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  • December 29, 2021

    By Clayton Dean, MD

    Historically, patients who needed spine surgery could expect a long recovery process, often with a week-long hospital stay. Today, Enhanced Recovery After Surgery (ERAS) protocols are helping patients return to work and life faster and with better outcomes. For patients who are healthy and motivated to take an active role in their care, ERAS protocols offer many advantages over traditional spine surgery recovery, including:

    • Fewer complications
    • Shorter hospital stays (and sometimes no hospital stay)
    • Less pain during and after surgery
    • More positive patient experiences
    • Better long-term results

    ERAS protocols are evidence-based, meaning they've been peer-reviewed and proven successful in real-life surgeries. While the "fast-track" recovery strategies aren't new to orthopedic surgery, they've only recently been applied to spinal surgery under the care of experienced teams trained to implement modern ERAS principles. Teamwork is critical to expedited recovery, requiring collaboration between the patient and specialists across different disciplines before, during, and after the procedure.

     

    Patients play a critical role in enhancing spine surgery recovery.

    Under ERAS protocols for spine surgery, your recovery plan begins before you even step foot in the operating room. At MedStar Orthopaedic Institute in Baltimore, we provide every patient with preoperative education and counseling designed to educate the patient on what to expect. Many patients share that going through the program helps them to feel equipped to be active participants in the healing process.


    Patients are also asked to participate in pre-surgery rehabilitation, or prehab. The prehab program improves the body's overall strength and function before surgery, allowing you to return to resume activity faster and more easily afterward. Every patient also benefits from a virtual consultation with our acute pain service. During the telemedicine visit, patients are asked about any current medications as well as their pain tolerance and goals. This information helps your care team anticipate your needs on the day of and the weeks after surgery.

    Modifying lifestyle habits before spine surgery can also lead to an expedited recovery, and patients are encouraged to:

    • Optimize their nutrition
    • Achieve a healthy body mass index (BMI)
    • Minimize or eliminate opioid, alcohol, and nicotine use

    Patients don't have to make these changes alone, as each patient is matched to a care coordinator who will help you navigate your surgical preparation and recovery. Our care coordinators are specially-trained healthcare professionals who work closely with your physician and care team to help you return to your active life as seamlessly as possible. Together, you'll develop a plan for rehabilitation that will help you reach your goals after surgery. 

     

    During surgery, your multidisciplinary team proactively manages pain and the risk of complications.

    A lot has changed when it comes to back surgery. Traditionally, patients were required to fast before undergoing an operation on the spine. Now, evidence proves that food and drink help to prevent your gastrointestinal system from shutting down during a procedure. Your care team will give you instructions for when you should stop eating and drinking before arriving at pre-op. In general, most patients are able to drink clear liquids up to two hours before surgery and solids up to six hours beforehand. Some patients benefit from a carb-loaded drink given once they arrive for surgery.


    There will be a team of medical professionals invested in your surgery, including your surgeon, an anesthesiologist, nurses, physical and occupational therapists, and counselors. When you arrive for your procedure, you'll meet with an anesthesiologist or nurse who will give you analgesics to help manage your pain and your body's stress response before you go into surgery. Whether you're having spinal fusion surgery or another type, back or neck surgery is major surgery that puts stress on the body. By using a combination of oral pain medication like Tylenol, non-steroidal anti-inflammatory drugs, and Gabapentin before the procedure begins, you're less likely to need opioid medications after surgery.

    During surgery, your surgeon and anesthesiologist work together to minimize blood loss that could lead to anemia. You'll also receive a regional or local anesthetic (pain medication injections) directly to the surgical site, which helps to control pain during the procedure. This multimodal approach to pain control results in earlier mobility, less pain, and minimized need for narcotics to manage pain following surgery. And, unlike other surgical procedures, most patients don't need a catheter, eliminating your risk of developing a urinary tract infection (UTI).

     

    Contemporary strategies for post-operative care significantly reduce nausea and vomiting, thereby speeding up recovery.

    In the past, patients weren't allowed to eat or drink until a day after surgery which meant that their gastrointestinal function was at risk for a partial or complete shutdown. As a result, nearly 50 percent of patients experienced nausea and vomiting that led to a prolonged hospital stay and recovery.


