A nerve decompression is a neurosurgical procedure to relieve chronic, direct pressure on a nerve to treat nerve entrapment, a pain syndrome characterized by severe chronic pain and muscle weakness. In this way a nerve decompression targets the underlying pathophysiology of the syndrome and is considered a first-line surgical treatment option for peripheral nerve pain. Despite treating the underlying cause of the disease, the symptoms may not be fully reversible as delays in diagnosis can allow permanent damage to occur to the nerve and surrounding microvasculature. Traditionally only nerves accessible with open surgery have been good candidates, however innovations in laparoscopy and nerve-sparing techniques made nearly all nerves in the body good candidates, as surgical access is no longer a barrier.
Surgical planning Surgical planning is distinct from diagnosis of entrapment. Diagnosis will focus on a binary decision: does the patient have entrapment or not? A diagnosis may not be enough information for surgery on its own as the area to explore may be too large. Surgical planning seeks to localize the specific area of entrapment to improve surgical outcomes. Identifying the level of entrapment is an important consideration for surgery as decompressing the wrong area will lead to a failed surgery (e.g. performing back surgery for extra-spinal sciatica), failure to treat nerve entrapment early can lead to permanent nerve injury, and the patient may be unnecessarily exposed to surgical complications.
Diagnostic blocks
Diagnostic nerve blocks can confirm the clinical diagnosis for chronic pain as well as identify the entrapment site. A diagnostic block is like an inverted palpation in the sense that palpation will cause a sensory nerve to send a signal (action potential) and a block will prevent a sensory nerve from sending a signal. By blocking nerve signals, the pain-contributing nerves can be identified or ruled out. Nerves are predisposed to entrapment in certain anatomical regions such as in an osteofibrous tunnels, through a muscle, adjacent to fibrous tissue. Consequently, knowledge of these anatomical regions as well as peripheral nerve anatomy is an essential component to planning successful diagnostic blocks. Ultrasound is a common form of image-guidance to place the needle properly, but it faces limitations visualizing small and deep nerves. CT- or MRI- guidance are better positioned to access deep nerves as well as identify the anatomic level of the needle.
Imaging MRI may be used to identify certain causes of entrapment such as a structural lesions pressing on a nearby nerve, but is prone to false negatives/positives and has poor correlation with the clinical examination. A major limitation with MRI is that nerve tissue is resistant to imaging. An advancement of MRI that takes advantage of the tissue properties of nerves, called MR neurography (MRN), provides more detail. MR tractography (MRT) can also be of use in surgical planning as it can identify peripheral nerve abnormalities with a high correlation to intraoperative findings and has higher accuracy than MR neurography alone. MRT uses diffusion tensor imaging to visualize the directional movement of water molecules along nerve tracts. Often an abnormality can be identified along tracts of nerve where water is not diffusing normally along the axis. MRT has been used to identify sacral nerve entrapment by the piriformis muscle, which would otherwise only be diagnosable with exploratory surgery.
List of surgeries A non-exhaustive list of nerve decompression surgeries includes
discectomy for spinal disc herniation laminectomy for cauda equina syndrome microvascular decompression for trigeminal neuralgia multiple nerve decompression surgery for diabetic peripheral neuropathy migraine surgery for migraines piriformis muscle release for piriformis syndrome sciatic nerve decompression for deep gluteal syndrome pudendal nerve decompression for pudendal neuralgia lateral femoral cutaneous nerve (LFCN) decompression for meralgia paresthetica sacral plexus decompression for intrapelvic nerve entrapments brachial plexus decompression, scalenectomy, first rib resection, and clavicle resection for thoracic outlet syndrome
Surgical outcomes Nerve decompressions are still a relatively new surgery, however a picture emerges from looking at the outcomes of some of the most studied nerve decompressions: carpal tunnel release, sciatic nerve decompression, and migraine surgery. Even within these commonly performed surgeries, the measurement of outcomes is not always standardized. Common ways of measuring outcomes are syndrome-specific disability questionnaires (e.g. Boston Carpal Tunnel Questionnaire, Oswestry low back disability questionnaire, and the migraine disability assessment); visual analog scale (VAS); physical examination findings; and subjective patient satisfaction.
Carpal tunnel release
Carpal tunnel surgery has a clinical success rate of 75-90%. Success is most frequently measured with the Boston Carpal Tunnel Questionnaire, physical examination (sensory function, motor function, pain, electrodiagnostic, trophic function), and patient self-assessments. One study found that while 86% of patients improved, only 26% had complete recovery of clinical and electrodiagnostic findings. Of the functional assessments, pain showed the greatest improvements following surgery. Another study compared carpal tunnel syndrome patients who elected surgery with those who chose not to. 77% of the surgery group said they were cured compared to 16% who did not elect surgery. While some of the success of surgery may just be due to the natural history of the disease, the surgery groups still have an improvement in outcomes over conservative measures. A systematic review found that surgical treatment outweighed the benefits over conservative treatment overall all outcome measures, however conservative treatment caused fewer complications.
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