A nerve decompression is a

neurosurgical Neurosurgery or neurological surgery, known in common parlance as brain surgery, is the medical specialty concerned with the surgical treatment of disorders which affect any portion of the nervous system including the brain, spinal cord and peri ...

procedure to relieve chronic, direct pressure on a nerve to treat

nerve entrapment Nerve compression syndrome, or compression neuropathy, or nerve entrapment syndrome, is a medical condition caused by direct pressure on a nerve. It is known colloquially as a ''trapped nerve'', though this may also refer to nerve root compress ...

, a pain syndrome characterized by severe

chronic pain Chronic pain is classified as pain that lasts longer than three to six months. In medicine, the distinction between acute and chronic pain is sometimes determined by the amount of time since onset. Two commonly used markers are pain that continues ...

and muscle weakness. In this way a nerve decompression targets the underlying

pathophysiology Pathophysiology ( physiopathology) – a convergence of pathology with physiology – is the study of the disordered physiological processes that cause, result from, or are otherwise associated with a disease or injury. Pathology is t ...

of the syndrome and is considered a first-line surgical treatment option for

peripheral nerve A nerve is an enclosed, cable-like bundle of nerve fibers (called axons) in the peripheral nervous system. A nerve transmits electrical impulses. It is the basic unit of the peripheral nervous system. A nerve provides a common pathway for the e ...

pain. Despite treating the underlying cause of the disease, the symptoms may not be fully reversible as delays in diagnosis can allow permanent damage to occur to the nerve and surrounding

microvasculature The microcirculation is the circulation of the blood in the smallest blood vessels, the microvessels of the microvasculature present within organ tissues. The microvessels include terminal arterioles, metarterioles, capillaries, and venules. ...

. Traditionally only nerves accessible with open surgery have been good candidates, however innovations in

laparoscopy Laparoscopy () is an operation performed in the abdomen or pelvis using small incisions (usually 0.5–1.5 cm) with the aid of a camera. The laparoscope aids diagnosis or therapeutic interventions with a few small cuts in the abdomen.Medl ...

and nerve-sparing techniques made nearly all nerves in the body good candidates, as surgical access is no longer a barrier.

Surgical planning

Surgical planning is distinct from diagnosis of entrapment. Diagnosis will focus on a binary decision: does the patient have entrapment or not? A diagnosis may not be enough information for surgery on its own as the area to explore may be too large. Surgical planning seeks to localize the specific area of entrapment to improve surgical outcomes. Identifying the level of entrapment is an important consideration for surgery as decompressing the wrong area will lead to a failed surgery (e.g. performing back surgery for extra-spinal sciatica), failure to treat nerve entrapment early can lead to permanent nerve injury, and the patient may be unnecessarily exposed to surgical complications.

Diagnostic blocks

CT image guided injection pudendal nerve

Diagnostic nerve blocks can confirm the clinical diagnosis for chronic pain as well as identify the entrapment site.Wiederhold BD, Garmon EH, Peterson E, et al. Nerve Block Anesthesia. pdated 2023 Apr 29 In: StatPearls nternet Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK431109/ A diagnostic block is like an inverted

palpation Palpation is the process of using one's hands to check the body, especially while perceiving/diagnosing a disease or illness. Usually performed by a health care practitioner, it is the process of feeling an object in or on the body to determine ...

in the sense that palpation will cause a

sensory nerve A sensory nerve, or afferent nerve, is a general anatomic term for a nerve which contains predominantly somatic afferent nerve fibers. Afferent nerve fibers in a sensory nerve carry sensory information toward the central nervous system (CNS) f ...

to send a signal (

action potential An action potential occurs when the membrane potential of a specific cell location rapidly rises and falls. This depolarization then causes adjacent locations to similarly depolarize. Action potentials occur in several types of animal cells, ...

) and a block will prevent a sensory nerve from sending a signal. By blocking nerve signals, the pain-contributing nerves can be identified or ruled out. Nerves are predisposed to entrapment in certain anatomical regions such as in an osteofibrous tunnels, through a muscle, adjacent to fibrous tissue. Consequently, knowledge of these anatomical regions as well as peripheral nerve anatomy is an essential component to planning successful diagnostic blocks.

