score right there, number 10. This woman coming in, I've helped her zero. And now I have this guy outside telling her everything I did didn't work. And there's a neuroma, which is what she started with. So Kyle, teed it up. Let's go, help me. Well, thanks for presenting that very easy case that all of us can solve quickly. Let me make sure I can get control here. Thank you very much to John and Amy for having me. I'll try to keep this quick so we can have a few minutes for discussion. And my charge is to talk about failed neuroma surgery. Here are my disclosures. They are relevant here. So in general, surgery for symptomatic neuromas is most often successful. Not every time, as we just saw, but most of the time it is. There's a lot of literature about this. This is a paper from Amy and Dr. McKinnon's group from 2017, where they show that in 70 patients, treating their symptomatic neuromas primarily with cut and bury techniques in this paper did result in improvement in DASH scores. So we do know that this works. However, how do we define failure? It's very hard for neuroma surgery. Why? Well, the principles are that surgery for symptomatic neuroma rarely yields a hundred percent improvement in pain. A lot of times patients will get better, their pain will improve, but rarely are patients a hundred percent better. And neuroma patients and those with chronic pain are inherently very challenging. They're difficult patients. There's a reason that not everyone wants to care for them. So my questions, and hopefully we can have a little discussion, is there a threshold for symptomatic improvement that defines success? In the literature, that would generally be an improvement in the visual analog scale of greater than three points, maybe four points, or an ultimate improvement to a less than four out of 10 in terms of pain. That's generally how it's defined. And another question is, is failure defined by those patients who undergo revision surgery for symptomatic neuroma, like the one that Amy just mentioned? So what is our literature? Well, this is a great meta-analysis in the Journal of Pain, another one from Amy. I'm giving you lots of shout outs here, Amy. But I'd like to highlight two things in the paper. One is that the overall treatment for neuropathic pain was 77% successful, and there was no difference between surgical techniques in this meta-analysis. Okay, that's important. We did a study we published in PRS in 2019, where we looked at over 600 patients who had neuroma surgery. And what we found is that about 8% of those patients who underwent surgery for symptomatic neuroma had secondary surgery for the symptomatic neuroma. So that means about one in 12 patients with neuroma surgery will have a secondary. So does the surgical technique matter when we're dealing with neuromas? We don't know, is the short answer. This is a paper that I wrote with Devon Duchik that kind of highlights what our techniques are. I do think that we have had a bit of a paradigm shift for the management of neuromas to a more active or reconstructive approach. Talk a little bit about that. And so if the distal target is available and the nerve is reconstructible, just like Amy did for that radial sensory nerve, I would generally favor reconstructing the nerve. And if it's an end neuroma, we have a whole host of techniques available to us. Just to go through them quickly, we have nerve implantation in the muscle. There are a couple of commercially available nerve caps. I don't know where those sort of fit. There is a centrocentral neuroraphy. If you're going to do that, make sure you don't put two live wires in the nerve together. There is relocation nerve grafting or nerve graft to nowhere. There are end to side type techniques, though that's a reverse end to side. And then TMR or RPNI. So in my practice, I most often will reconstruct the nerve if I can, if the terminal end of the nerve is available. And if reconstruction is not possible, or if it's a hostile environment, I'll go more proximal. I'll do a neurotomy or a resected neuroma and do something such as TMR or RPNI. So what do we do if neuroma surgery fails? The first thing, and this was mentioned by Dr. Curtin, is you got to load the boat with your colleagues. You got to get pain management involved, you got to have psychiatry, you got to have everyone on your side. If your plan A doesn't work, you got to go to a plan B. And there's only so many letters in our alphabet, but very often for these patients, you got to pull out all the stops. So in my final two slides, I'd like to talk you through how I think about failed neuroma surgery. So you got to figure out, what is the etiology of failure? Is it the patient or is it the pathophysiology? There