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Neurotherapeutics

, Volume 16, Issue 1, pp 9–25 | Cite as

The Role of the Peripheral Nerve Surgeon in the Treatment of Pain

  • Louis H. PopplerEmail author
  • Susan E. Mackinnon
Review

Abstract

Pain is a frequent cause of physician visits. Many physicians find these patients challenging because they often have complicated histories, emotional comorbidities, confusing examinations, difficult problems to fix, and the possibility of factitious complaints for attention or narcotic pain medications. As a result, many patients are lumped into the category of chronic, centralized pain and relegated to pain management. However, recent literature suggests that surgical management of carefully diagnosed generators of pain can greatly reduce patients’ pain and narcotic requirements. This article reviews recent literature on surgical management of pain and four specific sources of chronic pain amenable to surgical treatment: painful neuroma, nerve compression, myofascial/musculoskeletal pain, and complex regional pain syndrome type II.

Keywords

Neuralgia Chronic pain Hyperalgesia Neuroma Nerve compression Complex regional pain syndromes Causalgia Reflex sympathetic dystrophy Myofascial pain syndromes Peripheral nerve injury Surgery Plastic surgery Neurosurgery Orthopedic surgery 

Notes

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Supplementary material

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References

  1. 1.
    Dzau VJ, Pizzo PA. Relieving pain in America: insights from an Institute of Medicine committee. JAMA 2014;312(15):1507–8.Google Scholar
  2. 2.
    Gatchel RJ, Reuben DB, Dagenais S, Turk DC, Chou R, Hershey AD, et al. Research Agenda for the Prevention of Pain and Its Impact: Report of the Work Group on the Prevention of Acute and Chronic Pain of the Federal Pain Research Strategy. J Pain 2018;19(8):837–51.Google Scholar
  3. 3.
    Noordenbos W, Wall PD. Implications of the failure of nerve resection and graft to cure chronic pain produced by nerve lesions. J Neurol Neurosurg Psychiatry 1981;44(12):1068–73.Google Scholar
  4. 4.
    Cetas JS, Saedi T, Burchiel KJ. Destructive procedures for the treatment of nonmalignant pain: a structured literature review. J Neurosurg 2008;109(3):389–404.Google Scholar
  5. 5.
    Poppler LH, Parikh RP, Bichanich MJ, Rebehn K, Bettlach CR, Mackinnon SE, et al. Surgical interventions for the treatment of painful neuroma: a comparative meta-analysis. Pain 2018;159(2):214–23.Google Scholar
  6. 6.
    Koman AL, Smith BP, Smith TL. A Practical Guide for Complex Regional Pain Syndrome in the Acute Stage and Late Stage. In: Wolfe SW, editor. Green's Operative Hand Surgery. 2. 7th Edition. Philadelphia, PA: Elsevier; 2017. p. 1797–827.Google Scholar
  7. 7.
    Santosa KB, Lapidus JB, Larson EL, et al. Pattterns of Opiod Use Among Peripheral Nerve Surgery Patients. Presentation at American Society of Peripheral Nerve, Palm Springs, CA; January 2019.Google Scholar
  8. 8.
    Kehlet H, Jensen TS, Woolf CJ. Persistent postsurgical pain: risk factors and prevention. Lancet 2006;367(9522):1618–25.Google Scholar
  9. 9.
    Shipton E. Post-surgical neuropathic pain. ANZ J Surg 2008;78(7):548–55.Google Scholar
  10. 10.
    Yancey P, Brand P. The Gift of Pain: Why We Hurt and What We Can Do About It. Grand Rapids, MI: Zondervan Publishing House; 1997.Google Scholar
  11. 11.
    Bourne S, Machado AG, Nagel SJ. Basic anatomy and physiology of pain pathways. Neurosurg Clin N Am. 2014;25(4):629–38.Google Scholar