Ultrasound Ultrasound is sound waves with frequencies higher than the upper audible limit of human hearing. Ultrasound is not different from "normal" (audible) sound in its physical properties, except that humans cannot hear it. This limit varies fr ...

is a common form of image-guidance to place the needle properly, but it faces limitations visualizing small and deep nerves. CT- or

MRI Magnetic resonance imaging (MRI) is a medical imaging technique used in radiology to form pictures of the anatomy and the physiological processes inside the body. MRI scanners use strong magnetic fields, magnetic field gradients, and radio w ...

- guidance are better positioned to access deep nerves as well as identify the anatomic level of the needle.

Imaging

MRI may be used to identify certain causes of entrapment such as a structural lesions pressing on a nearby nerve, but is prone to false negatives/positives and has poor correlation with the clinical examination. A major limitation with MRI is that nerve tissue is resistant to imaging. An advancement of MRI that takes advantage of the tissue properties of nerves, called MR neurography (MRN), provides more detail. MR tractography (MRT) can also be of use in surgical planning as it can identify peripheral nerve abnormalities with a high correlation to intraoperative findings and has higher accuracy than MR neurography alone. MRT uses

diffusion tensor imaging Diffusion-weighted magnetic resonance imaging (DWI or DW-MRI) is the use of specific MRI sequences as well as software that generates images from the resulting data that uses the diffusion of water molecules to generate contrast in MR images. It ...

to visualize the directional movement of water molecules along nerve tracts. Often an abnormality can be identified along tracts of nerve where water is not diffusing normally along the axis. MRT has been used to identify sacral nerve entrapment by the piriformis muscle, which would otherwise only be diagnosable with

exploratory surgery Exploratory surgery is a diagnostic method used by doctors when trying to find a diagnosis for an ailment. With the invention of modern imaging techniques, exploratory surgery is becoming less common in humans. Due to the high cost and lower avail ...

List of surgeries

A non-exhaustive list of nerve decompression surgeries includes *

discectomy A discectomy (also called open discectomy, if done through a 1/2 inch or larger skin opening) is the surgical removal of abnormal disc material that presses on a nerve root or the spinal cord. The procedure involves removing a portion of an int ...

for

spinal disc herniation Spinal disc herniation is an injury to the cushioning and connective tissue between vertebrae, usually caused by excessive strain or trauma to the spine. It may result in back pain, pain or sensation in different parts of the body, and physica ...

laminectomy A laminectomy is a surgical procedure that removes a portion of a vertebra called the lamina, which is the roof of the spinal canal. It is a major spine operation with residual scar tissue and may result in postlaminectomy syndrome. Depend ...

for

cauda equina syndrome Cauda equina syndrome (CES) is a condition that occurs when the bundle of nerves below the end of the spinal cord known as the cauda equina is damaged. Signs and symptoms include low back pain, pain that radiates down the leg, numbness around th ...

microvascular decompression Microvascular decompression (MVD), also known as the Jannetta procedure, is a neurosurgical procedure used to treat trigeminal neuralgia (along with other cranial nerve neuralgias) a pain syndrome characterized by severe episodes of intense facial p ...

for

trigeminal neuralgia Trigeminal neuralgia (TN or TGN), also called Fothergill disease, tic douloureux, or trifacial neuralgia is a long-term pain disorder that affects the trigeminal nerve, the nerve responsible for sensation in the face and motor functions such as ...

* multiple nerve decompression surgery for diabetic peripheral neuropathy *

migraine surgery Migraine surgery is a surgical operation undertaken with the goal of reducing or preventing migraines. Migraine surgery most often refers to surgical decompression of one or several nerves in the head and neck which have been shown to trigger migra ...

for

migraines Migraine (, ) is a common neurological disorder characterized by recurrent headaches. Typically, the associated headache affects one side of the head, is pulsating in nature, may be moderate to severe in intensity, and could last from a few hou ...

piriformis muscle The piriformis muscle () is a flat, pyramidally-shaped muscle in the gluteal region of the lower limbs. It is one of the six muscles in the lateral rotator group. The piriformis muscle has its origin upon the front surface of the sacrum, and ...

