Decompressive surgery for treating nerve damage in leprosy. A Cochrane review
Decompressive surgery is used for treating nerve damage in leprosy. We assessed the effectiveness of decompressive surgery for patients with nerve damage due to leprosy. A broad search strategy was performed to find eligible studies, selecting randomised controlled trials (RCTs) comparing decompressive surgery alone or plus corticosteroids with corticosteroids alone, placebo or no treatment. Two authors independently assessed quality and extracted data. Where it was not possible to perform a meta-analysis, the data for each trial was summarised. We included two randomised controlled trials involving 88 people. The trials examined the added benefit of surgery over prednisolone for treatment of nerve damage of less than 6 months duration. After 2 years follow-up there was no significant difference in nerve function improvement between people treated with surgery plus prednisolone or with prednisolone alone. Adverse effects of decompression surgery were not adequately described. Evidence from randomised controlled trials does not show a significant added benefit of surgery over steroid treatment alone. Well-designed randomised controlled trials are needed to establish the effectiveness of the combination of surgery and medical treatment compared to medical treatment alone.
Decompressive surgery for treating nerve damage
in leprosy. A Cochrane review
NATASJA H.J. VAN VEEN*, TON A.R. SCHREUDERS**,
WILLEM J. THEUVENET***, AMIT AGRAWAL****
& JAN HENDRIK RICHARDUS*
*Department of Public Health, Erasmus MC, University Medical
Center Rotterdam, The Netherlands
**Rehabilitation Medicine, Erasmus MC, University Medical Center
Rotterdam, The Netherlands
***Plastic Surgery, Regional Hospitals of Apeldoorn, Deventer and
Zutphen, Apeldoorn, The Netherlands
****Division of Neurosurgery, Datta Meghe Institute of Medical
Sciences, Wardha, India
Accepted for publication 02 January 2009
Objective Decompressive surgery is used for treating nerve damage in leprosy. We
assessed the effectiveness of decompressive surgery for patients with nerve damage
due to leprosy.
Methods A broad search strategy was performed to ﬁnd eligible studies, selecting
randomised controlled trials (RCTs) comparing decompressive surgery alone or plus
corticosteroids with corticosteroids alone, placebo or no treatment. Two authors
independently assessed quality and extracted data. Where it was not possible to
perform a meta-analysis, the data for each trial was summarised.
Results We included two randomised controlled trials involving 88 people. The
trials examined the added beneﬁt of surgery over prednisolone for treatment of nerve
damage of less than 6 months duration. After 2 years follow-up there was no
signiﬁcant difference in nerve function improvement between people treated with
surgery plus prednisolone or with prednisolone alone. Adverse effects of
decompression surgery were not adequately described.
Conclusions Evidence from randomised controlled trials does not show a
signiﬁcant added beneﬁt of surgery over steroid treatment alone. Well-designed
randomised controlled trials are needed to establish the effectiveness of the
combination of surgery and medical treatment compared to medical treatment alone.
Correspondence to: Natasja H. J. van Veen, Department of Public Health, Erasmus MC, University Medical
Center Rotterdam, PO Box 2040, 3000 CA, The Netherlands (e-mail: firstname.lastname@example.org)
Lepr Rev (2009) 80, 3–12
0305-7518/09/064053+10 $1.00 q Lepra 3
This paper is based on a Cochrane review ﬁrst published in The Cochrane Library 2009,
Issue 1 (see http://www.thecochranelibrary.com/ for information). Cochrane reviews are
regularly updated as new evidence emerges and in response to feedback, and The Cochrane
Library should be consulted for the most recent version of the review.
Decompressive surgery or neurolysis as treatment for nerve damage has been done for
several decennia. The objective of this surgery is to relieve mechanical compression, due to
oedema caused by neuritis, of the affected nerve. Decompression is done by incision of the
thickened nerve sheath (epineurium) where the nerve is enlarged and often tender on
palpation. This incision is often of a considerable length at the place before entering the ﬁbro-
osseous tunnel which, during surgery, needs to be opened as well. Results of surgery from
non-randomised studies have been widely published.