    ERAS principles after surgery encourage patients to eat and drink early, which helps to expedite the return of gastrointestinal function. In combination with other strategies, this helps to minimize nausea and vomiting and speeds up recovery because you can regain strength more quickly with good nutrition. Your anesthesiologist will continue to help control your pain using the same multimodal approach applied during surgery. Research suggests that patients who participated in ERAS protocols were dramatically less likely to need pain medicine one month after surgery.


    #SpineSurgery patients who participate in advanced recovery protocols are dramatically less likely to need pain meds one month after surgery. Spine surgeon Dr. Clayton Dean shares why: https://bit.ly/3qBkd1o.
    Click to Tweet
     

    You can also expect to get moving around as early as possible with the help of a physical therapist. Early mobilization helps to minimize muscle weakness and increase circulation in the legs, lowering your risk of blood clots following surgery. We know that most patients actually recover better at home, and you can expect a shorter hospital stay—or even no hospital stay, in some instances.

     

    Expedited recovery is well-suited for healthy people planning elective back surgery.

    Patients who are healthy, have a strong support system, and are willing to engage in the educational program and preparation beforehand are great candidates for an expedited recovery following spine surgery. Most often, ERAS principles are applied to elective surgeries, such as treating a herniated disc. Not all surgeons and surgical centers are well-versed in implementing ERAS protocols, so it's important to ask your care provider. At MedStar Orthopaedic Institute, our team is at the forefront of advanced protocols, technology, and that help you safely get back in action faster and with less pain.


    When it comes to spine surgery, experience matters.

    To meet with Dr. Dean, call 410-877-8172 or click below.

    Request an Appointment

All Blogs

  • December 29, 2021

    By Clayton Dean, MD

    Historically, patients who needed spine surgery could expect a long recovery process, often with a week-long hospital stay. Today, Enhanced Recovery After Surgery (ERAS) protocols are helping patients return to work and life faster and with better outcomes. For patients who are healthy and motivated to take an active role in their care, ERAS protocols offer many advantages over traditional spine surgery recovery, including:

    • Fewer complications
    • Shorter hospital stays (and sometimes no hospital stay)
    • Less pain during and after surgery
    • More positive patient experiences
    • Better long-term results

    ERAS protocols are evidence-based, meaning they've been peer-reviewed and proven successful in real-life surgeries. While the "fast-track" recovery strategies aren't new to orthopedic surgery, they've only recently been applied to spinal surgery under the care of experienced teams trained to implement modern ERAS principles. Teamwork is critical to expedited recovery, requiring collaboration between the patient and specialists across different disciplines before, during, and after the procedure.

     

    Patients play a critical role in enhancing spine surgery recovery.

    Under ERAS protocols for spine surgery, your recovery plan begins before you even step foot in the operating room. At MedStar Orthopaedic Institute in Baltimore, we provide every patient with preoperative education and counseling designed to educate the patient on what to expect. Many patients share that going through the program helps them to feel equipped to be active participants in the healing process.


    Patients are also asked to participate in pre-surgery rehabilitation, or prehab. The prehab program improves the body's overall strength and function before surgery, allowing you to return to resume activity faster and more easily afterward. Every patient also benefits from a virtual consultation with our acute pain service. During the telemedicine visit, patients are asked about any current medications as well as their pain tolerance and goals. This information helps your care team anticipate your needs on the day of and the weeks after surgery.

    Modifying lifestyle habits before spine surgery can also lead to an expedited recovery, and patients are encouraged to:

    • Optimize their nutrition
    • Achieve a healthy body mass index (BMI)
    • Minimize or eliminate opioid, alcohol, and nicotine use

    Patients don't have to make these changes alone, as each patient is matched to a care coordinator who will help you navigate your surgical preparation and recovery. Our care coordinators are specially-trained healthcare professionals who work closely with your physician and care team to help you return to your active life as seamlessly as possible. Together, you'll develop a plan for rehabilitation that will help you reach your goals after surgery. 

     

    During surgery, your multidisciplinary team proactively manages pain and the risk of complications.

    A lot has changed when it comes to back surgery. Traditionally, patients were required to fast before undergoing an operation on the spine. Now, evidence proves that food and drink help to prevent your gastrointestinal system from shutting down during a procedure. Your care team will give you instructions for when you should stop eating and drinking before arriving at pre-op. In general, most patients are able to drink clear liquids up to two hours before surgery and solids up to six hours beforehand. Some patients benefit from a carb-loaded drink given once they arrive for surgery.


