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Çiçek F, Kurtoğlu Olgunus Z, Koç T. The effect of hallux valgus on the anatomy of the nerves around the first metatarsal bone. Surg Radiol Anat 2024; 46:433-441. [PMID: 38492026 DOI: 10.1007/s00276-024-03318-9] [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] [Received: 06/06/2023] [Accepted: 01/31/2024] [Indexed: 03/18/2024]
Abstract
OBJECTIVE To identify the variations in the location of the nerves that may be at risk in hallux valgus (HV) surgery, and to reveal whether these nerves are affected by the anatomical changes associated with HV. METHOD In the formalin fixed, 46 lower extremities (19 female, 27 male) (9 normal, 14 mild HV, 21 moderate/severe HV), extensor hallucis longus tendon (EHL), deep plantar artery, medial dorsal cutaneous (MDCN), deep fibular (DFN), common plantar digital (CPDN) and proper plantar digital (PPDN) nerves were examined. The branches of MDCN extending to the medial side of foot were recorded in three segments. The positional topography of nerves according to EHL were analyzed on 360° circle and clock models. RESULTS Sex-related differences observed in some parameters in direct measurements were not found in the clock model comparisons. In advanced HV angles (> 20°), DFN was closer to EHL in the distal part of the metatarsal bone, while there was no difference in the proximal. The intersection of the medial branch of the MDCN with the EHL was more proximal in HV cases than in normal feet. The location of the nerves in the clock pattern did not change in HV. Of the nerve branches reaching the medial side of the foot, 65.2% were in Part I, 71.7% in Part II, and 4.3% in Part III. CONCLUSION Sex differences in the distance of the nerves to the EHL disappeared when the size effect of the cross-section of the first metatarsal bone region was eliminated with the clock model. Only in advanced HVA (>20°) (not in mild HV), the DFN being closer to the EHL distally and the intersection of the medial branch of the MDCN with the EHL in HV being more proximal than in normal can be interpreted as specific reflections of HV progress. The variations we revealed in the number of branches reaching the inside of the foot may explain the diversity of neuromas or nerve injuries associated with HV surgery.
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Affiliation(s)
- Fatih Çiçek
- Department of Anatomy, Faculty of Medicine, Niğde Ömer Halisdemir University, Niğde, Turkey
| | | | - Turan Koç
- Department of Anatomy, Faculty of Medicine, Kahramanmaraş Sütçü İmam University, Kahramanmaraş, Turkey
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2
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Hwang CD, Hoftiezer YAJ, Raasveld FV, Gomez-Eslava B, van der Heijden EPA, Jayakar S, Black BJ, Johnston BR, Wainger BJ, Renthal W, Woolf CJ, Eberlin KR. Biology and pathophysiology of symptomatic neuromas. Pain 2024; 165:550-564. [PMID: 37851396 DOI: 10.1097/j.pain.0000000000003055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 06/07/2023] [Indexed: 10/19/2023]
Abstract
ABSTRACT Neuromas are a substantial cause of morbidity and reduction in quality of life. This is not only caused by a disruption in motor and sensory function from the underlying nerve injury but also by the debilitating effects of neuropathic pain resulting from symptomatic neuromas. A wide range of surgical and therapeutic modalities have been introduced to mitigate this pain. Nevertheless, no single treatment option has been successful in completely resolving the associated constellation of symptoms. While certain novel surgical techniques have shown promising results in reducing neuroma-derived and phantom limb pain, their effectiveness and the exact mechanism behind their pain-relieving capacities have not yet been defined. Furthermore, surgery has inherent risks, may not be suitable for many patients, and may yet still fail to relieve pain. Therefore, there remains a great clinical need for additional therapeutic modalities to further improve treatment for patients with devastating injuries that lead to symptomatic neuromas. However, the molecular mechanisms and genetic contributions behind the regulatory programs that drive neuroma formation-as well as the resulting neuropathic pain-remain incompletely understood. Here, we review the histopathological features of symptomatic neuromas, our current understanding of the mechanisms that favor neuroma formation, and the putative contributory signals and regulatory programs that facilitate somatic pain, including neurotrophic factors, neuroinflammatory peptides, cytokines, along with transient receptor potential, and ionotropic channels that suggest possible approaches and innovations to identify novel clinical therapeutics.
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Affiliation(s)
- Charles D Hwang
- Division of Plastic and Reconstructive Surgery, Department of General Surgery, Massachusetts General Hospital, Harvard University, Boston, MA, United States
| | - Yannick Albert J Hoftiezer
- Hand and Arm Center, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, United States
- Department of Plastic, Reconstructive and Hand Surgery, Radboudumc, Nijmegen, the Netherlands
| | - Floris V Raasveld
- Hand and Arm Center, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, United States
- Department of Plastic, Reconstructive and Hand Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Barbara Gomez-Eslava
- Hand and Arm Center, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, United States
- F.M. Kirby Neurobiology Center, Boston Children's Hospital and Department of Neurobiology, Harvard Medical School, Boston, MA, United States
| | - E P A van der Heijden
- Department of Plastic, Reconstructive and Hand Surgery, Radboudumc, Nijmegen, the Netherlands
- Department of Plastic, Reconstructive and Hand Surgery, Jeroen Bosch Ziekenhuis, Den Bosch, the Netherlands
| | - Selwyn Jayakar
- F.M. Kirby Neurobiology Center, Boston Children's Hospital and Department of Neurobiology, Harvard Medical School, Boston, MA, United States
| | - Bryan James Black
- Department of Biomedical Engineering, UMass Lowell, Lowell, MA, United States
| | - Benjamin R Johnston
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, MA, United States
| | - Brian J Wainger
- Departments of Anesthesia, Critical Care & Pain Medicine and Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | | | - Clifford J Woolf
- F.M. Kirby Neurobiology Center, Boston Children's Hospital and Department of Neurobiology, Harvard Medical School, Boston, MA, United States
| | - Kyle R Eberlin
- Division of Plastic and Reconstructive Surgery, Department of General Surgery, Massachusetts General Hospital, Harvard University, Boston, MA, United States
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3
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Telleman JA, Sneag DB, Visser LH. The role of imaging in focal neuropathies. HANDBOOK OF CLINICAL NEUROLOGY 2024; 201:19-42. [PMID: 38697740 DOI: 10.1016/b978-0-323-90108-6.00001-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2024]
Abstract
Electrodiagnostic testing (EDX) has been the diagnostic tool of choice in peripheral nerve disease for many years, but in recent years, peripheral nerve imaging has been used ever more frequently in daily clinical practice. Nerve ultrasound and magnetic resonance (MR) neurography are able to visualize nerve structures reliably. These techniques can aid in localizing nerve pathology and can reveal significant anatomical abnormalities underlying nerve pathology that may have been otherwise undetected by EDX. As such, nerve ultrasound and MR neurography can significantly improve diagnostic accuracy and can have a significant effect on treatment strategy. In this chapter, the basic principles and recent developments of these techniques will be discussed, as well as their potential application in several types of peripheral nerve disease, such as carpal tunnel syndrome (CTS), ulnar neuropathy at the elbow (UNE), radial neuropathy, brachial and lumbosacral plexopathy, neuralgic amyotrophy (NA), fibular, tibial, sciatic, femoral neuropathy, meralgia paresthetica, peripheral nerve trauma, tumors, and inflammatory neuropathies.