  12. 12.
    Nijs J, Torres-Cueco R, van Wilgen CP, Girbes EL, Struyf F, Roussel N, et al. Applying modern pain neuroscience in clinical practice: criteria for the classification of central sensitization pain. Pain Physician. 2014;17(5):447–57.Google Scholar
  13. 13.
    Woolf CJ. Central sensitization: implications for the diagnosis and treatment of pain. Pain. 2011;152(3 Suppl):S2–15.Google Scholar
  14. 14.
    Simon L. Partial denervation for pain relief in arthritis of the knee. Orv Hetil 1951;92(43):1406–8.Google Scholar
  15. 15.
    Zaidenberg EE, Palumbo D, Martinez E, Pastrana M, Farias Cisneros E, Zaidenberg CR. Innervation of the interphalangeal joint of the thumb: anatomical study. J Hand Surg Eur Vol 2018;43(6):631–4.Google Scholar
  16. 16.
    Tuffaha SH, Quan A, Hashemi S, et al. Selective Thumb Carpometacarpal Joint Denervation for Painful Arthritis: Clinical Outcomes and Cadaveric Study. J Hand Surg 2018.Google Scholar
  17. 17.
    Zhong G, Liang Z, Kan J, Muheremu A. Selective peripheral nerve resection for treatment of persistent pain around the knee joint after total knee arthroplasty. J Int Med Res 2018;46(6):2301–6.Google Scholar
  18. 18.
    Hohenberger GM, Maier MJ, Dolcet C, Weiglein AH, Schwarz A, Matzi V. Sensory nerve supply of the distal radio-ulnar joint with regard to wrist denervation. J Hand Surg Eur Vol 2017;42(6):586–91.Google Scholar
  19. 19.
    Geldmacher J, Legal HR, Brug E. Results of denervation of the wrist and wrist joint by Wilhelm’s method. Hand 1972;4(1):57–9.Google Scholar
  20. 20.
    Ducic I. Surgical Management of Chronic Headaches, Migraines, and Neuralgias. In: Mackinnon SE, editor. Nerve Surgery. New York, NY: Thieme; 2014. p. 572–90.Google Scholar
  21. 21.
    Davidge KM, Sammer DM. Median Nerve Entrapment and Injury. In: Mackinnon SE, editor. Nerve Surgery. New York, NY: Thieme; 2014. p. 207–50.Google Scholar
  22. 22.
    Davidge KM, Boyd KU. Ulnar Nerve Entrapment and Injury. In: Mackinnon SE, editor. Nerve Surgery. New York, NY: Thieme; 2014. p. 251–88.Google Scholar
  23. 23.
    Boyd KU, Brown JM. Injury and Compression Neuropathy in the Lower Extremity. In: Mackinnon SE, editor. Nerve Surgery. New York, NY: Thieme; 2014. p. 338–90.Google Scholar
  24. 24.
    Boyd KU, Dvali LT, Patterson MM, Patterson BM, Davidge KM. Radial Nerve Entrapment and Injury. In: Mackinnon SE, editor. Nerve Surgery. New York, NY: Thieme; 2014. p. 289–310.Google Scholar
  25. 25.
    Poppler LH, Groves AP, Sacks G, Bansal A, Davidge KM, Sledge JA, et al. Subclinical Peroneal Neuropathy: A Common, Unrecognized, and Preventable Finding Associated With a Recent History of Falling in Hospitalized Patients. Ann Fam Med 2016;14(6):526–33.Google Scholar
  26. 26.
    Mackinnon SE. Pathophysiology of nerve compression. Hand Clin 2002;18(2):231–41.Google Scholar
  27. 27.
    Mackinnon SE, Novak SB. Compression Neuropathies. In: Wolfe SW, editor. Green’s Operative Hand Surgery. 1. 7th ed. Philadelphia, PA: Elsevier; 2017. p. 921–58.Google Scholar
  28. 28.
    Narakas AO. The role of thoracic outlet syndrome in the double crush syndrome. Ann Chir Main Memb Super 1990;9(5):331–40.Google Scholar
  29. 29.
    Osterman AL. The double crush syndrome. Orthop Clin North Am 1988;19(1):147–55.Google Scholar
  30. 30.
    Upton AR, McComas AJ. The double crush in nerve entrapment syndromes. Lancet 1973;2(7825):359–62.Google Scholar
  31. 31.
