1
|
Ku YC, Akhavan AA, Hultman CS. Surgical Management of Chronic Neuropathic Burn Pain. Clin Plast Surg 2024; 51:419-434. [PMID: 38789151 DOI: 10.1016/j.cps.2024.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2024]
Abstract
Burn-related chronic neuropathic pain can contribute to a decreased quality of life. When medical and pharmacologic therapies prove ineffective, patients should undergo evaluation for surgical intervention, consisting of a detailed physical examination and elective diagnostic nerve block, to identify an anatomic cause of pain. Based on symptoms and physical examination findings, particularly Tinel's sign, treatments can vary, including a trial of laser therapies, fat grafting, or nerve surgeries (nerve decompression, neuroma excision, targeted muscle reinnervation, regenerative peripheral nerve interfaces, and vascularized denervated muscle targets). It is essential to counsel patients to establish appropriate expectations prior to treatment with a multidisciplinary team.
Collapse
Affiliation(s)
- Ying C Ku
- Department of Surgery, Campbell University School of Osteopathic Medicine, 4350 US Highway 421 South, Lillington, NC 27546, USA
| | - Arya Andre Akhavan
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Rutgers New Jersey Medical School, 90 Bergen St., Newark, NJ 07103
| | - Charles Scott Hultman
- Department of Plastic and Reconstructive Surgery, WPP Plastic and Reconstructive Surgery, WakeMed Health and Hospitals, 3000 New Bern Avenue, Raleigh, NC 27610, USA.
| |
Collapse
|
2
|
Hespe GE, Brown DL. Management of Neuropathic Pain with Neurectomy Combined with Dermal Sensory Regenerative Peripheral Nerve Interface (DS-RPNI). Semin Plast Surg 2024; 38:48-52. [PMID: 38495065 PMCID: PMC10942836 DOI: 10.1055/s-0043-1778041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Neuropathic pain affects a large percentage of the U.S. population and leads to tremendous morbidity. Numerous nonsurgical and surgical treatments have been utilized to try and manage neuropathic pain with varying degrees of success. Recent research investigating ways to improve prosthetic control have identified new mechanisms for preventing neuromas in both motor and sensory nerves with free muscle and dermal grafts, respectively. These procedures have been used to treat chronic neuropathic pain in nonamputees, as well, in order to reduce failure rates found with traditional neurectomy procedures. Herein, we focus our attention on Dermal Sensory-Regenerative Peripheral Nerve Interfaces (DS-RPNI, free dermal grafts) which can be used to physiologically "cap" sensory nerves following neurectomy and have been shown to significantly decrease neuropathic pain.
Collapse
Affiliation(s)
- Geoffrey E. Hespe
- Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - David L. Brown
- Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| |
Collapse
|
3
|
Wang Y, Yang S, Li B, Shuai C, Xiong X, Lu J. Epidemiology, risk factors, diagnosis, and treatment of intra-abdominal traumatic neuromas - a narrative review. BMC Gastroenterol 2023; 23:416. [PMID: 38017468 PMCID: PMC10683309 DOI: 10.1186/s12876-023-03049-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 11/09/2023] [Indexed: 11/30/2023] Open
Abstract
Traumatic neuroma (TN) is a disorganized proliferation of injured nerves arising from the axons and Schwann cells. Although TN rarely occurs in the abdominal cavity, the incidence of TN may be underestimated because of the large number of asymptomatic patients. TN can cause persistent pain, which seriously affects quality of life. TN of the biliary system can cause bile duct obstruction, leading to acute cholangitis. It is difficult to differentiate TN from malignancies or recurrence of malignancy, which results in a number of patients receiving aggressive treatment. We collected cases reports of intra-abdominal TN over the past 30 years form PubMed and cases diagnosed in our medical center over the past 20 years, which is the largest case series of intra-abdominal TN to the best of our knowledge. In this review, we discuss the epidemiology, pathophysiology, risk factors, classification, diagnosis, and management of intra-abdominal TN.
Collapse
Affiliation(s)
- Yaoqun Wang
- Division of Biliary Tract Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, 610041, China
- Research Center for Biliary Diseases, West China Hospital, Sichuan University, Chengdu, Sichuan, 610041, China
| | - Sishu Yang
- Division of Biliary Tract Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, 610041, China
| | - Bei Li
- Division of Biliary Tract Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, 610041, China
- Research Center for Biliary Diseases, West China Hospital, Sichuan University, Chengdu, Sichuan, 610041, China
| | - Cunyong Shuai
- Department of Hepatobiliary Surgery, Sichuan Provincial Corps Hospital, Chinese People's Armed Police Forces, Leshan, China.
| | - Xianze Xiong
- Division of Biliary Tract Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, 610041, China.
- Research Center for Biliary Diseases, West China Hospital, Sichuan University, Chengdu, Sichuan, 610041, China.
| | - Jiong Lu
- Division of Biliary Tract Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, 610041, China.
- Research Center for Biliary Diseases, West China Hospital, Sichuan University, Chengdu, Sichuan, 610041, China.
| |
Collapse
|
4
|
Mauch JT, Kao DS, Friedly JL, Liu Y. Targeted muscle reinnervation and regenerative peripheral nerve interfaces for pain prophylaxis and treatment: A systematic review. PM R 2023; 15:1457-1465. [PMID: 36965013 DOI: 10.1002/pmrj.12972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 01/28/2023] [Accepted: 03/10/2023] [Indexed: 03/27/2023]
Abstract
OBJECTIVE Nerve pain frequently develops following amputations and peripheral nerve injuries. Two innovative surgical techniques, targeted muscle reinnervation (TMR) and regenerative peripheral nerve interfaces (RPNI), are rapidly gaining popularity as alternatives to traditional nerve management, but their effectiveness is unclear. LITERATURE SURVEY A review of literature pertaining to TMR and RPNI pain results was conducted. PubMed and MEDLINE electronic databases were queried. METHODOLOGY Studies were included if pain outcomes were assessed after TMR or RPNI in the upper or lower extremity, both for prophylaxis performed at the time of amputation and for treatment of postamputation pain. Data were extracted for evaluation. SYNTHESIS Seventeen studies were included, with 14 evaluating TMR (366 patients) and three evaluating RPNI (75 patients). Of these, one study was a randomized controlled trial. Nine studies had a mean follow-up time of at least 1 year (range 4-27.6 months). For pain treatment, TMR and RPNI improved neuroma pain in 75%-100% of patients and phantom limb pain in 45%-80% of patients, averaging a 2.4-6.2-point reduction in pain scores on the numeric rating scale postoperatively. When TMR or RPNI was performed prophylactically, many patients reported no neuroma pain (48%-100%) or phantom limb pain (45%-87%) at time of follow-up. Six TMR studies reported Patient-Reported Outcomes Measurement Information System (PROMIS) scores assessing pain intensity, behavior, and interference, which consistently showed a benefit for all measures. Complication rates ranged from 13% to 31%, most frequently delayed wound healing. CONCLUSIONS Both TMR and RPNI may be beneficial for preventing and treating pain originating from peripheral nerve dysfunction compared to traditional techniques. Randomized trials with longer term follow-up are needed to directly compare the effectiveness of TMR and RPNI with traditional nerve management techniques.