release for

piriformis syndrome Piriformis syndrome is a condition which is believed to result from compression of the sciatic nerve by the piriformis muscle. Symptoms may include pain and numbness in the buttocks and down the leg. Often symptoms are worsened with sitting or ...

sciatic nerve The sciatic nerve, also called the ischiadic nerve, is a large nerve in humans and other vertebrate animals which is the largest branch of the sacral plexus and runs alongside the hip joint and down the lower limb. It is the longest and widest si ...

decompression for

deep gluteal syndrome Piriformis syndrome is a condition which is believed to result from compression of the sciatic nerve by the piriformis muscle. Symptoms may include pain and numbness in the buttocks and down the leg. Often symptoms are worsened with sitting or ru ...

pudendal nerve The pudendal nerve is the main nerve of the perineum. It carries sensation from the external genitalia of both sexes and the skin around the anus and perineum, as well as the motor supply to various pelvic muscles, including the male or ...

decompression for

pudendal neuralgia Pudendal nerve entrapment (PNE), also known as Alcock canal syndrome, is an uncommon source of chronic pain in which the pudendal nerve (located in the pelvis) is entrapped or compressed in Alcock's canal. There are several different types of ...

lateral femoral cutaneous nerve The lateral cutaneous nerve of the thigh (also called the lateral femoral cutaneous nerve) is a cutaneous nerve of the thigh. It originates from the dorsal divisions of the second and third lumbar nerves from the lumbar plexus. It passes under t ...

(LFCN) decompression for

meralgia paresthetica Meralgia paresthetica or meralgia paraesthetica is numbness or pain in the outer thigh not caused by injury to the thigh, but by injury to a nerve that extends from the spinal column to the thigh. This chronic neurological disorder involves a ...

sacral plexus In human anatomy, the sacral plexus is a nerve plexus which provides motor and sensory nerves for the posterior thigh, most of the lower leg and foot, and part of the pelvis. It is part of the lumbosacral plexus and emerges from the lumbar ver ...

decompression for intrapelvic nerve entrapments *

brachial plexus The brachial plexus is a network () of nerves formed by the anterior rami of the lower four cervical nerves and first thoracic nerve ( C5, C6, C7, C8, and T1). This plexus extends from the spinal cord, through the cervicoaxillary canal in th ...

decompression, scalenectomy, first rib resection, and clavicle resection for thoracic outlet syndrome

Surgical outcomes

Nerve decompressions are still a relatively new surgery, however a picture emerges from looking at the outcomes of some of the most studied nerve decompressions:

carpal tunnel release Carpal tunnel surgery, also called carpal tunnel release (CTR) and carpal tunnel decompression surgery, is a surgery in which the transverse carpal ligament is divided. It is a surgical treatment for carpal tunnel syndrome (CTS) and recommended whe ...

decompression, and

. Even within these commonly performed surgeries, the measurement of outcomes is not always standardized. Common ways of measuring outcomes are syndrome-specific disability questionnaires (e.g. Boston Carpal Tunnel Questionnaire, Oswestry low back disability questionnaire, and the migraine disability assessment);

visual analog scale The visual analogue scale (VAS) is a psychometric response scale that can be used in questionnaires. It is a measurement instrument for subjective characteristics or attitudes that cannot be directly measured. When responding to a VAS item, respond ...

(VAS); physical examination findings; and subjective patient satisfaction.

Carpal tunnel release

Carpal tunnel In the human body, the carpal tunnel or carpal canal is the passageway on the palmar side of the wrist that connects the forearm to the hand. The tunnel is bounded by the bones of the wrist and flexor retinaculum from connective tissue. Norma ...

surgery has a clinical success rate of 75-90%. Success is most frequently measured with the Boston Carpal Tunnel Questionnaire, physical examination (sensory function, motor function, pain, electrodiagnostic, trophic function), and patient self-assessments. One study found that while 86% of patients improved, only 26% had complete recovery of clinical and electrodiagnostic findings. Of the functional assessments, pain showed the greatest improvements following surgery. Another study compared carpal tunnel syndrome patients who elected surgery with those who chose not to. 77% of the surgery group said they were cured compared to 16% who did not elect surgery. While some of the success of surgery may just be due to the natural history of the disease, the surgery groups still have an improvement in outcomes over conservative measures. A systematic review found that surgical treatment outweighed the benefits over conservative treatment overall all outcome measures, however conservative treatment caused fewer complications.

