Surgical Treatment Strategies for Injuries of the "Unforgiving" Superficial Branch of the Radial Nerve.

BACKGROUND: Neuropathic pain caused by adhesions or neuroma formation of the superficial branch of the radial nerve (SBRN) is difficult to treat. The authors evaluated the effectiveness of different routinely used surgical techniques for SBRN neuralgia to provide a basis for future studies on SBRN neuralgia and explored the prognostic value of a preoperative diagnostic nerve block. METHODS: The authors performed a retrospective cohort study by reviewing surgical records for procedures to treat SBRN neuralgia. Patient satisfaction was scored as satisfied or unsatisfied, and pain intensity was scored with a numeric rating scale. RESULTS: The authors included 71 patients who had 105 surgeries on the SBRN. Patients with a neuroma ( n = 43) were most satisfied after proximal denervation with burying into the brachioradialis muscle compared with burying elsewhere (53 versus 0 percent; p < 0.001). Adhesions of the SBRN ( n = 28) were treated with neurolysis (39 percent satisfied). If neurolysis or denervation did not suffice, an additional denervation of the lateral antebrachial cutaneous nerve or posterior interosseous nerve led to satisfaction in 38 percent. A decrease of less than 3.5 points on the numeric rating scale score after diagnostic nerve block led to higher postoperative pain scores (4.0 versus 7.5; p = 0.014). The authors found that the outcome of the diagnostic nerve block can predict the outcome of SBRN denervation and burying into brachioradialis muscle. CONCLUSIONS: The most effective burying technique is burying the SBRN into the brachioradialis muscle. Future studies on the treatment of SBRN neuralgia should therefore compare newer techniques, with burying the SBRN into the brachioradialis muscle as the control group.

Clinical Assessment of Pain and Sensory Function in Peripheral Nerve Injury and Recovery: A Systematic Review of Literature.

Peripheral nerve injuries (PNIs) often present with variable symptoms, making them difficult to diagnose, treat, and monitor. When neurologic compromise is inadequately assessed, suboptimal treatment decisions can result in lasting functional deficits. There are many available tools for evaluating pain and functional status of peripheral nerves. However, the literature lacks a detailed, comprehensive view of the data comparing the clinical utility of these modalities, and there is no consensus on the optimal algorithm for sensory and pain assessment in PNIs. We performed a systematic review of the literature focused on clinical data, evaluating pain and sensory assessment methods in peripheral nerves. We searched through multiple databases, including PubMed/Medline, Embase, and Google Scholar, to identify studies that assessed assessment tools and explored their advantages and disadvantages. A total of 66 studies were selected that assessed various tools used to assess patient's pain and sensory recovery after a PNI. This review may serve as a guide to select the most appropriate assessment tools for monitoring nerve pain and/or sensory function both pre- and postoperatively. As the surgeons work to improve treatments for PNI and dysfunction, identifying the most appropriate existing measures of success and future directions for improved algorithms could lead to improved patient outcomes.

Failed Targeted Muscle Reinnervation: Findings at Revision Surgery and Concepts for Success.

Although it was initially described for improved myoelectric control, targeted muscle reinnervation (TMR) has quickly gained popularity as a technique for neuroma control. With this rapid increase in utilization has come broadening indications and variability in the described technique. As a result, it becomes difficult to interpret published outcomes. Furthermore, there is no literature discussing the management of failed cases which are undoubtedly occurring. Methods: This is a retrospective case series of two patients who underwent revision surgery for failed TMR. The authors also review the current literature on TMR and outline technical and conceptual pitfalls and pearls based on our local experience. Results: Excessive donor nerve redundancy, kinking, donor-recipient nerve size mismatch, superficial placement of the nerve coaptation, inappropriate target selection, and incomplete target muscle denervation were identified as technical pitfalls of TMR surgery. Techniques to avoid these pitfalls were described. Conclusions: Although TMR has been a major development in amputee care for both pain management and improved myoelectric control, it is important to acknowledge that it is not a foolproof surgery and does not provide a guaranteed result. Failed cases of TMR represent opportunities to learn about factors contributing to unfavorable outcomes and refine our techniques empirically.

Cross-Sectional Evaluation of the Economic Burden on Patients Seeking Surgical Treatment for Chronic Nerve Injuries.