    There will be a team of medical professionals invested in your surgery, including your surgeon, an anesthesiologist, nurses, physical and occupational therapists, and counselors. When you arrive for your procedure, you'll meet with an anesthesiologist or nurse who will give you analgesics to help manage your pain and your body's stress response before you go into surgery. Whether you're having spinal fusion surgery or another type, back or neck surgery is major surgery that puts stress on the body. By using a combination of oral pain medication like Tylenol, non-steroidal anti-inflammatory drugs, and Gabapentin before the procedure begins, you're less likely to need opioid medications after surgery.

    During surgery, your surgeon and anesthesiologist work together to minimize blood loss that could lead to anemia. You'll also receive a regional or local anesthetic (pain medication injections) directly to the surgical site, which helps to control pain during the procedure. This multimodal approach to pain control results in earlier mobility, less pain, and minimized need for narcotics to manage pain following surgery. And, unlike other surgical procedures, most patients don't need a catheter, eliminating your risk of developing a urinary tract infection (UTI).

     

    Contemporary strategies for post-operative care significantly reduce nausea and vomiting, thereby speeding up recovery.

    In the past, patients weren't allowed to eat or drink until a day after surgery which meant that their gastrointestinal function was at risk for a partial or complete shutdown. As a result, nearly 50 percent of patients experienced nausea and vomiting that led to a prolonged hospital stay and recovery.


    ERAS principles after surgery encourage patients to eat and drink early, which helps to expedite the return of gastrointestinal function. In combination with other strategies, this helps to minimize nausea and vomiting and speeds up recovery because you can regain strength more quickly with good nutrition. Your anesthesiologist will continue to help control your pain using the same multimodal approach applied during surgery. Research suggests that patients who participated in ERAS protocols were dramatically less likely to need pain medicine one month after surgery.


    #SpineSurgery patients who participate in advanced recovery protocols are dramatically less likely to need pain meds one month after surgery. Spine surgeon Dr. Clayton Dean shares why: https://bit.ly/3qBkd1o.
    Click to Tweet
     

    You can also expect to get moving around as early as possible with the help of a physical therapist. Early mobilization helps to minimize muscle weakness and increase circulation in the legs, lowering your risk of blood clots following surgery. We know that most patients actually recover better at home, and you can expect a shorter hospital stay—or even no hospital stay, in some instances.

     

    Expedited recovery is well-suited for healthy people planning elective back surgery.

    Patients who are healthy, have a strong support system, and are willing to engage in the educational program and preparation beforehand are great candidates for an expedited recovery following spine surgery. Most often, ERAS principles are applied to elective surgeries, such as treating a herniated disc. Not all surgeons and surgical centers are well-versed in implementing ERAS protocols, so it's important to ask your care provider. At MedStar Orthopaedic Institute, our team is at the forefront of advanced protocols, technology, and that help you safely get back in action faster and with less pain.


    When it comes to spine surgery, experience matters.

    To meet with Dr. Dean, call 410-877-8172 or click below.

    Request an Appointment

  • December 17, 2021

    By Kurtis Bertram, DPM

    Physical activity during every stage of life can help protect and maintain your overall health. But as your age increases, so does your risk of exercise-related injuries—such as a ruptured Achilles tendon.

     

    The Achilles tendon connects the heel to the calf. You use it to walk, run, and jump, so it’s constantly under pressure. Over time, this pressure can cause the tendon to become irritated or tear.


    A tear in the Achilles tendon (also known as a rupture or snap) is one of the most common Achilles injuries, occurring in about
    18 of every 100,000 patients. It typically occurs in men over 30 and continues to increase in patients age 40-59 for two main reasons:

    • Muscles and tendons stiffen with age, making them more likely to snap when stretched.
    • Patients in this age group tend to be “weekend warriors”: people who may not exercise as much during the week and then take part in recreational activities on weekends. This pattern can lead to foot and ankle pain, including Achilles tendon injuries.

    Minimally invasive surgery is the best option for patients who are in good health and want to get back in action as soon as possible after an Achilles tendon rupture. 


    However, before moving forward with treatment for any type of Achilles tendon injury, it’s important to understand why the injury occurred and how different treatment options and behavioral changes can prevent it from happening again.

    Identifying Achilles tendon injuries.

    Achilles tendon injuries are categorized as acute or chronic.