Sciatic nerve decompression

A systematic review has found that 90% of surgery patients see improved pain scores with scores improving on average from 6.7 preoperatively to 2.1 postoperatively. In the literature, the most common outcome measurement for sciatic nerve decompressions is the visual analog scale, where patients rate their pain on a 100mm horizontal line that gets converted into a numeric score from 0-10 or 0–100. The main disability questionnaires used are the modified Harris Hip score (mHHS) and the Oswestry low back disability questionnaire. One study found that all deep gluteal syndrome surgery patients who were taking narcotics for pre-operative pain (n = 21) no longer needed narcotics for the initial complaint after decompression surgery.

Migraine surgery

A systematic review has found that the improvement is seen in 68-100% of surgery patients and complete

migraine Migraine (, ) is a common neurological disorder characterized by recurrent headaches. Typically, the associated headache affects one side of the head, is pulsating in nature, may be moderate to severe in intensity, and could last from a few ho ...

elimination is seen in 8-86% of surgery patients. The outcomes are usually measured in migraine intensity, frequency, and duration (an early measurement, the migraine headache index, was just the product of these numerical values). The most common migraine disability questionnaires are the migraine disability assessment (MIDAS), headache impact test (HIT), and migraine specific quality of life questionnaire (MSQ). One randomized study compared the efficacy of migraine surgery to pharmacologic treatment and found that surgical treatment had a significantly higher success rate than medical treatment. Notably, 36% of patients in the surgical treatment group experienced complete elimination of migraine headaches, compared to and 4% in the medical treatment group. Another randomized study compared surgery to sham surgery. 57% of the surgery group experienced complete elimination of migraine headaches, compared on only 4% of the sham surgery group. A separate study examining outcomes found that there was a bimodal distribution (two main outcomes), where approximately >80% of patients saw either at least an 80% reduction in symptoms or less than 5% reduction. Of the patients seeing significant improvement, the mean improvement was 96%. Of the patients seeing minimal improvement, the average improvement was 0%. Paying special attention to complete elimination of migraines or measuring outcomes after long follow ups (e.g. years) may be important for assessing the efficacy of migraine surgery because headache research has found a strong

placebo effect A placebo ( ) is a substance or treatment which is designed to have no therapeutic value. Common placebos include inert tablets (like sugar pills), inert injections (like saline), sham surgery, and other procedures. In general, placebos can aff ...

. A large meta-analysis found that the placebo effect in acute migraine treatments was greatly reduced when the treatment outcome was "pain-free" (9% of patients) compared to "improved" (30% of patients). Studies that have compared migraine surgery to a control group have found similarly low placebo cure rates, both at 4%.

Complications

Complications can be

perioperative The perioperative period is the time period of a patient's surgical procedure. It commonly includes ward admission, anesthesia, surgery, and recovery. Perioperative may refer to the three phases of surgery: preoperative, intraoperative, and post ...

or postoperative. Among the generic set of surgical complications such as bleeding, infection, scarring, complications from

general anesthesia General anaesthesia (UK) or general anesthesia (US) is a medically induced loss of consciousness that renders the patient unarousable even with painful stimuli. This effect is achieved by administering either intravenous or inhalational general ...

, etc. nerve decompressions come with a risk of

nerve injury Nerve injury is an injury to nervous tissue. There is no single classification system that can describe all the many variations of nerve injuries. In 1941, Seddon introduced a classification of nerve injuries based on three main types of nerve ...