Collapse
Affiliation(s)
- Jaclyn T Mauch
- Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Dennis S Kao
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Janna L Friedly
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
| | - Yusha Liu
- Division of Plastic Surgery, Department of Surgery, University of Washington, Seattle, WA, USA
| |
Collapse
|
5
|
Saltzman EB, Jerome JTJ, Gaston RG. Current Concepts and Management of Upper Limb Amputees. J Hand Microsurg 2023; 15:245-246. [PMID: 37701319 PMCID: PMC10495203 DOI: 10.1055/s-0043-1773775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/14/2023] Open
|
6
|
Hendrickson NR, Cychsoz CC, Akoh CC, Phisitkul P. Republication of "Treatment of Postsurgical Neuroma in Foot and Ankle Surgery". FOOT & ANKLE ORTHOPAEDICS 2023; 8:24730114231188125. [PMID: 37506115 PMCID: PMC10369102 DOI: 10.1177/24730114231188125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/30/2023] Open
Affiliation(s)
- Nathan R Hendrickson
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, IA, USA
| | - Christopher C Cychsoz
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, IA, USA
| | - Craig C Akoh
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, IA, USA
| | - Phinit Phisitkul
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, IA, USA
| |
Collapse
|
7
|
Giannatos V, Ierodiakonou S, Koutas K, Argyropoulou E, Tsoumpos P, Kokkalis Z. Post Traumatic Neuroma in Continuity of the Median Nerve in a Child: A Case Report. Cureus 2023; 15:e38537. [PMID: 37273288 PMCID: PMC10239210 DOI: 10.7759/cureus.38537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/04/2023] [Indexed: 06/06/2023] Open
Abstract
An 8-year-old girl suffered a wrist laceration from a sharp glass, severing the median nerve. The nerve was end-to-end repaired at the time by a pediatric orthopedic surgeon. Six months later, the girl suffered wrist pain and hyperesthesia over the previous surgical incision, significantly affecting her daily activities. Physical examination revealed a palpable mass over the median nerve with a positive Tinel sign, and the diagnosis of a painful neuroma in continuity was set. She underwent another surgery where the defective neuroma in-continuity was excised, and the median nerve was reconstructed using sural nerve cable autografts. At 18 months follow-up after the second surgery, the girl appeared with a full passive and active painless range of motion and a negative Tinel sign. This is the first case of neuroma in continuity presenting in a child in the literature, successfully managed surgically.
Collapse
Affiliation(s)
- Vasileios Giannatos
- Orthopedics and Traumatology, General University Hospital of Patras, Rio, GRC
| | | | - Konstantinos Koutas
- Orthopedics and Traumatology, General University Hospital of Patras, Rio, GRC
| | | | - Pantelis Tsoumpos
- Orthopaedics, Karamandaneio Prefecture Children Hospital of Patras, Patras, GRC
| | - Zinon Kokkalis
- Orthopedics and Traumatology, General University Hospital of Patras, Rio, GRC
| |
Collapse
|
8
|
Walsh AR, Beutel BG, Tordjman D, da Costa AC, Melamed E. Neuroma-in-continuity: a review of pathophysiology and approach to the affected patient. HAND SURGERY & REHABILITATION 2023; 42:103-108. [PMID: 36758942 DOI: 10.1016/j.hansur.2023.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 01/30/2023] [Indexed: 02/10/2023]
Abstract
A neuroma-in-continuity is a neuroma resulting from a nerve injury in which internal neuronal elements are partially disrupted (with a variable degree of disruption to the endoneurium and perineurium) while the epineurium typically remains intact. The portion of injured axons are misdirected and embedded in connective tissue, which may give rise to local neuroma pain and a distal nerve deficit. The lesion may result from a multitude of injury mechanisms, and clinical presentation is often variable depending on the nerve affected. Clinical, electrodiagnostic, and imaging examinations are helpful in assessing the extent and degree of the lesion. If no clear evidence of recovery is identified within 3-4 months post-injury, the patient may benefit from operative exploration. Surgical management options include neurolysis, neuroma resection, nerve grafting, and nerve transfer, or a combination of modalities. A primary consideration of surgery is the possibility of further downgrading nerve function in the pursuit of more, thereby highlighting the need to carefully weigh the advantages and disadvantages prior to surgical intervention. The objective of this review article is to describe the current understanding of the pathophysiology of neuroma-in-continuity lesions, and to review the approach to the affected patient including clinical evaluation, ancillary testing, and intraoperative assessment and treatment options.
Collapse
Affiliation(s)
- Amanda R Walsh
- Division of Plastic and Reconstructive Surgery, Icahn School of Medicine at Mount Sinai, 79-01 Broadway, Elmhurst, New York, 11373, USA.
| | - Bryan G Beutel
- Kansas City University, 1750 Independence Avenue, Kansas City, Missouri, 64106, USA.
| | - Daniel Tordjman
- Hand Surgery Unit, Orthopedic Division, Tel-Aviv Sourasky Medical Center, 6 Weizmann Street, 6423906 Tel Aviv, Israel; Sackler Faculty of Medicine, Tel-Aviv University, P.O.B 39040, Ramat Aviv, Tel Aviv, Israel.
| | - Antonio Carlos da Costa
- Hand Surgery Division, Department of Orthopedics and Traumatology, Faculdade de Ciencias Medicas Santa Casa da Misericordia de São Paulo, R. Jaguaribe, 155 - Vila Buarque, São Paulo, Brazil.
| | - Eitan Melamed
- Division of Plastic and Reconstructive Surgery, Icahn School of Medicine at Mount Sinai, 79-01 Broadway, Elmhurst, New York, 11373, USA.