are some patients for whom our surgeries are just not going to work. And that may be the patient Amy's talking about. It's possible. Was there an interval relief prior to pain recurrence? If your neuroma surgery helped for about eight, nine, 10 months, and then they had pain, they may have a recurrent neuroma. That's probably not true if they never had relief of their symptoms. Was a different painful nerve not addressed, such as unmasking, like the LABC in the setting of a radiosensory nerve? Is there proximal nerve pathology in the cervical spine? Is there proximal nerve compression? One of the thoughts for Amy's case is, is the radiosensory nerve compressed between the BR and the ECRL, right where it emerges in the forearm? That can be another source. Is the pain nociceptive and not neuropathic? And then something I've been thinking about more, and I'd be interested to hear other thoughts. If you go proximal to the neuroma and you just address the nerve there, but you leave the terminal neuroma, I have had a few patients who've had a little trophic input into that terminal neuroma, and it still had pain, even though I've transected the nerve proximally. So I'm a little bit more aggressive about either going to the terminal neuroma or close by to do my intervention. So when we're deciding about whether to offer revision surgery, I do think that a nerve block, and I do that myself under ultrasound, is really helpful. If I can make their pain better with a nerve block, I'm very likely to offer them revision surgery. If I cannot, I will run the other way and not operate on the patient. Very often, I'm finding myself doing TMR, RP, and I, and I try to do it as deeply as possible, and I try to separate the nerve for a large mixed motor nerve into as many fascicles as possible, as I think this is helpful. I myself have put in a number of peripheral nerve stimulators. I do think that they're helpful. I think they're great for the surgical armamentarium in 2022. And then we have all of our backup plans, which is spinal cord stimulation and non-surgical modalities. So I'm going to stop there. I appreciate the opportunity to be on this panel and thank everyone for their time at the end of this meeting. Okay, nice. Okay, so that was great, Kyle, because I think you presented it in such a nice way. For my patient, again, I'm going to make it all about me. For my patient, I did do a radial tunnel release and I released the brachioradialis distally from it at the first surgery when I did the distal reconstruction. So now here we are with my patient, this ultrasound that tells me there's an aroma. What would you do? Well, every nerve repair gets an aroma, right? If you, any, even a perfect. Correct. So even a perfect median nerve repair, if you study it histologically or look ultrasonographically, there's going to be an aroma there. So to me, it's not a question of, is there an aroma? No kidding, there's an aroma, but can I make it better? So I would do a proximal nerve block for that patient. But honestly, those patients who have failed good intervention, I'm not certain you can make that patient better. I probably would do an erectomy of the radial sensory nerve and do proximal TMR deep in the forearm, maybe into the AIN, but I still, I would lay a tunnel crate. I'm not certain that that will work. Jamie? I mean, we should differentiate neuroma and painful neuroma. And in general, painful neuroma were made accidentally. I mean, I got pseudo nerves almost three times in the week. I have never had a single case of painful neuroma like this sort of patients we see. So even in the cutaneous branch, when I read a flap, I don't care about that. I'm sure there will be no consequence if I know I'm cutting, but if it's accidental, then you have this sort of problems. I think on your particular case, I would operate him again. I would cut approximately the superficial radial nerve. This is one point. And Kai just mentioned that if we do an aesthetic block, it would be nice. But there is a good and interesting point that I do on this complicated case. I have, I rather see all the distal nerves. I mean, not just the neuroma. If the radial nerve is here, I try to remove everything. I think there can be some contributions to adjacent nerves that can promote the neuroma. And I have seen a few of those cases operated and they did great. Even on the arm, on the forearm, and the lower limb that had the multiple operations for a stump pain, a phantom ghost pain. And I did, I removed approximately there and I rather stay supervising this stuff. I think it's a good option for your patient because he cannot live as a pain scoring 10. I would cut approximately and then remove everything distal. Okay. Wow. All