INTRODUCTION: Little emphasis has been paid toward characterizing the socioeconomic burdens experienced by patients seeking treatment for chronic nerve injuries. The aim of this study was to characterize the direct and indirect costs faced by patients with chronic nerve injuries and their attendant health care utilization. MATERIALS AND METHODS: A cross-sectional survey was distributed to all patients (N = 767) from a single nerve surgeon's practice treated for chronic nerve injuries in the ambulatory setting between 2014 and 2020. Data collected included demographics, etiology, comorbidities, duration and severity of symptoms, history of prior medical and interventional treatments, work or school time lost due to injury or treatment, money spent on treatment, and health care utilization. RESULTS: Of the 767 patients, 209 (27.2%) completed the survey. Average age was 48.8 (SD = 19.1) years, 68.9% female and 31.1% male. Patients with chronic nerve injury reported significant direct costs, indirect costs, and health care utilization associated with their nerve injury symptoms. Direct costs consisted of out-of-pocket spending (68.4% had spent >$1000 per year), physician specialists visits (71.3% had seen at least 4 specialists), and prior interventional procedures intended to address symptoms. Indirect costs included lost time from work or school (24.6% had missed more than 12 months). Health care utilization, represented by annual emergency room visits and hospitalizations related to nerve symptoms, was increased relative to the general population. Detailed statistics are presented in the manuscript. CONCLUSIONS: Chronic nerve injuries may be associated with a notable socioeconomic burden to the patient, including missed work or school, frequent physician visits and procedures, hospital visits, and out-of-pocket costs. Interdisciplinary algorithms recognizing a role for surgical evaluation in patients with chronic neuropathic pain due to underlying nerve injuries would facilitate future research into whether timely surgical intervention may reduce this economic burden.

Impact of Nerve Surgery on Opioid and Medication Use in Patients with Chronic Nerve Injuries.

INTRODUCTION: Limited information is available regarding the ability of nerve surgery to affect medication use patterns in patients with chronic pain or neuropathy due to nerve injury. METHODS: A retrospective survey was distributed to all operative patients (N = 767) from a single nerve surgeon's practice between 2014 and 2020. Data collected included demographics, specifics of the injury and symptoms, medication and opioid use before surgery, and medication/opioid use following surgery. RESULTS: Out of the 767 patients, 209 (27.2%) completed the survey. Average age was 48.8 (SD = 19.1) years; 68.9% female and 31.1% male. More than 50% of the patients took at least three medications. More than 50% of the patients after surgery did not need medication or had significant reduction; 54.1% of the patients took opioid medication daily, and 97.3% of patients reported that narcotic medications did not resolve their problem. Patients rated the effectiveness (Likert scale 0-10) of opioid medications in general at an average 3.25 ± 2.03. Of patients who took opioids regularly, 61.6% reported a negative effect of these medications on daily or professional activities. After surgery, more than 50% of the patients did not need opioids or had a significant reduction in opioid usage. CONCLUSIONS: Untreated nerve injuries lead to ongoing chronic pain, explaining why medications are mostly ineffective in eliminating symptoms. In this study, nerve surgery targeting the anatomical source of symptoms effectively reduced both opioid and nonopioid medication use.

Chronic Nerve Injuries and Delays in Surgical Treatment Negatively Impact Patient-reported Quality of Life.

Little emphasis has been paid to characterize quality of life (QoL) burdens experienced by patients seeking surgical treatment for nerve injuries and neuropathic pain. METHODS: A cross-sectional survey was distributed to all patients (N = 767) from a single nerve surgeon's practice between 2014 and 2019. Data collected included demographics, specifics of the injury and symptoms, time to referral, and effects of the injury, surgery, and timing of surgery on QoL. RESULTS: Of the 767 patients, 209 (27.2%) completed the survey. Average age was 48.8 years; 68.9% of patients were women and 31.1% men. At presentation, 68% had experienced symptoms for more than 1 year; 86.1% reported severity as being profound; 97.6% reported QoL was at least moderately negatively impacted by nerve injury; 70% felt they should have been referred earlier for surgical evaluation; 51.2% were not told that nerve surgery was an option for their problem; 83.1% felt that earlier referral would have improved their QoL. After surgery, symptoms were significantly mitigated in 55.5% of the patients, moderately mitigated in 21.5%. Patients reported QoL was significantly (59.8%) or at least moderately (76.6%) improved by nerve surgery. CONCLUSIONS: The majority of patients reported that nerve injuries imparted a moderate to severe impact on QoL, and that surgical treatment improved QoL. Most patients felt that earlier referral for surgical intervention would have led to better outcome and positively impacted QoL. Interdisciplinary treatment algorithms, including a role for surgical intervention, may be helpful in facilitating timely diagnosis, referral, and thus improved outcomes.