    Acute injuries include:

    • Rupture: the result of overuse and the lack of a proper warmup before exercise. It often occurs during sports such as soccer, basketball, volleyball, and softball. When a patient pushes their foot off the ground, they feel a snap as if someone stepped on or threw a ball at the back of their leg.

    • Tendonitis: inflammation that occurs when patients ramp up their exercise too quickly. It can cause ongoing pain and swelling in the heel, ankle, and back of the leg.

    Chronic injuries include:

    • Haglund’s deformity: a painful bump that forms on the back of the heel and rubs against the Achilles tendon. It can be caused by a tight Achilles tendon, shoes that are too tight in the heel, or constant walking on the outside of the heel.
    • Heel spur: a pointy calcium buildup on the back of the heel that can cause the Achilles tendon to become more inflamed and harden. It can also be caused by tight shoes and constant pressure on the heel bone.
    • Tendinosis: tendon damage that occurs when tendonitis is not treated. It causes the Achilles tendon to become hard and rubbery.

    To diagnose your injury, your doctor will physically examine your foot and ankle and ask you to demonstrate your range of motion. Then, they’ll perform imaging tests to look for damage in your Achilles tendon. 


    Full recovery from an Achilles injury usually takes six to 12 months, regardless of the treatment method. However, the speed at which patients can rebuild strength during this time depends on the type of injury and treatment they have, as well as their personal fitness goals.


    Your weekend basketball games could lead to a torn #AchillesTendon. Learn why minimally invasive surgery may be the best way to get back on the court: https://bit.ly/3maGJwL.
    Click to Tweet

     

    The benefits of minimally invasive surgery.

    Ruptures are often treated surgically in patients who are healthy and want to return to their former level of activity. Some studies have shown that surgical treatment can decrease the risk of a re-rupture more than nonsurgical treatment. 

    I often recommend minimally invasive surgery for a faster, less painful recovery.

    Minimally invasive repair allows the patient to start putting weight on their injured foot sooner than they would with open surgery or nonsurgical care. And the sooner their foot can handle weight, the faster they can start physical therapy and work on getting stronger; early weight bearing leads to better health and strength after six months.

    During traditional open surgery, the surgeon makes a 12-cm incision on the back of the leg to access and repair the Achilles tendon. Minimally invasive techniques allow the surgeon to make a 3-cm incision over the Achilles tendon and two smaller incisions at the back of the heel to reattach the tendon to the heel bone.

    Smaller incisions result in:
    • Easier wound care 
    • Lower risk of blood loss, scarring, and infection 
    • Shorter recovery

    Patients leave the hospital with a cast or boot the same day they have surgery. After a week or so, l check on their pain level and discuss how they feel about putting weight on their injured foot. If they’re ready, I guide them through basic physical therapy exercises to prepare them for more strength building. 


    Once we both feel confident about moving forward, I connect them with one of our physical therapists, who customize treatment plans to each patient’s overall health and lifestyle.

    Alternative treatments, from casting to tendon lengthening.

    Nonsurgical treatment for ruptures and all other types of Achilles injuries are recommended for older and less active patients. It typically requires a cast or boot to ensure proper rest for four to 12 weeks; timing depends on how severe the injury is. Ice and over-the-counter pain medications can be used as needed.

     

    Once the patient can put weight on the injured foot, they begin physical therapy to strengthen and stretch the tendon and surrounding muscles. To avoid reinjury, they may need to permanently modify or avoid certain activities.

      

    If a chronic injury is severe, surgery may be an option to:

    • Transfer another tendon to the area to assist with foot push-off.
    • Remove the damaged portion of the tendon.
    • Lengthen the tendon—ongoing stress can cause it to shorten.

    While you can still walk or even run after an Achilles injury, putting off treatment will only make the injury worse. Seek care immediately to lessen the damage and shorten your road to recovery.


    Practical prevention tips.

    At the start of the COVID-19 pandemic, I saw an increase in Achilles injuries. Patients were antsy to get outside, and they started hiking, running, and walking long distances without ramping up appropriately. 


    Taking certain precautions can decrease the risk of injury:

    • Before any form of exercise, warm up for at least five to 10 minutes with a quick walk or jog, in addition to dynamic stretches such as lunges and high-knee skips.
    • Wear athletic shoes that fit.
    • Slowly increase the intensity of your workouts. For example, if you regularly run three miles at a time, don’t suddenly start running five or more; increase your distance no more than 10% each week. 
    • Try different workouts. Repeating the same motion over and over again leads to more pressure on the Achilles tendon. Mix activities that require running with walking, biking, swimming, or yoga.
    • Always stretch after exercising and pay extra attention to calf muscles. Tight calves can increase pressure on the tendon.

