Prof. Dr. Mehmet Şenoğlu — Brain, Nerve and Spine Surgery
When brain and nerve surgery is mentioned, only the brain and the spine come to most people’s minds. Yet this field has another very valuable, but relatively little-known, branch: peripheral nerve surgery. For a large proportion of my patients who come to my office saying “My hand goes numb, I wake up from my sleep at night” or “My foot keeps catching, it’s as if I’m about to fall,” the problem lies not in the brain or the spine, but in the compression of a peripheral nerve going to the arm, the leg, the hand, or the foot.
In this article, I want to explain in clear language what peripheral nerve surgery is, in which conditions it comes into play, how it is performed, and what it promises and does not promise. Let me note something reassuring from the very start: the great majority of these conditions are managed with non-surgical methods; surgery is a solution that comes into play for the right patient, at the right time.
What Is the Peripheral Nervous System?
We can divide our nervous system into two. The central nervous system consists of the brain and the spinal cord; it is the command center. The peripheral nervous system, on the other hand, is the network of nerves that leaves this center and spreads throughout the entire body — much like the cables of an electrical installation running from the central point to every room of the house.
These nerves do three fundamental jobs:
- Producing movement (motor): They carry the command coming from the brain to the muscles; they enable you to move your finger and to walk.
- Carrying sensation (sensory): They transmit sensations such as touch, pain, temperature, and vibration to the brain.
- Regulating autonomic functions: They manage involuntary functions such as sweating and vascular tone.
When there is compression, crushing, cutting, or a tumor anywhere along these cables, numbness, pain, loss of strength, or loss of sensation appears in the region that nerve serves. This is exactly what peripheral nerve surgery deals with.
What Is Peripheral Nerve Surgery?
Peripheral nerve surgery is the field concerned with the surgical treatment of conditions of the peripheral nerves that lie outside the brain and the spinal cord. Its fundamental aims are as follows:
- To release (decompression): To free a compressed nerve from the structure pressing on it.
- To repair: To rejoin a cut or injured nerve, or to bridge it by placing tissue (a graft) in between.
- To remove: To take out tumors developing on or within the nerve.
- To relieve pain: To apply surgical techniques in some stubborn nerve-pain pictures.
For Which Conditions Is Peripheral Nerve Surgery Used?
Nerve Compressions (Entrapment Neuropathies)
This group is the most frequent reason for peripheral nerve surgery. The nerve comes under pressure while passing through an anatomically narrow canal. The ones we encounter most often:
- Carpal tunnel syndrome: This is the compression of the median nerve at the wrist; it is the most common entrapment neuropathy. It causes numbness in the thumb, index, and middle finger, tingling that increases at night and wakes one from sleep, and, in advanced cases, loss of strength and grip in the hand.
- Cubital tunnel syndrome: This is the compression of the ulnar nerve on the inner side of the elbow. Numbness in the ring and little fingers, complaints that increase on bending the elbow, and, in the later stage, thinning of the hand (muscle wasting) are seen. Among the public, it is confused with the sensation felt when the elbow strikes the “funny bone.”
- Guyon’s canal syndrome: This is the compression of the ulnar nerve at the level of the wrist.
- Peroneal nerve compression: It is compressed on the outer side of the knee; it leads to difficulty in raising the foot upward (foot drop) and to catching while walking.
- Tarsal tunnel syndrome: This is the compression of the tibial nerve at the ankle; it causes burning and numbness in the sole of the foot.
- Meralgia paresthetica: This is the compression, in the groin region, of the sensory nerve going to the outer surface of the thigh; it gives a burning and numb sensation in the thigh.
- Thoracic outlet syndrome: This is the compression of the vessel–nerve bundle between the neck and the armpit; it causes pain, numbness, and weakness in the arm.
Nerve Injuries (Traumatic)
Sharp-object injuries, glass cuts, traffic accidents, and nerve damage accompanying fractures fall into this group. If a nerve is completely cut, it does not resolve on its own; surgical repair is required. Here, timing is very important — in some situations, early intervention markedly affects the outcome.
Brachial Plexus Injuries
This is injury to the complex network of nerves (the brachial plexus) that leaves the neck and goes to the arm. It is frequently seen after motorcycle accidents and birth traumas. This picture, which can lead to severe loss of strength in the arm, is a special surgical field that requires experience.
Peripheral Nerve Tumors
Most of the tumors arising from the nerve sheath (such as schwannoma and neurofibroma) are benign. The aim is to protect the nerve fibers as much as possible while removing the tumor; this requires microsurgical precision.
Nerve Pain Surgery
In some stubborn pain pictures (for example, in pain arising from a neuroma that forms after surgery or trauma), surgical techniques may come onto the agenda.
Symptoms: What Does the Body Say When a Nerve Is Compressed?