Evidence-Based Approach to Timing of Nerve Surgery: A Review.

ABSTRACT: Events causing acute stress to the health care system, such as the COVID-19 pandemic, place clinical decisions under increased scrutiny. The priority and timing of surgical procedures are critically evaluated under these conditions, yet the optimal timing of procedures is a key consideration in any clinical setting. There is currently no single article consolidating a large body of current evidence on timing of nerve surgery. MEDLINE and EMBASE databases were systematically reviewed for clinical data on nerve repair and reconstruction to define the current understanding of timing and other factors affecting outcomes. Special attention was given to sensory, mixed/motor, nerve compression syndromes, and nerve pain. The data presented in this review may assist surgeons in making sound, evidence-based clinical decisions regarding timing of nerve surgery.

Chronic postoperative complications and donor site morbidity after sural nerve autograft harvest or biopsy.

BACKGROUND: The sural nerve is the most frequently harvested nerve autograft and is most often biopsied in the workup of peripheral neuropathy. While the complication types associated with these two procedures are well known, their clinical significance is poorly understood and there is a paucity of data regarding the complication rates. METHODS: Pubmed search identified studies regarding complications after sural nerve harvest and biopsy. The data was grouped into sensory deficits, chronic pain, sensory symptoms, wound infections, wound complications, other postoperative complications, and complications impacting daily life. The incidence of each complication was calculated, and a chi-square analysis was performed to determine if there were any differences between nerve biopsies and graft harvest with respect to each complication. RESULTS: Twelve studies yielded 478 sural nerve procedures. Sensory deficits occurred at a rate of 92.9%, chronic pain at 19.7%, sensory symptoms at 41.1%, wound infections at 5.7%, noninfectious wound complications at 7.8%, and impact on daily life at 5.0%. The differences in wound infections, sensory symptoms, and impact on daily life between biopsies versus graft excisions were found to reach statistical significance (p < .05). CONCLUSIONS: Sural nerve excisions can cause chronic postoperative donor-site complications. Given these complications, alternative available mediums for nerve reconstruction should be explored and utilized wherever appropriate. If an alternative medium is unavailable and nerve autograft must be harvested for nerve reconstruction, then patients should be counseled about risks for developing donor site complications that may negatively affect quality of life.

Diagnostic Criteria for Symptomatic Neuroma.

INTRODUCTION: After nerve injury, disorganized or incomplete nerve regeneration may result in a neuroma. The true incidence of symptomatic neuroma is unknown, and the diagnosis has traditionally been made based on patient history, symptoms, physical examination, and the anatomic location of pain, along with response to diagnostic injection. There are no formally accepted criteria for a diagnosis of neuroma. MATERIALS AND METHODS: A literature search was performed to identify articles related to neuroma: Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed and Pubmed, Embase, and the Cochrane Library were searched for all relevant articles pertaining to neuroma. Articles were screened by title and abstract for relevance. If an article was considered potentially relevant, the full article was reviewed. After consideration, 50 articles were included in this systematic review. RESULTS: No previous articles directly addressed diagnostic criteria for symptomatic neuroma. Factors related to neuroma diagnosis gleaned from previous studies include pain and cold intolerance (patient history), positive Tinel sign or diminished 2-point discrimination (physical examination findings), response to diagnostic nerve block, and presence of neuroma on diagnostic imaging (ultrasound or magnetic resonance imaging). Based on literature review, the importance and number of references, as well as clinical experience, we propose criteria for diagnosis of symptomatic neuroma. To receive a diagnosis of symptomatic neuroma, patients must have (1) pain with at least 3 qualifying "neuropathic" characteristics, (2) symptoms in a defined neural anatomic distribution, and (3) a history of a nerve injury or suspected nerve injury. In addition, patients must have at least 2 of the following 4 findings: (1) positive Tinel sign on examination at/along suspected nerve injury site, (2) tenderness/pain on examination at/along suspected nerve injury site, (3) positive response to a diagnostic local anesthetic injection, and (4) ultrasound or magnetic resonance imaging confirmation of neuroma. CONCLUSIONS: The diagnosis of neuroma is based on a careful history and physical examination and should rely on the proposed criteria for confirmation. These criteria will be helpful in more precisely defining the diagnosis for clinical and research purposes.

