Nerve surgery

Nerve surgery

Posted by AskNurseLinda on Jan 22, 2018 11:09 am

b7cb40d67ddad00542d4cbd7097ae2d0-huge-isThe decision to have any type of surgery is never one that should be made in haste. Sometime, emergencies happen so the decision is quickly made for you or one that has no other option. However, planned or elective surgeries should be carefully considered.

When you have a chronic condition, you want to make arrangements ahead of time for your personal care. If you have paralysis especially, spinal cord injury, you will want to meet with the nurse manager of the area where you will recover. At a minimum, express your needs for your skin, bowel, bladder and how you safely swallow. Any special concerns should be brought up and a plan written so you and the staff have a copy.

You might even want to include special needs such as care for a helper pet or other unique considerations. These specialty items may or may not be possible but you can ask. Some facilities will be able to accommodate your requests and others not. Do not ask for things that you normally do not have at home. Asking for a shower or weighing you might be something that you can have at a facility that is not available at home but asking for a 4 star dining experience is over the top in expectations.

There are many reasons to have elective surgery. Individuals with spinal cord injury might want procedures to help them with activities of daily living. One type of surgery that is coming into possibility is specialty nerve surgery. This type of surgery was not possible years ago but started to grow in potential over the years. You will be hearing more and more about this type of surgery in the future as techniques become refined and options available.

The study of nerves has become more refined in understanding. There is still a long way to go but there are many surgeries now evolving. At the start of my career, nerve surgery was just beginning with variable results. Now, actual nerves are mapped, within the nerve as well as how the nerve is controlled by the brain.

Nerve function is better understood by mapping the brain for function. Pioneers in this discovery include Christopher Reeve who took on extensive therapy to restore function. He then had a functional MRI which is a MRI where movement is performed during the procedure. The results indicated that due to his enhanced movement (including all parts of his body, but not against gravity) different parts of his brain were taking control of the activity. This was previously thought impossible. However, a vast collection of similar results are being reported.

Initially, nerves were likened to a ponytail. Cut the pony tail off or even partially cut it and you knew they hairs would not reattach. Then it was thought that you could reattach the nerves but each nerve fiber had to go back to the original fiber or each hair of the ponytail had to be reattached to the original hair. Now, it is clear that other nerves will connect or transfer information to working nerves to make a connection within the brain. This is pretty outstanding. You just need to make a connection or enhance the connection, not a reconnection. The body, including the nervous system, attempts to heal itself. This is going on inside your body right now.

Surgery of structures surrounding peripheral nerves have been the majority performed. These include releasing nerves that are in too tight of areas. Most familiar are carpel tunnel releases at the wrist, and other releases at the elbow, shoulder area and in several locations in the leg. The peripheral nerves travel through ‘tunnels’ of tissue to keep them protected and in line to their ultimate endpoint. Sometimes, these ‘tunnels’ become too tight and pinch the nerve. A little release of the tunnel tissue allows the nerve to pass through more easily.

Sometimes, peripheral nerves that are damaged can be re-grafted together. This is a very delicate and precise operation. Other options for peripheral nerves include transfers and even splitting of a functioning nerve to a nerve that has been damaged. The body is much like the functioning of a computer. With a computer, there is always two ways to perform the same activity. Nerves can act in the same way, moving one nerve perform the function of another.

Peripheral nerve transfers have been performed with great success. Typically, these are very specific for certain functional activities especially arm and hand movement. Nerves can be relocated to provide function where none or very minimal was existing. The rule for regeneration is the same, one inch per month so the recovery can take some time. Generally, improving function, even though not the same as pre-paralysis is welcomed.

There are studies that are being conducted to assess peripheral nerve transfers from one person to another. Although this surgery is similar to nerve transfers within a person, the transfer from another person produces a particular difficulty. When tissue from one person is placed in another, rejection is a factor. This is the same with a kidney transplant, heart or lung transplant. Since individuals with spinal cord injury can have immunosuppression issues, nerve transplants can include serious rejection issues. Researchers are actively searching for solutions to the rejection issues.

When peripheral nerves are surgically repaired, they will regenerate at a rate of one inch per month. This can be a long recovery time. If you think about a repaired peripheral nerve in the wrist, the time to recovery would be 7-10 months as it is that distance in inches from the wrist to the tip of the long finger. If you can imagine peripheral nerve repair in the lower back, recovery would be 36-48 months or 3 to 4 years for complete regeneration of that nerve from the lower back to the toe.

Surgery of the central nervous system includes surrounding structures, not directly to the nerves at this time. This can include removal or de-bulking of a tumor or removal of a blood from hemorrhage. This decompression of the area reduces the obstruction on the central nerves allowing messages to get through to their target.

Other considerations for nerve surgery include if the nerves are upper motor neurons (UMN) or lower motor neuron. Both have considerations for enhancing function. Currently, lower motor neurons have more opportunity for surgical repair since they are outside of the central nervous system, in the peripheral nervous system’s domain.

One surgery that has been used is in the cauda equina or the ‘horse’s tail’. These are the nerves that exit at the very end of the spinal cord, becoming peripheral nerves. In pediatrics, a very extensive evaluation of the functional ability of these nerves are directly evaluated, one by one, during surgery. Nerves that lead to spasticity as in cerebral palsy are very sparingly affected. Non affected nerves are left as is. The reduction in spasticity will result in an improved gait and abilities.

This technique is being explored by researchers for other improvements in function in adults with paralysis. Sometime, electrodes can be placed directly on nerves to improve bowel, bladder and sexual function, especially in men. As research becomes more developed, this type of surgery will become more available for all individuals.

The Christopher & Dana Reeve Foundation is a supporter of electrical stimulation for improvements in function. The Big Idea is a study of implantation of electrodes directly into the spine or actually, on the spinal nerves. The first round of implants have demonstrated dramatic results. The next study should produce more ideas and significance.

As more and more studies are carried out both within the peripheral nervous system and with creativity of the Big Idea, techniques for surgery to improve function after paralysis will be growing. These solutions are approaching quickly, not some mystical time in the future but advances are gigantic today.

Nurse LindaI'm online in this community every Wednesday from 8-9 PM ET to answer your SCI and paralysis related questions.

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