. A nerve can be directly injured due to transection (cutting), traction (pulling), crush injuries (squeezing), destroying a blood vessel that supplied the nerve, etc. While nerve sparing techniques have been developed to mitigate nerve injury, the radical nature of decompression surgeries cannot eliminate the risk. In a large national study of carpal tunnel decompression postoperative complications, the serious complications seen were wound dehiscence, wound infection, tendon injury, and neurovascular injury. Serious postoperative complications, defined as requiring re-admittance to a hospital within 90 days, was relatively rare, at 0.1% over approximately 850,000 surgeries. Endoscopic sciatic nerve decompression has similarly low rates of complication. Two studies with a combined 95 patients found no complications. A systematic review also found a 0% major complication rate and a 1% minor complication rate for the endoscopic approach. A systematic review on migraine surgeries found a major complication rate of 1% and a liberal estimate on the minor complication rate of approximately 32%. The most common complications were

numbness Hypoesthesia or numbness is a common side effect of various medical conditions that manifests as a reduced sense of touch or sensation, or a partial loss of sensitivity to sensory stimuli. In everyday speech this is generally referred to as nu ...

paresthesia Paresthesia is an abnormal sensation of the skin (tingling, pricking, chilling, burning, numbness) with no apparent physical cause. Paresthesia may be transient or chronic, and may have any of dozens of possible underlying causes. Paresthesias ar ...

and itching. Another systematic review found the adverse event rate to be 11.6%. One of the challenges in cataloging the complication rate of migraine surgery is that it's a relatively new surgery and so the surgical treatment can be extremely heterogeneous across different surgeons (e.g. remove artery, remove muscle, decompress nerve, remove nerve all across one or more trigger sites).

Other procedures

An alternative to a decompression is a nerve resection. When the nerve does not have any motor fibres and loss of sensation is acceptable, removing the nerve in its entirety may be a more "complete" solution as it will address a much wider

dermatome Dermatome may refer to: * Dermatome (anatomy), an area of skin that is supplied by a single pair of dorsal roots * Dermatome (embryology), the portion of the embryonic paraxial mesoderm, the somite, which gives rise to dermis * Dermatome (instrument ...

(all distal nerve fibres from the point of excision). Nerve decompressions, in contrast, cannot explore the entire course of a nerve and all its branches and so may potentially miss the true entrapment point. For this reason, a nerve resection may be considered after a failed decompression. Examples of nerves that may be good candidates for resection are

zygomaticotemporal The zygomaticotemporal nerve (zygomaticotemporal branch, temporal branch) is a small nerve of the face. It is derived from the zygomatic nerve, a branch of the maxillary nerve (CN V2). It is distributed to the skin of the side of the forehead. It ...

branch of the

trigeminal nerve In neuroanatomy, the trigeminal nerve (literal translation, lit. ''triplet'' nerve), also known as the fifth cranial nerve, cranial nerve V, or simply CN V, is a cranial nerve responsible for Sense, sensation in the face and motor functions ...

, the

posterior femoral cutaneous nerve The posterior cutaneous nerve of the thigh (also called the posterior femoral cutaneous nerve) is a sensory nerve in the thigh. It supplies the skin of the posterior surface of the thigh, leg, buttock, and also the perineum. Structure The po ...

, and the

middle Middle or The Middle may refer to: * Centre (geometry), the point equally distant from the outer limits. Places * Middle (sheading), a subdivision of the Isle of Man * Middle Bay (disambiguation) * Middle Brook (disambiguation) * Middle Creek (d ...

superior cluneal nerves The superior cluneal nerves are pure sensory nerves that innervate the skin of the upper part of the buttocks. They are the terminal ends of the L1-L3 spinal nerve dorsal rami lateral branches.Waldman SD. Atlas of Uncommon Pain Syndromes. 3rd ed ...

. It's not clear whether a nerve resection is superior to a nerve decompression when both treatments may be suitable. A study on

occipital neuralgia Occipital neuralgia (ON) is a painful condition affecting the posterior head in the distributions of the greater occipital nerve (GON), lesser occipital nerve (LON), third occipital nerve (TON), or a combination of the three. It is paroxysmal, ...

in 2017 found that there was not enough data to make a determination. A study on

Meralgia Paraesthetica Meralgia paresthetica or meralgia paraesthetica is numbness or pain in the outer thigh not caused by injury to the thigh, but by injury to a nerve that extends from the spinal column to the thigh. This chronic (medicine), chronic neurological d ...

found higher success rates for nerve resection and that most patients were not bothered by numbness following the procedure.