    Campbell JN. Neuroma Pain. In: Gebhart GF, Schmidt RF, editors. Encyclopedia of pain (2nd ed). Berlin: Springer-Verlag; 2013. p. 2056–8.Google Scholar
  32. 32.
    Aasvang E, Kehlet H. Chronic postoperative pain: the case of inguinal herniorrhaphy. Br J Anaesth 2005;95(1):69–76.Google Scholar
  33. 33.
    Fisher GT, Boswick JA, Jr. Neuroma formation following digital amputations. J Trauma 1983;23(2):136–42.Google Scholar
  34. 34.
    Gotoda Y, Kambara N, Sakai T, Kishi Y, Kodama K, Koyama T. The morbidity, time course and predictive factors for persistent post-thoracotomy pain. Eur J Pain 2001;5(1):89–96.Google Scholar
  35. 35.
    Carroll I. Pharmacologic Management of Upper Extremity Chronic Nerve Pain. Hand Clin 2016;32(1):51–61.Google Scholar
  36. 36.
    Schwartzman RJ, Erwin KL, Alexander GM. The natural history of complex regional pain syndrome. Clin J Pain 2009;25(4):273–80.Google Scholar
  37. 37.
    Tajerian M, Clark JD. New Concepts in Complex Regional Pain Syndrome. Hand Clin 2016;32(1):41–9.Google Scholar
  38. 38.
    Harden RN, Bruehl S, Stanton-Hicks M, Wilson PR. Proposed new diagnostic criteria for complex regional pain syndrome. Pain Med. 2007;8(4):326–31.Google Scholar
  39. 39.
  40. 40.
    Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand) [corrected]. The Upper Extremity Collaborative Group (UECG). Am J Ind Med 1996;29(6):602–8.Google Scholar
  41. 41.
    Joyce CR, Zutshi DW, Hrubes V, Mason RM. Comparison of fixed interval and visual analogue scales for rating chronic pain. Eur J Clin Pharmacol. 1975;8(6):415–20.Google Scholar
  42. 42.
    Bieri D, Reeve RA, Champion GD, Addicoat L, Ziegler JB. The Faces Pain Scale for the self-assessment of the severity of pain experienced by children: development, initial validation, and preliminary investigation for ratio scale properties. Pain 1990;41(2):139–50.Google Scholar
  43. 43.
    Jenkinson C, Coulter A, Wright L. Short form 36 (SF36) health survey questionnaire: normative data for adults of working age. BMJ. 1993;306(6890):1437–40.Google Scholar
  44. 44.
    Melzack R. The short-form McGill Pain Questionnaire. Pain 1987;30(2):191–7.Google Scholar
  45. 45.
    Bellamy N, Campbell J, Haraoui B, Buchbinder R, Hobby K, Roth JH, et al. Dimensionality and clinical importance of pain and disability in hand osteoarthritis: Development of the Australian/Canadian (AUSCAN) Osteoarthritis Hand Index. Osteoarthr Cartil. 2002;10(11):855–62.Google Scholar
  46. 46.
    Chung KC, Pillsbury MS, Walters MR, Hayward RA. Reliability and validity testing of the Michigan Hand Outcomes Questionnaire. J Hand Surg. 1998;23(4):575–87.Google Scholar
  47. 47.
    Beaton DE, Wright JG, Katz JN. Development of the QuickDASH: comparison of three item-reduction approaches. J Bone Joint Surg Am. 2005;87(5):1038–46.Google Scholar
  48. 48.
    MacDermid JC, Tottenham V. Responsiveness of the disability of the arm, shoulder, and hand (DASH) and patient-rated wrist/hand evaluation (PRWHE) in evaluating change after hand therapy. J Hand Ther. 2004;17(1):18–23.Google Scholar
  49. 49.
    Domeshek LF, Krauss EM, Snyder-Warwick AK, Laurido-Soto O, Hasak JM, Skolnick GB, et al. Surgical Treatment of Neuromas Improves Patient-Reported Pain, Depression, and Quality of Life. Plast Reconstr Surg. 2017;139(2):407–18.Google Scholar
  50. 50.
    Li Y, Dorsi MJ, Meyer RA, Belzberg AJ. Mechanical hyperalgesia after an L5 spinal nerve lesion in the rat is not dependent on input from injured nerve fibers. Pain. 2000;85(3):493–502.Google Scholar
  51. 51.