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Affiliation(s)
- Johan A Telleman
- Department of Neurology and Clinical Neurophysiology, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - Darryl B Sneag
- Department of Radiology and Imaging, Hospital for Special Surgery, New York, NY, United States
| | - Leo H Visser
- Department of Neurology and Clinical Neurophysiology, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands.
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4
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Kolbenschlag J, Prahm C, Hurth H, Grimm A, Schuhmann M, Winter N, Daigeler A, Heinzel J. [Diagnostics and surgical treatment of painful neuromas]. DER NERVENARZT 2023; 94:1106-1115. [PMID: 37857991 DOI: 10.1007/s00115-023-01563-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/29/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND Painful neuromas that often develop after peripheral nerve injury require adequate diagnosis and treatment because of the suffering they cause. The scientific basis for the development of painful neuromas has not yet been sufficiently investigated. In addition to conservative procedures, a larger number of surgical techniques are available for treatment of painful neuromas. OBJECTIVE A review of the basic principles, diagnostic and treatment options for painful neuromas. MATERIAL AND METHODS Presentation of the scientific basis regarding the development of painful neuromas. Illustration and discussion of the most common diagnostic and treatment procedures. RESULTS The scientific basis regarding the development of painful neuromas after peripheral nerve injury has not yet been adequately developed. In order to be able to make a correct diagnosis, the use of standardized diagnostic criteria and adequate imaging techniques are recommended. In the sense of a paradigm shift, the use of the formerly neuroma-bearing nerve for reinnervation of target organs is to be preferred over mere burying in adjacent tissue. CONCLUSION In addition to standardized diagnostics the management of painful neuromas often requires a surgical intervention after all conservative therapeutic measures have been exhausted. As an alternative to restoring the continuity of the injured nerve, targeted reinnervation of electively denervated target organs by the formerly neuroma-bearing nerve is preferable over other techniques.
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Affiliation(s)
- Jonas Kolbenschlag
- Klinik für Hand‑, Plastische, Rekonstruktive und Verbrennungschirurgie, BG Klinik Tübingen, Schnarrenbergstr. 95, 72076, Tübingen, Deutschland.
| | - C Prahm
- Klinik für Hand‑, Plastische, Rekonstruktive und Verbrennungschirurgie, BG Klinik Tübingen, Schnarrenbergstr. 95, 72076, Tübingen, Deutschland
| | - H Hurth
- Klinik für Neurochirurgie am Universitätsklinikum Tübingen, Eberhard Karls Universität Tübingen, Tübingen, Deutschland
| | - A Grimm
- Klinik für Neurologie am Universitätsklinikum Tübingen, Eberhard Karls Universität Tübingen, Tübingen, Deutschland
| | - M Schuhmann
- Klinik für Neurochirurgie am Universitätsklinikum Tübingen, Eberhard Karls Universität Tübingen, Tübingen, Deutschland
| | - N Winter
- Klinik für Neurologie am Universitätsklinikum Tübingen, Eberhard Karls Universität Tübingen, Tübingen, Deutschland
| | - A Daigeler
- Klinik für Hand‑, Plastische, Rekonstruktive und Verbrennungschirurgie, BG Klinik Tübingen, Schnarrenbergstr. 95, 72076, Tübingen, Deutschland
| | - J Heinzel
- Klinik für Hand‑, Plastische, Rekonstruktive und Verbrennungschirurgie, BG Klinik Tübingen, Schnarrenbergstr. 95, 72076, Tübingen, Deutschland
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5
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Ferreira KS, Speciali JG. Chronic Unilateral Headache Related to Scar Neuromas. J Med Cases 2023; 14:217-221. [PMID: 37435109 PMCID: PMC10332870 DOI: 10.14740/jmc4087] [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: 04/03/2023] [Accepted: 06/05/2023] [Indexed: 07/13/2023] Open
Abstract
Postcraniotomy and posttraumatic headaches can result in scars generating local pain or referred pain following a neuropathic pattern. One hypothesis is that the pain can be caused and maintained by scar neuromas, developed after the nerve injury during the surgical process or trauma. This study reports two patients with chronic unilateral headaches: the first one with a posttraumatic scar in the parietal region and the other with a postsurgical scar in the mastoid region. In both patients, the headache was ipsilateral to the scar, suggesting primary headaches (trigeminal autonomic cephalalgia (TAC), as hemicrania continua and chronic cluster headache). Pharmacological treatment for these conditions failed. Instead, there was complete remission of the headache with anesthetic blockade of scar neuromas (demonstrated by clinical examination in both patients). An active search for traumatic or nontraumatic scars is recommended in all patients with refractory unilateral headaches, and anesthetic blocks for scar neuromas can be effective in treating this pain.
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Affiliation(s)
- Karen S. Ferreira
- Department of Neurology, Suroit Hospital, Salaberry-de-Valleyfield, QC, Canada
| | - Jose G. Speciali
- Department of Neurology, Faculty of Medicine of Ribeirao Preto, University of Sao Paulo, Brazil
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6
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de Castro JC, Wang D, Strakowski J, Emril DR, Chang Chien GC. Alpha-2 macroglobulin for the treatment of neuroma pain in the stump of a below-knee amputee patient. Pain Manag 2023; 13:335-341. [PMID: 37551540 DOI: 10.2217/pmt-2023-0005] [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: 08/09/2023] Open
Abstract
This case report describes the successful treatment of neuroma pain in the setting of below knee amputations using alpha-2-macroglobulin (A2M). A 34-year-old female patient presented with 9 months of stump pain despite conservative treatment. The exam revealed persistent pain through rest periods and weight-bearing status during therapy. Ultrasound showed neuroma formation with neovascularization. The patient underwent two A2M hydrodissection treatments, 2 weeks apart. The patient reported significant pain relief. Ultrasound showed decreases in neovascularization and cross-sectional area of the neuroma. The patient was able to ambulate pain-free for 2 years and reported no pain since. A2M may be a treatment for patients with neuroma pain in the setting of amputations.
