Neuropathic Pain Relief after Surgical Neurolysis in Patients with Traumatic Brachial Plexus Injuries: A Preliminary Report

Abstract

Objective. To evaluate the usefulness of surgical neurolysis for neuropathic pain relief in patients with posttraumatic brachial plexus injury (BPI). Methods. A prospective, longitudinal, nonrandomized, self-controlled before and after study was performed to evaluate the pain changes according to their intensity using the Visual Analogue Scale (VAS), and the sensory recovery after surgery using the British Medical Research Council (BMRC) scale for sensory recovery. To establish significant changes, a paired T-test was performed, and in order to determine the magnitude of these changes, an effect size was measured. α = 0.05. Results. Ten patients were included with an average follow-up of 61.9 ± 53.62 months. The main mechanism of injury was vehicular trauma (70%). A significant decrease in pain after the surgical intervention was observed resulting from an average preoperative state according to VAS of 8.4 ± 1.58, to a postoperative state of 3.4 ± 3.27 (59.52%, p = 0.005, Δ = 1.572), added to a mean sensory improvement (25%) from 2.8 ± 1.62 to 3.5 ± 0.97 after surgery according to BMRC, without statistically significant changes ( p = 0.062 ), showing a moderate effect size (Δ = 0.413). Almost all patients showed improvement in the continuous and paroxysmal pattern of pain. No postoperative complications were observed. Discussion. These results suggest that in cases of BPI that originates from a compressive syndrome secondary to the posttraumatic fibrosis that surrounds the nerve structures causing strangulation and inducing hypernociception, the use of surgical neurolysis is an appropriate alternative for patients with medically refractory neuropathic pain.

Neuropathic Pain and Positive Sensory Symptoms in Brachial Plexus Neuropathy: An Exploratory Study of Outcomes after Surgical Decompression and Proposal of a New Sensory Frequency of Symptoms Scale

“…The results of the studies are encouraging, showing a decrease between 59% and 78% according to the VAS scale [8,16,32], these being very similar to those observed in the present study (84%). Based on the results recently published in our last article on the use of decompression for pain relief, we decided to exclude those patients who showed signs of nerve transection in the preoperative electrophysiological analysis or during the surgical procedure [32]. Conversely, Morgan R et al [8] reported motor recovery after the use of surgical decompression in trauma patients [8], these results are relevant, so we decided exclusevely to disccuss the clinical outcomes of these patients in motor terms in another article with a systematic review of the literature (on published).…”

“…However, the usefulness of surgical decompression to reduce pain in patients with a chronic BPI associated with compressive neuropathy has recently been suggested, a phenomenon previously explained (development of fibrosis secondary to trauma that conditions ischemia and upregulation of inflammatory cytokines) [4,27]. The results of the studies are encouraging, showing a decrease between 59% and 78% according to the VAS scale [8,16,32], these being very similar to those observed in the present study (84%). Based on the results recently published in our last article on the use of decompression for pain relief, we decided to exclude those patients who showed signs of nerve transection in the preoperative electrophysiological analysis or during the surgical procedure [32].…”

“…However, we understand the relevance of these manifestations due to their close relationship with motor function and protection mechanism against nociceptive stimuli, so we suggest that they be considered for future studies. Finally, the sample size is relativelly small; however, a previous study perfomed a sample size calculation to evaluate the effectivenes of surgical decompression for pain relief [32], these measures were based on the observations described by Morgan R et al [8]. The analysis showed that due to the large effect of surgery (1.6), 7 patients are enough to have a statistical power of 80% (minimun required for external validity).…”

Motor Recovery after Surgical Neurolysis in Brachial Plexus Neuropathy: A Case series and Systematic Review

“…(6) If feasible, blinding will be implemented for patients, treating physicians, and the individuals performing statistical analyses. (7) Potential sources of bias, such as demographic characteristics, mechanism of injury (etiology), severity, and extension of the injury, interval between injury and surgery [34], location of the injury, preservation of muscle trophism, and integrity of muscle/nervous structures defined through electromyographic and nerve conduction analysis [2,35], will be carefully considered and addressed in the study design.…”

“…However, a recent systematic review comparing motor outcomes of various surgical techniques for brachial plexus injuries demonstrated that neurolysis presented the highest proportion of motor recovery (85%) compared to other techniques, which showed recovery rates below 73% [5]. Conversely, a study by Morgan R. et al (2020) evaluating 21 patients with distal brachial plexus injury who underwent surgical neurolysis and open fasciotomy observed an improvement in the motor component, and other studies have shown effectiveness in pain relief and sensory recovery [6,7]. Although the study by Morgan R. et al did not evaluate surgical neurolysis as an isolated technique, it provides valuable insights into its potential usefulness.…”