| |
Collapse
|
9
|
Cha SM, Shin HD, Kim YK, Kim SG. Finger injuries by eyebrow razor blades in infants. HAND SURGERY & REHABILITATION 2023; 42:80-85. [PMID: 36336263 DOI: 10.1016/j.hansur.2022.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 10/04/2022] [Accepted: 10/07/2022] [Indexed: 11/06/2022]
Abstract
Infants are occasionally injured while playing with their mother's eyebrow razor, and we have treated several infants with flexor tendon injuries, which in some cases were accompanied by damage to the corresponding digital nerves and/or vessels. Here, we report the outcomes in a retrospective case series, with a review of literature. Between January 2013 and October 2019, 8 patients who met our inclusion criteria were initially investigated. The inclusion criteria were: (1) injured by an eyebrow razor during fiddling or grasping, and (2) the availability of complete medical records and radiological data, with follow-up of at least 2 years. The core sutures were performed using a modified Becker (4-strand) method for flexor digitorum profundus (FDP). Nerves and/or vessels were repaired under microscopy. A long-arm mitten cast was then applied, with the fingers slightly flexed in a resting position, for 3 weeks. Then, the children were allowed to return to unrestricted activity. Formal outpatient hand therapy was not performed. Mean postnatal age was 6.3 months. The FDP was injured in zones 1 and 2 in 3 and 5 infants, respectively. Most of the infants were injured near a dressing table, in the bedroom used by their mother. The colors of these razors were all bright, except for one achromatic (white) razor. All of the razors had been left uncovered, without their cap, or were left open in the case of hinged razors. At a mean follow-up of 35.8 months, range of motion was evaluated by the Strickland and modified Strickland methods; all results were "excellent". We encountered no significant complications in any digit: neuroma, tendon retear, stiffness or necrosis. Uncapped or unfolded colorful eyebrow razors pose a high risk of tendon section with concurrent neurovascular injury in infants. Although satisfactory outcomes can be expected, it seems important to prevent the injury through fastidious parental care and changing razor design and color. LEVEL OF EVIDENCE: Level IV, retrospective case series.
Collapse
Affiliation(s)
- S M Cha
- Department of Orthopedic Surgery, Regional Rheumatoid and Degenerative Arthritis Center, Chungnam National University Hospital, Chungnam National University School of Medicine, 266 Munwha-ro, Jung-Gu, 35015 Daejeon, Republic of Korea
| | - H D Shin
- Department of Orthopedic Surgery, Regional Rheumatoid and Degenerative Arthritis Center, Chungnam National University Hospital, Chungnam National University School of Medicine, 266 Munwha-ro, Jung-Gu, 35015 Daejeon, Republic of Korea.
| | - Y K Kim
- Department of Orthopedic Surgery, Regional Rheumatoid and Degenerative Arthritis Center, Chungnam National University Hospital, Chungnam National University School of Medicine, 266 Munwha-ro, Jung-Gu, 35015 Daejeon, Republic of Korea
| | - S G Kim
- Department of Orthopedic Surgery, Regional Rheumatoid and Degenerative Arthritis Center, Chungnam National University Hospital, Chungnam National University School of Medicine, 266 Munwha-ro, Jung-Gu, 35015 Daejeon, Republic of Korea
| |
Collapse
|
10
|
Update on Upper Limb Neuroma Management. J Craniofac Surg 2023; 34:1140-1143. [PMID: 36728490 DOI: 10.1097/scs.0000000000009164] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 10/04/2022] [Indexed: 02/03/2023] Open
Abstract
Painful terminal neuromas in the upper limb due to nerve injury are common. Neuroma symptoms include a sharp and burning sensation, cold intolerance, dysesthesia, pain, numbness, and paresthesia. These symptoms could have a negative impact on the functional ability of the patient and quality of life. In addition, Prostheses use might be abandoned by amputees due to neuroma-induced pain. Many clinicians face challenges while managing neuromas. Contemporary "active" methods like regenerative peripheral nerve interface (RPNI), targeted muscle reinnervation (TMR), and processed nerve allograft repair (PNA) are replacing the conventional "passive" approaches such as excision, transposition, and implantation techniques. RPNI involves inducing axonal sprouting by transplanting the free end of a peripheral nerve into a free muscle graft. TMR includes reassigning the role of the peripheral nerve by the transfer of the distal end of a pure sensory or a mixed peripheral nerve to a motor nerve of a nearby muscle segment. To give the peripheral nerve a pathway to re-innervate its target tissue, PNA entails implanting a sterile extracellular matrix prepared from decellularized and regenerated human nerve tissue with preserved epineurium and fascicles. Of these, RPNI and TMR appear to hold a promising treatment for nerve-ending neuromas and prevent their relapse. In contrast, PNA may reduce neuroma pain and allow meaningful nerve repair. The aim of this article is to provide an overview of the newer approaches of TMR, RPNI, and PNA and discuss their implications, surgical techniques, and reported consequences.
Collapse
|
11
|
Rogers MJ, Daryoush JR, Kazmers NH. Contemporary Review: Targeted Muscle Reinnervation for Foot and Ankle Applications. Foot Ankle Int 2022; 43:1595-1605. [PMID: 36299247 DOI: 10.1177/10711007221129990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Miranda J Rogers
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA
| | - Joshua R Daryoush
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA
| | - Nikolas H Kazmers
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA
| |
Collapse
|
12
|
Grimm PD, Wheatley BM, Tomasino A, Leonhardt C, Hunter DA, Wood MD, Moore AM, Davis TA, Tintle SM. Controlling axonal regeneration with acellular nerve allograft limits neuroma formation in peripheral nerve transection: An experimental study in a swine model. Microsurgery 2022; 42:603-610. [PMID: 35925036 DOI: 10.1002/micr.30943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 06/06/2022] [Accepted: 07/14/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Symptomatic neuromata are a common indication for revision surgery following amputation. Previously described treatments, including traction neurectomy, nerve transposition, targeted muscle re-innervation, and nerve capping, have provided inconsistent results or are technically challenging. Prior research using acellular nerve allografts (ANA) has shown controlled termination of axonal regrowth in long grafts. The purpose of this study was to determine the ability of a long ANA to prevent neuroma formation following transection of a peripheral nerve in a swine model. MATERIALS AND METHODS Twenty-two adult female Yucatan miniature swine (Sus scrofa; 4-6 months, 15-25 kg) were assigned to control (ulnar nerve transection only, n = 10), treatment (ulnar transection and coaptation of 50 mm ANA, n = 10), or donor (n = 2) groups. Nerves harvested from donor group animals were treated to create the ANA. After 20 weeks, the transected nerves including any neuroma or graft were harvested. Both qualitative (nerve architecture, axonal sprouting) and quantitative histologic analyses (myelinated axon number, cross sectional area of nerve tissue) were performed. RESULTS Qualitative histologic analysis of control specimens revealed robust axon growth into dense scar tissue. In contrast, the treatment group revealed dwindling axons in the terminal tissue, consistent with attenuated neuroma formation. Quantitative analysis revealed a significantly decreased number of myelinated axons in the treatment group (1232 ± 540) compared to the control group (44,380 ± 7204) (p < .0001). Cross sectional area of nerve tissue was significantly smaller in treatment group (2.83 ± 1.53 mm2 ) compared to the control group (9.14 ± 1.19 mm2 ) (p = .0012). CONCLUSIONS Aberrant axonal growth is controlled to termination with coaptation of a 50 mm ANA in a swine model of nerve injury. These early results suggest further investigation of this technique to prevent and/or treat neuroma formation.