    Even the most disciplined athletes can suffer from Achilles tendon injuries. We collaborate with other specialists, from primary care providers to physical therapists, to ensure patients get the personalized care they need to get back to their favorite activities.


    Get back in the game with personalized Achilles tendon treatment.

    Schedule an appointment with a foot and ankle specialist today.

    Call 202-877-DOCS (3627) or Request an Appointment

  • November 12, 2021

    By Nicholas Samuel Streicher, MD, MPH

    Chronic traumatic encephalopathy (CTE) is increasingly in the news—often in connection to severe mood and behavior changes in former athletes. You may be asking the same question as many people within and outside of the scientific community: Why?


    Like Alzheimer’s and Parkinson's disease, CTE is a neurodegenerative condition. This brain disease occurs when the nerve cells that help you think, feel, and move gradually break down. When these cells stop working, patients may experience personality changes and lose memory and muscle control. 


    Unique to CTE is what appears to cause this cell breakdown: recurring head trauma, compounded by age and genetics. Because of these factors, older athletes and veterans are more at risk.


    Our medical understanding of CTE has come a long way, but we have a lot to learn. Currently, CTE can only be diagnosed after death. As we study its symptoms and causes, our goal is to diagnose the disease in living patients and develop treatment options and more effective preventive strategies.


    The concussion link.

    Research continues to show that recurring concussions, in addition to blows to the head that don’t result in a concussion, can lead to neurodegeneration over time. These injuries are commonly sustained during contact sports such as football, boxing, soccer, and hockey, and military service, as soldiers are often exposed to multiple explosions.

    A 2017 study examined 111 brains from former NFL players and found evidence of CTE in 99% of them. Two years later, after studying more brains of former amateur and professional football players, researchers determined that for every 2.6 years of heavy contact sport play, the risk of CTE doubles. The cumulative effect of continuous head injuries throughout several years of play is what contributes to the deterioration of nerve cells.

     

    Less CTE-specific data exists for veterans, as symptoms are similar to those of post-traumatic stress disorder, a primary area of study. However, CTE continues to be found in veterans’ brains and the Defense and Veterans Brain Injury Center reported almost 414,000 traumatic brain injuries in U.S. service members between 2000 and 2019. The Department of Veterans Affairs is dedicating more research to the long-term impact of these injuries.

     

    CTE symptoms: Development and detection.

    CTE is characterized by four stages of symptoms:

    • Stage 1: Short-term memory loss; mild aggression and depression; headaches.
    • Stage 2: Severe depression, outbursts, and mood swings.
    • Stage 3: Aggression; apathy; memory loss; lack of spatial awareness; executive dysfunction (inability to successfully complete activities that require time management, organization, and problem-solving).
    • Stage 4: More severe Stage 3 symptoms; paranoia; difficulty with language and muscle movement.

    Symptoms occur when the nerve cells that control specific functions are damaged. Nerve cells use complex networks within the brain to send signals to each other to initiate different behaviors, thoughts, and actions. The damage caused by a concussion prevents some of these cells from sending signals and alters the structure of a protein within the cells called tau. 

     

    When tau proteins change shape, they detach from the cells and start moving along the brain’s networks, forcing other cells to stop functioning and causing more tau to break free and build up. Every form of neurodegeneration is like taking the yellow line or the red line on the subway; an abnormal protein gets a “ticket” to a particular brain network, and wherever it starts and stops determines a patient’s symptoms and disease course.

     

    All neurodegenerative diseases function this way—the difference is the pathway they follow. Think of starting at the Bethesda Metro stop and going to Union Station vs. starting at Shady Grove and going to Bethesda; it's the same red line, but you get there differently. Depending on the cells damaged by a disease’s pathway, some patients’ cognitive functions are heavily disrupted, while others experience more movement difficulties—and if it’s the same “line” or type of neurodegeneration, may end up with the same set of symptoms in the end.


    Neurons within the brain’s visual processing and coordination network are often damaged when a concussion occurs, which is why many people experience symptoms such as dizziness and vertigo in addition to cognitive dysfunction such as memory loss.
    Repetitive injury over time and evaluating the ‘pathway’ of a patient’s symptoms help us find patterns that match the stages of CTE and distinguish it from other conditions.

