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Nerve Entrapment

  • Jose Carlos GarciaJr.Email author
Chapter
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Abstract

The nerve entrapment syndromes are an important issue in microsurgery.

Microsurgeons need to be able to recognize and choose the best approach to each case.

Advances in endoscopy have led surgeons to use this method to release nerves, achieving the best results by using a minimally invasive procedure.

Recently, the robotic surgery has also been introduced as a new surgical possibility presenting the following benefits: best gesture control, magnification and movement scaling.

The combination of both robotic surgery and endoscopy may be almost perfect for using in all nerve surgeries.

The evolution is dynamic and we are sure that many procedures will change in the future from open to robotic and finally to endorobotic surgery, and others directly from endoscopic to endorobotic.

We are experiencing an evolution of the surgical methods; thus we will share our current experience and future expectations in order to accomplish the state of the art in the release of the nerve entrapment syndromes.

All this evolution will require modifications in the robot. Indeed, by creating new robotic tools and new technologies, the possibilities will certainly expand.

The current framework for nerve decompression is presented in this chapter; however, as mentioned above, the possibilities can be expanded in the future.

Keywords

Carpal Tunnel Syndrome Carpal Tunnel Ulnar Nerve Axillary Nerve Nerve Entrapment 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

13.1 Introduction

One of the main advantages of using the surgical robot is minimizing surgical scar. During nerve entrapment releases, one of the tenets of successful surgery is to maintain the nerve in an unscarred bed to prevent postoperative adhesions. However, in many neurolysis procedures, large incisions are placed directly over the site of the nerve. This chapter reviews basic principles of nerve entrapment releases and then demonstrates the advantage of neurolysis with endoscopic and robotic procedures.

Open surgical treatment is the gold standard for peripheral nerve entrapment when conservative treatment is no longer effective. If at surgical exploration the nerve appears intact but compressed by scar, neurolysis is indicated. If a neuroma in continuity is present and a nerve action potential does not conduct along this segment [10], resection of the neuroma and primary grafting should be considered. If a transection or rupture of the nerve is discovered, primary reapproximation and nerve grafting are options.

The procedure should be adapted to the location of the entrapment. For musculocutaneous nerve entrapment, neurolysis is accompanied by an excision of a triangular wedge of the biceps tendon overlying the nerve. Posterior exploration of the quadrilateral space and release of scar or fibrous bands will decompress the axillary nerve [1, 3]. For the suprascapular nerve, an open approach to release of the structures that compress the nerve is technically difficult [14].

The surgical treatment of the thoracic outlet syndrome depends on the structures involved in the pathology. Resection of cervical rib, clavicular osteotomies and osteosynthesis for fractures or fracture sequelae, release of the pectoralis minor, scalenectomy, and simple release are all surgical options. Excellent and good results have been achieved in around 86 % of these surgical procedures [7]. The nerve release may be performed to remove scar tissue and neuromas for spinal accessory nerve entrapment and grafting may be necessary. The dorsal scapular nerve may need scalenectomy of the scalenus medius and neurolysis in order to be decompressed. Surgical options are available for treating injury to the long thoracic nerve in the early stages. Some have favored neurolysis of the nerve with decompression at the level of the scalenus medius or scalenectomy [2]. Other strategies are to perform neurotization (or nerve transfer) using one or two intercostal nerves or the thoracodorsal nerve. In late cases, muscle transfer and scapula-thoracic fusion should be considered [9, 12, 15].

For the radial nerve, attention is directed to releasing compression of the nerve at its division between the posterior interosseous and dorsal sensory branch of the radial nerve as well as at the arcade of Frohse, where the posterior interosseous nerve divides into branches. For Wartenberg syndrome, the fascia between the brachioradialis and extensor carpi radialis longus is released to free the radial sensory nerve from distal to proximal. For the ulnar nerve, the surgical options are neurolysis alone, neurolysis and anterior translocation of the ulnar nerve (subcutaneous or submuscular), or neurolysis and epicondylectomy. For the median nerve, the release of the ligament of Struthers and supracondyloid process, lacertus fibrosus, fascia of the flexor digitorum superficialis muscle, pronator teres, carpal tunnel, or anomalous structures are all surgical options.

