American Society for Peripheral Nerve

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Surgical Results, Postoperative Complications And Patient-Reported Outcomes Following Free Muscle Flap In Case Of Therapy Resistant Neuropathy: A Long-Term Retrospective Follow-Up Study
Sara Van Bekkum, MD; Dirk van der Avoort, MD; Michiel Zuidam, MD, PhD; J. Henk Coert, MD, PhD
University Medical Center Rotterdam, Rotterdam, Netherlands

Background: Persistent neuropathic pain has a big impact on physical functioning and quality of life. Patients have a history of multiple operations, with minimal impact on pain reduction. Numerous strategies have been published. However, optimal surgical management of persistent neuropathy remains unclear. As last treatment option to establish pain reduction, extensive neurolysis with a subsequent free muscle flap can be performed. This study examined effects and long-term outcomes of a free muscle flap as a final treatment option for persistent neuropathic pain.

Materials and methods: In a retrospective, cross-sectional, long-term follow up, single surgeon study, all consecutive patients who had received an extensive microsurgical neurolysis with a subsequent free muscle flap for persistent neuropathic pain between 2007 and 2014 were identified. Patient-reported upper extremity function and QoL were assessed using the 36-item short form health survey (SF-36), the disabilities of the arm, should, and hand questionnaire (DASH), and the Michigan hand outcomes questionnaire (MHQ).

Results: Seventeen patients were identified, of whom the majority had neuropathy due to nerve injury (82%). Patients had an average of 3.4 previous surgeries (1 to 6). Most patients received a free gracilis flap (88%). 65% had some kind of complication; flap loss occurred in 24%, these patients all received a new free flap, whereof one again failed. At the last follow up, the VAS score (median 4.0) significantly differed from the pre-operative VAS score (median 9.0, p < 0.001). The median post-operative VAS decline was 5.0 points. Twelve patients (75%) responded to the questionnaires with a mean follow up 5.1 Ī 2.4 year. Patients reported poorer SF-36 “Physical Component Score” and “Bodily Pain” (p = 0.006 and p = 0.001, respectively) compared to a normal population. Affected nerve, complications and post-operative VAS score were not related to patient reported outcomes. Patient-reported pain had a negative correlation with the total scores of the DASH, MHQ and SF-36. However, according to the MHQ, only 33% of the patients had still always (very) severe pain.

Conclusion: Extensive neurolysis with a free muscle flap coverage for persistent neuropathic pain show a positive effect on pain reduction on the short-term follow up, but also at 5 years follow-up. There is still an impact of pain on their functional outcomes. Nevertheless, most patients still have a sufficient pain reduction.

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