    Recurring #concussions can cause CTE, a #neurodegenerative disease that spreads through the brain in the same way you ride the train. Learn how it affects mood and movement over time: https://bit.ly/3o9G0Mt.
    Click to Tweet
     

    Aging and genetics can increase the risk of CTE.

    A key reason we see higher rates of neurodegeneration in older populations is because aging is a long, slow neurodegenerative process. It’s natural “wear and tear” on the brain. My 99-year-old grandmother, for example, does not have dementia but she can’t remember things as well as she did 20 years ago—however, she recalls the 1920s perfectly. 


    Not everyone who experiences recurring brain trauma develops CTE, so genetics are likely another factor. Research is underway to identify genes that increase a patient’s risk of CTE in the same way that the APOE-e4 gene increases the risk of Alzheimer’s disease; the same gene may also increase the risk of CTE.


    Humans are living longer than ever before, but natural selection hasn’t caught up with today’s average life expectancy. Gene variants that could protect against age-related diseases aren’t typically passed on because there hasn’t been a need until relatively recently, in respect to longevity. 


    A collaborative approach to cognitive care.

    Managing emotions can be difficult at any age. It gets even harder when concussions continually disrupt the networks your brain uses to help you control them—especially later in life when you’re living with more challenges.


    We can’t completely avoid the risk of concussion, but we can minimize it through safer sports equipment and practices, educating more people about the long-term effects of concussions, and providing exceptional concussion recovery care.


    A multidisciplinary approach is critical. With physical and occupational therapists, social workers, psychologists, and neurologists working together as a team, we have a better chance of catching early warning signs such as mood and memory changes.


    Neuropsychological testing is one of the best ways to assess brain function and help us understand which brain networks are being affected by cell degeneration. It evaluates everything from reasoning and reading to problem-solving and personality shifts. 


    Future goals: Biomarkers and better brain imaging.

    Several studies are looking to develop effective testing methods based on biomarkers such as spinal fluid and blood. Some research has found that people who have concussion damage have higher levels of certain proteins in their blood: tau, neurofilament light, and glial fibrillary acidic protein. Developing standard tests for these protein levels could help us detect CTE in living patients.


    Stronger imaging is important as well; if we had the ability to see a buildup of tau protein forming in a patient’s brain in a pattern reflecting the stages of CTE, we could prevent further cell breakdown that would push them into later stages of CTE. 


    As interest in CTE grows, so does our understanding. But until we develop the necessary tests and tools, it’s important to seek care that is already available and improving patients’ quality of life, from customized concussion treatments to neurological exams.



    Has a traumatic brain injury affected your quality of life?

    From mood swings to muscle coordination, our multidisciplinary neurology team treats specific symptoms with individualized plans.

    Call 202-877-DOCS (3627) or Request an Appointment

  • November 05, 2021

    By Kerry Strom, RD, LDN, Dietitian Educator at MedStar Franklin Square Medical Center

    Approximately 10% of the general population may experience chronic pain caused by nerve damage. Most of the patients referred to our plastic surgery clinic for nerve pain are seeking relief from peripheral nerve damage, which can affect any nerves outside the central nervous system (the brain and spinal column). 


    Nearly 90% of patients with peripheral nerve damage can experience the following symptoms in their limbs, hands, or feet:

    • Tingling
    • Numbness
    • Burning pain
    • Hypersensitivity
    • Weakness

    Peripheral nerve damage can be caused by a range of factors outside a patient’s control—including treatments for other health conditions. Many patients struggle with nerve pain after recovering from:

    • Injury: This can include fractures or sprains. Often, we treat brachial plexus injuries, in which an arm is severely stretched or pulled in a vehicle accident, contact collision, or knife or gunshot wound.
    • Disease: Infections, nutritional imbalances, diabetes, and medications such as chemotherapy can temporarily or permanently damage nerves. 
    • Surgery: A nerve may be damaged or irritated during major—yet fine—surgeries such as a hand or foot fracture repair, joint replacement, or mastectomy.

    Some patients try medication or physical therapy with limited improvement before visiting me for other options. Many are worried they’ll have to have surgery to relieve the pain. Surgery should be a last resort—but when no better options exist, improvement can be significant. 

