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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_612_Библиотеки_им_академика_М_И_Перельмана
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doi:10.1097/SLA.0000000000003088
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CHAPTER 9 Management of Neuroma
Pain
Timothy J. Irwin and Ian L. Valerio
KEY POINTS
Painful neuromas occur from disorganized sensory
axonal regeneration after nerve injury.
Primary neuroma management (prevention) involves
treatment at time of nerve injury, while secondary
neuroma management occurs after initial injury/formation
of painful neuroma.
Surgical management often is dependent upon the
presence or absence of the injured, distal nerve end.
There exists a myriad of techniques for surgical treatment
of painful neuromas, and this chapter will outline and
illustrate the various techniques available currently.
INTRODUCTION
Symptomatic neuromas are a common cause of pain after peripheral
nerve injury. Common mechanical causes of peripheral nerve
injuries include traumatic causes spanning laceration, crush, and
ballistic injuries as well as iatrogenic injuries (eg, secondary to
oncologic resection, postsurgical complications, and/or amputation
surgery).
1,2
After the initial injury, the distal nerve end undergoes
Wallerian degeneration, while the proximal nerve end attempts to
regenerate toward the distal nerve target. Unsuccessful,
disorganized nerve regeneration results in neuroma formation.
1,2
Although not all neuromas are “symptomatic” or painful, a
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symptomatic neuroma can adversely affect quality of life and
contribute to increased healthcare costs.
3
EVALUATION AND DIAGNOSIS
A detailed history and thorough clinical examination should be
performed in any patient presenting with possible peripheral nerve
injury. Many times, the diagnosis will be clear based on history
alone, but description of the type of pain and triggering activities and
if the pain radiates can be informative and help direct treatment
options. Patients usually present with pain, dysesthesia,
hypesthesia, paresthesia, cold intolerance, and or radiating
symptoms within the anatomical distribution of the injured peripheral
nerve. Published diagnostic criteria for a symptomatic neuroma also
includes at least one of the following: a positive Tinel sign, a positive
response to lidocaine injection, or imaging such as an ultrasound
and/or magnetic resonance imaging confirmation of neuroma
4
(Figure 9.1).
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FIGURE 9.1 Diagnostic criteria for symptomatic neuroma.
MRI, magnetic resonance imaging; US, ultrasonography.
(Reprinted with permission from Arnold DMJ, Wilkens SC,
Coert JH, et al. Diagnostic criteria for symptomatic
neuroma. Ann Plast Surg. 2019;82(4):420-427.)
PRINCIPLES OF SYMPTOMATIC NEUROMA
MANAGEMENT
Nonsurgical Management
Nonsurgical treatments have been used alone or in conjunction with
surgical treatment. These treatments include various oral or
injectable pharmacotherapeutic measures (eg, neuromodulators and
nonsteroidal, steroidal, and pain medications), radiofrequency
ablation, neuromodulation, and desensitization.5-7 Unfortunately,
pharmacotherapy alone or other symptomatic nonsurgical options
may often be unsatisfactory in successfully treating neuropathic pain.
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Inadequate addressment of sources of neuropathic pain including
symptomatic neuroma can result in centralization of pain through
reorganization of the somatosensory cortex. This clinical scenario
can lead to worse outcomes with subsequent nonsurgical and
surgical treatment measures. For these reasons, early recognition
and pairing of nonsurgical methods in combination with early
diagnosis, clinical recognition, and adoption of surgical treatment can
be more effective and beneficial in alleviating symptomatic neuromas
and reducing a significant source of this contributor to neuropathic
pain.
Surgical Management Principles
The overarching principle of painful neuroma management is to give
the proximal peripheral nerve end “somewhere to go and something
to do.”8 After identification of the symptomatic neuroma, the injured
nerve should be excised back to the level of healthy fascicles.
Inadequate excision of scarred and injured nerve will result in poor
outcomes regardless of surgical technique employed. This concept
is similar to preparing a nerve for a nerve repair and/or transfer,
which was presented in the previous chapter.
After excision of the symptomatic neuroma, surgeons can employ
either passive (ablative) or active (reconstructive) surgical
techniques for management of the nerve end (Table 9.1).
8
Techniques are considered passive if they only address the neuroma
itself but do not incorporate the future regenerative potential of the
nerve (ie, “something to do”). In general, active or reconstructive
techniques are favored when possible for the management of
symptomatic neuromas. These techniques can be employed based
on the absence or presence of the distal end of the injured nerve
being treated (Figures 9.2-9.4).
TABLE 9.1. CATEGORIZATION OF SURGICAL
INTERVENTION FOR PAINFUL NEUROMA
Passive/Ablative Active/Reconstructive
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Excision only or traction
neurectomy
Excision and implantation
(muscle, bone)
Centrocentral connectorassisted neurorrhaphy
Nerve cap
Relocation nerve grafting
Hollow tube
reconstruction
Allograft or
autograft
reconstruction
“End-to-side”
neurorrhaphy
TMR
RPNI
Reprinted with permission from Eberlin KR, Ducic I. Surgical algorithm for
neuroma management: a changing treatment paradigm. Plast Reconstr Surg Glob
Open. 2018;6(10):e1952.
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FIGURE 9.2 Surgical techniques categorized based on
availability of distal nerve end. (Reprinted with permission
from Eberlin KR, Ducic I. Surgical algorithm for neuroma
management: a changing treatment paradigm. Plast
Reconstr Surg Glob Open. 2018;6(10):e1952.)
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FIGURE 9.3. Schematic showing scenarios where distal
nerve is intact, including neuroma in continuity (A). Active
reconstructive techniques after resection of neuroma (B).
(Reprinted with permission from Eberlin KR, Ducic I.
Surgical algorithm for neuroma management: a changing
treatment paradigm. Plast Reconstr Surg Glob Open.
2018;6(10):e1952.)
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FIGURE 9.4. Surgical options when the distal target is
unavailable for reconstruction after neuroma excision.
(Reprinted with permission from Eberlin KR, Ducic I.
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