    Sheth RN, Dorsi MJ, Li Y, Murinson BB, Belzberg AJ, Griffin JW, et al. Mechanical hyperalgesia after an L5 ventral rhizotomy or an L5 ganglionectomy in the rat. Pain. 2002;96(1–2):63–72.Google Scholar
  52. 52.
    Fuentes J, Armijo-Olivo S, Funabashi M, Miciak M, Dick B, Warren S, et al. Enhanced therapeutic alliance modulates pain intensity and muscle pain sensitivity in patients with chronic low back pain: an experimental controlled study. Phys Ther. 2014;94(4):477–89.Google Scholar
  53. 53.
    Louis DS, Kasdan ML. Factitious Disorders. In: Wolfe SW, editor. Green’s Operative Hand Surgery. 2. 7 ed. Philadelphia, PA: Elsevier; 2017. p. 1828–31.Google Scholar
  54. 54.
    Groves JE. Taking care of the hateful patient. N Engl J Med. 1978;298(16):883–7.Google Scholar
  55. 55.
    Strous RD, Ulman AM, Kotler M. The hateful patient revisited: Relevance for 21st century medicine. Eur J Intern Med. 2006;17(6):387–93.Google Scholar
  56. 56.
    Darnall BD. Pain Psychology and Pain Catastrophizing in the Perioperative Setting: A Review of Impacts, Interventions, and Unmet Needs. Hand Clin. 2016;32(1):33–9.Google Scholar
  57. 57.
    Granot M, Ferber SG. The roles of pain catastrophizing and anxiety in the prediction of postoperative pain intensity: a prospective study. Clin J Pain. 2005;21(5):439–45.Google Scholar
  58. 58.
    Helmerhorst GT, Vranceanu AM, Vrahas M, Smith M, Ring D. Risk factors for continued opioid use one to two months after surgery for musculoskeletal trauma. J Bone Joint Surg Am. 2014;96(6):495–9.Google Scholar
  59. 59.
    Sullivan MJ, Bishop SR, Pivik J. The Pain Catastrophizing Scale: development and validation psychological assessment. Psychol Assess. 1995;7(4):524–32.Google Scholar
  60. 60.
    Strauch B, Lang A. The ten test revisited. Plast Reconstr Surg. 2003;112(2):593–4.Google Scholar
  61. 61.
    Shy ME, Frohman EM, So YT, Arezzo JC, Cornblath DR, Giuliani MJ, et al. Quantitative sensory testing: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. 2003;60(6):898–904.Google Scholar
  62. 62.
    Brown JM, Mokhtee D, Evangelista MS, Mackinnon SE. Scratch Collapse Test Localizes Osborne’s Band as the Point of Maximal Nerve Compression in Cubital Tunnel Syndrome. Hand. 2010;5(2):141–7.Google Scholar
  63. 63.
    Cheng CJ, Mackinnon-Patterson B, Beck JL, Mackinnon SE. Scratch collapse test for evaluation of carpal and cubital tunnel syndrome. J Hand Surg. 2008;33(9):1518–24.Google Scholar
  64. 64.
    Davidge KM, Gontre G, Tang D, Boyd KU, Yee A, Damiano MS, et al. The "hierarchical" Scratch Collapse Test for identifying multilevel ulnar nerve compression. Hand. 2015;10(3):388–95.Google Scholar
  65. 65.
    Gillenwater J, Cheng J, Mackinnon SE. Evaluation of the scratch collapse test in peroneal nerve compression. Plast Reconstr Surg. 2011;128(4):933–9.Google Scholar
  66. 66.
    Makanji HS, Becker SJ, Mudgal CS, Jupiter JB, Ring D. Evaluation of the scratch collapse test for the diagnosis of carpal tunnel syndrome. J Hand Surg Eur Vol. 2013.Google Scholar
  67. 67.
    Curtin C. Pain Examination and Diagnosis. Hand Clin. 2016;32(1):21–6.Google Scholar
  68. 68.
    Kahn LC, Yee A, Mackinnon SE. Important Details in Performing and Interpreting the Scratch Collapse Test. Plast Reconstr Surg. 2018;141(2):399–407.Google Scholar
  69. 69.
    Dellon, AL. Tinel or not tinel. J Hand Surg [Am]. 1984;9(2):216.Google Scholar
  70. 70.
    Lifchez SD, Means KR, Jr., Dunn RE, Williams EH, Dellon AL. Intra- and inter-examiner variability in performing Tinel’s test. J Hand Surg. 2010;35(2):212–6.Google Scholar