Decompressive surgery is not
recommended without medical treatment. Indications for surgery are mainly based on
common practice but not well deﬁned. These may include the presence of nerve abscess,
nerve pain or nerve function impairment that does not respond to medical treatment.
Decompressive surgery is frequently used for treating nerve damage in leprosy. The effect
of surgery, especially in the long term, is uncertain and it is unclear whether surgery is more
beneﬁcial than medical treatment alone. While this review focused on evidence from
randomised controlled trials (RCTs), it was expected that only a few RCTs had been
conducted in this area. Therefore, the results were also considered in the light of non-
randomised evidence in the Discussion section.
We searched the Cochrane Neuromuscular Disease Group Trials Register (November 2007)
using the following terms: leprosy or Hansen disease and decompression or neurolysis or
epicondylectomy or epineurotomy or neuritis or nerve damage or nerve loss or nerve function
impairment or neuropath* or nerve problem or nerve involvement or nerve pain. This search
strategy, combined with a search strategy for identifying randomised trials, was adapted to
include additional search terms where necessary and was modiﬁed to search the Cochrane
Central Register of Controlled Trials in The Cochrane Library (Issue 4, 2007); MEDLINE
(from January 1950 to November 2007) and EMBASE (from January 1980 to November
2007); AMED (Allied and Complementary Medicine, from January 1985 to November
2007), CINAHL (from January 1982 to November 2007), and LILACS (Latin American and
Caribbean Health Science Information database, from January 1982 to November 2007).
We checked reference lists of the studies identiﬁed, the Current Controlled Trials Register
(www.controlled-trials.com), conference proceedings and contacted trial authors. There were
no language restrictions. Two authors independently screened the titles and abstracts of all the
publications identiﬁed to examine whether studies were eligible.
Studies were eligible if they were (quasi-) randomised controlled trials (RCTs) assessing
decompressive surgery versus corticosteroids, placebo or no treatment for patients with
N. H. J. van Veen et al.4
leprosy and related nerve damage. Nerve damage or nerve function impairment (NFI) was
deﬁned as clinically detectable impairment of motor or sensory nerve function. It did not
include impairment of nerve conduction that was only detectable by electrophysiological
Outcome measures of interest were: improvement in sensory nerve function as
measured with graded nylon ﬁlaments
or a ball-point pen after 1 or 2 years, improvement in
motor nerve function, assessed with the modiﬁed MRC grading scale
after 1 or 2 years,
change in nerve pain and tenderness after 1 year, changes in quality of life, and adverse
The methodological quality of the included studies was based on the following criteria:
concealment of allocation; blinding of participants and outcome assessors; loss to follow-up;
baseline differences and explicit outcome measures mentioned. Each criterion was assessed
as A: adequate, B: unclear or C: inadequate. If one of the criteria was not described in the
study, it was labelled ‘inadequate’. Two authors independently assessed the included studies
for methodological quality.
DATA EXTRACTION AND ANALYSIS
Two authors extracted data regarding methodology and outcome measures from the included
studies onto a data extraction form. If there were missing data, the trial authors were
contacted. Authors were not blinded to trial author, journal or institution. We used the
Cochrane statistical package, Review Manager, for statistical data analysis. Results were
expressed as mean differences with 95% conﬁdence intervals (CI) for continuous outcome
measures and relative risks (RR) with 95% CI for dichotomous outcomes. In case of clinical
heterogeneity, or if data were lacking, the results for each trial were summarised.
We identiﬁed 10 potentially relevant studies and excluded seven, because they were not
randomised. Two RCTs (one RCT was described in two papers) were included.
Characteristics of the studies included are shown in Table 1.
Both studies tested decompression surgery plus oral corticosteroids versus oral
corticosteroids alone. One tested treatment of ulnar neuritis of less than 6 months
and one tested treatment of neuritis of several types of less than 6 months
The primary outcomes ‘improvement in sensory nerve function 1 year after registration’ and
‘improvement in motor nerve function 1 year after registration’ were evaluated in one trial.