Reconstructive Options for Inferior Alveolar and Lingual Nerve Injuries After Dental and Oral Surgery: An Evidence-Based Review.

PURPOSE: The investigators wanted to evaluate, analyze, and compare the current microsurgical repair modalities (primary repair, autograft, tube conduit, and allograft reconstruction) in achieving functional sensory recovery in inferior alveolar and lingual nerve reconstructions due to injury. METHODS: A literature review was undertaken to identify studies focusing on microsurgical repair of inferior alveolar and lingual nerve injuries. Included studies provided a defined sample size, the reconstruction modality, and functional sensory recovery rates. A Fischer exact test analysis was performed with groups based on the nerve and repair type, which included subgroups of specific nerve gap reconstruction modalities. RESULTS: Twelve studies were analyzed resulting in a sample consisting of 122 lingual nerve and 137 inferior alveolar nerve reconstructions. Among the nerve gap reconstructions for the lingual nerve, processed nerve allografts and autografts were found to be superior in achieving functional sensory recovery over the conduits with P values of 0.0001 and 0.0003, respectively. Among the nerve gap reconstructions for the inferior alveolar nerve, processed nerve allografts and autografts were also found to be superior in achieving functional sensory recovery over the conduits with P values of 0.027 and 0.026, respectively. Overall, nerve gap reconstructions with allografts and autografts for inferior alveolar and lingual nerve reconstruction were superior in achieving functional sensory recovery with a P value of <0.0001. CONCLUSIONS: The data analyzed in this study suggest that primary tension-free repair should be performed in inferior alveolar and lingual nerve reconstructions when possible. If a bridging material is to be used, then processed nerve allografts and autografts are both superior to conduits and noninferior to each other. In addition, allografts do not have the complications related to autograft harvesting such as permanent donor site morbidity. Based on the conclusions drawn from these data, we provide a reproducible operative technique for inferior alveolar and lingual nerve reconstruction.

Treatment of Neuroma-induced Chronic Pain and Management of Nerve Defects with Processed Nerve Allografts.

Symptomatic neuromas can cause significant chronic pain and negatively impact quality of life. Symptoms often persist despite narcotics and nonoperative interventions, which are largely ineffective. With the opioid crisis, treatments for chronic pain that limit narcotics are needed. Traditional surgical options may result in neuroma recurrence. Autograft reconstruction often results in donor-site morbidity. Processed nerve allografts facilitate axonal growth, nerve regeneration, and eliminate donor-site morbidity. METHODS: A literature review was performed to identify studies in which chronic neuroma pain was treated with excision and processed nerve allograft reconstruction. PubMed was queried, and data from the studies were grouped into treatment effective and ineffective groups. Statistical analyses were performed on these groups, and further subgroup analysis was performed on overall change of preoperative and postoperative pain scores using a paired t test. RESULTS: Seven studies fulfilled inclusion criteria yielding 42 patients. Greater than 90% of patients had improvement of pain postoperatively. The preoperative and postoperative pain scores could be determined for 40 patients. The mean preoperative score was 7.9, and the mean postoperative score was 3.54. These results were statistically significant using a paired t test with a P value of <0.001. CONCLUSIONS: Chronic pain resulting from symptomatic neuromas can be treated with neuroma excision and nerve stump reconstruction with processed nerve allograft. This obviates autograft-associated donor-site morbidity and provides a platform to potentially restore sensation to the involved nerve whenever a distal nerve end is available. Addressing the root cause is an important paradigm shift for treating symptomatic neuromas.

Surgical Algorithm for Neuroma Management: A Changing Treatment Paradigm.