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Affiliation(s)
| | | | - Jeffrey Strakowski
- The Ohio State University, Department of Physical Medicine & Rehabilitation, Columbus, OH, 43214, USA
| | - Dessy R Emril
- Medical Faculty of Universitas Syiah Kuala, Aceh, Indonesia
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Karinja SJ, Gorky J, Valerio IL, Ruscic KJ, Eberlin KR. The Neuroma Startle Sign: A Surgical Indicator of Proximity to an Injured Nerve. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e4890. [PMID: 36936466 PMCID: PMC10017393 DOI: 10.1097/gox.0000000000004890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 02/03/2023] [Indexed: 03/17/2023]
Abstract
During operative intervention for the treatment of symptomatic neuromas, the authors have observed a hypersensitive "startle" response to stimulation in proximity to the painful nerve. This physiologic sign is an indicator of the specific anatomic localization of the painful stimulus, commonly a symptomatic neuroma, that appears to be reproducible. The aim of this article is to describe this "neuroma startle sign," posit the underlying mechanism for this observation, and propose how this phenomenon could be clinically harnessed for innovation and optimization in both surgery and anesthesia for more effective symptomatic neuroma localization.
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Affiliation(s)
- Sarah J. Karinja
- From the Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Jonathon Gorky
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Ian L. Valerio
- From the Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Katarina J. Ruscic
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Kyle R. Eberlin
- From the Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
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8
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Macionis V. Chronic pain and local pain in usually painless conditions including neuroma may be due to compressive proximal neural lesion. FRONTIERS IN PAIN RESEARCH 2023; 4:1037376. [PMID: 36890855 PMCID: PMC9986610 DOI: 10.3389/fpain.2023.1037376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 01/12/2023] [Indexed: 02/22/2023] Open
Abstract
It has been unexplained why chronic pain does not invariably accompany chronic pain-prone disorders. This question-driven, hypothesis-based article suggests that the reason may be varying occurrence of concomitant peripheral compressive proximal neural lesion (cPNL), e.g., radiculopathy and entrapment plexopathies. Transition of acute to chronic pain may involve development or aggravation of cPNL. Nociceptive hypersensitivity induced and/or maintained by cPNL may be responsible for all types of general chronic pain as well as for pain in isolated tissue conditions that are usually painless, e.g., neuroma, scar, and Dupuytren's fibromatosis. Compressive PNL induces focal neuroinflammation, which can maintain dorsal root ganglion neuron (DRGn) hyperexcitability (i.e., peripheral sensitization) and thus fuel central sensitization (i.e., hyperexcitability of central nociceptive pathways) and a vicious cycle of chronic pain. DRGn hyperexcitability and cPNL may reciprocally maintain each other, because cPNL can result from reflexive myospasm-induced myofascial tension, muscle weakness, and consequent muscle imbalance- and/or pain-provoked compensatory overuse. Because of pain and motor fiber damage, cPNL can worsen the causative musculoskeletal dysfunction, which further accounts for the reciprocity between the latter two factors. Sensitization increases nerve vulnerability and thus catalyzes this cycle. Because of these mechanisms and relatively greater number of neurons involved, cPNL is more likely to maintain DRGn hyperexcitability in comparison to distal neural and non-neural lesions. Compressive PNL is associated with restricted neural mobility. Intermittent (dynamic) nature of cPNL may be essential in chronic pain, because healed (i.e., fibrotic) lesions are physiologically silent and, consequently, cannot provide nociceptive input. Not all patients may be equally susceptible to develop cPNL, because occurrence of cPNL may vary as vary patients' predisposition to musculoskeletal impairment. Sensitization is accompanied by pressure pain threshold decrease and consequent mechanical allodynia and hyperalgesia, which can cause unusual local pain via natural pressure exerted by space occupying lesions or by their examination. Worsening of local pain is similarly explainable. Neuroma pain may be due to cPNL-induced axonal mechanical sensitivity and hypersensitivity of the nociceptive nervi nervorum of the nerve trunk and its stump. Intermittence and symptomatic complexity of cPNL may be the cause of frequent misdiagnosis of chronic pain.
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9
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Yu AX, Wang Z, Yi XZ. Regenerative peripheral nerve interface prevents neuroma formation after peripheral nerve transection. Neural Regen Res 2023; 18:814-818. [DOI: 10.4103/1673-5374.353498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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10
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Thomajan CH. A Method for Entubulating Exposed Nerve Ends Following Neurectomy Using a Porcine Extracellular Matrix Nerve Cap. Foot Ankle Spec 2022; 15:579-585. [PMID: 35778874 PMCID: PMC9643824 DOI: 10.1177/19386400221106642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Compression and irritation at the plantar aspect of the transverse intermetatarsal ligament may lead to a compressive neuropathy called Morton's neuroma. There are many treatment options for Morton's neuroma, with the most common surgical option being traction neurectomy. While there has been success in many surgical procedures, up to 35% of patients treated with traction neurectomy have recurrent pain and up to one-third of these patients have a recurrent stump neuroma. These neuromas are caused by abnormal axonal growth during regeneration, leading to an unorganized mass of fibrotic collagenous tissues, Schwann cells, and axons. More recent surgical treatments of neuromas have included nerve capping, which has been proposed to prevent painful neuroma formation by isolating the nerve end from external chemosignaling and reducing disorganized axonal outgrowth. An off-the-shelf, biocompatible porcine small intestine submucosa (pSIS) derived nerve cap with internal chambering has been investigated in a rodent study, which showed less pain sensitivity and less axonal swirling indicative of reduced likelihood of neuroma formation. Furthermore, a recent clinical study indicated that patients experienced a significant reduction in pain 3 months after Morton's neuroma excision followed by repair using a nerve cap. This article describes the surgical technique of the aforementioned clinical study to mitigate neuroma formation, where a Morton's neuroma is excised, and the remaining proximal nerve stump is inserted within a nerve cap and buried in the surrounding muscle.Level of Evidence: Level V: Expert opinion.
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Affiliation(s)
- Craig H. Thomajan
- Craig H. Thomajan, DPM, Austin Foot and
Ankle Specialists, 5000 Bee Caves Road, Suite 202, Austin, TX 78746; e-mail:
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11
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Tham JL, Sood A, Saffari TM, Khajuria A. The effect of targeted muscle reinnervation on post-amputation pain and functional outcomes: a systematic review and meta-analysis. EUROPEAN JOURNAL OF PLASTIC SURGERY 2022. [DOI: 10.1007/s00238-022-02021-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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12
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Cohen PR, Calame A. Tender Nasal Traumatic (TNT) Neuroma: Case Report and Review. Cureus 2022; 14:e30957. [DOI: 10.7759/cureus.30957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2022] [Indexed: 11/05/2022] Open
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Pathophysiological and Neuroplastic Changes in Postamputation and Neuropathic Pain: Review of the Literature. Plast Reconstr Surg Glob Open 2022; 10:e4549. [PMID: 36187278 PMCID: PMC9521753 DOI: 10.1097/gox.0000000000004549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 08/05/2022] [Indexed: 10/24/2022]
Abstract
Despite advancements in surgical and rehabilitation strategies, extremity amputations are frequently associated with disability, phantom limb sensations, and chronic pain. Investigation into potential treatment modalities has focused on the pathophysiological changes in both the peripheral and central nervous systems to better understand the underlying mechanism in the development of chronic pain in persons with amputations. Methods Presented in this article is a discussion outlining the physiological changes that occur in the peripheral and central nervous systems following amputation. In this review, the authors examine the molecular and neuroplastic changes occurring in the nervous system, as well as the state-of-the-art treatment to help reduce the development of postamputation pain. Results This review summarizes the current literature regarding neurological changes following amputation. Development of both central sensitization and neuronal remodeling in the spinal cord and cerebral cortex allows for the development of neuropathic and phantom limb pain postamputation. Recently developed treatments targeting these pathophysiological changes have enabled a reduction in the severity of pain; however, complete resolution remains elusive. Conclusions Changes in the peripheral and central nervous systems following amputation should not be viewed as separate pathologies, but rather two interdependent mechanisms that underlie the development of pathological pain. A better understanding of the physiological changes following amputation will allow for improvements in therapeutic treatments to minimize pathological pain caused by amputation.
