Improving Outcomes of Peripheral Nerve Surgery
Chronic pain in burn survivors can result from a range of causes, including direct nerve injury, neuroma formation, or nerve compression.
As survival rates for patients with burns have improved, the need for effective treatments for chronic pain in this population has become more pressing.1 In one survey, 52% of this patient population reported ongoing pain an average of 12 years after the injury, and more than half of these respondents reported pain-related interference with rehabilitation and quality of life.2
Chronic pain in burn survivors can result from a range of causes, including direct nerve injury, neuroma formation, or nerve compression. Although peripheral nerve decompression has been found to be an effective strategy to relieve symptoms such as paresthesias, pruritis, allodynia, and motor dysfunction in patients with burns, uncertainty remains regarding appropriate indications and outcomes of this procedure.3 An approach that may help to elucidate such questions is the educational model of practice-based learning and improvement.4
Practice-based learning and improvement “is one of the competencies of graduate medical education, in which trainees must learn how to analyze their own practices for effectiveness and efficacy,” explained C. Scott Hultman, MD, MBA, the Ethel F. and James A. Valone Distinguished Professor of Plastic Surgery at the University of North Carolina (UNC) at Chapel Hill School of Medicine, chief emeritus and professor of plastic surgery at UNC, and founder and senior advisor of the UNC Aesthetic, Laser, and Burn Center. In a recent study published in Clinics in Plastic Surgery, Dr Hultman and colleagues used this approach to “[look] back at 15 years' worth of peripheral nerve surgery to identify trends in how I approached nerve pathology in burn patients,” he told Clinical Pain Advisor.5
He and his co-authors suspected that the number of procedures to treat neuropathic pain had increased at their institution from 2011 to 2015, along with improved outcomes, compared with Dr Hultman's prior 10 years of experience. To investigate these trends, they conducted a retrospective review of all non-emergent, symptomatic patients in need of burn reconstruction who had undergone elective peripheral nerve surgery between 2000 and 2015. They inspected consultation notes, operative and postoperative notes, and pharmacologic history to determine patients' extent of improvement (the study's main outcome).
The results showed that 105 patients underwent a total of 141 sessions of reconstructive nerve surgery between 2000 and 2010, and 118 patients underwent a total of 143 sessions between 2011 and 2015. All combined procedures encompassed 460 current procedural terminology codes, representing nerve decompression, transposition, neurolysis, and neuroma excision with or without muscle implantation.
Although the change in overall complication rates between the time periods was nonsignificant, analysis per anatomic site demonstrated a significant reduction, from 12.7% to 7.3% (P =.039), which appeared to be primarily the result of a reduction in dehiscence (from 15.2% to 6.8%; P =.042). In addition, a decrease — albeit not statistically significant — in surgical site infection was also observed.
The number of complications for the early cohort were as follows: dehiscence (n=16), surgical site infection (n=10), reoperation (n=2), herpetic whitlow (n=1), hematoma (n=1), seroma (n=1), and asymptomatic nerve injury (n=1). For the later cohort, complications included dehiscence (n=8), surgical site infection (n=5), reoperation (n=2), excessive sedation (n=1), asymptomatic nerve injury (n=1), postoperative nausea and vomiting (n=1), seroma (n=1), and sinus tract problem (n=1).
Definitive to moderate improvement, defined as discontinuation of medication and/or nearly complete symptom relief, was observed in 86.7% of patients in the early cohort, compared with 95.8% of patients in the later cohort (P =.015). Notably, no patients reported worsening of symptoms or function.
To sum up these results, Dr Hultman noted that “neuropathic pain after burn injury is quite common, can present late after the initial trauma, but may have anatomic explanations that are treatable surgically.” He offered the following takeaways for pain clinicians:
- Neuropathic pain after burn injury should be managed by a multidisciplinary team that involves plastic surgery, neurology, anesthesia, physiatry, and psychiatry.
- Physical examination, combined with detailed history, often reveals an anatomic cause of peripheral neuropathy that can be treated surgically.
- New modalities, such as fat grafting and laser resurfacing of the scar, can be combined with traditional approaches, involving nerve decompression and neuroma resection, to relieve chronic neuropathic pain in patients with burns.
“Burn recovery involves restoring quality of life and facilitating return to work, school, and society,” Dr Hultman noted. Future research in this area should focus on the long-term benefits of scar management and peripheral nerve surgery, with the aim of helping patients with burns discontinue medication and achieve relief from chronic pain.
“Carefully selected patients with an anatomic cause of chronic neuropathic pain unequivocally benefit from surgical intervention,” Dr Hultman and his co-authors concluded. “In addition, assessment of clinicians' experience, through practice-based learning, reveals the presence of discrete learning curves, which often contain inflection points of incremental and disruptive innovation.” As suggested by the present findings, this type of clinician self-analysis can lead to improved outcomes in the management of patients with burns who have chronic neuropathic pain.
- Gauffin E, Öster C, Sjöberg F, Gerdin B, Ekselius L. Health-related quality of life (EQ-5D) early after injury predicts long-term pain after burn. Burns. 2016;42(8):1781-1788.
- Dauber A, Osgood PF, Breslau AJ, Vernon HL, Carr DB. Chronic persistent pain after severe burns: a survey of 358 burn survivors. Pain Med. 2002;3(1):6-17.
- Wu C, Calvert CT, Cairns BA, Hultman CS. Lower extremity nerve decompression in burn patients. Ann Plast Surg. 2013;70(5):563-567.
- Moore DE Jr, Pennington FC. Practice-based learning and improvement. J Contin Educ Health Prof. 2003;23(Suppl 1):S73-S80.
- Rapolti M, Wu C, Schuth OA, Hultman CS. Under pressure: applying practice-based learning and improvement to the treatment of chronic neuropathic pain in patients with burns. Clin Plast Surg. 2017; 44(4):925-934.