NI FEATURE: TIMELESS REVERBERATIONS - COMMENTARY
|Year : 2019 | Volume
| Issue : 7 | Page : 2--3
My tryst with peripheral nerve surgery
Bhabani Shankar Das
Department of Neurosurgery, NIMHANS, Bengaluru, Karnataka, India
Prof. Bhabani Shankar Das
Department of Neurosurgery, NIMHANS, Bengaluru, Karnataka
|How to cite this article:|
Das BS. My tryst with peripheral nerve surgery.Neurol India 2019;67:2-3
|How to cite this URL:|
Das BS. My tryst with peripheral nerve surgery. Neurol India [serial online] 2019 [cited 2019 Apr 23 ];67:2-3
Available from: http://www.neurologyindia.com/text.asp?2019/67/7/2/250705
As undergraduate and postgraduate students, several of us might have preferred to set aside the chapter on the peripheral nerves to be browsed through at the last minute before the examination. An exposition involving 11 cranial nerves, 30 spinal nerves, the tangle of the cervical and lumbosacral plexuses, their divisions, subdivisions, and reunions of nerves could be confusing, to say the least. Indeed, the realization that the anatomy and physiology of the peripheral nerves are stereotyped and relatively straightforward dawns much later. There is a lot of perceived glamour in the subspecialties of neurosurgery like vascular neurosurgery, skull-base surgery, spinal instrumentation, and endoscopic neurosurgery. I do not blame the street-smart, young neurosurgeon for his/her preference of any of these either.
I believe, it is neurosurgeons who are best equipped with the knowledge of the tenuous course of the peripheral nerves as they ramify through the body. However, they lag behind the plastic surgeons and the trauma surgeons in the attention they shower on peripheral nerve surgery. In fact, surgery for the prolapsed intervertebral disc – a form of nerve root decompression – is now shared with the “spine surgeons”. So, are we losing ground?
There are a number of technical nuances and improvisations to deal with the unpredictability in peripheral nerve surgery. It relies heavily on accurate fascicular matching during perineural suturing. Facilitating axonal growth across the suture sites, approximating corresponding fascicles, and preserving vascularity of the nerve are some of the crucial factors that determine the outcome. Even when all these are taken care of, the normal growth of the axons itself is extremely tardy – a mere, millimeter per day. The much awaited and expected result takes a long while. It is no wonder that brachial plexus surgery remains a veritable challenge. There is no instant karma like in surgery for aneurysms.
It was not until late in my chequered career that I was seriously involved in peripheral nerve surgery. A few months after joining NIMHANS in 1981, I listened intently to a senior neurosurgeon speaking on peripheral nerve surgery. He advised every neurosurgeon to have a hobby beyond one's focus or area of expertise. Such a “hobby” could be the surgery of peripheral nerves, childhood skull defects, surgery in the orbit, etc. It would serve many neglected patients and develop core competencies in those niche areas. His lecture on peripheral nerves was motivating and opened a vista.
At NIMHANS, Bangalore, I had the referrals that were copious enough to facilitate a sincere indulgence in the then esoteric branch of peripheral nerve surgery. Common procedures like carpal tunnel decompression, nerve transfer for tardy palsy, nerve anastomosis, and excision of schwannomas soon figured in the operation theater list amidst an extremely busy schedule. Fascicular suturing and cable grafting had a different charm altogether. Often, some of the patients, long lost to follow-up, made a surprise appearance at the clinic with unbelievable functional results. Such moments were a treat for the operating team and reiterated one's belief in the adage that every cloud has a silver lining. It was nature's way of testing the patience of the surgeon and the arduous efforts were often rewarding.
Today, the diagnosis and decision-making have been simplified by technological advances in imaging and clinical electrophysiology. MRI images of brachial plexus demonstrate the site of neural discontinuity and root avulsion with astonishing clarity. The clinical findings, electroneuromyographic [ENMG] studies, and the imaging can be pieced together to construct a reasonable prognosis and we can offer realistic counseling. High-end operative microscopes, fine-quality suture materials, and microsurgical techniques have enabled precise suturing of the tiny fascicles. Fibrin glue has been successfully used for nerve approximation. Conduits for directing the growing axons to bridge the nerve gaps have not delivered their promise. Most of the patients mandate periodic postoperative follow-up. The pivotal role of the physical medicine and rehabilitation personnel to keep the muscles active and healthy to receive the growing axons cannot be underestimated. Periodic muscle charting and ENMG studies are essential to monitor and document the slow but steady progress.
It is true that the allied infrastructure for managing peripheral nerve surgery is best available in a specialized unit or in an institutional setup. Clinics with stringent follow-up must match the inpatient service. At NIMHANS, peripheral nerve surgery, an arena close to my heart, has flourished to achieve this distinction. It is heartwarming to note that so many neurosurgeons are devoting time and energy to peripheral nerve surgery for such patients, who would otherwise have no other center to turn to for relief.