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Fulton ZW, Boothby BC, Phillips SA. Targeted Muscle Reinnervation for Trauma-Related Amputees: A Systematic Review. Cureus 2022; 14:e28474. [PMID: 36176851 PMCID: PMC9512320 DOI: 10.7759/cureus.28474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/27/2022] [Indexed: 11/05/2022] Open
Abstract
While amputation techniques have improved over time, questions remain around how to best treat neuromas and severed nerves in the amputee population, specifically for trauma-related amputees. This systematic review investigates and summarizes outcomes following targeted muscle reinnervation (TMR) for the trauma-related amputee population. Studies were classified based on primary or secondary TMR and relevant outcomes, including the ability to use a prosthesis, post-TMR opioid use, Patient-Reported Outcomes Measurement Information System (PROMIS) scores for phantom limb pain and residual limb pain, and overall pain resolution/reduction. Following TMR for trauma-related amputation, most patients experienced neuroma pain resolution (86.2%, 95% confidence interval [CI]: 67.2-95.0%) and overall pain reduction/resolution (90.7%, 95% CI: 82.2-95.4%). No differences were seen between primary and secondary TMR. Preliminary evidence indicates that TMR is effective for preventing or treating pain in patients with trauma-related amputation, whether used in the acute or delayed setting.
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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.
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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,
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16
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Changes in Patient-Reported Pain Interference After Surgical Treatment of Painful Lower Extremity Neuromas. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2022; 5:97-101. [PMID: 36704377 PMCID: PMC9870789 DOI: 10.1016/j.jhsg.2022.03.005] [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: 01/18/2022] [Accepted: 03/29/2022] [Indexed: 01/29/2023] Open
Abstract
Purpose Painful neuromas commonly cause neuropathic pain, in up to 1 in 20 cases of traumatic or iatrogenic nerve injury. Despite the multiple surgical treatment types that reduce pain, no type has been universally accepted. Methods We performed a retrospective cohort study by administering follow-up surveys to all surgical patients treated in our department for lower-extremity neuroma from September 1, 2015, to October 22, 2021, that could be contacted, excluding those with Morton neuroma. In addition to the Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference (PI) questionnaire, survey questions covered the time to pain reduction, use of physical or occupational therapy, and characteristics of the pain. When available, previously collected preoperative and postoperative PROMIS PI data were used for patients who could not be contacted for the telephone survey. Paired-sample nonparametric testing was used to compare preoperative and postoperative PROMIS PI scores. Results Initial query in the medical record by Current Procedural Terminology codes yielded 1,812 patients for chart review, of whom 33 were eligible to call. In total, 9 (27%) patients completed both preoperative and postoperative PROMIS PIs: 6 (18.2%) completed full telephone surveys and 3 (9.1%) had preoperative and postoperative PROMIS PI data in the chart review but could not be contacted for the full telephone survey. Four of the 6 telephone-survey respondents reported pain reduction within 12 months of their surgery. Wilcoxon signed-rank testing demonstrated a moderate but nonstatistically significant reduction in PROMIS PI scores, with a median difference of -4.85 (P = .1; 95% CI -12 to 1.2). Conclusions There were notable improvements in our cohort, but larger studies are needed to determine whether surgical treatment of lower-extremity neuroma results in a clinically important and significant difference in PROMIS PI scores, as well as to discern the advantages each treatment. Type of study/level of evidence Therapeutic IV.
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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]
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Pi W, Li C, Zhang M, Zhang W, Zhang PX. Myelin-associated glycoprotein combined with chitin conduit inhibits painful neuroma formation after sciatic nerve transection. Neural Regen Res 2021; 17:1343-1347. [PMID: 34782580 PMCID: PMC8643036 DOI: 10.4103/1673-5374.327351] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Studies have shown that myelin-associated glycoprotein (MAG) can inhibit axon regeneration after nerve injury. However, the effects of MAG on neuroma formation after peripheral nerve injury remain poorly understood. In this study, local injection of MAG combined with nerve cap made of chitin conduit was used to intervene with the formation of painful neuroma after sciatic nerve transfection in rats. After 8 weeks of combined treatment, the autotomy behaviors were reduced in rats subjected to sciatic nerve transfection, the mRNA expression of nerve growth factor, a pain marker, in the proximal nerve stump was decreased, the density of regenerated axons was decreased, the thickness of the myelin sheath was increased, and the ratio of unmyelinated to myelinated axons was reduced. Moereover, the percentage of collagen fiber area and the percentage of fibrosis marker alpha-smooth muscle actin positive staining area in the proximal nerve stump were decreased. The combined treatment exhibited superior effects in these measures to chitin conduit treatment alone. These findings suggest that MAG combined with chitin conduit synergistically inhibits the formation of painful neuroma after sciatic nerve transection and alleviates neuropathic pain. This study was approved by the Animal Ethics Committee of Peking University People’s Hospital (approval No. 2019PHE027) on December 5, 2019.