Review of surgery for nerve damage 5
Table 1. Characteristics of included studies. From Van Veen, et al. Cochrane Database Sys Review 2009; CD006983; with permission
Study Methods Participants Interventions Outcomes Results Notes
Boucher 1999 Randomised,
parallel group trial
31 leprosy patients with
nerve deﬁcit , 6 months
Unit of randomisation: ulnar,
median, common peroneal,
or posterior tibial nerve
Unit of analysis: nerve
Nerves randomised: unclear
Nerves analysed: 93
(a: 47, b: 46)
(a) prednisone start at
40 mg/day for 15 days and
thereafter gradually tapered
with 5 mg/15 or 30 days until
6 months completed (total
(b) same intervention plus
decompression and a simple,
Sensory improvement (SI)
after 2 years, motor
improvement (MI) after
2 years, nerve pain
after 2 years
No data Single
parallel group trial
57 leprosy patients with ulnar
neuritis , 6 months duration
Unit of randomisation:
Unit of analysis: ulnar nerve
Persons randomised: 57 with
75 ulnar nerves (18 bilateral
Nerves analysed: 62 of 44
persons (a: 31, b: 31) after
one year, 57 of 39 persons
(a: 28, b: 29) after two years
(a) prednisolone 30 mg/day
for one week, reducing the
daily dose by 5 mg every
week for 6 weeks (total
(b) same intervention plus
decompression and a simple,
Sensory improvement (SI)
after 1 and 2 years, motor
improvement (MI) after 1
and 2 years
After one year: Change
in SI: MD ¼ 0·08
(95% CI 2 2·45; 2·61)
% with SI: RR ¼ 1·30
(95% CI 0·48; 3·54)
Change in MI:
MD ¼ 0·82 (95% CI
2 1·34; 2·98)
% with MI: RR ¼ 0·74
(95% CI 0·26; 2·17)
Change in SI:
MD ¼ 0·08 (95% CI
2 2·45; 2·61)
After two years:
Change in SI:
MD ¼ 2 0·02 (95% CI
2 2·82; 2·78)
Change in MI:
MD ¼ 0·22 (95% CI
2 2·39; 2·83)
N. H. J. van Veen et al.6
The secondary outcome ‘improvement in nerve function 2 years after registration’ was
evaluated in two trials.
‘Change in nerve pain and in nerve tenderness’ was assessed in
1 year after registration and in two trials
2 years after registration. None of the
trials evaluated ‘changes in quality of life.’ Adverse events were not well-reported in any of
Randomisation was considered adequate in one trial,
while the other trial used alternation as
randomisation procedure which was considered inadequate.
Participant and outcome
assessor blinding was not possible in any of the trials. One trial
had 6% loss to follow-up of
participants, but did not report how many nerves were involved. The other trial
loss to follow-up of nerves after 1 year and 24% loss to follow-up of nerves after 2 years.
None of the trials reported how many participants or nerves were lost to follow up in each
arm. Boucher et al. described the reasons for losses. Baseline characteristics in both treatment
arms were similar in the trials.
MEDIAL EPICONDYLECTOMY PLUS ORAL CORTICOSTEROIDS VERSUS ORAL
CORTICOSTEROIDS ALONE FOR PARTICIPANTS WITH ULNAR NEURITIS OF LESS
THAN SIX MONTHS DURATION
Results were available for 77% (44/57) of the participants. After 1 year the mean difference in
sensory score was 2·08 (95% CI 0·28 to 3·88) in the surgery group and 2·00 (95% CI 0·06 to
3·94) in the medical group indicating a mean sensory improvement in both. The improvement
was slightly greater in the surgery group but the mean difference 0·08 (95% CI 2 2·45 to 2·61)
between the two groups was not signiﬁcant. In the surgery group 18 out of 31 nerves (58%)
had sensory improvement after 1 year compared with 16 out of 31 nerves (52%) in the
medical group. The difference was not signiﬁcant (relative risk 1·30, 95% CI 0·48 to 3·54).