Successful treatment of the painful neuroma is a particular challenge to the nerve surgeon. Historically, symptomatic neuromas have primarily been treated with excision and implantation techniques, which are inherently passive and do not address the terminal end of the nerve. Over the past decade, the surgical management of neuromas has undergone a paradigm shift synchronous with the development of contemporary techniques aiming to satisfy the nerve end. In this article, we describe the important features of surgical treatment, including the approach to diagnosis with consideration of neuroma type and the decision of partial versus complete neuroma excision. A comprehensive list of the available surgical techniques for management following neuroma excision is presented, the choice of which is often predicated upon the availability of the terminal nerve end for reconstruction. Techniques for neuroma reconstruction in the presence of an intact terminal nerve end include hollow tube reconstruction and auto- or allograft nerve reconstruction. Techniques for neuroma management in the absence of an intact or identifiable terminal nerve end include submuscular or interosseous implantation, centro-central neurorrhaphy, relocation nerve grafting, nerve cap placement, use of regenerative peripheral nerve interface, "end-to-side" neurorrhaphy, and targeted muscle reinnervation. These techniques can be further categorized into passive/ablative and active/reconstructive modalities. The nerve surgeon must be aware of available treatment options and should carefully choose the most appropriate intervention for each patient. Comparative studies are lacking and will be necessary in the future to determine the relative effectiveness of each technique.

Sensory restoration of breast reconstruction - The search for the ideal approach continues.

Contemporary reconstructive modalities focus on breast anatomy and attempt to reconstruct breasts that are soft, of adequate shape, size, and symmetry. However, a functional component, i.e. sensation, has largely been ignored. Flap neurotization addresses this shortcoming. While we are still in search of the ideal surgical technique to achieve this goal, a novel approach that limits nerve harvest to the sensory branch only, thus, minimizing abdominal donor-site morbidity, is presented.

Anatomical Considerations to Optimize Sensory Recovery in Breast Neurotization with Allograft.

BACKGROUND: Breast numbness is a recognized problem following mastectomy and subsequent reconstruction. Contemporary literature acknowledges the positive role of breast neurotization, but it is characterized by a variety of technical approaches and substantial heterogeneity with respect to the degree of recovered sensibility that remains suboptimal in comparison with other sensory nerve reconstructions. This study's purpose was to provide an anatomical basis for observed inconsistencies and therein provide a principle that can be used to develop a technical approach that will optimize sensory recovery. METHODS: Anatomical dissections on 6 fresh cadavers, that is, 12 hemi-abdominal flaps and 12 hemi-chest dissections, were performed. The technical aspects of harvesting the abdominal flap with a nerve target, that is, inclusion of a sensory nerve branch only, recipient nerves in the chest, and the applications of allograft for acquired nerve gap reconstruction were investigated. RESULTS: Abdominal flaps that include sensory-only intercostal nerve 10-12 segments and identification of recipient chest wall intercostal nerves 2-4 could be consistently performed. The dissection and extraction of the donor sensory nerve target allowed preservation of the motor rectus innervation. The acquired nerve gap was easily bridged by an interposing allograft, allowing free arch of rotation for flap inset, suitable for either single or dual neurotization. CONCLUSIONS: We provide a likely anatomical explanation for suboptimal sensory recovery after deep inferior epigastric perforator (DIEP) flap breast neurotization, as mixed intercostal autograft is prohibitive to maximal sensory recovery. Breast neurotization with allograft that bridges sensory donor intercostal nerves to sensory recipient intercostal nerves should anatomically optimize restoration of breast sensibility.

Interdisciplinary treatment of post-concussion and post-traumatic headaches.

INTRODUCTION: Chronic headaches following concussion are debilitating and difficult to treat. Commonly employed initial therapeutic modalities include pharmacologic, physical, and psychological interventions. Despite these efforts, a subset of patients with chronic pain remains. Peripheral nerve surgery has never before been reported as an effective treatment for the management of post-concussion headaches. In this study, we report on our early outcomes following peripheral nerve surgery for this novel indication. METHODS: A retrospective review of 28 consecutive patients with post-concussion headaches who underwent occipital nerve surgery was performed. Preoperative and postoperative headache pain was evaluated on visual analog scale (VAS) in 24 patients with at least 6 months follow-up. RESULTS: The average VAS headache pain reduced from 6.4 preoperatively, to 1.4 (P < 0.0001). Twenty-one patients (88%) had a successful outcome of at least a 50% reduction in their VAS following peripheral nerve surgery. Additionally, twelve patients (50%) were pain free at time of final follow-up. There were no surgical complications. CONCLUSIONS: Early results indicate peripheral nerve surgery is a safe and effective new therapy for post-concussion headaches in the properly selected patients, whose chronic pain persists despite initial treatments by a neurologist, specialized in headache management. Future studies should focus on larger patient populations, and examine the long-term durability of outcome. In the meantime, an interdisciplinary approach involving neurologists and a peripheral nerve surgeon is suggested for the care of patients with refractory chronic post-concussion occipital neuralgia and other post-traumatic chronic headaches.

