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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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Surgical algorithm for neuroma management: a changing
treatment paradigm. Plast Reconstr Surg Glob Open.
2018;6(10):e1952.)
SURGICAL TECHNIQUES
Nerve Reconstruction—Distal End Available
Allograft/Autograft
If the distal end of the injured nerve can be identified, and a
considerable gap exists after proximal neuroma excision, then
reconstruction with an allograft or autograft nerve can be utilized
9
(Figures 9.5 and 9.6). While autograft nerve is considered the
standard, there are drawbacks. Major disadvantages are the creation
of secondary surgical site and donor site morbidity including
numbness, pain, and potential for formation of painful neuroma.
10
Indications for allograft have continued to expand based on current
data with acceptable use in nerve gaps up to 70 mm.11 Cost is a
major consideration when deciding which graft to use in nerve
reconstruction. Recent cost analysis showed comparable inpatient
and outpatient costs for both autograft and allograft nerve
reconstruction when taking into consideration operating time,
hospital stay, and implant cost.
12
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FIGURE 9.5. Cable autograft from sural nerve donor site
for reconstruction of tibial nerve. Picture left, distal.
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FIGURE 9.6. Symptomatic neuroma of the medial
antebrachial cutaneous nerve, prior to excision of neuroma
(A). Excision back to healthy fascicles (B) and
reconstruction with nerve allograft (C) nerve gap
measured at 4 cm (D) .
Hollow Tube Constructs/Conduits
If the nerve gap after neuroma excision is small, a hollow tube
construct (connector, conduit, or vein) may be used to bridge the
nerve gap. These techniques have been shown to be effective in
small-caliber nerves with short gaps.
13,14
A recent systematic review
and meta-analysis showed inferior outcomes when compared with
autograft or allograft reconstruction in larger gaps.12 Hollow tube
constructs can also be utilized at the site of neurorrhaphy to offload
tension on nerve coaptation when indicated.
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Neuroma-in-Continuity
Neuroma-in-continuity is the presence of a neuroma in the
substance of an otherwise intact peripheral nerve. These are
frequently seen in cases of blunt trauma or traction injuries.
Management of such may involve difficult decision making as
excision may have a significant impact on the function of the nerve.
15
It is important to consider the function of the effected nerve as well
as the degree of disability the painful neuroma is imparting on the
patient. If the benefits of neuroma excision outweigh the possible
deficits, then selective neuroma excision with intraneural dissection
may be attempted to preserve the intact fascicles while selectively
identifying and excising the neuroma fascicles and scar tissue
contributing to the neuropathic pain.15 After the neuroma and scar
tissue are excised, reconstruction with the above techniques should
be attempted (Figure 9.7).
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FIGURE 9.7. Neuroma-in-continuity of the second
intermetatarsal plantar nerve (A). Excision of neuroma and
reconstruction with allograft and connector assisted
neurorrhaphy (B). Nerve gap measured 4 cm after
resection and preparation for reconstruction.
Nerve Reconstruction—Distal End Unavailable
Implantation Into Adjacent Tissue
Historically, implantation of proximal nerve ends into adjacent tissue
(fat, muscle, bone, or veins) had been the most widely practiced
technique for neuroma management.16-18 Although this technique
has been described with satisfactory results, longer-term follow-up
has seen recurrence of painful neuromas despite prior implantation.
This situation happens as the peripheral nerve end continues to
regrow despite its new location and/or surroundings, resulting in a
recurrent, painful neuroma reformation (see also Figure 9.4).
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Implantation into adjacent tissue has many advantages as it is a
simplistic technique that requires no additional materials. It has
previously shown to improve quality of life in certain patients with
upper or lower extremity painful neuromas.19 However, this
technique is considered a passive method that does not attempt to
reconstruct the proximal nerve end, thus contributing to a higher rate
of subsequent painful neuroma reformation.
20
Centrocentral Neurorrhaphy
Centrocentral neurorrhaphy coapts two adjacent proximal nerve
ends to decrease end neuroma formation in both nerves (Figure
9.8). It can also be employed in larger-caliber nerves by
intrafascicular dissection and coaptation of the separate fascicular
bundles. This technique has limited applications and mixed results.
21
It has been shown to produce less painful stump neuromas in
patients after digital amputation but with less overall sensitivity when
compared with traction neurectomy.22 More often, surgeons utilize a
nerve graft and/or hollow tube between the nerve ends to aid in
“dwindling out” or dissipating the regenerative nerve fibers so that
the sources of regenerating axons are impaired in their regrowth
potential. This technique is another example of a passive strategy for
symptomatic neuroma management.
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FIGURE 9.8. Painful digital neuromas of the index finger
treated previously with traction neurectomy (A).
Centrocentral neurorrhaphy performed between digital
nerves (B). (Courtesy of Mark Rekant, Philadelphia Hand
to Shoulder Center.)
Relocation Nerve Grafting
Relocation nerve grafting utilizes a long nerve graft (autograft or
allograft) to direct nerve regeneration after neuroma resection toward
a more favorable location. This technique can be used in hostile
wound beds or when the nerve is superficial and prone to irritation or
compression. Use of a long nerve allograft is most common and
provides a runway for dissipated nerve growth.8 The distal end of the
nerve graft can be placed in a more desirable location (vascularized
wound bed, intramuscular, etc.) (Figure 9.9). As a passive technique,
there is no reconstruction of the nerve and it will not result in
recovery of sensation or function.
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FIGURE 9.9. Large, symptomatic sciatic neuroma after
above knee amputation (A). Excision back to healthy
nerve fascicles (B). Internal neurolysis into four separate
fascicular groups reconstructed with relocation nerve
grafting utilizing long allograft nerve grafts (C). Distal ends
of nerve allograft are buried deep in different directions
into muscle away from working surface for prothesis (D) .
End-to-Side Neurorrhaphy
After symptomatic neuroma resection, the proximal nerve end can
be coapted to an adjacent nerve through the creation of an epineural
window (Figure 9.10). The intact, adjacent nerve provides a pathway
and target for nerve regeneration where regenerating axons either
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are pruned or can reestablish end-organ contact.23 Multiple studies
have shown prevention of symptomatic neuroma formation in rat
models using this technique.23-25 This reconstructive technique is an
active type of reconstruction that does permit the peripheral nerve
end some opportunity for regrowth and has been increasingly utilized
in the clinical setting, but longer-term follow-up and reporting of
clinical outcomes are desired.
FIGURE 9.10. Neuroma of radial sensory nerve branch
(A). After neuroma resection, end-to-side neurorrhaphy
performed to adjacent, intact radial sensory nerve branch
(B). (Courtesy of Jonathan Winograd, MD, Massachusetts
General Hospital.)
Nerve Cap
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Various nerve caps that have been manufactured from a variety of
materials have been trialed to control disorganized regrowth of the
proximal end of the injured nerve.26 The proximal end is sutured or
secured into the nerve cap, and the cap acts as a barrier to the
regrowth of the proximal nerve stump. Differing strategies in these
cap designs have been reported. For example, some caps utilize
internal chambers that act to redirect nerve axonal regeneration into
separate partitions, which have been shown in rat and animal
models to control axonal outgrowth resulting in decreased pain
response and decreased neuroma formation
27,28
(Figure 9.11).
Advantages of nerve caps include limited dissection to the proximal
nerve end and further donor site morbidity related to active
techniques; however, material costs and reimbursement for their use
are important considerations. Furthermore, reporting of clinical
outcomes and related studies are necessary to better understand the
potential of this treatment strategy in the surgical treatment of
neuromas.
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