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Affiliation(s)
- Wei Pi
- Department of Orthopedics and Trauma, Peking University People's Hospital; Key Laboratory of Trauma and Neural Regeneration, Peking University; National Center for Trauma Medicine, Beijing, China
| | - Ci Li
- Department of Orthopedics and Trauma, Peking University People's Hospital; Key Laboratory of Trauma and Neural Regeneration, Peking University; National Center for Trauma Medicine, Beijing, China
| | - Meng Zhang
- Department of Orthopedics and Trauma, Peking University People's Hospital; Key Laboratory of Trauma and Neural Regeneration, Peking University; National Center for Trauma Medicine, Beijing, China
| | - Wei Zhang
- Department of Orthopedics and Trauma, Peking University People's Hospital; Key Laboratory of Trauma and Neural Regeneration, Peking University; National Center for Trauma Medicine, Beijing, China
| | - Pei-Xun Zhang
- Department of Orthopedics and Trauma, Peking University People's Hospital; Key Laboratory of Trauma and Neural Regeneration, Peking University; National Center for Trauma Medicine, Beijing, China
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Barros A, Queiruga-Piñeiro J, Lozano-Sanroma J, Alcalde I, Gallar J, Fernández-Vega Cueto L, Alfonso JF, Quirós LM, Merayo-Lloves J. Small fiber neuropathy in the cornea of Covid-19 patients associated with the generation of ocular surface disease. Ocul Surf 2021; 23:40-48. [PMID: 34781021 PMCID: PMC8588585 DOI: 10.1016/j.jtos.2021.10.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 10/18/2021] [Accepted: 10/29/2021] [Indexed: 12/17/2022]
Abstract
Purpose To describe the association between Sars-CoV-2 infection and small fiber neuropathy in the cornea identified by in vivo corneal confocal microscopy. Methods Twenty-three patients who had overcome COVID-19 were recruited to this observational retrospective study. Forty-six uninfected volunteers were also recruited and studied as a control group. All subjects were examined under in vivo confocal microscopy to obtain images of corneal subbasal nerve fibers in order to study the presence of neuroma-like structures, axonal beadings and dendritic cells. The Ocular Surface Disease Index (OSDI) questionnaire and Schirmer tear test were used as indicators of Dry Eye Disease (DED) and ocular surface pathology. Results Twenty-one patients (91.31%) presented alterations of the corneal subbasal plexus and corneal tissue consistent with small fiber neuropathy. Images from healthy subjects did not indicate significant nerve fiber or corneal tissue damage. Eight patients reported increased sensations of ocular dryness after COVID-19 infection and had positive DED indicators. Beaded axons were found in 82.60% of cases, mainly in patients reporting ocular irritation symptoms. Neuroma-like images were found in 65.22% patients, more frequently in those with OSDI scores >13. Dendritic cells were found in 69.56% of patients and were more frequent in younger asymptomatic patients. The presence of morphological alterations in patients up to 10 months after recovering from Sars-CoV-2 infection points to the chronic nature of the neuropathy. Conclusions Sars-CoV-2 infection may be inducing small fiber neuropathy in the ocular surface, sharing symptomatology and morphological landmarks with DED and diabetic neuropathy.
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Affiliation(s)
| | | | | | - Ignacio Alcalde
- Instituto Universitario Fernández-Vega, Universidad de Oviedo & Fundación de Investigación Oftalmológica, Oviedo, Spain; Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain.
| | - Juana Gallar
- Instituto de Neurociencias, Universidad Miguel Hernández-CSIC, San Juan de Alicante, Spain
| | - Luis Fernández-Vega Cueto
- Instituto Oftalmológico Fernández-Vega, Oviedo, Spain; Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain.
| | - José F Alfonso
- Instituto Oftalmológico Fernández-Vega, Oviedo, Spain; Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain; Department of Surgery and Medical-Surgical Specialties, Universidad de Oviedo, Oviedo, Spain
| | - Luis M Quirós
- Instituto Universitario Fernández-Vega, Universidad de Oviedo & Fundación de Investigación Oftalmológica, Oviedo, Spain; Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain; Department of Functional Biology, Universidad de Oviedo, Oviedo, Spain
| | - Jesús Merayo-Lloves
- Instituto Oftalmológico Fernández-Vega, Oviedo, Spain; Instituto Universitario Fernández-Vega, Universidad de Oviedo & Fundación de Investigación Oftalmológica, Oviedo, Spain; Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain; Department of Surgery and Medical-Surgical Specialties, Universidad de Oviedo, Oviedo, Spain
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Clinical Outcomes of Symptomatic Neuroma Resection and Reconstruction with Processed Nerve Allograft. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3832. [PMID: 34616638 PMCID: PMC8489892 DOI: 10.1097/gox.0000000000003832] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 07/22/2021] [Indexed: 01/10/2023]
Abstract
Background: Neuromas causing sensory disturbance can substantially affect nerve function and quality of life. Historically, passive termination of the nerve end and proximal relocation to muscle or bone has been performed after neuroma resection, but this method does not allow for neurologic recovery or prevent recurrent neuromas. The use of processed nerve allografts (PNAs) for intercalary reconstruction of nerve defects following neuroma resection is reasonable for neuroma management, although reported outcomes are limited. The purpose of this study was to assess the outcomes of pain reduction and functional recovery following neuroma resection and intercalary nerve reconstruction using PNA. Methods: Data on outcomes of PNA use for peripheral nerve reconstruction were collected from a multicenter registry study. The registry database was queried for upper extremity nerve reconstruction with PNA after resection of symptomatic neuroma. Patients completing both pain and quantitative sensory assessments were included in the analysis. Improvement in pain-related symptoms was determined via patient self-reported outcomes and/or the visual analog scale. Meaningful sensory recovery was defined as a score of at least S3 on the Medical Research Council Classification scale. Results: Twenty-five repairs involving 21 patients were included in this study. The median interval from injury to reconstruction was 386 days, and the average nerve defect length was 31 mm. Pain improved in 80% of repairs. Meaningful sensory recovery was achieved in 88% of repairs. Conclusion: Neuroma resection and nerve reconstruction using PNA can reduce or eliminate chronic peripheral nerve pain and provide meaningful sensory recovery.
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Bajaj J, Doddamani R, Chandra SP, Ratre S, Parihar V, Yadav Y, Sharma D. Comparison of Peripheral Neurectomy vs. Medical Treatment for Migraine: A Randomized Controlled Trial. Neurol India 2021; 69:S110-S115. [PMID: 34003156 DOI: 10.4103/0028-3886.315973] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background Migraine is a common form of primary neurologic headache. Many patients are chronic migraineurs and suffer from a significant disability and adverse effects of drugs. There are various surgical options available to treat migraines, including peripheral neurectomies. Objective To study the surgical and functional outcomes of migraine surgeries using peripheral neurectomies and compare them with conservatively treated patients. Materials and Methods Migraine patients who had a unilateral onset pain were given local bupivacaine block at the suspected trigger site, and those who were relieved were given the option for surgery. In the operative group, the peripheral nerve of the trigger site was lysed under local anesthesia. The conservative group was continued with the standard treatment. Evaluations with a baseline and 6 months visual analog score (VAS), migraine headache index (MHI), migraine disability assessment test (MIDAS), and pain self-efficacy questionnaire (PSEQ) scores were done. Results A total of 26 patients got benefitted with the local bupivacaine block, out of which 13 underwent surgery. At baseline, the VAS, MHI, MIDAS, and PSEQ scores were similar in both the groups. The operative group had significant (P < 0.001) improvement in all these parameters 6 months after the surgery. All patients of the operative group got free from prophylactic migraine treatment; however, 11 out of 13 patients still needed occasional use of analgesics. There was one complication of transient temporal numbness. Conclusion Migraine surgery using peripheral neurectomies was more effective than chronic drug treatment in appropriately selected patients.