I often ask my patients: “Where do your complaints begin, and where do they spread?” Because peripheral nerve problems have a language of their own:
- Numbness and tingling in specific fingers or a body region
- Complaints that increase at night and pass when the hand is shaken (the classic sign of carpal tunnel)
- Loss of strength: Being unable to open a jar, to button a button, the foot catching
- Muscle wasting in advanced cases (thinning in the hand or the leg)
- Burning, electric-shock-like pains
- Reduced sensation in the affected region
An important distinction: These complaints can sometimes also stem from a cervical or lumbar disc herniation. In what we call “double crush,” the nerve can be compressed both in the neck and at the wrist. For this reason, determining the correct level is critical for the success of treatment.
How Is the Diagnosis Made?
The diagnosis rests not on a single test but on the whole picture. The first and most valuable step is a detailed history and neurological examination; I assess which nerve’s territory the complaint fits, muscle strength, loss of sensation, and special examination tests (such as Tinel and Phalen).
Then, when needed, we turn to the following methods:
- EMG (electromyography) and nerve conduction study: This is the most valuable test in peripheral nerve conditions. It measures where and how much the nerve is compressed and the degree of the damage.
- Ultrasound and MRI: They show the structure of the nerve, the pressure around it, and a tumor if there is one.
- Blood tests: To investigate systemic causes affecting the nerves, such as diabetes, vitamin deficiency, and thyroid problems.
Does Every Nerve Compression Require Surgery?
Absolutely not. This is one of the points I emphasize most. Especially in early and moderate compressions, non-surgical (conservative) treatment is the first choice:
- Resting with a splint: For example, in carpal tunnel, a night wrist splint is very helpful.
- Activity adjustment: Avoiding repetitive, straining movements.
- Medication and, when needed, local injections (such as steroid).
- Physical therapy and nerve-gliding exercises.
- Treating the underlying cause: Diabetes control, weight loss, correcting a vitamin deficiency.
These methods provide marked relief in many patients. Surgery only comes onto the agenda when these treatments prove insufficient, or when there is serious damage from the outset.
When Is Surgery Needed?
I generally recommend surgery in the following situations:
- Complaints that do not go away despite non-surgical treatment applied for an adequate period and that disrupt quality of life
- Progressive loss of strength or muscle wasting (this is a warning that our leeway to wait is decreasing)
- Findings of advanced-degree nerve damage on EMG
- A completely cut nerve or a tumor growing on the nerve
Here I would like to underline: if muscle wasting has begun, it is important not to delay in the decision to operate. Because a nerve that has been severely damaged may not fully return to its former function even if it is released with surgery. Time is, most of the time, the most critical factor in nerve surgery.
Methods Used in Peripheral Nerve Surgery
Decompression (Nerve Release)
This is the most frequently applied procedure. The ligament, tunnel wall, or tissue compressing the nerve is removed from over it, letting the nerve breathe. For example, in carpal tunnel surgery, the ligament crossing the wrist is loosened. It can generally be done through a small incision, most of the time under local anesthesia.
Nerve Repair (Neurorrhaphy)
This is the joining of the two ends of a cut nerve with very fine sutures under a microscope. If the ends can be brought together end to end without tension, a direct repair is performed.
Nerve Graft
If the distance between the two ends is too wide to allow repair, a piece of nerve (a graft) taken from another part of the body is placed in between as a bridge. Usually a sensory nerve taken from the patient’s own leg, whose loss does not create a significant problem, is used.
Nerve Transfer (Neurotization)
Especially in severe injuries such as those of the brachial plexus, the aim is to restore movement by transferring a branch of a nearby working nerve to a nerve that has lost its function.
Tumor Removal
Nerve-sheath tumors are removed carefully with a microsurgical technique, in a way that protects the nerve fibers.
The Elements That Make Surgery Safe
In all these procedures, the surgical microscope and microsurgical techniques are essential, because peripheral nerves are millimetric structures. Monitoring nerve function during the operation (neuromonitoring) also increases safety in some cases.
The Recovery Process: A Journey That Requires Patience
I must be honest here: in peripheral nerve surgery, recovery is, most of the time, a process that requires patience.
After a simple decompression operation (for example, carpal tunnel), the numbness and night pains recede quickly in most patients. However, when a cut nerve is repaired, the story is different. The nerve begins to grow again from the point of repair, and this growth is very slow — roughly about one millimeter per day. For this reason, especially in long-distance repairs, the return of function can take months, sometimes periods exceeding a year.
In this process, physical therapy and rehabilitation are an inseparable part of the operation. Surgery repairs or releases the nerve; regaining the muscles and movement, meanwhile, becomes possible with regular exercise.
Managing Expectations: What Does Surgery Promise, and What Does It Not?
I am including this heading in particular. The area in which peripheral nerve surgery is at its strongest is relieving nerve compressions in the early and moderate period; in these cases, the results are generally very satisfying.
