Neuropathic pain may be a result of focal injury to a peripheral nerve. The treatment algorithm begins with nonoperative, then operative, options. In our practice, first-line surgical treatment should directly treat the injured nerve. Nerve decompression or neurolysis is useful in patients with entrapment syndromes and in cases where the course and/or the function of the nerve is altered by local scar or pathoanatomy. Neurectomy is an option in primary cases where numbness is an acceptable alternative to dysesthetic pain, or as an alternative following failed neurolysis. Nerve repair or reconstruction may improve pain by guiding axons past the neuroma.
Key points
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Careful examination, including detailed sensory and motor findings and the presence of percussion tenderness, assists in the localization of nerve injury and the potential site of intervention.
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In our experience, the presence of at least 3 supportive features (history, physical examination, electrophysiologic studies, imaging findings, and diagnostic blocks) should support the diagnosis of neuropathic pain before operative intervention is considered.
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Nerve-related procedures, including neurolysis/decompression, neurectomy, and nerve repair/reconstruction, are considered first-line interventions.
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Nerve decompression/neurolysis should be considered in the setting of entrapment or significant scarring that may impair nerve transmission and cause pain.
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Neurectomy can be considered for sensory nerves when numbness is an acceptable trade-off for painful dysesthesias, or after failed neurolysis of a sensory nerve.
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Nerve repair/reconstruction is generally performed with the goal of regaining motor function but also plays a role in improving neuropathic pain by directing axons past the neuroma.
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