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Affiliation(s)
- Jitin Bajaj
- Department of Neurosurgery, NSCB Medical College, Jabalpur, Madhya Pradesh, India
| | - Ramesh Doddamani
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Sarat P Chandra
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Shailendra Ratre
- Department of Neurosurgery, NSCB Medical College, Jabalpur, Madhya Pradesh, India
| | - Vijay Parihar
- Department of Neurosurgery, NSCB Medical College, Jabalpur, Madhya Pradesh, India
| | - Yadram Yadav
- Department of Neurosurgery, NSCB Medical College, Jabalpur, Madhya Pradesh, India
| | - Dhananjaya Sharma
- Department of Surgery, NSCB Medical College, Jabalpur, Madhya Pradesh, India
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MRI features of symptomatic amputation neuromas. Eur Radiol 2021; 31:7684-7695. [PMID: 33866387 DOI: 10.1007/s00330-021-07954-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 03/13/2021] [Accepted: 03/26/2021] [Indexed: 01/15/2023]
Abstract
OBJECTIVES To demonstrate the magnetic resonance imaging (MRI) features of amputation neuromas in lower extremity amputees and investigate independent predictive MRI features for symptomatic neuromas. METHODS This retrospective study included 45 amputation neuromas in 44 lower extremity amputees. Two radiologists assessed the imaging features, including shape, size, type (end-bulb or spindle), signal intensity (SI), heterogeneity, margins, enlarged fascicles, dark outer rim, tail sign, target sign, enhancement, perilesional fibrosis, and muscle denervation. The neuromas were categorized into symptomatic (n = 24) or asymptomatic (n = 21). Symptomatic neuromas were determined based on neuropathic pain characteristics, the presence of Tinel's sign or tenderness, and response to local anesthetic injection. Univariate and multivariate analyses were performed to identify independent predictive MRI features. RESULTS Of 45 neuromas, 80% (36/45) were end-bulb neuromas and 20% (9/45) were spindle-type neuromas. Eighty percent of the neuromas (36/45) were heterogeneous on T2-weighted images (WIs). Enlarged fascicles were present in 42% (19/45) and dark outer rims in 27% (12/45) of the neuromas. Among the 23 neuromas with enhanced images, 78% (18/23) showed enhancement. Heterogeneity on T2-WIs and enhancement ratios were significantly different between the asymptomatic and symptomatic neuroma groups (p < 0.05). The multivariate analyses indicated that heterogeneity on T2-WIs was an independent factor associated with symptomatic neuromas (p < 0.001). CONCLUSIONS Heterogeneity on T2-WIs could be a predictive indicator for symptomatic neuromas in lower extremity amputees. KEY POINTS • Amputation neuromas are classified as either end-bulb or spindle-type. They can show enlarged fascicles, dark outer rims, and enhancement. • Heterogeneity on T2-weighted images could be a predictive indicator for symptomatic neuromas. • Predicting the symptomatic neuroma on MRI would help in effective management of stump pain.
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Perineural fat grafting in end-neuroma pain treatment: long-term outcomes. EUROPEAN JOURNAL OF PLASTIC SURGERY 2021. [DOI: 10.1007/s00238-020-01664-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Nerve Ultrasound in Traumatic and Iatrogenic Peripheral Nerve Injury. Diagnostics (Basel) 2020; 11:diagnostics11010030. [PMID: 33375348 PMCID: PMC7823340 DOI: 10.3390/diagnostics11010030] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 12/22/2020] [Accepted: 12/23/2020] [Indexed: 01/04/2023] Open
Abstract
Peripheral nerve injury is a potentially debilitating disorder that occurs in an estimated 2–3% of all patients with major trauma, in a similar percentage of medical procedures. The workup of these injuries has traditionally been clinical, combined with electrodiagnostic testing. However, this has limitations, especially in the acute phase of the trauma or lack of any recovery, when it is very important to determine nerve continuity and perform surgical exploration and repair in the case of the complete transection or intraneural fibrosis. Ultrasound can help in those situations. It is a versatile imaging technique with a high sensitivity of 93% for detecting focal nerve lesions. Ultrasound can assess the structural integrity of the nerve, neuroma formation and other surrounding abnormalities of bone or foreign bodies impeding the nerve. In addition, this can help to prevent iatrogenic nerve injury by marking the nerve before the procedure. This narrative review gives an overview of why and how nerve ultrasound can play a role in the detection, management and prevention of peripheral nerve injury.
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Managing Neuroma and Phantom Limb Pain in Ontario: The Status of Targeted Muscle Reinnervation. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e3287. [PMID: 33425599 PMCID: PMC7787323 DOI: 10.1097/gox.0000000000003287] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 09/23/2020] [Indexed: 11/30/2022]
Abstract
Supplemental Digital Content is available in the text. Background: Painful neuromas (PN) and phantom limb pain (PLP) are common following amputation and are unreliably treated, which impacts quality of life. Targeted muscle reinnervation (TMR) is a microsurgical technique that repairs the severed proximal nerve end to a redundant motor nerve in the amputated stump. Evidence supports TMR as effective in treating PN and PLP; however, its adoption has been slow. This study aimed to characterize: (1) the populations experiencing post-amputation PN/PLP; (2) current trends in managing PN/PLP; and (3) attitudes toward routine use of TMR to manage PN/PLP. Methods: A cross-sectional survey was distributed to all orthopedic surgeons, plastic surgeons, and physiatrists practicing in Ontario, via publicly available emails and specialty associations. Data were collected on demographics, experience with amputation, managing post-amputation pain, and attitudes toward routine use of TMR. Results: Sixty-six of 698 eligible participants submitted complete surveys (9.5% response rate). Respondents had a greater experience with surgical management of PN (71% PN versus 10% PLP). However, surgery was considered a 3rd-line option for PN and not an option for PLP in 57% and 59% of respondents, respectively. Thirty participants (45%) were unaware of TMR as an option, and only 8 respondents have currently incorporated TMR into their practice. Many (76%) would be willing to incorporate TMR into their practice as either an immediate or delayed surgical technique. Conclusions: Despite its promise in managing post-amputation pain, awareness of TMR as a surgical option is generally poor. Several barriers to the widespread adoption of this technique are defined.