Results of changes in motor nerve function were provided. After 1 year the mean
difference in motor score was 3·08 (95% CI 2·12 to 4·04) in the surgery group and 2·26 (95%
CI 0·21 to 4·31) in the medical group indicating a mean improvement in both. The
improvement was greater in the surgery group but the mean difference 0·82 (95% CI 2 1·34
to 2·98) between the two groups was not signiﬁcant. In the surgery group 20 out of 31 nerves
(65%) had motor improvement after 1 year compared with 22 out of 31 nerves (71%) in the
medical group. The difference was not signiﬁcant (relative risk 0·74, 95% CI 0·26 to 2·17).
Results after 2 years were available for 68% (39/57) of the participants. After 2 years the
mean difference in sensory score was 2·89 (95% CI 0·94 to 4·84) in the surgery group and 2·91
(95% CI 0·73 to 5·09) in the medical group indicating a mean improvement in both. The
improvement was slightly greater in the medical group but the mean difference 2 0·02 (95%
CI 2 2·82 to 2·78) between the two groups was not signiﬁcant. The mean difference in motor
score after 2 years was 2·79 (95% CI 1·03 to 4·55) in the surgery group and 2·57 (95% CI 0·49
to 4·65) in the medical group indicating a mean improvement in both. The improvement was
greater in the surgery group but the mean difference 0·22 (95% CI 2 2·39 to 2·83) between the
two groups was not signiﬁcant. Nerve pain and tenderness had disappeared in both groups
after 1 year and no new nerve pain or tenderness between the ﬁrst and second year was
reported. The trial did not report any adverse events or reasons of loss to follow-up.
Contacting the authors did not yield additional information.
Review of surgery for nerve damage 7
Longitudinal epineurotomy plus oral corticosteroids versus oral corticosteroids alone for
participants with neuritis of less than six months duration
Results were available for 97% (30/31) of the participants. Outcomes were given after 2 years
of follow-up and were expressed as median improvement, meaning that 50% of the data had
greater improvement than this value and 50% of the data had less improvement than this
median. In the surgery group median sensory improvement was 25% compared to 20%
median improvement in the medical group. The difference was not signiﬁcant at a 5% level
(Tukey box plot test). Median motor improvement was 30% in the surgery group and 20% in
the medical group. The difference was not signiﬁcant at a 5% level (Tukey box plot test). No
numbers, test values or 95% conﬁdence interval values were given. In the surgery group
median nerve pain relief was 11% compared to 0% in the medical group. The difference was
signiﬁcant at a 5% level (Tukey box plot test). One participant was excluded from the study
due to haemorrhage, but it was unclear if it was caused by the intervention. The study did not
provide any numbers, test values or 95% conﬁdence interval values. Contacting the author
revealed that original data were not available anymore.
Two randomised controlled trials were available for this review. One trial compared the
added beneﬁt of medial epicondylectomy over corticosteroids for participants with ulnar
neuritis of less than 6 months duration.
The other trial compared the added beneﬁt of
longitudinal epineurotomy over corticosteroids for participants with ulnar, median, common
peroneal or posterior tibial nerve involvement of less than 6 months duration.
interventions and outcomes were too heterogeneous to be combined in a meta-analysis. The
numbers of participants included in the trials were small and did not allow for subgroup
analysis. The variability between studies and the limitations in study design and sample size
made it difﬁcult to draw any robust conclusions.
None of the trials found a signiﬁcant difference in improved nerve function between surgery
and medical group after a follow-up of 1 or 2 years. This result may have been biased by the
selection criteria used for inclusion of patients and nerves. Only a small proportion may beneﬁt
from decompressive surgery. Results from a study indicate that only 5–10% of nerves may
improve after surgery (Naafs, personal communication). The other nerves need no
decompression. By taking all nerves together, results may be diluted and the conclusion clouded.
The two trials had some drawbacks. One major drawback of both trials was that they used
sometimes more than one nerve from individual patients in the analyses thereby considering
the outcomes from each nerve independent. The trial of Pannikar and Ebenezer included
18 patients with ulnar nerve damage at both sides (bilateral involvement). The right side was
allocated to the group drawn by random selection and the left side was allocated to the other
group. The ﬁnal results reﬂect the outcomes of all nerves. No separate analysis was done
using only one independent outcome from each patient. Original data were not available. The
trial of Boucher included 31 patients with 93 nerves in total. It is unclear how many nerves
each patient contributed. The ﬁnal results reﬂect the outcomes of all nerves. No separate
analysis was done using only one independent outcome from each patient. Original data were
not available. The results from these studies should be treated with considerable caution,
N. H. J. van Veen et al.8
because results from a patient contributing outcomes from more than one nerve will be
treated, in the analysis, as having more weight as a patient contributing only one nerve.