Collapse
Affiliation(s)
- Patrick D Grimm
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, Maryland, USA.,Orthopaedics, Uniformed Services University of the Health Sciences-Walter Reed Department of Surgery, Bethesda, Maryland, USA
| | - Benjamin M Wheatley
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, Maryland, USA.,Orthopaedics, Uniformed Services University of the Health Sciences-Walter Reed Department of Surgery, Bethesda, Maryland, USA
| | - Allison Tomasino
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, Maryland, USA
| | - Crystal Leonhardt
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, Maryland, USA.,The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
| | - Daniel A Hunter
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Matthew D Wood
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Amy M Moore
- Department of Plastic and Reconstructive Surgery, The Ohio State University, Columbus, Ohio, USA
| | - Thomas A Davis
- Department of Surgery, Uniformed Services University of the Health Sciences-Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Scott M Tintle
- Orthopaedics, Uniformed Services University of the Health Sciences-Walter Reed Department of Surgery, Bethesda, Maryland, USA
| |
Collapse
|
13
|
Shamoun F, Shamoun V, Akhavan A, Tuffaha SH. Target Receptors of Regenerating Nerves: Neuroma Formation and Current Treatment Options. Front Mol Neurosci 2022; 15:859221. [PMID: 35866159 PMCID: PMC9295905 DOI: 10.3389/fnmol.2022.859221] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 05/06/2022] [Indexed: 11/16/2022] Open
Abstract
Neuromas form as a result of disorganized sensory axonal regeneration following nerve injury. Painful neuromas lead to poor quality of life for patients and place a burden on healthcare systems. Modern surgical interventions for neuromas entail guided regeneration of sensory nerve fibers into muscle tissue leading to muscle innervation and neuroma treatment or prevention. However, it is unclear how innervating denervated muscle targets prevents painful neuroma formation, as little is known about the fate of sensory fibers, and more specifically pain fiber, as they regenerate into muscle. Golgi tendon organs and muscle spindles have been proposed as possible receptor targets for the regenerating sensory fibers; however, these receptors are not typically innervated by pain fibers, as these free nerve endings do not synapse on receptors. The mechanisms by which pain fibers are signaled to cease regeneration therefore remain unknown. In this article, we review the physiology underlying nerve regeneration, the guiding molecular signals, and the target receptor specificity of regenerating sensory axons as it pertains to the development and prevention of painful neuroma formation while highlighting gaps in literature. We discuss management options for painful neuromas and the current supporting evidence for the various interventions.
Collapse
Affiliation(s)
- Feras Shamoun
- Peripheral Nerve Lab, Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Johns Hopkins University, Baltimore, MD, United States
| | - Valentina Shamoun
- Department of Biological Sciences, University of Toronto at Scarborough, Scarborough, ON, Canada
| | - Arya Akhavan
- Peripheral Nerve Lab, Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Johns Hopkins University, Baltimore, MD, United States
| | - Sami H. Tuffaha
- Peripheral Nerve Lab, Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Johns Hopkins University, Baltimore, MD, United States
- *Correspondence: Sami H. Tuffaha,
| |
Collapse
|
14
|
Outcomes of Flexor Tendon Repair in Patients With Concurrent Neurovascular Injuries of Multiple Digits in Zone 1. Ann Plast Surg 2022; 89:173-179. [PMID: 35703203 DOI: 10.1097/sap.0000000000003214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE We treated several patients with multiple flexor (flexor digitorum profundus; FDP) injuries accompanied by injuries to the digital nerve or vessels around the distal interphalangeal crease (zone 1). Here, we retrospectively report the outcomes and review the literature. MATERIALS AND METHODS Between January 2010 and December 2018, 16 patients who met the study inclusion criteria were investigated. Tendons were repaired using the cross-locked cruciate (Adelaide) technique (6-strand) or modified Becker method (4-strand). The neurovascular structures were repaired under a microscope. RESULTS Sixteen patients (47 digits) were treated. According to the criteria of Moiemen and Elliot, the lacerated areas were in zones IA and IB in 7 and 40 digits, respectively. The mean ranges of motion were 149.27 ± 7.78 and 66.43 ± 2.04 degrees according to the Strickland and modified Strickland assessments, respectively. The mean 2-point discrimination was 5.00 ± 0.63 mm. Four patients (group 1) presented with injuries to 2 digits, and 9 (group 2) and 3 (group 3) patients had 3 and 4 injured digits, respectively. The outcomes were satisfactory in terms of the mean range of motion; 2-point discrimination; cold tolerance; visual analog scale pain score; Disabilities of the Arm, Shoulder, and Hand score; and grip strength. There were no differences among the groups. CONCLUSIONS Open multiple-finger injuries involving flexor digitorum profundus rupture with concurrent neurovascular injuries on one or both sides occasionally occur in industrial environments. Fortunately, each digit exhibits a consistent injury type in a particular anatomical location; appropriate repair yields satisfactory outcomes despite the presence of multiple injuries.
Collapse
|
15
|
Surgically Treated Neuroma in Upper Extremity: Patient Characteristics and Factors Influencing Outcome of Surgery. PLASTIC AND RECONSTRUCTIVE SURGERY - GLOBAL OPEN 2022; 10:e4076. [PMID: 35186631 PMCID: PMC8849272 DOI: 10.1097/gox.0000000000004076] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 11/12/2021] [Indexed: 11/26/2022]
Abstract
Neuroma formation occurs after inappropriately or untreated nerve injuries. Patients surgically treated for neuroma were characterized and factors influencing outcome evaluated.