A review of current evidence in the surgical treatment of migraine headaches.

SUMMARY: Migraines affect 18% of women and 6% of men and result in an estimated $1 billion in medical costs and $16 billion productivity loss in the United States annually. Migraine headaches persist as a problem of this scale because pharmacologic treatments for migraines are frequently incompletely effective, resulting in a population of patients with significant residual disability. In the last decade, novel approaches to the treatment of migraines have been developed based on the theory that extracranial sensory branches of the trigeminal and cervical spinal nerves can be irritated, entrapped, or compressed at points throughout their anatomic course, ultimately leading to the cascade of physiologic events that results in migraine. Botulinum toxin (Botox) injection and surgical decompression of these trigger points have been shown to reduce or eliminate migraines in patients who are incompletely treated by traditional medical management. Despite the recent advances made with Botox, this treatment strategy most commonly results in only temporary migraine prevention. However, the evidence supporting the efficacy and safety of permanent surgical decompression of peripheral trigger points is accumulating rapidly, and the overall success rate of surgery has approached 90%. In addition, an abundance of literature investigating the precise anatomical dissections associated with trigger points has been published concurrently. This article reviews the most up-to-date clinical and anatomic evidence available and seeks to provide a comprehensive, concise resource for the current state of the art in the surgical treatment of migraine headaches.

Nerve Injuries in Aesthetic Breast Surgery: Systematic Review and Treatment Options.

BACKGROUND: The risk of nerve injuries in aesthetic breast surgery has not been well explored. OBJECTIVES: The authors conducted a systematic review to provide evidence-based information on the incidence and treatment of nerve injuries resulting from aesthetic breast surgery. METHODS: A broad literature search of Medline, Embase, and the Cochrane Database of Systematic Reviews was undertaken to identify studies in which nerve injury occurred after breast augmentation or mastopexy. Specific inclusion and exclusion criteria were established before the search was performed. RESULTS: The initial 4806 citations were narrowed by topic, title, and abstract to 53 articles. After full-text review, 36 studies were included. The risk of any nerve injury after breast augmentation ranged from 13.57% to 15.44%. Specific nerve injury rates were calculated for the intercostal cutaneous nerves, branches to the nipple-areola complex, intercostobrachial nerve, long thoracic nerve, and brachial plexus. Also calculated were the total estimated risks of chronic pain, hyperesthesia, hypoesthesia, and numbness. The meta-analysis showed no associations between the rates of breast nerve injury or sensation change and implant size, incision type, or implant position in patients who underwent breast augmentation. The data were insufficient to determine rates of nerve injury in mastopexy. CONCLUSIONS: The possibility of nerve injury, sensation change, or chronic pain with breast augmentation is real, and estimating the incidences of these conditions is useful to both patients and surgeons. Optimizing patient outcomes requires timely treatment by a multidisciplinary team and may include peripheral nerve surgery. LEVEL OF EVIDENCE: 3.

Abdominoplasty-related nerve injuries: systematic review and treatment options.

