Jeffrey DeNigris was working out in a gym when he bent over a bench with his knees locked. A burning pain shot from the bottom of his right foot up to his buttocks and then went away.

If Mr. DeNigris's story ended there, it might have been a cautionary "lesson learned" for other weight lifters. But five years after the gym incident, the pain returned--never consistently, but with a vengance.

"Some days I had numbness in the toes, other times it was a sharp feeling in the ankle or the heel," says Mr. DeNigris. "But never did a day go by that I didn't cringe in pain."

It hurt so much to walk, run, or play with his three young children that he began taking six Advil at a time, with little relief. Neurotin was also prescribed and provided at least some relief so he could get some sleep, otherwise 3-4 hours was all he could get before waking up in pain.

For the next two years, the Rhode Island man went from one doctor to the next looking for answers. His right ankle was operated on because one specialist thought perhaps a bone defect close to the sciatic nerve, which travels from the thigh down to the foot, needed to be "cleaned up to relieve pressure." The procedure was, in Mr. DeNigris's mind, "a waste of time."

Finally, about one year ago, a neurologist ordered a high-resolution MRI of Mr. DeNigris's right hip and thigh, and there was the answer: a golf-ball sized tumor on the sciatic nerve. Schwannomas, the type of tumor he had, grow on the nerve sheath, or covering, and are often benign. Nonetheless, they can be painful and cause weakness or sensory changes.

Mr. DeNigris's doctors in Rhode Island recommended exploratory surgery, but he wanted the schwannoma removed. He did research on the Internet and sent e-mails to some neurosurgeons who specialized in peripheral nerve surgery. Dr. Allen Maniker, director of The Peripheral Nerve Center- Neurological Institute of New Jersey at University Hospital, was one of the doctors who answered back. Mr. DeNigris was willing to travel three hours to Newark partly because he's a native New Jerseyan with family still in the state, but also because "to Dr. Maniker, my case was routine."

"Schwannomas are very slow growing and usually benign," says Dr. Maniker, a board-certified neurosurgeon and fellowship trained specialist in peripheral nerve surgery, "and, as Mr. DeNigris experienced, they can be very painful. Surgical removal of schwannomas has a 95 percent success rate, usually causing no neurological deficit. While schwannomas can grow large enough to be felt during an exam and can be viewed using MRI, a final pathology on the tumor after the operation confirms the diagnosis."

The photo above illustrates a tumor on the leg. This tumor was removed entirely and the patient regained normal sensation and motor strength in his foot.

After the surgery, Mr. DeNigris had some minor post-operative discomfort, but he was able to go home the next day.

"Since the recovery period, I haven't had one twinge or inkling of pain," says Mr. DeNigris. "I work out at the gym three times a week and can play with my children. It's as though I never had a problem."

Schwannomas are one of many conditions that can affect the peripheral nervous system, the nerves that carry messages between the body and the brain. 

Sometimes these diseases and disorders can be successfully treated with medical management, while in other cases surgery is necessary. Whichever course is appropriate, the Peripheral Nerve Center at University Hospital has the expertise to evaluate and treat a wide range of peripheral nerve problems.

Many people are familiar with carpal tunnel syndrome, an entrapped nerve disorder that affects the wrist.  The median nerve that runs through the wrist becomes pinched by inflamed tendons adjacent to the nerve, causing pain and numbness in the hand. Wearing a brace at night and taking anti-inflammatory drugs helps relieve the pain for some patients; others need surgery to take the pressure off the nerve.

Neuropathic pain, often described as a burning, stabbing, or shooting pain, is caused by "firing" of damaged nerves. Diabetes accounts for about one-third of neuropathic pain cases; other conditions where neuropathic pain occurs include multiple scelrosis and "phantom limb pain" caused by amputation.

Another type of tumor, neurofibromas, grow on the fibers of the nerves. "Unlike schwannomas, which are found in the general population, neurofibromas most often are part of a genetic disease called neurofibromatosis," says Dr. Maniker. "Another significant difference is that neurofibromas can become malignant."  Because of this possibility, and that they can sometimes be painful, neurofibromas are either removed surgically or treated with radiation.

To diagnose a peripheral nerve disease or disorder, it's important for the doctor to see images of the nerves. With traditional MRI, it is difficult to discern between peripheral nerves and soft tissue. The Peripheral Nerve Center uses MRI neurography, essentially MRI with special software, to produce cross-sectional images of the nerves. Another study, electromyography, measures muscle contractions in response to electrical stimulation of the nerves. Dr. Denise Campagnolo is head of electromyography for the Peripheral Nerve Center.

When accidents happen

Peripheral nerves, like any part of the body, can be affected by trauma. Motor vehicle accidents (particularly those involving motorcycles), electrical burn injuries, gunshot wounds, and cutting incidents with chainsaws or knives can sever or tear the nerves to varying degrees. Peripheral nerves can be torn from the spine, torn but not where they are attached to the spine, or damaged but not torn.

"What often happens during a motorcycle accident, for example, is that when the bike goes down, the rider's arm is dragged behind," says Dr. Maniker. "This pulls on the nerve roots and injures the brachial plexus, the nerves that extend from the neck and control arm and hand movement."

The repair of peripheral nerves depends on the injury. A patient whose peripheral nerves are severed in a jagged fashion, by a gunshot wound, for example, does not immediately have them repaired successfully. Those nerve ends are identified, and in about two weeks, the neurosurgeon comes back to see how well they have healed. The portions that haven't recovered are removed, and healthy nerves from another part of the patient's body are grafted in place.

How does the neurosurgeon determine nerve function? One assessment tool available at University Hospital is intraoperative nerve action potential. During surgery, nerves can be stimulated to determine if they respond with an electrical signal.

Erb's palsy and Klumpke's palsy, two brachial plexus conditions found in infants are, in effect, birth traumas. 

"When there's a breech birth, a forceps delivery, or even a very large baby, there's potential for injury to the brachial plexus as the baby descends through the birth canal," says Dr. Maniker. "Erb's palsy refers to trauma to the nerves of the upper brachial plexus -- the C5 and C6 roots -- and Klumpke's palsy affects the lower brachial plexus at the C8-T1 roots."

An Erb's baby could have paralysis or weakness in the upper arm, while the hands are affected in Klumpke's infants.

About 95 percent of the time, says Dr. Maniker, the injured nerves will heal well enough on their own within a few months, and the child will have normal to near-normal use of the arm or hand. Physical therapy exercises are prescribed to keep joints supple during those months, he notes, but don't necessarily improve the underlying condition. If there is no improvement by the time the child's first birthday, surgery is recommended to repair the nerves.

"At that point, the choices for the parents are possible recovery through surgery or to have a child with a totally non-functioning arm or hand. The window of opportunity for spontaneous recovery is closed," says Dr. Maniker, one of the few neurosurgeons nationally who specializes in the treatment of Erb's and Klumpke's palsies.

During the operation, which takes between 4-5 hours, the brachial plexus is exposed and the nerves are tested for electrical signals. "Dead" nerves are removed and replaced with nerves from other parts of the body. The surgery's success takes between one year to 18 months to determine, as nerves regenerate at about one inch per month.

"From a parent's perspective, it's difficult to watch their baby be unable to move their hand or arm," says Dr. Maniker. "But when the surgery is successful, it opens a new world for both the child and his or her family."

To contact the Peripheral Nerve Center, call (973) 972-2908, or visit our web site at: www.theuniversityhospital.com/peripheral/