Collapse
|
16
|
Regenerative Peripheral Nerve Interfaces for Advanced Prosthetic Control and Mitigation of Postamputation Pain. Tech Orthop 2021. [DOI: 10.1097/bto.0000000000000542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
17
|
Long Acellular Nerve Allografts Cap Transected Nerve to Arrest Axon Regeneration and Alter Upstream Gene Expression in a Rat Neuroma Model. Plast Reconstr Surg 2021; 148:32e-41e. [PMID: 34014904 DOI: 10.1097/prs.0000000000008051] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Treatments to manage painful neuroma are needed. An operative strategy that isolates and controls chaotic axonal growth could prevent neuroma. Using long acellular nerve allograft to "cap" damaged nerve could control axonal regeneration and, in turn, regulate upstream gene expression patterns. METHODS Rat sciatic nerve was transected, and the distal nerve end was reversed and ligated to generate a model end-neuroma. Three groups were used to assess their effects immediately following this nerve injury: no treatment (control), traction neurectomy, or 5-cm acellular nerve allograft cap attached to the proximal nerve. Regeneration of axons from the injured nerve was assessed over 5 months and paired with concurrent measurements of gene expression from upstream affected dorsal root ganglia. RESULTS Both control and traction neurectomy groups demonstrated uncontrolled axon regeneration revealed using Thy1-GFP rat axon imaging and histomorphometric measures of regenerated axons within the most terminal region of regenerated tissue. The acellular nerve allograft group arrested axons within the acellular nerve allograft, where no axons reached the most terminal region even after 5 months. At 5 months, gene expression associated with regeneration and pain sensitization, including Bdnf, cfos, and Gal, was decreased within dorsal root ganglia obtained from the acellular nerve allograft group compared to control or traction neurectomy group dorsal root ganglia. CONCLUSIONS Long acellular nerve allografts to cap a severed nerve arrested axon regeneration within the acellular nerve allograft. This growth arrest corresponded with changes in regenerative and pain-related genes upstream. Acellular nerve allografts may be useful for surgical intervention of neuroma.
Collapse
|
18
|
Abstract
Upper limb amputations, ranging from transhumeral to partial hand, can be devastating for patients, their families, and society. Modern paradigm shifts have focused on reconstructive options after upper extremity limb loss, rather than considering the amputation an ablative procedure. Surgical advancements such as targeted muscle reinnervation and regenerative peripheral nerve interface, in combination with technological development of modern prosthetics, have expanded options for patients after amputation. In the near future, advances such as osseointegration, implantable myoelectric sensors, and implantable nerve cuffs may become more widely used and may expand the options for prosthetic integration, myoelectric signal detection, and restoration of sensation. This review summarizes the current advancements in surgical techniques and prosthetics for upper limb amputees. Cite this article: Bone Joint J 2021;103-B(3):430-439.
Collapse
Affiliation(s)
- Michael Geary
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, USA
| | - Raymond Glenn Gaston
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, USA.,Reconstructive Center for Lost Limbs, OrthoCarolina Hand Center, Charlotte, North Carolina, USA
| | - Bryan Loeffler
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, USA.,Reconstructive Center for Lost Limbs, OrthoCarolina Hand Center, Charlotte, North Carolina, USA
| |
Collapse
|
19
|
Reset Neurectomy for Cutaneous Nerve Injuries. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3401. [PMID: 33680654 PMCID: PMC7929540 DOI: 10.1097/gox.0000000000003401] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 12/10/2020] [Indexed: 11/26/2022]
Abstract
Diffuse cutaneous nerve injuries, often caused by a crush mechanism, are challenging for the nerve surgeon. Discrete nerve transections and focal neuromas are easier to identify and have a more distinct treatment algorithm. Following crush injury to a noncritical sensory nerve, a successful local anesthetic block proximal to the injury may help determine the possibility of surgical intervention. In these cases, we describe a technique of “reset neurectomy” whereby a neurectomy is performed proximal to the zone of injury, and immediate repair or reconstruction (with or without a nerve graft) is performed. This technique may be useful in cases of diffuse, nontransection nerve injuries in which neuropathic pain is the primary symptom.
Collapse
|
20
|
Abstract
Postamputation stump and phantom pain are highly prevalent but remain a difficult condition to treat. The underlying mechanisms are not fully clarified, but growing evidence suggests that changes in afferent nerves, including the formation of neuromas, play an important role. The main objective of this cross-sectional study was to investigate whether ultrasound-verified neuroma swellings are more frequent in amputees with postamputation pain than in amputees without pain (primary outcome). Sixty-seven amputees were included. Baseline characteristics including the frequency and intensity of spontaneous stump and phantom pain were obtained, and sensory characteristics and evoked responses were assessed. A high-frequency ultrasound examination of the amputated extremity was performed to obtain information on the presence, size, and elasticity of swollen neuromas and pressure pain thresholds. Swollen neuromas were present in 53 (79.1%) of the 67 amputees included in the study, in 47 (82.5%) of 57 amputees with pain and in 6 (60.0%) of 10 amputees without pain (P = 0.2). No difference was found in stump pain intensity (P = 0.42) during the last week or in phantom pain intensity in the last month (P = 0.74) between amputees with and without swollen neuromas. Our findings suggest that it is not the presence of swollen neuromas itself that drives postamputation pain. However, changes in the transected nerve endings may still be crucial for driving postamputation pain because a positive Tinel sign was significantly more frequent in amputees with pain, irrespectively of the degree of neuroma swelling.