Other limitations of the study of Pannikar were that randomisation was done by
alternation, which is considered an inadequate randomisation procedure. With regard to loss
to follow-up, 23% of the participants were lost to follow-up after 1 year and 32% after
2 years. No reasons for these losses were reported and no intention-to-treat analysis was
The randomisation procedure and loss to follow-up (6%) were considered adequate in the
study of Boucher. Outcomes were expressed as median improvement. No numbers or original
data were available to calculate mean differences or relative risks making comparison and
interpretation of the results difﬁcult. Subgroup analyses showed no difference in median
improvement between operated or non-operated nerves with respect to type of leprosy
(lepromatous or non-lepromatous), type of antibacillary drug therapy (mono or multi), type of
nerve function impairment (motor or sensory), and duration of neuritis (0- to 3 months or 3- to
6 months). There were signiﬁcant differences for pain relief and severity of the neuritis before
surgery. Operated nerves had higher median pain relief compared to non-operated nerves. In
the group with considerable loss of nerve function the operated nerves had higher median
improvement compared to non-operated nerves.
The occurrence of adverse effects was not adequately reported in the trials. One study
excluded a participant with haemorrhage during the course of the trial, but it was unclear
whether this was due to the intervention. The literature reviewing decompressive surgery in
leprosy often does not take adverse effects into account, but stresses the importance of having
adequate techniques and instruments and competent surgeons to prevent unfavourable
Complications of decompressive surgery in general may be painful scars,
wound problems, haematoma, infection and damage to nerves, arteries or tendons.
21 – 23
None of the trials included quality of life measures or cost-effectiveness calculations
which could be useful indicators of the effectiveness of interventions.
Many published and unpublished non-randomised studies have examined the effect of
decompressive surgery for treating nerve damage in leprosy. While the two RCTs give
insufﬁcient evidence in favour of decompressive surgery in addition to steroid treatment,
most non-randomised studies report beneﬁcial effects of decompressive surgery. Relief of
nerve pain and tenderness is the most frequently and consistently reported beneﬁt. Nerve
function improvement is frequently reported, but the response to surgery seems to depend on
several factors, such as severity and duration of neuritis before surgery, the type of leprosy,
the nerve involved and the surgical technique used. Nerves which are partially damaged, have
neuritis of less than 6 months duration and are associated with multibacillary (MB) leprosy
show better results.
Studies examining the effects of surgery reported sensory
improvement varying from about 38% to 97% and motor improvement varying from about
26% to 63%.
2,4,7,19,25 – 33
Comparison of these studies is difﬁcult due to differences in surgical
techniques used, duration and severity of neuritis, type of leprosy, follow-up time, and
Several non-randomised studies compared operated versus non-operated nerves. One
study evaluated nerve function in nine individuals with neuritis of less than 6 months
duration. Three patients underwent ulnar nerve decompression, three patients received
corticosteroid therapy for ulnar neuritis and three patients underwent median nerve
decompression. The study found an average nerve function improvement of 35% for ulnar
Review of surgery for nerve damage 9
nerve decompression (n ¼ 3), 32% for steroid treatment of 8 weeks (n ¼ 3) and 18% median
nerve decompression (n ¼ 3) 6 months after surgery or start of treatment.
Three studies examined surgery alone versus surgery plus steroids. One study compared
medial epicondylectomy alone (n ¼ 7) with medial epicondylectomy plus steroids (n ¼ 7)
given 2 weeks post-operatively for ulnar neuritis of less than 1 month duration. After a 5 month
follow-up motor improvement was not better in the group receiving additional steroids.