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Prevention of symptomatic neuroma in traumatic digital amputation: A RAND/UCLA appropriateness method consensus study. Injury 2020; 51 Suppl 4:S103-S107. [PMID: 32178845 DOI: 10.1016/j.injury.2020.03.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 02/22/2020] [Accepted: 03/07/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The appearance of a symptomatic neuroma following finger amputation is a devastating consequence for patient's quality of life. It could be cause of chronic neuropathic pain. The prevention of neuroma formation is a challenging effort for hand surgeons. The biological mechanisms leading to neuroma formation are mostly unknown and different preventing procedures have been tried without certain results. In this paper, a panel of Italian hand surgeons have been asked to express appropriateness about potentially preventive techniques of neuroma formation following the RAND/UCLA appropriateness protocol. METHODS A literature review was preliminarily performed identifying the most employed methods to reduce the pathologic nerve scar. Afterwards, the selected panelists were asked to score the appropriateness of each procedure in a double scenario: in case of a sharp amputation or in a tear injury. The appropriateness was evaluated according to RAND/UCLA protocol. RESULTS Nine Italian hand surgeons were included in the panel. Of them 5 were orthopaedic surgeons, 4 plastic surgeons. The identified appropriate procedures were: revision amputation should be done in operating room, the neurovascular bundles should be identified and is mandatory to treat surrounding soft tissues. Only in case of clean-cut amputation, it is appropriate to perform a proximal extension of the dissection, to use diathermocoagulation and coverage with local flaps. Procedures such as shortening in tension of the nerve stump, bone shortening, implantation of the nerve end in the soft tissue, treatment in the emergency room and, in both scenarios, certain results are evaluated as uncertain. DISCUSSION In order to prevent the formation of a distal stump neuroma few methods were judged appropriate. It is mandatory to identify the neurovascular bundles and treat also the surrounding tissues, but no certain results could be obtained with local flap, bone shortening and other ancillary surgical acts. Moreover, it is not possible to guarantee the non arising of neuroma in any cases, also when every procedure has been temped. CONLUSIONS The prevention of distal neuroma is actually a challenge, without a well known strategy due to the variability of response of nervous tissue to injury.
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Daggubati LC, Davanzo JR, Rizk EB. Peripheral nerve stimulator for terminal sciatic nerve neuromas in an amputee. NEUROSURGICAL FOCUS: VIDEO 2020; 3:V7. [PMID: 36285269 PMCID: PMC9542685 DOI: 10.3171/2020.7.focvid2029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 07/01/2020] [Indexed: 11/08/2022]
Abstract
Neuromas are a difficult-to-treat peripheral nerve pathology that can cause crippling pain. Optimal treatment is widely debated as pharmacological intervention frequently is not sufficient and surgical interventions are plagued with recurrence. The majority of amputees report severe and chronic stump pain. Avoiding complex surgery at the stump site would prevent infection or wound dehiscence. Recent advances in neuromodulation with external pulse emitters allow for pain relief with localized nerve stimulation. The authors describe the novel placement of a sciatic nerve stimulator in a 77-year-old man for painful stump neuromas of the common peroneal and tibial nerves. The video can be found here: https://youtu.be/96kKs3qjtqc
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Ducic I, Yoon J, Buncke G. Chronic postoperative complications and donor site morbidity after sural nerve autograft harvest or biopsy. Microsurgery 2020; 40:710-716. [PMID: 32277511 PMCID: PMC7540447 DOI: 10.1002/micr.30588] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 02/01/2020] [Accepted: 03/27/2020] [Indexed: 01/24/2023]
Abstract
Background The sural nerve is the most frequently harvested nerve autograft and is most often biopsied in the workup of peripheral neuropathy. While the complication types associated with these two procedures are well known, their clinical significance is poorly understood and there is a paucity of data regarding the complication rates. Methods Pubmed search identified studies regarding complications after sural nerve harvest and biopsy. The data was grouped into sensory deficits, chronic pain, sensory symptoms, wound infections, wound complications, other postoperative complications, and complications impacting daily life. The incidence of each complication was calculated, and a chi‐square analysis was performed to determine if there were any differences between nerve biopsies and graft harvest with respect to each complication. Results Twelve studies yielded 478 sural nerve procedures. Sensory deficits occurred at a rate of 92.9%, chronic pain at 19.7%, sensory symptoms at 41.1%, wound infections at 5.7%, noninfectious wound complications at 7.8%, and impact on daily life at 5.0%. The differences in wound infections, sensory symptoms, and impact on daily life between biopsies versus graft excisions were found to reach statistical significance (p < .05). Conclusions Sural nerve excisions can cause chronic postoperative donor‐site complications. Given these complications, alternative available mediums for nerve reconstruction should be explored and utilized wherever appropriate. If an alternative medium is unavailable and nerve autograft must be harvested for nerve reconstruction, then patients should be counseled about risks for developing donor site complications that may negatively affect quality of life.
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Affiliation(s)
- Ivica Ducic
- Washington Nerve Institute, McLean, Virginia, USA.,Department of Surgery, The George Washington University, Washington, District of Columbia, USA
| | - Joshua Yoon
- Department of Surgery, The George Washington University, Washington, District of Columbia, USA
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Briand MM, Boudier-Réveret M, Rodrigue X, Sirois G, Chang MC. A Moving Residual Limb: Botulinum Toxin to the Rescue. Transl Neurosci 2020; 11:34-37. [PMID: 32161684 PMCID: PMC7053396 DOI: 10.1515/tnsci-2020-0006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 02/10/2020] [Indexed: 12/23/2022] Open
Abstract
Movement disorders post-amputation are a rare complication and can manifest as the jumping stump phenomenon, a form of peripheral myoclonus. The pathophysiology remains unknown and there is currently no standardized treatment. We describe the case of a 57-year-old male with unremitting stump myoclonus, starting one month after transtibial amputation, in his residual limb without associated phantom or neurological pain. The consequence of the myoclonus was a reduction in prosthetic wearing time. Failure to respond to oral medication led us to attempt the use of botulinum neurotoxin Type A injections in the involved muscles of the residual limb. Injection trials, over a two-year period, resulted in an improvement of movement disorder, an increased prosthetic wearing time and a higher satisfaction level of the patient. Injection of botulinum toxin type A should be considered as an alternative treatment for stump myoclonus to improve prosthetic wearing time and comfort.
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Affiliation(s)
| | - Mathieu Boudier-Réveret
- Department of Physical Medicine and Rehabilitation, Centre hospitalier de l'Université de Montréal, Montreal, Canada
| | - Xavier Rodrigue
- Institut de réadaptation en déficience physique de Québec, Québec, Canada
| | - Geneviève Sirois
- Institut de réadaptation en déficience physique de Québec, Québec, Canada
| | - Min Cheol Chang
- Department of Physical Medicine and Rehabilitation, College of Medicine, Yeungnam University 317-1, Daemyungdong, Namku, Taegu 705-717, Republic of Korea
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Treatment of Neuroma-induced Chronic Pain and Management of Nerve Defects with Processed Nerve Allografts. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 7:e2467. [PMID: 32537284 PMCID: PMC7288900 DOI: 10.1097/gox.0000000000002467] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 08/02/2019] [Indexed: 01/19/2023]
Abstract
Symptomatic neuromas can cause significant chronic pain and negatively impact quality of life. Symptoms often persist despite narcotics and nonoperative interventions, which are largely ineffective. With the opioid crisis, treatments for chronic pain that limit narcotics are needed. Traditional surgical options may result in neuroma recurrence. Autograft reconstruction often results in donor-site morbidity. Processed nerve allografts facilitate axonal growth, nerve regeneration, and eliminate donor-site morbidity. Methods A literature review was performed to identify studies in which chronic neuroma pain was treated with excision and processed nerve allograft reconstruction. PubMed was queried, and data from the studies were grouped into treatment effective and ineffective groups. Statistical analyses were performed on these groups, and further subgroup analysis was performed on overall change of preoperative and postoperative pain scores using a paired t test. Results Seven studies fulfilled inclusion criteria yielding 42 patients. Greater than 90% of patients had improvement of pain postoperatively. The preoperative and postoperative pain scores could be determined for 40 patients. The mean preoperative score was 7.9, and the mean postoperative score was 3.54. These results were statistically significant using a paired t test with a P value of <0.001. Conclusions Chronic pain resulting from symptomatic neuromas can be treated with neuroma excision and nerve stump reconstruction with processed nerve allograft. This obviates autograft-associated donor-site morbidity and provides a platform to potentially restore sensation to the involved nerve whenever a distal nerve end is available. Addressing the root cause is an important paradigm shift for treating symptomatic neuromas.