right. Glenn, Jonathan, Catherine. Radial sensory, such a bad actor. Yeah, we all hate it. A few quick thoughts. Number one, I think a big factor is how much pain medicine they are in advance and what kind of medications. If they've got a large amount of pain meds in advance, they develop a cortically imprinted pain cycle that you cannot break with any surgery. And we found that in a lot of our amputee patients. So first step is winning them down before you do any revision peripheral nerve surgery. And then you have a better chance to win. In terms of radial sensory nerve, to me, if I explore it the first time around, there's no obvious neuroma. I agree with John. This is the place I really do like a vein wrap and that's where I use it. If there's no obvious neuroma, no nodularity to the nerve. If it's nodular neuroma and continuity or an N neuroma with a distal target, just like Kyle said, I personally would favor a reconstruction exactly like you did cut back to the zone and grafted. If they continue to have pain and they weren't on a ton of pain medicine, and I didn't think there was that element to deal with, I would personally do TMR in that case. And I'd go in, we've done radial sensory to BR, just did one last week. And I think that's been a pretty reliable one for us. Okay, good. Catherine, Jonathan. Well, again, I would want her to have some pain relief with a block before I did anything. And like I said, I really liked the nerve stimulators because sometimes people with multiple surgeries, it's just been a lot and it's pretty low risk. And when it works, it's quite lovely. So someone you've already done a bunch of surgery on, you're still struggling, if they respond to a block, then I would say, well, let's try something other than surgery and I might try a nerve stim. Okay, good. Jonathan. I probably, in this case, and I know how the case ends, but even saying that, I kind of am with Jamie. I think that sometimes there are patients that, and I'm a little bit cynical, but are just never going to get better no matter what you do. And I think what you did was a very, very reasonable approach to their problem. And to me, sometimes you say, all right, we've done what we can, I can't help you any further, so. Okay, so here's what I did in the final moments. Oh, I took her back because she convinced me. I go in and I find this. So, okay, but because she had gotten a preoperative, I tried to knock her down with local, it helped her. I said, well, we're going to go to this. And so then I did TMR to BR, cut it, and she's down 50%. And so I am here, very happy. And the reality is, is who knows how long it'll last? I mean, this, I probably just saw her three months, which was just like probably two weeks ago to get this. It was whenever I talked to you, Jonathan. So very, very standstill. I am very cautious that she'll just rise back up again. And I think I'll have to think about those nerve stems. Well, great, so- Amy, can I make a really quick comment? I know we're out of time, but I think it's really interesting that this patient seems to have done better when you went more proximally. She didn't have any real relief when you grafted her. And it's really hard to decide on whom we should be grafting them initially and on whom we should go proximally. That's the hardest thing I have to decide. I usually try to do what you did to reconstruct it, but some patients were better off doing this, and I don't know how to select them. Yeah, me neither, clearly. Great, she's going to do good. When they do good like that initially in TMRs, at least traditionally, the ones we've seen, I think Kyle will agree. She's going to do good, actually, Amy. She'll hang in there. Yeah, God, it'd be so great. It makes you drop and feel better. All right, Jonathan, I'm going to pass it on to you to close this out. I want to thank everybody, all the faculty and the audience. When we put this together, I always get this anxiety that, gosh, will we fill up an hour and a half and almost always, this is exactly what happens. We run out of time and wish we had more time. I feel that we cut a couple of discussions a little bit shorter than we would have preferred, but it is what it is. We're out of time, and I'd like to conclude the webinar. Again, thank everybody for participating. Audience members, please select your evaluation, and everybody have a good night. Thank you. Thank you. Great job, everybody. Thank you all. Bye.

Failed Nerve Surgery

Nerve Reconstruction

Carpal Tunnel Release

Scar Tissue Compression

Ulnar Nerve Transposition

Cubital Tunnel Syndrome

Autologous Fat Wraps

Nerve Transfers

Pain Management in Nerve Surgery

Diagnostic Blocks

NSAIDs

Nerve Gliding

Multidisciplinary Approach