History

The treatment of each peripheral

has its own history, making any single narrative incomplete. The symptoms of nerve injury in the early 1900s were called nerve palsy (today neuropathy or neuritis are more common terms). The concept of injuries causing nerve palsy was understood at that time. For example, wrist fractures were known to be a cause of nerve palsy through compression, and this could be treated by liberating the nerve. It was freeing the nerve after post-traumatic injuries that early nerve decompressions occurred. However, non-traumatic causes of nerve palsy were less clear, in some cases having no known explanation (

idiopathic An idiopathic disease is any disease with an unknown cause or mechanism of apparent spontaneous origin. From Greek ἴδιος ''idios'' "one's own" and πάθος ''pathos'' "suffering", ''idiopathy'' means approximately "a disease of its own kind ...

). The development of carpal tunnel syndrome to explain idiopathic tardy median nerve palsy formalized the concept of nerve compression at anatomic areas of narrowing, and influenced the development of other tunnel syndromes. This expanded the indications for nerve decompression both to idiopathic neuropathies as well as many parts of the body that exhibited anatomic areas of narrowing in the vicinity of a nerve. Nerve decompressions have benefited from advances in technology and peripheral nerve surgery. For example, use of the operating microscope (surgery that uses this microscope is now known as

microsurgery Microsurgery is a general term for surgery requiring an operating microscope. The most obvious developments have been procedures developed to allow anastomosis of successively smaller blood vessels and nerves (typically 1 mm in diameter) wh ...

) was important to the development of the Jannetta procedure for

Endoscopic surgery An endoscopy is a procedure used in medicine to look inside the body. The endoscopy procedure uses an endoscope to examine the interior of a hollow organ or cavity of the body. Unlike many other medical imaging techniques, endoscopes are inser ...

was an important advancement, as this allowed greatly expanded surgical access compared to open surgery. In particular, endoscopic surgery gave much better access to the pudendal nerve as well as the sciatic nerve, and allowed the possibility of decompressing the sacral plexus. The use of image-guided diagnostic

nerve blocks Nerve block or regional nerve blockade is any deliberate interruption of signals traveling along a nerve, often for the purpose of pain relief. Local anesthetic nerve block (sometimes referred to as simply "nerve block") is a short-term block, u ...

provided better capabilities to identify the entrapped nerve as well as the site of entrapment, leading to more accurate diagnosis and reducing the need for surgical exploration. The use of

magnetic resonance neurography Magnetic resonance neurography (MRN) is the direct imaging of nerves in the body by optimizing selectivity for unique MRI water properties of nerves. It is a modification of magnetic resonance imaging. This technique yields a detailed image of a n ...

(MRN) and

(DTI) have allowed better visualization of nerves, at times identifying the site of entrapment without the need for extensive surgical exploration.

Robot-assisted surgery Robotic surgery are types of surgical procedures that are done using robotic systems. Robotically assisted surgery was developed to try to overcome the limitations of pre-existing minimally-invasive surgical procedures and to enhance the capabi ...

is still in the early stages, not yet achieving widespread use for nerve decompressions or even for peripheral nerve surgery, however it can provide dexterity, precision, and stability not possible by hand. 1878: first

ulnar nerve In human anatomy, the ulnar nerve is a nerve that runs near the ulna bone. The ulnar collateral ligament of elbow joint is in relation with the ulnar nerve. The nerve is the largest in the human body unprotected by muscle or bone, so injury is c ...

decompression. However, it did not gain much traction at the time. 1933: first published

carpal tunnel surgery Carpal tunnel surgery, also called carpal tunnel release (CTR) and carpal tunnel decompression surgery, is a surgery in which the transverse carpal ligament is divided. It is a surgical treatment for carpal tunnel syndrome (CTS) and recommended whe ...

for post-traumatic compression 1946: first carpal tunnel surgery for idiopathic compression 1958: cubital tunnel surgery described 1962: tarsal tunnel surgery described 1967: Janetta procedure for trigeminal neuralgia 1989: endoscopic carpal tunnel surgery 1992:

