Ongoing Clinical Challenges in Nerve Surgery (Nerve SPACE 2025)

Where are we?: There have been numerous advances over the last decade in peripheral nerve surgery and rehabilitation following nerve transfers. In particular, advances in nerve allografts, nerve wraps, peripheral nerve sheath tumor treatment, and bionic limb technology have expanded the therapeutic landscape for patients with nerve injuries, tumors, and limb loss. Rehabilitation strategies have improved significantly, largely through advances such as the Donor Activation Focused Rehabilitation Approach. Nerve allografts show promise for short digital nerve gaps, though outcomes for proximal injuries remain controversial. Nerve wraps and connectors are widely available, but their efficacy has been controversial, perhaps due to heterogeneity in materials and limited high-quality research studies. In peripheral nerve sheath tumors, molecular subtyping has improved classification, yet reliable preoperative distinction between benign and malignant tumors remains a challenge. Bionic limb reconstruction has been improved through advances in targeted reinnervation, osseointegration, and myoelectric control, although prosthetic abandonment, phantom limb pain, and high costs remain barriers. Where do we need to go?: Future progress requires rigorous empirical evidence to define effective rehabilitation protocols, clarifying the role of allografts versus autografts and determining the clinical utility of nerve wraps and connectors. Improved diagnostic tools are necessary for accurate tumor characterization, and novel systemic therapies are needed for malignant tumors with poor survival outcomes. In bionic limb reconstruction, future advances should integrate intuitive prosthetic control, sensory feedback, and improve pain management while ensuring equitable access to these technologies. How do we get there?: Achieving these goals will require multicenter, nonconflicted, randomized clinical trials; the development of standardized outcome measures; and investment in translational research across cellular biology, imaging, and device development. Collaborative interdisciplinary research is critical to developing evidence-based protocols and technologies. Together, these strategies can continue to accelerate our understanding of peripheral nerve injury, disease, and rehabilitation.