Another study compared neurolysis (n ¼ 21) with neurolysis in combination with perineural
corticosteroid injections (n ¼ 18) for ulnar neuritis of less than 6 months duration. The
injections were administered around the thickened nerve after surgery and 2 and 3 weeks later.
One year after surgery the mean difference between ﬁnal and initial nerve function score was
14 for the surgery only group and 21 for the surgery plus steroids group.
The third study
compared decompressive surgery alone (n ¼ 59) with surgery plus steroids (n ¼ 25) given for
3 to 4 months for sensory impairment of the posterior tibial nerve of varying duration.
Satisfactory recovery of nerves with duration of anaesthesia of less than 6 months was 60% in
the surgery group and 83% in the surgery plus steroids group 4 weeks after surgery.
One study compared operated nerves with contralateral non-operated nerves. Prior to
surgery all participants had received 3 months of steroid treatment. The most affected nerves
underwent surgical decompression and were compared with the contralateral non-operated
nerves 1 year or more after surgery. Of the more than 100 nerve decompressions four
operated nerves had decreased nerve function after 1 year of follow-up. The other operated
nerves had unchanged or improved nerve function 1 year after surgery. It is unclear how
many of the contralateral non-operated nerves improved or deteriorated.
After losses to follow-up, another study compared operated nerves (n ¼ 195) of 95 patients
with non-operated nerves of 96 patients, matched for type of leprosy, age and duration of
sensory loss but not randomised, on changes in sensation. Participants, in whom no
improvement of sensory nerve function was found after a standard steroid treatment (40 mg
prednisolone daily for 3 weeks after which the dosage was reduced by 5 mg per week), were
included in the study. Between 27% and 66% of the nerves had deﬁnite improvement 2 years
after surgery compared to 7% of the non-operated nerves which improved.
more likely if the sensory loss had been present for a shorter time. Studies from Carayon et al.
favour surgery plus medical treatment above medical treatment alone.
Corticosteroids are the cornerstone of management in acute nerve damage in leprosy, are
recommended by the WHO and are widely available. But corticosteroids have some
shortcomings. The effects of corticosteroids in the long-term remain uncertain and a
considerable proportion of people treated for nerve damage do not beneﬁt from corticosteroid
treatment. Long-term therapy may cause serious adverse effects, such as peptic ulcer,
cataract, or psychosis. Spontaneous improvement or recovery of nerve function in untreated
or placebo treated individuals has been reported and needs more investigation. The
limitations of corticosteroids urge the need to ﬁnd alternative therapeutic approaches.
Surgery alone as therapy for treating neuritis is not recommended, but there is discussion
about whether the combination of surgery and medical treatment (e.g. steroids) will give
better results than medical treatment alone and there is a call for appropriate trials examining
N. H. J. van Veen et al.10
IMPLICATIONS FOR PRACTICE
Evidence from the two randomised controlled trials is insufﬁcient to draw robust conclusions
about the effect of decompressive surgery for treating nerve damage in leprosy. Two trials
examining the added beneﬁt of surgery over steroids for neuritis of less than 6 months
duration did not show signiﬁcantly better outcomes with steroids plus surgery than steroids
alone in the long-term. Adverse effects of decompressive surgery for treating nerve damage
in leprosy are not well-documented.
IMPLICATIONS FOR RESEARCH
There is a need to identify factors which will predict a favourable response to decompressive
surgery or groups of patients or nerves that will be likely to beneﬁt from surgery. Future
randomised controlled trials should be well-designed to establish the usefulness and
effectiveness of the combination of decompressive surgery and medical treatment compared
to medical treatment alone. New trials should pay more attention to non-clinical aspects, such
as costs and impact on quality of life, because these are highly relevant indicators for both
policy makers and participants.
We would like to thank the Netherlands Leprosy Relief for ﬁnancial support, Dr P Bourrel,
Dr M Ebenezer, Dr J Millan and Dr B Naafs for providing additional information and the
Cochrane Neuromuscular Disease Group for advice and help.
Carayon A, van Droogenbroeck J, Courbil J et al. [Treatment of leprotic neuritis. Exclusive medical treatment or
combined with decompression] Evolution du traitement des nevrites hanseniennes. Traitement medical exclusif
ou associe a la decompression. Med Trop (Mars), 1993; 53: 493 –504.