Magnetic resonance neurography Magnetic resonance neurography (MRN) is the direct imaging of nerves in the body by optimizing selectivity for unique MRI water properties of nerves. It is a modification of magnetic resonance imaging. This technique yields a detailed image of a n ...

described. First clinical study on nerve decompressions to relieve symptoms of diabetic peripheral neruopathy. 1994:

Diffusion tensor imaging Diffusion-weighted magnetic resonance imaging (DWI or DW-MRI) is the use of specific MRI sequences as well as software that generates images from the resulting data that uses the diffusion of water molecules to generate contrast in MR images. It ...

described 1997 endoscopic pudendal nerve decompression 2000: correlation found between brow lifts and migraine reduction. This is the precursor to modern

. 2003: arthroscopic piriformis muscle release 2005: Magnetic resonance neurography and image-guided injections used in a clinical research study to improve nerve decompression outcomes 2010: endoscopic sciatic nerve decompression 2015: laparoscopic sacral plexus decompression; robotic pudendal nerve decompression

Society and culture

Controversy

Surgical nerve decompression has caused controversy across various medical specialties. The controversy is generally over the interpretation of available evidence and quality of evidence necessary to consider nerve decompression as a valid treatment option for specific diseases/syndromes.

Critics

Critics generally believe the results of specific nerve decompression surgeries are attributable to either the

(patient expectations influencing outcomes) or natural history (patients getting better on their own). Critics sometimes reject the validity of nerve decompression surgery because the thesis of

nerve compression Nerve compression syndrome, or compression neuropathy, or nerve entrapment syndrome, is a medical condition caused by direct pressure on a nerve. It is known colloquially as a ''trapped nerve'', though this may also refer to nerve root compress ...

conflicts with preexisting theories about how certain diseases work. In diabetic peripheral neuropathy (treatable in some cases with multiple nerve decompressions) and

(

is a nerve decompression), critics dispute the interpretation of the results because the majority of studies are of retrospective case series (reports of surgeries performed in the past) rather than

prospective Prospective refers to an event that is likely or expected to happen in the future. For example, a ''prospective student'' is someone who is considering attending a school. A prospective cohort study is a type of study, e.g., in sociology or medic ...

randomized controlled trials A randomized controlled trial (or randomized control trial; RCT) is a form of scientific experiment used to control factors not under direct experimental control. Examples of RCTs are clinical trials that compare the effects of drugs, surgical te ...

(RCTs), and so any positive results of surgery could be influenced by methodological flaws such as lack of proper

control groups In the design of experiments, hypotheses are applied to experimental units in a treatment group. In comparative experiments, members of a control group receive a standard treatment, a placebo, or no treatment at all. There may be more than one tr ...

. Critics may believe that given the lack of RCTs on nerve decompression surgery, and the known risk of surgical complications (however small), nerve decompression should not be recommended.

Proponents

Proponents have alleged that the success of treating previously untreatable patients validates decompression as a treatment. That RCTs in surgical research have ethical issues, as a proper control group would receive a placebo surgery and be exposed to surgical complications. That prospective RCTs should not be the only way to reason about whether a therapy is effective given the challenges in using RCTs to study surgery (a suggested alternative is to compare surgery to the best existing treatments). That potential bias in existing studies doesn't account for the large, reproducible effects of nerve decompression, so the results should not be discounted just because the studies aren't RCTs. That the improvement from surgery is clearly much larger than the studied magnitude of the placebo effect, and so cannot be explained by it. That suggesting surgery is placebo is a double standard when these same treatment-resistant patients do not benefit from the placebo effect of failed non-surgical treatments and even prior failed surgical treatments. Proponents have noted that nerve compressions are seen in many other nerves, and that we should expect to see some number of patients with entrapments of any given peripheral nerve. Proponents have asserted that some critics have gone beyond healthy skepticism, exaggerated proponents' claims, argued against positions the proponents did not make, levied non-constructive criticism, and misinterpreted the placebo effect in ways not supported by peer-reviewed research.

References

{{reflist Surgical procedures and techniques