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Raasveld FV, Weigel DT, Liu WC, Mayrhofer-Schmid M, Gomez-Eslava B, Tereshenko V, Hwang CD, Wainger BJ, Renthal W, Fleming M, Valerio IL, Eberlin KR. Neuroma morphology: A macroscopic classification system. Muscle Nerve 2024. [PMID: 39295574 DOI: 10.1002/mus.28261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 09/05/2024] [Accepted: 09/07/2024] [Indexed: 09/21/2024]
Abstract
INTRODUCTION/AIMS Neuromas come in different shapes and sizes; yet the correlation between neuroma morphology and symptomatology is unknown. Therefore, we aim to investigate macroscopic traits of excised human neuromas and assess the validity of a morphological classification system and its potential clinical implications. METHODS End-neuroma specimens were collected from prospectively enrolled patients undergoing symptomatic neuroma surgery. Protocolized images of the specimens were obtained intraoperatively. Pain data (Numeric rating scale, 0-10) were prospectively collected during preoperative interview, patient demographic and comorbidity factors were collected from chart review. A morphological classification is proposed, and the inter-rater reliability (IRR) was assessed. Distribution of neuroma morphology with patient factors, was described. RESULTS Forty-five terminal neuroma specimens from 27 patients were included. Residual limb patients comprised 93% of the population, of which 2 were upper (8.0%) and 23 (92.0%) were lower extremity residual limb patients. The proposed morphological classification, consisting of three groups (bulbous, fusiform, atypical), demonstrated a strong IRR (Cohen's kappa = 0.8). Atypical neuromas demonstrated higher preoperative pain, compared with bulbous and fusiform. Atypical morphology was more prevalent in patients with diabetes and peripheral vascular disease. DISCUSSION A validated morphological classification of neuroma is introduced. These findings may assist surgeons and researchers with better understanding of symptomatic neuroma development and their clinical implications. The potential relationship of neuroma morphology with the vascular and metabolic microenvironment requires further investigation.
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Affiliation(s)
- Floris V Raasveld
- Hand and Arm Center, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Plastic, Reconstructive and Hand Surgery, Erasmus Medical Center, Erasmus University, Rotterdam, the Netherlands
- Division of Plastic and Reconstructive Surgery, Department of General Surgery, Massachusetts General Hospital, Harvard University, Boston, Massachusetts, USA
| | - Daniel T Weigel
- Hand and Arm Center, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Wen-Chih Liu
- Hand and Arm Center, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Orthopaedic Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Maximilian Mayrhofer-Schmid
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg, Germany
| | - Barbara Gomez-Eslava
- F.M. Kirby Neurobiology Center, Boston Children's Hospital and Department of Neurobiology, Harvard Medical School, Boston, Massachusetts, USA
| | - Vlad Tereshenko
- Division of Plastic and Reconstructive Surgery, Department of General Surgery, Massachusetts General Hospital, Harvard University, Boston, Massachusetts, USA
| | - Charles D Hwang
- Division of Plastic and Reconstructive Surgery, Department of General Surgery, Massachusetts General Hospital, Harvard University, Boston, Massachusetts, USA
| | - Brian J Wainger
- Departments of Anesthesia, Critical Care & Pain Medicine and Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - William Renthal
- Department of Neurology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Mark Fleming
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ian L Valerio
- Division of Plastic and Reconstructive Surgery, Department of General Surgery, Massachusetts General Hospital, Harvard University, Boston, Massachusetts, USA
| | - Kyle R Eberlin
- Division of Plastic and Reconstructive Surgery, Department of General Surgery, Massachusetts General Hospital, Harvard University, Boston, Massachusetts, USA
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van Vliet E, Raasveld FV, Liu WC, Valerio IL, Eberlin KR, Newman ET, Jarraya M, Simeone FJ, Husseini JS. Evaluation of MRI features of neuromas in oncological amputees, and the relation to pain. Skeletal Radiol 2024:10.1007/s00256-024-04779-0. [PMID: 39264418 DOI: 10.1007/s00256-024-04779-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Revised: 08/05/2024] [Accepted: 08/20/2024] [Indexed: 09/13/2024]
Abstract