  71. 71.
    Colbert SH. Painful sequelae of Peripheral Nerve Injuries. In: Nerve Surgery. Susan E. Mackinnon, Editor. New York, NY: Thieme; 2014. p. 591–619.Google Scholar
  72. 72.
    Nathan PA, Keniston RC, Meadows KD, Lockwood RS. Predictive value of nerve conduction measurements at the carpal tunnel. Muscle Nerve. 1993;16(12):1377–82.Google Scholar
  73. 73.
    Rubin DI. Technical issues and potential complications of nerve conduction studies and needle electromyography. Neurol Clin. 2012;30(2):685–710.Google Scholar
  74. 74.
    Witt JC, Hentz JG, Stevens JC. Carpal tunnel syndrome with normal nerve conduction studies. Muscle Nerve. 2004;29(4):515–22.Google Scholar
  75. 75.
    Buchberger W, Schon G, Strasser K, Jungwirth W. High-resolution ultrasonography of the carpal tunnel. J Ultrasound Med. 1991;10(10):531–7.Google Scholar
  76. 76.
    Bignotti B, Signori A, Sormani MP, Molfetta L, Martinoli C, Tagliafico A. Ultrasound versus magnetic resonance imaging for Morton neuroma: systematic review and meta-analysis. Eur Radiol. 2015;25(8):2254–62.Google Scholar
  77. 77.
    Mehrpour M, Mirzaasgari Z, Rohani M, Safdarian M. Diagnostic value of median nerve ultrasonography for screening of carpal tunnel syndrome in hypothyroid patients: A cross-sectional study. Iran J Neurol. 2016;15(2):70–4.Google Scholar
  78. 78.
    Kollmer J, Bendszus M, Pham M. MR Neurography: Diagnostic Imaging in the PNS. Clin Neuroradiol. 2015;25 Suppl 2:283–9.Google Scholar
  79. 79.
    Bendszus M, Wessig C, Solymosi L, Reiners K, Koltzenburg M. MRI of peripheral nerve degeneration and regeneration: correlation with electrophysiology and histology. Exp Neurol. 2004;188(1):171–7.Google Scholar
  80. 80.
    Dailey AT, Tsuruda JS, Filler AG, Maravilla KR, Goodkin R, Kliot M. Magnetic resonance neurography of peripheral nerve degeneration and regeneration. Lancet. 1997;350(9086):1221–2.Google Scholar
  81. 81.
    Kalkman CJ, Visser K, Moen J, Bonsel GJ, Grobbee DE, Moons KG. Preoperative prediction of severe postoperative pain. Pain. 2003;105(3):415–23.Google Scholar
  82. 82.
    Dwyer CL, Soong M, Hunter A, Dashe J, Tolo E, Kasparyan NG. Prospective Evaluation of an Opioid Reduction Protocol in Hand Surgery. J Hand Surg. 2018;43(6):516–22.e1.Google Scholar
  83. 83.
    Pavlin DJ, Sullivan MJ, Freund PR, Roesen K. Catastrophizing: a risk factor for postsurgical pain. Clin J Pain. 2005;21(1):83–90.Google Scholar
  84. 84.
    Shibuya N, Humphers JM, Agarwal MR, Jupiter DC. Efficacy and safety of high-dose vitamin C on complex regional pain syndrome in extremity trauma and surgery--systematic review and meta-analysis. J Foot Ankle Surg. 2013;52(1):62–6.Google Scholar
  85. 85.
    Yang Y, Xia Z, Meng Q, Liu K, Xiao Y, Shi L. Dexmedetomidine relieves neuropathic pain by inhibiting hyperpolarization-activated cyclic nucleotide-gated currents in dorsal root ganglia neurons. Neuroreport. 2018;29(12):1001–6.Google Scholar
  86. 86.
    Kalappa S, Sridhara RB, Kumaraswamy S. Dexmedetomidine as an Adjuvant to Pre-Emptive Caudal Epidural Ropivacaine for Lumbosacral Spine Surgeries. J Clin Diagn Res. 2016;10(1):Uc22–4.Google Scholar
  87. 87.
    Dai S, Qi Y, Fu J, Li N, Zhang X, Zhang J, et al. Dexmedetomidine attenuates persistent postsurgical pain by upregulating K(+)-Cl(−) cotransporter-2 in the spinal dorsal horn in rats. J Pain Res. 2018;11:993–1004.Google Scholar
  88. 88.