     

    Most patients benefit from less invasive therapies that can significantly reduce peripheral pain and improve quality of life. However, nerve surgery may be the best option if we can narrow down the source of pain to one specific nerve or small set of nerves.

     

    ‘Try it before you buy it’: How nerve blocks help determine treatment options.

    A damaged nerve is only one potential reason a patient might have chronic pain or other nerve symptoms. If the pain is in just one or two fingers, for example, or one part of your foot, it’s likely due to one damaged nerve. If it’s spread across a larger area, it could be due to several nerves or other tissues.

     

    The best diagnostic tool for peripheral nerve pain is a temporary, ultrasound-guided nerve block, which numbs the nerve we think is causing the pain. Using ultrasound imaging, we inject local anesthetic around a specific nerve that we believe may be the cause of a patient’s pain, which should numb any pain the damaged nerve is causing for four to six hours. 


    The pain relief you experience from a nerve block is similar to what you would experience after a nerve surgery. If you still feel the same amount of pain, that nerve is not the cause of the pain, and nerve surgery will not relieve your pain. However, if you feel temporary pain relief after the injection, we can attribute the pain to that nerve, and surgery might be an option.

     

    Chronic #NervePain may not be your first thought when you hear #PlasticSurgery. But if lasting peripheral nerve pain doesn’t improve with medication or physical therapy, 3 types of #ReconstructiveSurgery may reduce pain: https://bit.ly/3bETx92.
    Click to Tweet
     

    The three ‘Rs’ of peripheral nerve surgery: Release, repair, removal.

    A successful nerve surgery typically provides significant but not total relief. We consider more than 50% improvement to be successful. Depending on the type of nerve damage, we’ll perform one of three surgeries:

    • Releasing a compressed (or “pinched”) nerve: If your nerve pain starts a few weeks or months after a surgery, it’s likely because a nerve is being compressed by scar tissue that built up as your body healed. During a procedure called neurolysis, we release the nerve from this pressure by removing the excess scar tissue. You will need to perform specific movements and stretches on a regular basis to improve the nerve’s range of motion and prevent further scarring.
    • Repairing a damaged nerve: If your pain starts almost immediately after an operation, a nerve might have been severed or damaged. Our first step is to repair the nerve by sewing the severed ends back together. If the ends are too frayed to be reconnected, we may be able to perform a nerve transfer. That means we connect the damaged nerve to a nearby functioning one. You can think of a cut nerve as a frayed cord with exposed live wire that must be reconnected to restore the “circuit” between the nerve and brain. Once a nerve is repaired and functioning more normally, its fibers will grow back within six months to a year.
    • Removing a damaged nerve: If your nerve is too damaged to be repaired, we can remove it to prevent the nerve from sending pain signals to your brain. However, because peripheral nerves can grow back, the pain likely will return in less than a year. To reduce the severity of the pain, we will recommend ongoing therapies such as medications or exercises to help increase blood flow, strengthening the nerve tissue. Evidence consistently shows that physical activity can alleviate peripheral nerve pain.

    For each type of surgery, we use an operating microscope that can magnify the affected area up to 40 times, which helps us accurately perform such an intricate procedure using specialized microsurgical instruments. Many patients notice a dramatic improvement shortly after surgery, though the incision area may be sore for a few weeks.


    Seek nerve care early to improve long-term pain relief. 

    Research to better understand peripheral nerve pain is ongoing, and surgical techniques are continually studied and improved to decrease complications such as nerve damage. Nerve pain caused by an injury or operation is not preventable, but it is progressive; the longer you wait, the less effective treatment will be. See your doctor right away if you experience symptoms of nerve damage.


    If we can’t attribute the pain to a nerve, we’ll order more imaging for a closer look at the affected area or refer you to a specialist, such as an orthopedic surgeon, to evaluate for structural causes of pain such as bone and joint issues. Unfortunately, chronic nerve pain rarely goes away completely. However, a combination of multidisciplinary treatments, such as physical therapy, regular exercise, medication, and pain management treatment can hopefully provide significant relief.


    I see patients at MedStar Washington Hospital Center and MedStar Georgetown University Hospital. Our team understands the many ways chronic nerve pain impacts quality of life and will work with you and our MedStar Health pain management experts to develop a creative, customized treatment plan that can help you more easily resume your favorite activities.

     

     

    Are you experiencing peripheral nerve pain?

    Our pain management specialists can help.

    Call 202-877-DOCS (3627) or Request an Appointment