OBJECTIVE The impact of time on neuroma growth and morphology on pain intensity is unknown. This study aims to assess magnetic resonance imaging (MRI) differences between symptomatic and non-symptomatic neuromas in oncological amputees, and whether time influences MRI-detected neuroma dimensions and their association with pain. MATERIAL AND METHODS Oncological patients who underwent traditional extremity amputation were included. Post-amputation MRIs were assessed before decision for neuroma surgery. Chart review was performed for residual limb pain (numeric rating scale, 0-10) and the presence of neuropathic symptoms. Neuromas were classified as symptomatic or non-symptomatic, with neuroma size expressed as radiological neuroma-to-nerve-ratio (NNR). RESULTS Among 78 neuromas in 60 patients, the median NNR was 2.0, and 56 neuromas (71.8%) were symptomatic with a median pain score of 3.5. NNR showed no association with symptomatology or pain intensity but correlated with a longer time-to-neuroma-excision interval and a smaller nerve caliber. Symptomatic neuromas were associated with lower extremity amputation, T2 heterogeneity, and the presence of heterotopic ossification. Lower extremity amputation, T2 heterogeneity, perineural edema, and presence of heterotopic ossification were associated with more painful neuromas. CONCLUSION MRI features associated with symptomatic neuromas and pain intensity were identified. Awareness of the potential clinical significance of these imaging features may help in the interpretation of MRI exams and may aid clinicians in patient selection for neuroma surgery in oncological amputees.
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Affiliation(s)
- Eva van Vliet
- Hand and Arm Center, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Floris V Raasveld
- Hand and Arm Center, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Plastic, Reconstructive and Hand Surgery, Erasmus Medical Center, Erasmus University, Rotterdam, The Netherlands
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Wen-Chih Liu
- Hand and Arm Center, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Orthopedics, Kaohsiung Medical University Hospital, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ian L Valerio
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Kyle R Eberlin
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Erik T Newman
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Mohamed Jarraya
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - F Joseph Simeone
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jad S Husseini
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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Endo Y, Nwawka OK, Sneag DB. Iatrogenic "overshoot" nerve injuries: imaging features. Skeletal Radiol 2024; 53:1173-1181. [PMID: 38165469 DOI: 10.1007/s00256-023-04550-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 12/05/2023] [Accepted: 12/14/2023] [Indexed: 01/03/2024]
Abstract
OBJECTIVE Describe features of iatrogenic "overshoot" nerve injuries on ultrasound and MRI, which occur when an instrument passes through the bone and injures the nerve after it penetrates the opposite cortex. MATERIALS AND METHODS After a keyword search of the radiology database at a tertiary care orthopedic hospital from January 2016 to December 2022, those fulfilling the inclusion criteria of (1) instrumentation through the bone during surgery, (2) acute neuropathy immediately after surgery, (3) nerve injury confirmed on electrodiagnostics, and (4) imaging consistent with overshoot nerve injury were included. Imaging studies were retrospectively evaluated to determine primary and secondary signs of an overshoot nerve injury. RESULTS Six patients (3 females, mean age 26.7 (range 10-49) years) had nerve injury fitting the mechanism of injury: 3 injuries to the radial nerve during fixation of distal humerus fractures, 1 tibial nerve and 1 superficial peroneal nerve injury during fixation of tibial fractures, and 1 posterior interosseous nerve injury during biceps tendon repair. Ultrasounds were performed in all while 4 also had MRI. Secondary signs included (1) cortical defect adjacent to injured nerve (n=2); (2) scar extending from bone to injured nerve (n=2); (3) screw tip pointing to injured nerve (n=1, 4) tract in bone on MRI from previous instrumentation pointing to injured nerve (n=2). CONCLUSION In addition to primary signs such as laceration or neuroma, secondary signs of "overshoot" nerve injury include cortical defect, scar extending to nerve, screw tip pointing to nerve, and linear tract in the bone on MRI.