Collapse
|
21
|
van Bekkum S, van der Avoort DJJC, Zuidam JM, Coert JH. Free muscle flap coverage as last resort for therapy-resistant neuropathic pain in the upper extremity: A long-term retrospective follow-up study. J Plast Reconstr Aesthet Surg 2020; 73:2171-2177. [PMID: 32601015 DOI: 10.1016/j.bjps.2020.05.080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 03/27/2020] [Accepted: 05/15/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Persistent neuropathic pain severely impacts physical functioning and quality of life (QoL). However, optimal surgical management of persistent neuropathic pain remains unclear. Extensive neurolysis with subsequent free muscle flap coverage, a new surgical procedure for neuropathic pain in the upper extremity, can be performed as a final option to establish pain reduction. METHODS All consecutive patients who received extensive microsurgical neurolysis with subsequent free muscle flap for persistent neuropathic pain in the upper extremity between 2007 and 2014 were identified. Patient-reported upper extremity function and QoL were assessed using three questionnaires (36-item short-form health survey (SF-36), the disabilities of the arm, shoulder, and head questionnaire, and the Michigan hand outcomes questionnaire). RESULTS Fifteen patients were identified; 80% had neuropathic pain in the upper extremity due to nerve injury and a median of 3.0 previous surgeries (range 1-6). Sixty-seven percent developed some kind of complication, flap loss occurred in 22%, and all received a new free flap (one failed again). At last follow-up, pre- and postoperative visual analog scale (VAS) scores significantly differed (p = 0.002), and the median VAS at last follow-up was 1.5. Ten patients (67%) responded to the questionnaires after a median follow-up of 5.7 year (range 2.6-7.3 years). Patients on average reported poorer SF-36 "Physical Component Score" (PCS) and "Bodily Pain" compared to Dutch norms. Forty percent of patients reported still having always (very) severe pain. However, 64% had a postoperative decrease of at least 3.0 on VAS. CONCLUSION Extensive neurolysis with free muscle flap coverage for persistent neuropathic pain in the upper extremity showed a positive effect on pain reduction on short-term follow-up, and also at five-year follow-up. The impact of pain on functional outcomes remained. Nevertheless, 60% of the patients still experience sufficient pain reduction.
Collapse
Affiliation(s)
- Sara van Bekkum
- Department of Plastic and Reconstructive Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Dirk-Jan J C van der Avoort
- Department of Plastic and Reconstructive Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - J Michiel Zuidam
- Department of Plastic and Reconstructive Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - J Henk Coert
- Department of Plastic and Reconstructive Surgery, UMCU, University Medical Center Utrecht, Utrecht, the Netherlands.
| |
Collapse
|
22
|
Chabra R, Anand N, Gray A, Wood A. Ultrasound based macroarchitecture delineation and injection of complex stump neuroma. J Clin Anesth 2020; 64:109819. [PMID: 32330834 DOI: 10.1016/j.jclinane.2020.109819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 03/07/2020] [Accepted: 04/04/2020] [Indexed: 11/15/2022]
Affiliation(s)
- Ranjeev Chabra
- Albany Medical College, Albany Medical Center, New Scotland Ave, Albany, NY, USA
| | - Neelesh Anand
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA, USA
| | - Andrew Gray
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA, USA
| | - Arthur Wood
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA, USA
| |
Collapse
|
23
|
Abstract
Neuroma formation occurs because of some degree of nerve injury followed by improper intrinsic nerve repair. The cause of neuroma pain is incompletely understood, but appears to be multifactorial in nature, including local and system changes. A comprehensive understanding of nerve anatomy, injury, and repair techniques should be used when dealing with neuroma formation and its physical manifestations. Diagnosis of neuroma is clinically characterized by pain associated with scar, altered sensation within the given nerve distribution, and a Tinel sign. The pathophysiology of neuroma formation is reviewed.
Collapse
|
24
|
Yildiran G, Sutcu M, Akdag O, Tosun Z. Long-Term Outcomes of Digital Nerve Repair Accompanied by Digital Artery Injury in Flexor Zone 2. Surg J (N Y) 2019; 6:e7-e9. [PMID: 31799405 PMCID: PMC6887569 DOI: 10.1055/s-0039-3400229] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 09/16/2019] [Indexed: 11/18/2022] Open
Abstract
Objectives
Better healing results of any tissue or area is closely linked with a well-blood supply in reconstructive surgery. Peripheric nerve healing is closely related to blood supply as well. We aimed to assess whether there was any difference between digital nerve healing with and without extrinsic blood supply.
Methods
We assessed 48 patients with unilateral digital nerve injury at zone 2. Twenty-four of them had unrepairable arterial injury and other 24 had no arterial injury. The 24 patients in the “unrepaired artery group” (UA) and 24 patients in the “intact artery group” (IA) were compared.
Results
Mean follow-up time was 17.7 months. The mean two-point discrimination (2PD) was 5.29 mm in IA group and 5.37 mm in UA group. One neuroma in IA group and two neuromas in UA group were determined. We found no statistically significant difference between these groups in terms of neuroma, 2PD, and cold intolerance. The results of British Medical Research Council sensory recovery clinical scale were comparable for these two groups.
Conclusion
Digital nerve healing is related to numerous factors. We hypothesized that blood flow may be one of these factors; however, at this zone digital artery repair is not the foremost determinant for digital nerve healing. Further researches should be done for upper injury levels. Despite this result, we argue not to leave the digital artery without repairment and we propose to repair both artery and nerve to achieve the normal anatomical integrity and to warrant finger blood flow in possible future injuries.
Collapse
Affiliation(s)
- Gokce Yildiran
- Division of Hand Surgery, Department of Plastic, Reconstructive and Aesthetic Surgery, Selcuk University Medical Faculty, Konya, Turkey
| | - Mustafa Sutcu
- Division of Hand Surgery, Department of Plastic, Reconstructive and Aesthetic Surgery, Selcuk University Medical Faculty, Konya, Turkey
| | - Osman Akdag
- Division of Hand Surgery, Department of Plastic, Reconstructive and Aesthetic Surgery, Selcuk University Medical Faculty, Konya, Turkey
| | - Zekeriya Tosun
- Division of Hand Surgery, Department of Plastic, Reconstructive and Aesthetic Surgery, Selcuk University Medical Faculty, Konya, Turkey
| |
Collapse
|
25
|
Ives GC, Kung TA, Nghiem BT, Ursu DC, Brown DL, Cederna PS, Kemp SWP. Current State of the Surgical Treatment of Terminal Neuromas. Neurosurgery 2019; 83:354-364. [PMID: 29053875 DOI: 10.1093/neuros/nyx500] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Accepted: 09/10/2017] [Indexed: 12/15/2022] Open
Abstract
Painful terminal neuromas resulting from nerve injury following amputation are common. However, there is currently no universally accepted gold standard of treatment for this condition. A comprehensive literature review is presented on the treatment of terminal neuromas. Four categories of terminal neuroma surgical procedures are assessed: epineurial closure; nerve transposition with implantation; neurorrhaphy, and alternate target reinnervation. Significant patient and case studies are highlighted in each section, focusing on surgical technique and patient outcome metrics. Studies presented consisted of a PubMed search for "terminal neuromas," without year limitation. The current available research supports the use of implantation into muscle for the surgical treatment of terminal neuromas. However, this technique has several fundamental flaws that limit its utility, as it does not address the underlying physiology behind neuroma formation. Regenerative peripheral nerve interfaces and targeted muscle reinnervation are 2 techniques that seem to offer the most promise in preventing and treating terminal neuroma formation. Both techniques are also capable of generating control signals which can be used for both motor and sensory prosthetic control. Such technology has the potential to lead to the future restoration of lost limb function in amputees. Further clinical research employing larger patient groups with high-quality control groups and reproducible outcome measures is needed to determine the most effective and beneficial surgical treatment for terminal neuromas. Primary focus should be placed on investigating techniques that most closely approximate the theoretically ideal neuroma treatment, including targeted muscle reinnervation and regenerative peripheral nerve interfaces.