BACKGROUND: Abdominoplasty is a common cosmetic procedure; nerve injury is an underexplored risk of the procedure. OBJECTIVE: The authors review existing literature to examine the incidence and treatment of nerve injuries after abdominoplasty procedures and provide a treatment algorithm based on their results. METHODS: A search of the literature on MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews was undertaken. After full-text review, 23 articles met our criteria. Any mentions of nerve injury, including references to a lack of nerve injury, were documented. All data were pooled for analysis. From our combined data, we calculated the risks of postabdominoplasty nerve injury by dividing the total number of nerve injuries by the total number of patients. RESULTS: Pooled data showed that 1.94% of patients sustained specific nerve injury, and 1.02% of patients sustained permanent injury after abdominoplasty. In addition, 7.67% experienced decreased sensation, 1.07% reported chronic pain, and 0.44% reported temporary weakness or paralysis. Nerves directly injured were the lateral femoral cutaneous (1.36% of patients) and iliohypogastric (0.10%) nerves. Nerves injured from surgical positioning were the brachial plexus (0.10%), musculocutaneous (0.10%), radial (0.05%), sciatic (0.19%), and common peroneal (0.05%) nerves. CONCLUSIONS: Although our results showed a low incidence of postabdominoplasty nerve injury, the lasting impact on affected patients' quality of life can be significant. Appropriate and timely treatment by a multidisciplinary team is critical to optimize patient outcomes. Better reporting of nerve injuries in future studies of abdominoplasty will provide more accurate information about the incidence and consequences of these injuries. LEVEL OF EVIDENCE: 4.

Correlating patient-reported outcomes and ambulation success following microsurgical lower extremity reconstruction in comorbid patients.

INTRODUCTION: Microsurgical lower extremity flap reconstruction provides a valuable option for soft tissue reconstruction in comorbid patients. Limb salvage with flap reconstruction can result in limb length preservation. Despite this, few studies have examined the impact of salvage on patient-centered metrics in this cohort of patients. Therefore, we investigated quality of life and patient satisfaction following microsurgical lower extremity reconstruction in this high-risk patient population. Factors that resulted in improved patient-centered outcomes were also identified. METHODS: A retrospective review was conducted of all patients who had lower extremity free flap reconstruction (FFR) following lower extremity wounds. High-risk patients were identified as having multiple comorbidities and chronic wounds. Patients with traumatic wounds were excluded from analysis. Quality of life was evaluated with the Short Form-12 (SF-12) validated survey. Phone interviews were conducted for survey evaluations. RESULTS: From 2005 to 2010, 57 patients had lower extremity flap reconstruction that met the inclusion criteria. Average follow-up was 236.6 weeks (range, 111-461). Comorbidities included diabetes (36%), PVD (24.6%), and ESRD (7%). Limb length preservation and ambulation occurred in 82.5% (47/57). Revisional surgery occurred in 33.3% (19/57). Survey response rate was 63%. Average SF-12 PCS and MCS scores were 44.9 and 59.8 for patients able to achieve ambulation and 27.6 and 61.2 for nonambulatory patients. CONCLUSIONS: Microsurgical flap reconstruction is a valuable reconstructive option in high-risk patients. Quality of life is comparable with a normalized population if limb salvage is successful. Quality of life is decreased significantly when failure to ambulate occurs in this patient cohort.

Greater occipital nerve excision for occipital neuralgia refractory to nerve decompression.

BACKGROUND: Patients who undergo occipital nerve decompression for treatment of migraine headaches due to occipital neuralgia have already exhausted medical options for treatment. When surgical decompression fails, it is unknown how best to help these patients. We examine our experience performing greater occipital nerve (GON) excision for pain relief in this select, refractory group of patients. METHODS: A retrospective chart review supplemented by a follow-up survey was performed on all patients under the care of the senior author who had undergone GON excision after failing occipital nerve decompression. Headache severity was measured by the migraine headache index (MHI) and disability by the migraine disability assessment. Success rate was considered the percentage of patients who experienced a 50% or greater reduction in MHI at final follow-up. RESULTS: Seventy-one of 108 patients responded to the follow-up survey and were included in the study. Average follow-up was 33 months. The success rate of surgery was 70.4%; 41% of patients showed a 90% or greater decrease in MHI. The MHI changed, on average, from 146 to 49, for an average reduction of 63% (P < 0.001). Migraine disability assessment scores decreased by an average of 49% (P < 0.001). Multivariate analysis revealed that a diagnosis of cervicogenic headache was associated with failure of surgery. The most common adverse effect was bothersome numbness or hypersensitivity in the denervated area, occurring in up to 31% of patients. CONCLUSIONS: Excision of the GON is a valid option for pain relief in patients with occipital headaches refractory to both medical treatment and surgical decompression. Potential risks include failure in patients with cervicogenic headache and hypersensitivity of the denervated area. To provide the best outcome to these patients who have failed all previous medical and surgical treatments, a multidisciplinary team approach remains critical.