13.2 Endoscopic Treatment

Endoscopic treatment for nerve release has been used successfully in many nerve entrapment syndromes such as the carpal tunnel, cubital tunnel, and suprascapular nerve compression. The suprascapular nerve release (Fig. 13.1) has a high rate of successful outcomes but demands a high level of arthroscopic/endoscopic expertise [4, 11]. The carpal tunnel endoscopic release is easy, fast, and presents the advantages of a minimally invasive procedure [13]. Endoscopic release of the ulnar nerve requires advanced endoscopic skills and the surgeon must believe that anterior translocation is unnecessary [8].
Fig. 13.1

Suprascapular endoscopic release (SSN suprascapular nerve, TSL transverse superior ligament)

Cadaveric studies have also reported of brachial plexus endoscopic exploration. In vivo endoscopic decompression for pectoralis minor syndrome (Fig. 13.2) and anterior axillary nerve release (Fig. 13.3) has been reported.
Fig. 13.2

Pectoralis minor detachment from the coracoids

Fig. 13.3

Axillary nerve endoscopic release

The advantage of endoscopic procedures is release of large segments of the nerve through small incisions. A major limitation of endoscopic treatment is the two-­dimensional view due to the absence of depth perception. The instruments are also limited, lacking three degrees of freedom in order to better access some nerve entrapments sites. Future improvement of endoscopic devices may expand indications for endoscopic release of nerve entrapment.

13.3 Robotic-Assisted Treatment

The techniques focusing endorobotic (robotic endoscopy) surgery are still in ­development in cadaveric models. For thoracic outlet syndrome, anesthetic block landmarks have been used in order to establish the portals. The first supraclavicular portal was made at the lateral border of the sternocleidomastoid muscle, approximately 5 cm above its point of insertion on the clavicle and the second one just above the middle of the clavicle. For other procedures, we are still studying the best choice for portal locations. Some endorobotic procedures, such as suprascapular nerve release, require new tools and different optical angles (30º and 70º) in order to be feasible. Some procedures, such as the carpal tunnel syndrome are already feasible (Fig. 13.4) [6], but the open and endoscopic techniques are faster and cheaper.
Fig. 13.4

Carpal tunnel release (Courtesy of Philippe Liverneaux)

At this time, for some procedures in surgical patients, we are doing open robotic surgery, in which we follow the same steps as conventional open surgery mentioned above but use the robot instead of conventional instruments (Figs. 13.5). The release and anterior translocation of the ulnar nerve are already possible by endorobotic surgery (Figs. 13.613.8). To make the ulnar nerve procedures by endorobotic surgery one will need to create a cavity through the portal of the optic, since there are no natural cavities to access the ulnar nerve. The optic’s portal is located in the middle third of the arm just above the nerve’s path, the other 2 portals are for the robotic arms. They are located 1 to 3 cm distal of the first portal, one medial and the other lateral (Fig. 13.9). A needle can be used to certify the best location of these 2 portals [5].

Robotic-assisted surgery allows for the performance of high dexterity operations with the help of robotic arms and improves technique due to tremor filtration, motion scaling, and ergonomics. The surgeon actually performs a better, more precise, and more highly controlled surgical procedure under high magnification, which may result in an optimal surgical outcome. Other advantages are asepsia instead of antisepsia, with protection of the patient and the surgeon from possible accidents that can spread contagious diseases.
Fig. 13.5

Installation for robotic scalenectomy and brachial plexus release

Fig. 13.6

Ulnar nerve endoscopic release. (a) Ulnar Nerve (b) Cubital Tunnel

Fig. 13.7

Ulnar nerve endoscopic release. (a) Medial epicondyle of the humerus (b) Cubital ­tunnel released (c) Osbourn arcade

Fig. 13.8

Ulnar nerve endoscopic release. (a) Medial epicondyle of the humerus (b) Ulnar released

Fig. 13.9

Ulnar nerve endoscopic release in the elbow, external view

Options for augmented reality also exist. In the future, while the surgeon is performing the surgery, he may simultaneously be able to access 3D patient exams, consult a colleague who is also using a robot online, and browse the Internet for further information. Submicron in vivo histology with real-time functional imaging and diagnosis may help the surgeon in making decision for compressive syndromes secondary to tumors and rheumatic diseases. Specific antibodies and fluorescing markers will be helpful for recognizing structures to access and structures to avoid.

13.4 Conclusion

In the future, the surgeon will certainly be able to treat brachial plexus injuries, decompress thoracic outlet syndrome, release the teres pronator syndrome and may be also endorobotically access all the other nerve entrapment syndromes. The endorobotic cubital tunnel release and anterior translocation of the ulnar nerve are already in use by the author.

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Copyright information

© Springer-Verlag France 2013

Authors and Affiliations

  1. 1.Division of Shoulder and Elbow SurgeryNAEON-Center for Advanced Studies in Orthopedics and NeurosurgerySão PauloBrazil

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