Collapse
Affiliation(s)
- Graham C Ives
- Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, Michigan
| | - Theodore A Kung
- Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, Michigan
| | - Bao Tram Nghiem
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Daniel C Ursu
- Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, Michigan
| | - David L Brown
- Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, Michigan
| | - Paul S Cederna
- Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, Michigan.,Department of Biomedical Engineering, University of Michigan, Ann Arbor, Michigan
| | - Stephen W P Kemp
- Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, Michigan.,Department of Biomedical Engineering, University of Michigan, Ann Arbor, Michigan
| |
Collapse
|
26
|
Abstract
Secondary surgery following digital replantation and revascularization is common and is often performed to improve range of motion, tendon gliding, sensibility, and/or contour. In this article, the authors present the most common secondary procedures performed after digital replantation or revascularization and discuss current techniques. The importance of patient selection and postoperative compliance with ongoing hand therapy is paramount to achieving good outcomes.
Collapse
|
27
|
Abstract
BACKGROUND Neuroma results from disorganized regeneration following nerve injury and may be symptomatic. The aim of this study was to investigate the causes, treatment, and outcomes of operatively treated sural neuromas, and to describe the factors associated with persistent or unchanged postoperative pain symptoms. METHODS Consecutive patients with surgically treated sural neuromas in a 14-year period were identified using Current Procedural Terminology (CPT) codes ( n = 49), followed by a chart review to collect patient and treatment characteristics. Postoperative pain symptoms were categorized as complete resolution of pain, improvement of pain, no change in pain, or worse pain. The median patient age was 46.5 years (interquartile range [IQR], 39.1-51.3), and median follow-up was 4.0 years (IQR, 1.9-9.2). RESULTS Ninety percent of symptomatic sural neuromas developed as a result of previous lower extremity surgery. Initial surgery of sural neuroma led to improvement in pain in 63% of patients, and an additional 8.2% of the patients had improvement after secondary neuroma surgery. Pain relief after diagnostic injection showed a trend toward an association with postoperative pain improvement. Neuroma excision and implantation in muscle was the most common surgical technique used (67%). Four of the 7 patients that underwent a second neuroma operation reported symptom improvement. CONCLUSION Sural neuromas may arise from prior surgery or trauma to the lower extremity. Surgical intervention resulted in either improvement or complete resolution of pain symptoms in 71% of patients, although occasionally more than one procedure was required to obtain symptomatic relief. Preoperative anesthetic injection may help identify patients that benefit from neuroma surgery. Level of Evidence: Level IV, retrospective case series.
Collapse
Affiliation(s)
- Jonathan Lans
- 1 Department of Orthopedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Linda Gamo
- 2 Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Christopher W DiGiovanni
- 3 Orthopaedic Foot and Ankle Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Neal C Chen
- 2 Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Kyle R Eberlin
- 2 Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
28
|
|
29
|
Rummings WA, Honeycutt PB, Jernigan EW, Weinhold PS, Draeger RW. Effect of Nerve-Cutting Technique on Nerve Microstructure and Neuroma Formation. J Hand Microsurg 2018; 11:28-34. [PMID: 30911209 DOI: 10.1055/s-0038-1654751] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Accepted: 04/16/2018] [Indexed: 10/28/2022] Open
Abstract
Background Peripheral neuroma formation results from partial or complete nerve division. Elucidating measures to prevent the development of peripheral neuromas is of clinical importance. The aim of this study was to determine the effect of various surgical nerve-cutting techniques on nerve microstructure and resultant neuroma formation. Methods Twenty Sprague-Dawley rats were randomly assigned to one of the following nerve-cutting techniques: No. 15 scalpel blade with tongue depressor, micro-serrated scissors, nerve-cutting guide forceps with straight razor, and bipolar cauterization. The right sciatic nerve was transected using the assigned nerve-cutting technique. Neuromas were harvested 6 weeks postoperatively, and samples were obtained for histologic analysis. The contralateral sciatic nerve was transected at euthanasia and analyzed with histology and with scanning electron microscopy in a subset of the rats. Results Fifteen of the 20 rats survived the 6-week experiment. Scanning electron microscopy of the No. 15 scalpel blade group showed the most visual damage and disorganization whereas the nerve-cutting guide forceps and micro-serrated scissors groups resulted in a smooth transected surface. Bipolar cauterization appeared to enclose the fascicular architecture within a sealed epineurium. Each neuroma was significantly larger than contralateral controls. There were no significant differences in neuroma caliber between nerve transection groups. No substantial differences in microstructure were evident between transection groups. Conclusion Despite disparate microscopic appearances of the cut surfaces of nerves using various nerve-cutting techniques, we found no significant differences in the caliber or incidence of neuroma formation based on nerve-cutting technique. Nerve-cutting technique used when transecting peripheral nerves may have little bearing on the formation or size of resultant neuroma formation.
