Technical Bulletin 4

4.  Preliminary Recommendations On The Use Of Surgery For The Treatment Of Leprosy Neuritis: Caution Concerning The Use Of Surgery In Prevention Of Deformities

1.  THE PLACE OF DIRECT NERVE SURGERY IN PREVENTION OF DEFORMITIES

Deformities and disabilities are the consequence of leprosy neuritis, thus the best prevention of deformities is:

• First, the early detection and treatment of as many patients as possible.
• Then, the early detection and appropriate treatment of reactions which involve the nerves.

The therapy of leprosy now uses well tried MDT regimens and new drugs for treatment of both uncomplicated disease and leprosy reactions. Unfortunately, chemotherapy is not always used early enough, is not always well conducted, well tolerated or well followed.

In addition, anti-inflammatory treatment, even with corticosteroids (or thalidomide in ENL neuritis), cannot always relieve inflammation of nerves nor the mechanical compressions which occurs in a thickened sheath, especially where the inflamed hypertrophied nerve passes through an unyielding osteo-fibrous tunnel and this also contributes to the destruction of nerve bundles.

Thus, when medical treatment alone is not sufficient to relieve nerve damage, it is clear that mechanical compression could be relieved by opening the tunnel and incision of the thickened sheath.

This nerve surgery has a long history and has been claimed to give good results when performed before the damage becomes irreversible.

However, many therapists still have doubts about the efficiency of nerve decompression. They think it is not possible to determine whether nerve surgery will give better results than medical treatment alone.

There are three main explanations for their doubts:

• Even if for more than thirty years, good results of nerve surgery in leprosy have been reported by many authors, these authors have not had the same data and methods of evaluation. In particular, the duration or the type of neuritis and the duration of follow-up have hardly been specified. Furthermore, all surgeons have not had the same facilities and not all have used the same indications for surgery. Many of them have practised full time in the hospitals of main cities, in institutes, or in research centres and some of them have practised in the field, in provincial or district hospitals.
• Sometimes, quite sincere therapists, who have asked surgeons for nerve decompression, have thought the immediate result of surgical decompression was a failure because they do not know that recovery is not immediate. Usually recovery duration may take some months or even one year for ulnar nerve.
• Many authors have reported good results with medical treatment alone and they consider that the need for both external and internal nerve surgical decompression has been very much reduced. Nevertheless, it may be observed:

• That medical treatment alone may have drawbacks.
• That in some published cases (but how many are unpublished?) of corticosteroid treatment, sometimes prolonged for more than one or even two years, there was no recovery. If nerve surgery is then subsequently performed, it has no utility.

In some of those cases, in which pain is finally relieved, it could be said that medical treatment alone has finally brought an improvement. However, decreased pain is not necessarily an indication of improvement of the nerve because pain may decrease as nerve function decreases.

In these cases, earlier surgical nerve decompression might have given recovery and therefore shortened the corticosteroid treatment duration of neuritis.

Indeed, some ‘good’ results of MDT in a country where experienced surgeons are available have recently been reported ‘with no record of disability over grade 1’. What will be the evolution of these grade 1 disabilities in three or five years?

2.  RESEARCH STUDY ON THE PLACE OF SURGICAL NERVE DECOMPRESSION

Over two years ago, it was proposed to the ILEP Medical Commission to undertake a complementary investigation on ‘direct nerve surgery’. This proposal which was originally put forward during the ILA Hague Congress in September 1988 was accepted.

This multicentered and comparative study has to be undertaken with:

• Statistically significant trials despite the large number of variables.
• A necessarily long follow-up.

And the objectives are:

• To compare surgical decompression with treatment of neuritis by medical treatment alone.
• To confirm whether nerve surgical decompression is effective (when medical treatment is not sufficient to improve nerve damage).

So far, not one of these results has been supported by a convincing controlled study. However, at the time when the ILEP Medical Commission Therapy Discipline is developing a research study on ‘Reversal Reaction Treatment in Borderline (BT - BL) Leprosy’, this seems a good opportunity for a study on ‘The place of Nerve Surgery for better Treatment of Reaction Neuritis’. It could be conducted by the ILEP Rehabilitation Discipline in liaison with the Therapy Discipline research study.

Co-ordination of these trials will make the comparative study easier, broader, quicker and an assessment of the results by both surgeons and therapists more objective and less debatable.

3.  RECOMMENDATIONS ON INDICATIONS AND TECHNIQUES NOW AGREED FOR NERVE SURGERY

Until the results of a multi-centre trial on the value of surgical decompression are reported, only basic recommendations are possible.

The recommendations listed below were agreed by a working group of the Rehabilitation Discipline of the ILEP Medical Commission which met 5 - 6 July 1990 in London:

4.  RECOMMENDATIONS

• In a certain number of cases in addition to medical treatment, surgery may be required for the prevention/recovery of nerve damage.
• Surgery without medical treatment is not recommended.
• The technique of surgery should not be undertaken by untrained medical personnel.
• The following surgical techniques are not recommended:

• Nerve decapsulation.
• Complete fascicular neurolysis.

• The following conditions are not acceptable:

• Surgery done by therapists who are not surgeons.
• Surgery without strict asepsis.

• Neither surgical nor medical treatment should be undertaken without standardised pre and post treatment VMT (Voluntary Muscle Testing) and ST (Sensory Testing) assessments of nerve function.

Original text prepared by Professor P Bourrel.

ILEP is a Federation of autonomous anti-leprosy Associations. The advice contained in this publication is not binding on ILEP Members.

The text of this Technical Bulletin can be freely quoted subject to acknowledgement of its source.