A better understanding Peripheral Nerve Surgery

Many patients are searching for answers to their chronic pain with lower extremity problems and they are not fully informed that there are surgical options which they can pursue. Peripheral nerve surgery is done to relieve the patient of chronic nerve pain in the leg and foot.

At Table Mountain Foot and Ankle, we pride ourselves in the knowledge and advanced procedures our doctors perform. This surgery is unique to our practice because not every pediatric physician, surgeon, or lower extremity surgeon can do it. Dr. Still focuses some of his surgical procedures on peripheral nerve surgery and failed prior surgeries that have resulted in nerve damage.

How does peripheral nerve surgery work?

The process of peripheral nerve surgery can vary depending on the particular pathology or what nerve is involved, including how long it has been damaged or injured and whether the injury be from an injury or prior surgery.

Sometimes it can involve a nerve graft, which can be pretty complex or sometimes just a nerve cap, which is a cap on the end of the nerve to prevent regrowth of the nerve and subsequent pain.

How do I know if I need peripheral nerve surgery?

You could be a candidate for peripheral nerve surgery if your chronic pain is incapacitating and intense, more so than a fracture or tendon injury, and you are in pain daily. Some patients experience a sharp, jabbing, intense pain and sometimes, their pain is so bad they become almost mentally unstable.

These patients have usually been to numerous doctors already in hopes of finding a way to manage their pain, however no other tactics have worked. Often, they have increased their use of medications, whether it be narcotics or other pain modifying drugs to help with nerve pain. Sometimes, the pain can affect their jobs, their family life, and some of these patients are under quite a bit of stress with their children or marriages.

Dr. Still believes this surgery makes the most sense when the patient is at the end of their rope or they have exhausted many other options and are still dealing with incapacitating pain. 

However, it is important to understand there are cases where peripheral nerve surgery is not the best option. It does not make sense is a patient’s their pain is fairly well controlled by other methods and the potential for surgical success is low. If we can control a patient’s pain without surgery, then of course we will try that first.

Specific cases where doctors will not recommend peripheral nerve surgery include if the doctor feels they patient is at too high of a risk for healing, or maybe their circulation is inadequate. If their mental state or psychiatric stability is questionable, then doctors may not want to perform a surgical procedure.

What causes a need for peripheral nerve surgery?

Typically, patients need peripheral nerve surgery after an injury or a previously failed surgery. Most commonly, a need for this surgery stems from a cut nerve, whether that be from an injury where a nerve got lacerated or from a bad surgery where the nerve was cut accidentally.

There are several scenarios for injuries. It could be someone who has had an elective operation, such as foot and ankle surgery — from for example, a fracture or tendon repair, or even a bunion surgery — and somehow a nerve got injured or lacerated, and resulted in chronic pain.

Separately, a patient can have a severe ankle sprain and overstretch some nerves. This is a commonly overlooked problem that results in chronic pain. Finally, a patient’s nerve damage can be caused by a blunt trauma such as a skiing or snowboarding injury.

Alternatives to peripheral nerve surgery

If a patient’s pain can be managed by other options besides surgery, we like to try these options first. Sometimes, patients will have spinal cord stimulators, visit interventional pain management physicians, get certain types of medications, get spinal nerve blocks, or peripheral nerve blocks. There has also been an increase in radiofrequency ablation for some lower extremity problems.

There is nothing wrong with these options. However, Dr. Still thinks some options are over utilized by the interventional pain management clinics and only provide temporary relief to the patient. These patients are going to chronically need procedures and injections. In situations where a peripheral nerve surgery would be successful, Dr. Still does think it is a better option. However, it is not always possible or the best option, which is why thorough evaluation is needed.

The benefits of peripheral nerve surgery

For peripheral nerve surgeries, patients are usually experiencing severe, incapacitating pain and have been seen by many different doctors already, but nothing has helped their pain. So what is life like afterwards? It is better, but not perfect. Dr. Still considers the procedure successful if 70% of the patient’s pain is reduced. We are also pleased if more than 70% of the pain is reduced because these are complex and difficult problems to solve.

Usually, the quality of life of the patient will improve. Ultimately, we are trying to reduce the use of medications, especially narcotics, and others which have side effects. So overall, the patient’s life generally is better. Results of peripheral nerve surgery almost always show some degree of improvement.

Often, patients sometimes forget how much pain they were having before the surgery. In summary, for life after surgery, we hope for a reduction of medication, a happier patient who is getting along with people better, and the ability to be more active so that they can enjoy their life.

You think you may be a candidate for peripheral nerve surgery…now what?

Patients with chronic pain of the lower extremity are complex patients with complex problems. If somebody comes in and they have a standard problem, like a bunion deformity or a fracture, we can get them in quickly and get things fixed within a couple of weeks. Our more complex patients often take more appointments pre-surgery, maybe more testing, the visits are longer, and their doctor may have more to think about.

Sometimes, it can be a four to six week process just to even get the surgery set up and get everything lined up to see what we need to fix them. To help make this process more efficient, we ask patients to come in with a good summary of things that have taken place, whether they had surgery or not, a timeline of what has happened over the last year or however long they have had symptoms.

We also would like to see a complete list of medications and surgeries so that we have a good handle on their health history and can help them make the best decisions possible.

Peripheral nerve surgery post care

In general, peripheral nerve surgery patients require more follow-up for a longer period of time than patients with general problems that may require surgery such as a fracture, torn ligament, or sprained ankle. After surgery, patients typically come in to see the surgeon fairly often. On average, patients are meeting with their surgeon four times in the first six weeks.

These patients continue to see the surgeon for one to three years for regular checkups after their procedure.

After the surgery, many patients will continue using narcotic medications or medications they were already on to manage pain. Some of these patients may already have an interventional pain management doctor, so we take a teamwork approach with those doctors, but patients will typically need pain medications for a while to help control the pain of the nerves until things begin to heal, which takes a few months. We also recommend MLS laser therapy as a pain management technique.

Often, we are asked if peripheral nerve surgery can be reversed. While we can reverse these surgeries, we typically do not because these patients’ symptoms do not worsen. The surgery is either successful and reduces their pain, or it is not as successful and their level of pain remains the same. Peripheral nerve procedures are good because a patients’ pain typically does not get any worse — usually because these patients are already at their worst.

Bringing it all together

Peripheral nerve surgery is a great option for patients suffering from chronic pain of the lower extremity. While there are many factors to weigh when deciding to get peripheral nerve surgery, we recommend consulting your podiatrist if you think you may be a candidate.

Overall we wish patients knew that peripheral nerve surgery is available and that there are surgeons who can perform the procedure. It is a great option for patients instead of living with chronic pain or solely consulting interventional pain management clinics for medications and repeated injections. The sooner you talk to your doctor about peripheral nerve surgery, the sooner you can return to living an active and pain-free life!