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Zhang X, Shao X, Shen Q, Yu Y, Li Y, Fan A. Use of the First Dorsal Metacarpal Artery-Based Fascial Flap for Reconstruction of Small Defects on the Dorsum of the Hands. J Hand Surg Am 2019; 44:1096.e1-1096.e6. [PMID: 31109774 DOI: 10.1016/j.jhsa.2019.02.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 01/17/2019] [Accepted: 02/15/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To describe the reconstruction of small defects on the dorsum of the hands using a first dorsal metacarpal artery-based fascial flap harvested through the borders of the defect. METHODS From January, 2015 to May, 2017, 29 patients (29 hands) with soft tissue defects on the dorsum of the hand were treated using a first dorsal metacarpal artery-based fascial flap. At final follow-up, we measured range of motion of the metacarpophalangeal joints and the first web span. RESULTS Average size of the defects was 2.7 × 2.5 cm. Average size of the flaps was 2.9 × 2.7 cm. Average length of the pedicle was 2.9 cm. All flaps survived. Range of motion of the second to fourth metacarpophalangeal joints reached 93% to 98% of the opposite hand. The span of the first web reached 98% of the opposite hand. CONCLUSIONS A first dorsal metacarpal artery-based fascial flap can be an alternative for reconstruction of small defects on the dorsum of the hands. Flap harvesting through the border of the defect avoided an additional scar at the donor site. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Xu Zhang
- Department of Hand Surgery, Third Hospital of Hebei Medical University
| | - Xinzhong Shao
- Department of Hand Surgery, Third Hospital of Hebei Medical University.
| | - Qiang Shen
- Department of Hand and Foot Surgery, Armed Police Corps Hospital of Hebei, Shijiazhuang
| | - Yadong Yu
- Department of Hand Surgery, Third Hospital of Hebei Medical University
| | - Yanchuang Li
- Department of Hand Surgery, Shanhaiguan Bridge Plant Hospital, Shanhaiguan, Qinhuangdao
| | - Anwei Fan
- Orthopaedic Department, Orthopaedic Hospital of Xingtai, Xingtai, Hebei, China
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Chen W, Zhang H, Huang J, Li Y, Zhang Z, Peng Y. Traumatic neuroma in mastectomy scar: Two case reports and review of the literature. Medicine (Baltimore) 2019; 98:e15142. [PMID: 30985684 PMCID: PMC6485883 DOI: 10.1097/md.0000000000015142] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 02/24/2019] [Accepted: 03/14/2019] [Indexed: 02/05/2023] Open
Abstract
RATIONALE Traumatic neuroma is a reparative proliferative response of the nerve after trauma or surgery, which rarely occurs in the breast. However, it must be distinguished from tumor recurrence. PATIENT CONCERNS A 78-year-old woman underwent left-sided modified radical mastectomy for invasive carcinoma, 7 years before this case. Two painless nodules near the mastectomy scar were discovered in regular follow-up physical examination. A 62-year-old woman had received right-sided modified radical mastectomy for intraductal carcinoma, 4 years before this case. An asymptomatic nodule near the mastectomy scar was detected during follow-up ultrasound (US) examination. DIAGNOSIS The lesions in both patients were diagnosed as traumatic neuroma. INTERVENTIONS The first patient underwent excisional biopsy. The second patient underwent US guided core-needle aspiration, followed by conservative therapy. OUTCOMES Neither patient complained of any discomfort, nor both exhibited normal physical and US findings during follow-up examinations. LESSONS Newly discovered nodules with the benign imaging features near the mastectomy site of a patient, especially with the tail sign, traumatic neuromas should be taken into consideration. Routine US examination is important for follow-up of breast cancer patients who have undergone mastectomy.
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Affiliation(s)
| | | | | | | | - Zhang Zhang
- Department of Pathology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
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Han GH, Peng J, Liu P, Ding X, Wei S, Lu S, Wang Y. Therapeutic strategies for peripheral nerve injury: decellularized nerve conduits and Schwann cell transplantation. Neural Regen Res 2019; 14:1343-1351. [PMID: 30964052 PMCID: PMC6524503 DOI: 10.4103/1673-5374.253511] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
In recent years, the use of Schwann cell transplantation to repair peripheral nerve injury has attracted much attention. Animal-based studies show that the transplantation of Schwann cells in combination with nerve scaffolds promotes the repair of injured peripheral nerves. Autologous Schwann cell transplantation in humans has been reported recently. This article reviews current methods for removing the extracellular matrix and analyzes its composition and function. The development and secretory products of Schwann cells are also reviewed. The methods for the repair of peripheral nerve injuries that use myelin and Schwann cell transplantation are assessed. This survey of the literature data shows that using a decellularized nerve conduit combined with Schwann cells represents an effective strategy for the treatment of peripheral nerve injury. This analysis provides a comprehensive basis on which to make clinical decisions for the repair of peripheral nerve injury.
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Affiliation(s)
- Gong-Hai Han
- Kunming Medical University, Kunming, Yunnan Province; Institute of Orthopedics, Chinese PLA General Hospital, Beijing, China
| | - Jiang Peng
- Institute of Orthopedics, Chinese PLA General Hospital, Beijing, China
| | - Ping Liu
- Shanxi Medical University, Taiyuan, Shanxi Province, China
| | - Xiao Ding
- Shihezi University Medical College, Shihezi, Xinjiang Uygur Autonomous Region, China
| | - Shuai Wei
- Shihezi University Medical College, Shihezi, Xinjiang Uygur Autonomous Region, China
| | - Sheng Lu
- 920th Hospital of Joint Service Support Force, Kunming, Yunnan Province, China
| | - Yu Wang
- Institute of Orthopedics, Chinese PLA General Hospital, Beijing, China
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