Chaise F, Roger B. Neurolysis of the common peroneal nerve in leprosy. A report on 22 patients. J Bone Joint
Surg Br, 1985; 67: 426–429.
Ramarorazana S, Rene JP, Schwartzl E et al. One-year follow-up of 466 nerve decompressions in 123 lepers
during multidrug therapy in Madagascar. Med Trop (Mars), 1995; 55: 146–150.
Ramarorazana S, Rene JP, Schwartzl E et al. [One-year follow-up of 466 nerve decompressions in 123 lepers
during multidrug therapy in Madagascar] Resultats a un an de 466 decompressions nerveuses realisees chez 123
lepreux en cours de polychimiotherapie a Madagascar. Med Trop (Mars), 1995; 55(2): 146–150.
Rao KS, Siddalinga Swamy MK. Sensory recovery in the plantar aspect of the foot after surgical decompression
of posterior tibial nerve. Possible role of steroids along with decompression. Lepr Rev, 1989; 60: 283–287.
Dandapat MC, Sahu DM, Mukherjee LM et al. Treatment of leprous neuritis by neurolysis combined with
perineural corticosteroid injection. Lepr Rev, 1991; 62: 27–34.
Brandsma JW, Nugteren WA, Andersen JB, Naafs B. Functional changes of the ulnar nerve in leprosy patients
following neurolysis. Lepr Rev, 1983; 54: 31–38.
Chaise F. [Current management of hand leprosy]. Chir Main, 2004; 23: 1 –16.
Malaviya GN. Shall we continue with nerve trunk decompression in leprosy? Indian J Lepr, 2004; 76: 331– 342.
Richard B. Surgical management of neuritis. In: Schwarz R and Brandsma W (eds). Surgical reconstruction &
rehabilitation in leprosy and other neuropathies, 1st edn. Ekta Books, Kathmandu, 2004.
Kazen R. Role of surgery of nerves in leprosy in the restoration of sensibility in hands and feet of leprosy patients.
Indian J Lepr, 1996; 68: 55–65.
Review of surgery for nerve damage 11
Palande DD. Preventive nerve surgery in leprosy. Lepr India, 1980; 52: 276–298.
Croft RP, Richardus JH, Nicholls PG, Smith WC. Nerve function impairment in leprosy: design, methodology,
and intake status of a prospective cohort study of 2664 new leprosy cases in Bangladesh (The Bangladesh Acute
Nerve Damage Study). Lepr Rev, 1999; 70: 140–159.
van Brakel WH, Nicholls PG, Das L et al. The INFIR Cohort Study: investigating prediction, detection and
pathogenesis of neuropathy and reactions in leprosy. Methods and baseline results of a cohort of multibacillary
leprosy patients in north India. Lepr Rev, 2005; 76: 14–34.
Brandsma W. Basic nerve function assessment in leprosy patients. Lepr Rev, 1981; 52: 161–170.
Pannikar VK, Ramprasad S, Reddy NR et al. Effect of epicondylectomy in early ulnar neuritis treated with
steroids. Int J Lepr Other Mycobact Dis, 1984; 52: 501 – 505.
Ebenezer M, Andrews P, Solomon S. Comparative trial of steroids and surgical intervention in the management of
ulnar neuritis. Int J Lepr Other Mycobact Dis, 1996; 64: 282–286.
Boucher P, Millan J, Parent M, Moulia-Pela JP. [Randomized controlled trial of medical and medico-surgical
treatment of Hansen’s neuritis] Essai compare randomise du traitement medical et medico-chirurgical des nevrites
hanseniennes. Acta Leprol, 1999; 11: 171– 177.
Bernardin R, Thomas B. Surgery for neuritis in leprosy: indications for and results of different types of procedures.
Lepr Rev, 1997; 68: 147–154.
Bourrel P. Preliminary recommendations on the use of surgery for the treatment of leprosy neuritis: caution
concerning the use of surgery in prevention of deformities. ILEP Technical Bulletin 1992(4).