Collapse
Affiliation(s)
- Wayne A Rummings
- Department of Orthopaedics, University of North Carolina, Chapel Hill, North Carolina, United States
| | - P Barrett Honeycutt
- Department of Orthopaedics, University of North Carolina, Chapel Hill, North Carolina, United States
| | - Edward W Jernigan
- Department of Orthopaedics, University of North Carolina, Chapel Hill, North Carolina, United States
| | - Paul S Weinhold
- Department of Orthopaedics, University of North Carolina, Chapel Hill, North Carolina, United States
| | - Reid W Draeger
- Department of Orthopaedics, University of North Carolina, Chapel Hill, North Carolina, United States
| |
Collapse
|
30
|
Hendrickson NR, Cychsoz CC, Akoh CC, Phisitkul P. Treatment of Postsurgical Neuroma in Foot and Ankle Surgery. FOOT & ANKLE ORTHOPAEDICS 2018. [DOI: 10.1177/2473011418764452] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Affiliation(s)
- Nathan R. Hendrickson
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, IA, USA
| | | | - Craig C. Akoh
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, IA, USA
| | - Phinit Phisitkul
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, IA, USA
| |
Collapse
|
31
|
|
32
|
Abstract
A nerve injury has a profound impact on the patient’s daily life due to the impaired sensory and motor function, impaired dexterity, sensitivity to cold as well as eventual pain problems. To perform an appropriate treatment of nerve injuries, a correct diagnosis must be made, where the injury is properly classified, leading to an optimal surgical approach and technique, where timing of surgery is also important for the outcome. Knowledge about the nerve regeneration process, where delicate processes occur in neurons, non-neuronal cells (i.e. Schwann cells) and other cells in the peripheral as well as the central nervous systems, is crucial for the treating surgeon. The surgical decision to perform nerve repair and/or reconstruction depends on the type of injury, the condition of the wound as well as the vascularity of the wound. To reconnect injured nerve ends, various techniques can be used, which include both epineurial and fascicular nerve repair, and if a nerve defect is caused by the injury, a nerve reconstruction procedure has to be performed, including bridging the defect using nerve-grafts or nerve transfer techniques. The patients must be evaluated properly and regularly after the surgical procedure and appropriate rehabilitation programmes are useful to improve the final outcome.
Cite this article: EFORT Open Rev 2017;2. DOI: 10.1302/2058-5241.2.160071. Originally published online at www.efortopenreviews.org
Collapse
Affiliation(s)
- Lars B Dahlin
- Department of Translational Medicine - Hand Surgery, Lund University, and Skåne University Hospital, Malmö, Sweden
| | - Mikael Wiberg
- Department of Surgical and Perioperative Science, University Hospital, and Department of Integrative Medical Biology, Umeå University, Sweden
| |
Collapse
|
33
|
Chakrabarty S, Foderingham N, O’Hara H. Selected Disorders of the Musculoskeletal System. Fam Med 2017. [DOI: 10.1007/978-3-319-04414-9_121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
34
|
Jeon SM, Lee JY, Byeon SJ. Traumatic Neuroma at the Inferior Mesenteric Artery Stump after Rectal Cancer Surgery: A Case Report and Literature Review. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2016; 68:279-283. [PMID: 27871166 DOI: 10.4166/kjg.2016.68.5.279] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Traumatic neuroma results from regeneration attempts of the proximal end of an injured or severed nerve, resulting in a non-neoplastic nodular lesion. The lower extremity after amputation is the most common site, followed by the head and neck. Traumatic neuromas occurring in the abdomen, however, are rare. In the abdominal region, traumatic neuromas occur in the cystic duct stump and the common bile ducts as well as around the celiac trunk. This study reports a case of a 59-year-old man who presented with a traumatic neuroma arising at the stump of the inferior mesenteric artery after rectal cancer surgery. Traumatic neuromas at the stump of the inferior mesenteric artery have not been previously reported. The lesion exhibited atypical imaging features, including a well-enhanced nodule, a significant interval growth in size and a mild increase in 18F-fluo-rodeoxyglucose uptake, resembling lymph node metastasis. This case report will help physicians understand the sites of occurrence and imaging features of traumatic neuromas in the abdomen.
Collapse
Affiliation(s)
- Sung Mi Jeon
- Department of Education and Training, Seoul National University Hospital, Seoul, Korea
| | - Jae Young Lee
- Department of Radiology, Seoul National University Hospital, Seoul, Korea
| | - Sun Ju Byeon
- Department of Pathology, Asan Medical Center, Seoul, Korea
| |
Collapse
|
35
|
Abstract
INTRODUCTION Hand tumours of neural origin are rare in clinical practice. The aim of this work is to present our experience in operative treatment of benign nerve tumours located in the hand. Special emphasis has been put on determining the occurrence rates of particular tumour types characterized by their unique histopathological patterns and describing detailed location of the lesions. The obtained results of treatment were assessed. MATERIALS AND METHODS The study comprised of 26 patients, both female (19) and male (7). The mean age and age range of the female and male patients were 44.8 years (range, 21-73 years) and 39.6 years (range, 21-74 years), respectively. The patients underwent operative treatment for tumours of neurogenic origin located in the hand between the years 1990 and 2013. In total, 31 tumours in 26 patients were removed. The most common site of tumour origin was small cutaneous branches and only exceptionally the tumours arose from common digital nerves (2 patients). No patient was lost to postoperative follow-up. The shortest period of postoperative follow-up covered 1 year. RESULTS No tumour recurrence was detected during postoperative follow-up examinations. The patients reported neither pain nor presence of paraesthesias. Neurofibromas (17 tumours) predominated in the gathered clinical material, while the second most common group of tumours were schwannomas (12 tumours). CONCLUSIONS (1) Benign nerve tumours of the hand are rare. Neurofibromas and schwannomas predominate among them. Tumours having other histopathological patterns are extremely uncommon. (2) The prognosis after resection of benign nerve tumours located in the hand is good and the risk of postoperative complications and recurrence is low.
Collapse
|
36
|
Hind B, Badredine H, Kaoutar Z. Cutaneous neuromas following a burn injury. Int J Dermatol 2015; 55:e161-2. [PMID: 26566987 DOI: 10.1111/ijd.13058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Revised: 04/05/2015] [Accepted: 04/08/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Benhiba Hind
- Department of Dermatology, Ibn Sina Hospital, Mohammed V University, Rabat, Morocco.
| | - Hassam Badredine
- Department of Dermatology, Ibn Sina Hospital, Mohammed V University, Rabat, Morocco
| | - Znati Kaoutar
- Department of Pathology, Ibn Sina Hospital, Mohammed V University, Rabat, Morocco
| |
Collapse
|
37
|
Abstract
There are many options in the management of fingertip or finger amputations. Injudicious revision amputation may cause complications. These complications can be prevented by tension-free closure of the amputation stump or primary coverage with appropriate flap. Replantation is the best way to keep the original length and maintain digital function. Patent vein repair or venous drainage with bleeding until neovascularization to the replanted part is the key to successful replantation. Prevention and management of complications in replantation and revision amputation increase patients' satisfaction and decrease costs. Research is needed to define new indications of replantation for digital amputation.
Collapse
|
38
|
Bobkiewicz A. Neuroma Model. Plast Reconstr Surg 2015. [DOI: 10.1007/978-1-4471-6335-0_65] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
39
|
Selected Disorders of the Musculoskeletal System. Fam Med 2014. [DOI: 10.1007/978-1-4939-0779-3_121-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
|