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Affiliation(s)
- Yoshimi Endo
- Department of Radiology and Imaging, Hospital for Special Surgery, New York, NY, USA.
| | - Ogonna K Nwawka
- Department of Radiology and Imaging, Hospital for Special Surgery, New York, NY, USA
| | - Darryl B Sneag
- Department of Radiology and Imaging, Hospital for Special Surgery, New York, NY, USA
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Pitman J, Lin Y, Tan ET, Sneag D. Magnetic Resonance Neurography of the Lumbosacral Plexus. Radiol Clin North Am 2024; 62:229-245. [PMID: 38272617 DOI: 10.1016/j.rcl.2023.09.008] [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: 01/27/2024]
Abstract
Pain and weakness in the low back, pelvis, and lower extremities are diagnostically challenging, and imaging can be an important step in the workup and management of these patients. Technical advances in magnetic resonance neurography (MRN) have significantly improved its utility for imaging the lumbosacral plexus (LSP). In this article, the authors review LSP anatomy and selected pathology examples. In addition, the authors will discuss technical considerations for MRN with specific points for the branch nerves off the plexus.
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Affiliation(s)
- Jenifer Pitman
- Musculoskeletal Imaging, Department of Radiology, Johns Hopkins Hospital, 601 N Caroline Street, 3rd Floor, Baltimore, MD, USA.
| | - Yenpo Lin
- Radiology Department, Hospital For Special Surgery, 535 East 70th Street, 3rd Floor, New York, NY, USA; Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Ek Tsoon Tan
- Radiology Department, Hospital For Special Surgery, 535 East 70th Street, 3rd Floor, New York, NY, USA
| | - Darryl Sneag
- Radiology Department, Hospital For Special Surgery, 535 East 70th Street, 3rd Floor, New York, NY, USA
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Lee SK, Serhal AM, Serhal M, Michalek J, Omar IM. The role of high-resolution ultrasound and MRI in the evaluation of peripheral nerves in the lower extremity. J Ultrason 2023; 23:e328-e346. [PMID: 38020505 PMCID: PMC10668932 DOI: 10.15557/jou.2023.0038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 08/22/2023] [Indexed: 12/01/2023] Open
Abstract
Lower extremity peripheral neuropathy is a commonly encountered neurologic disorder, which can lead to chronic pain, functional disability, and decreased quality of life for a patient. As diagnostic imaging modalities have improved, imaging has started to play an integral role in the detection and characterization of peripheral nerve abnormalities by non-invasively and accurately identifying abnormal nerves as well as potential causes of neuropathy, which ultimately leads to precise and timely treatment. Ultrasound, which has high spatial resolution and can quickly and comfortably characterize peripheral nerves in real time along with associated denervation muscle atrophy, and magnetic resonance neurography, which provides excellent contrast resolution between nerves and other tissues and between pathologic and normal segments of peripheral nerves, in addition to assessing reversible and irreversible muscle denervation changes, are the two mainstay imaging modalities used in peripheral nerve assessment. These two modalities are complimentary, and one may be more useful than the other depending on the nerve and location of pathology. Imaging must be interpreted in the context of available clinical information and other diagnostic studies, such as electrodiagnostic tests. Here, we offer a comprehensive overview of the role of high-resolution ultrasound and magnetic resonance neurography in the evaluation of the peripheral nerves of the lower extremity and their associated neuropathies.
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Affiliation(s)
- Steven Kyungho Lee
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Ali Mostafa Serhal
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Muhamad Serhal
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Julia Michalek
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Imran Muhammad Omar
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, USA
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