    Peng K, Zhang J, Meng XW, Liu HY, Ji FH. Optimization of Postoperative Intravenous Patient-Controlled Analgesia with Opioid-Dexmedetomidine Combinations: An Updated Meta-Analysis with Trial Sequential Analysis of Randomized Controlled Trials. Pain Physician. 2017;20(7):569–96.Google Scholar
  89. 89.
    Felder JM 3rd, Mackinnon SE, Patterson MM. The 7 Structures Distal to the Elbow That Are Critical to Successful Anterior Transposition of the Ulnar Nerve. Hand. 2018:1558944718771390.Google Scholar
  90. 90.
    Mackinnon SE. Nerve Surgery. 1st. Ed. ed. New York, NY: Thieme; 2014 9/15/2014. 624 p.Google Scholar
  91. 91.
    Moore AM, MacEwan M, Santosa KB, Chenard KE, Ray WZ, Hunter DA, et al. Acellular nerve allografts in peripheral nerve regeneration: a comparative study. Muscle Nerve. 2011;44(2):221–34.Google Scholar
  92. 92.
    Saheb-Al-Zamani M, Yan Y, Farber SJ, Hunter DA, Newton P, Wood MD, et al. Limited regeneration in long acellular nerve allografts is associated with increased Schwann cell senescence. Exp Neurol. 2013;247C:165–77.Google Scholar
  93. 93.
    Poppler LH, Ee X, Schellhardt L, Hoben GM, Pan D, Hunter DA, et al. Axonal Growth Arrests After an Increased Accumulation of Schwann Cells Expressing Senescence Markers and Stromal Cells in Acellular Nerve Allografts. Tissue Eng Part A. 2016;22(13–14):949–61.Google Scholar
  94. 94.
    Poppler LH, Davidge K, Lu JC, Armstrong J, Fox IK, Mackinnon SE. Alternatives to sural nerve grafts in the upper extremity. Hand. 2015;10(1):68–75.Google Scholar
  95. 95.
    Goheen-Robillard B, Myckatyn TM, Mackinnon SE, Hunter DA. End-to-side neurorrhaphy and lateral axonal sprouting in a long graft rat model. Laryngoscope 2002;112(5):899–905.Google Scholar
  96. 96.
    Watson CPN, Mackinnon SE, Dostrovsky JO, Bennett GJ, Farran RP, Carlson T. Nerve resection, crush and re-location relieve complex regional pain syndrome type II: A case report. Pain. 2014;155(6):1168–73.Google Scholar
  97. 97.
    Ives GC, Kung TA, Nghiem BT, Ursu DC, Brown DL, Cederna PS, et al. Current State of the Surgical Treatment of Terminal Neuromas. Neurosurgery. 2018;83(3):354–64.Google Scholar
  98. 98.
    Souza JM, Cheesborough JE, Ko JH, Cho MS, Kuiken TA, Dumanian GA. Targeted muscle reinnervation: a novel approach to postamputation neuroma pain. Clin Orthop Relat Res. 2014;472(10):2984–90.Google Scholar
  99. 99.
    Woo SL, Kung TA, Brown DL, Leonard JA, Kelly BM, Cederna PS. Regenerative Peripheral Nerve Interfaces for the Treatment of Postamputation Neuroma Pain: A Pilot Study. Plast Reconstr Surg Glob Open. 2016;4(12):e1038.Google Scholar
  100. 100.
    Ho Kim S, Mo Chung J. An experimental model for peripheral neuropathy produced by segmental spinal nerve ligation in the rat. Pain 1992;50(3):355–63.Google Scholar
  101. 101.
    Rodrigues-Filho R, Santos ARS, Bertelli JA, Calixto JB. Avulsion injury of the rat brachial plexus triggers hyperalgesia and allodynia in the hindpaws: a new model for the study of neuropathic pain. Brain Res 2003;982(2):186–94.Google Scholar
  102. 102.
    Ellis RF, Hing WA. Neural mobilization: a systematic review of randomized controlled trials with an analysis of therapeutic efficacy. J Man Manip Ther 2008;16(1):8–22.Google Scholar

Copyright information

© The American Society for Experimental NeuroTherapeutics, Inc. 2018

Authors and Affiliations

  1. 1.Department of Orthopedic SurgeryMayo ClinicRochesterUSA
  2. 2.Division of Plastic and Reconstructive SurgeryWashington University in St. LouisSt. LouisUSA

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