In contrast, in a nerve that has been compressed for a long time and severely damaged, expectations should be more measured. Surgery most of the time stops the progression and reduces the complaints; however, if permanent damage has occurred, it cannot always guarantee that function will fully return to its former state. This is why early diagnosis and timely treatment are so valuable.
What Can You Do to Protect Yourself?
- Take breaks during repetitive movements: If you use a keyboard, mouse, or hand tool for long periods, take regular breaks.
- Pay attention to ergonomics: Keep your wrist in a neutral position, and do not rest your elbow on a hard surface for long periods.
- Keep your diabetes under control: Uncontrolled blood sugar is one of the greatest enemies of the nerves.
- Weight control and balanced nutrition: Vitamin deficiencies such as B12 impair nerve health.
- Avoid smoking and excessive alcohol: Both damage nerve tissue.
- Do not ignore complaints: Presenting early is the most effective way to prevent permanent damage.
For Which Symptoms Should a Doctor Be Consulted Without Delay?
The following situations require evaluation without loss of time:
- Suddenly starting, progressive loss of strength in an arm or leg
- Visible muscle wasting (thinning) in the hand or foot
- Loss of sensation/movement in the hand, arm, or leg after a sharp-object or glass injury — this may be a sign of a cut nerve, and early intervention is important
- Foot drop: Being unable to raise the foot upward, constantly catching while walking
- Stubborn numbness and pains that wake one from sleep at night and continue during the day as well
- A steadily increasing loss of dexterity in the hand (difficulty with buttoning, with writing)
Findings such as loss of strength and muscle wasting, in particular, are warning signs about which one should not say, “Let’s wait a little longer.”
Frequently Asked Questions
Below, I have gathered the most frequently asked questions about peripheral nerve surgery along with brief answers. These answers are for general information; the information that applies to your specific situation is the one given by the doctor who examines you.
What is peripheral nerve surgery, and for which conditions is it used?
It is the surgical treatment of conditions of the peripheral nerves outside the brain and the spinal cord. Its most frequent area of application is nerve compressions (such as carpal tunnel and cubital tunnel). It is also used in the repair of cut nerves, in brachial plexus injuries, in the removal of nerve tumors, and in some stubborn nerve pains.
Which department should one go to for carpal tunnel surgery?
Nerve compressions can be handled by Neurosurgery (Brain and Nerve Surgery), Orthopedics, and Plastic Surgery; in the diagnosis and conservative-treatment process, Neurology and Physical Medicine and Rehabilitation play an important role. The nature of your complaint determines the right department; guidance is provided with an examination and EMG.
Does every nerve compression require surgery?
No. Especially in early and moderate compressions, resting with a splint, activity adjustment, medication, injection, and physical therapy are the first choice. Surgery comes onto the agenda in cases that do not respond to these treatments, or that have progressive loss of strength or muscle wasting.
How long does recovery take after nerve surgery?
It varies greatly according to the procedure performed. After a simple decompression (such as carpal tunnel), the numbness and night pains recede quickly in most patients. However, after the repair of a cut nerve, because the nerve grows very slowly, roughly one millimeter per day, the return of function can take months, sometimes exceeding a year.
Does a cut nerve return to its former state?
When repaired early and appropriately, a nerve can repair itself to a large extent. However, the outcome depends on the type of the cut nerve, the distance, the patient’s age, and the time of intervention. In long-distance and delayed injuries, full recovery may not always be possible. For this reason, presenting early is very important.
Is carpal tunnel surgery a major operation?
It is generally a short procedure done through a small incision, most of the time under local anesthesia. Most patients go home the same day. Even so, like every surgical procedure, it has its own specific risks; I recommend discussing these with the surgeon who evaluates you.
What are the risks of nerve surgery?
Bleeding, infection, wound-site problems, temporary sensory changes, and, rarely, nerve damage are among the possible risks. Thanks to microsurgical techniques, serious complications are rare. Only the surgeon who evaluates you can explain the risk profile specific to you.
Is the numbness in my hand from a cervical disc herniation or from carpal tunnel?
Both can cause similar complaints and sometimes occur together (“double crush”). We make the distinction by which fingers the numbness is in, the examination findings, and EMG. Determining the correct level is essential for the correct treatment; for this reason, being evaluated rather than diagnosing yourself is important.
Disclaimer (Legal Notice)
The information contained in this article has been prepared for general informational purposes only and in no way replaces a medical examination, diagnosis, or treatment. The diagnosis of peripheral nerve conditions, the decision regarding treatment and surgery, the method to be applied, the risks, and the recovery process vary greatly according to the type of the condition, the degree of nerve damage, the severity of the complaints, and the person’s general state of health, and can only be determined by a doctor who evaluates you. For any decision regarding diagnosis and treatment, always consult a specialist physician. If the emergency symptoms mentioned above are present, go to the nearest healthcare facility without delay.