Thoma A, Veltri K, Haines T, Duku E. A systematic review of reviews comparing the effectiveness of endoscopic
and open carpal tunnel decompression. Plast Reconstr Surg, 2004; 113: 1184–1191.
Scholten RJ, Mink van der Molen A, Uitdehaag BM et al. Surgical treatment options for carpal tunnel syndrome.
Cochrane Database Syst Rev, 2007; (4): CD003905.
Malaviya GN. Unfavourable outcomes after reconstructive surgery in leprosy. In: Schwarz R, Brandsma W (eds).
Surgical reconstruction & rehabilitation in leprosy and other neuropathies, 1st edn. Ekta Books, Kathmandu,
2004, pp. 47– 64.
Pandya SS. Surgery on the peripheral nerves in leprosy. Neurosurg Rev, 1983; 6: 153–154.
Antia NH, Vankani B, Pandya NJ. Surgical decompression of the ulnar nerve in leprous neuritis. Lepr India, 1976;
48: 362– 370.
Chaise F, Sedel L, Medevielle D, Witvoet J. Ulnar neuritis in Hansen’s disease results of ﬁfty neurolyses in the
arm and elbow. Ann Chir Main, 1982; 1: 326 –335.
Chaise F, Boucher P. [Remote results of the surgical decompression of the posterior tibial nerve in the
neuropathies of Hansen’s disease] Les resultats eloignes de la decompression chirurgicale du nerf tibial posterieur
dans les neuropathies de la maladie de Hansen. J Chir (Paris), 1987; 124: 315– 318.
Husain S, Mishra B, Prakash V, Malaviya GN. Evaluation of results of surgical decompression of median nerve in
leprosy in relation to sensory–motor functions. Acta Leprol, 1997; 10: 199–201.
Husain S, Mishra B, Prakash V, Malaviya GN. Results of surgical decompression of ulnar nerve in leprosy. Acta
Leprol, 1998; 11: 17– 20.
Kumar K. Surgical management of leprous ulnar neuritis. Clin Orthop, 1982; (163): 235 –242.
Malaviya GN, Ramu G. Role of surgical decompression in ulnar neuritis of leprosy. Lepr India, 1982; 54:
Palande DD. A review of twenty-three operations on the ulnar nerve in leprous neuritis. J Bone Joint Surg Am,
1973; 55: 1457– 1464.
Pandya NJ. Surgical decompression of nerves in leprosy. An attempt at prevention of deformities. A clinical,
electrophysiologic, histopathologic and surgical study. Int J Lepr Other Mycobact Dis, 1978; 46: 47 –55.
Shah A. Evaluation of nerve function deﬁcit. Its improvement by nerve decompression or corticosteroid therapy.
Indian J Lepr, 1986; 58: 216–224.
Oommen PK. Ulnar nerve decompression by medial epicondylectomy of the humerus and a method of assessing
muscle power status by totalling the muscle grading. Lepr India, 1979; 51: 336–340.
Van Droogenbroeck JBA, Naafs B. Surgical nerve release in leprosy: a study with comparison with non operated
opposite nerves. Med Trop (Mars), 1977; 37: 771–776.
Theuvenet WJ, Gavin-Finlay K, Roche PW. Change of sensation in leprosy by selective meshing of the
epineurium. Eur J Plast Surg, 2006; 28: 393 –399.
Carayon A, Van Droogenbroeck J. [Surgical decompression of neuritis of Hansen’s disease] Decompression
chirurgicale des nevrites de la maladie de Hansen. Acta Leprol, 1985; 3: 37– 66.
Carayon A, Van Droogenbroeck JB, Boucher P, Hirzel C. [Results of treatment of 206 patients with recent neuritis
(C.M.S.-P.E.R.)] Resultats du traitement de 206 porteurs de nevrites recentes (C.M.S.-P.E.R.). Acta Leprol, 1985;
3: 155– 162.
Van Veen NH, Nicholls PG, Smith WC, Richardus JH. Corticosteroids for treating nerve damage in leprosy.
Cochrane Database Syst Rev, 2007; (2): CD005491.
N. H. J. van Veen et al.12