Reply: Surgery for Symptomatic Neuroma: Anatomic Distribution and Predictors of Secondary Surgery.

Abstract

Sir: We appreciate the comments and continued interest regarding our article,1 and agree with the noted limitations of our study. We fundamentally agree with the important assertion that we, as peripheral nerve surgeons, have a critical role in the management of symptomatic neuromas by targeting interventions to the root cause of the problem. Studying the treatment of symptomatic neuromas can be difficult, as there previously have been no standardized criteria for diagnosis. We have recently proposed diagnostic criteria that may be useful for surgeons and are currently utilized in our institution.2 Our article is a retrospective cohort study, and the purpose was to evaluate the demographics and presence of secondary surgery in patients undergoing surgical intervention for symptomatic neuroma. Overall, our findings suggest that addressing the nerve ending with an active treatment strategy following neuroma excision may lead to fewer reoperations. The odds for secondary neuroma surgery were higher following neuroma excision alone (OR, 4.9) and neuroma excision with nerve implantation in bone or soft tissue (OR, 3.4) compared with neuroma excision followed by nerve repair or reconstruction. Although secondary surgery is not a perfect surrogate for operative success, these findings are commensurate with results of other studies.3–6 The commenting authors state that digital neuromas can be challenging; we agree with this statement and found that the majority of the digital nerve endings were implanted in the interosseous or hypothenar muscles following neuroma excision.4 Other contemporary options for surgical treatment of digital neuromas include relocation nerve grafting or targeted muscle reinnervation.7,8 Neuromas of the radial sensory nerve can also be challenging because of known overlapping cutaneous innervation. Critical assessment of patients with a suspected symptomatic neuroma on the dorsoradial aspect of the wrist is important, and local anesthetic injections may help to differentiate the affected nerve(s) before intervention. The patients in our study1 were treated by plastic surgeons, orthopaedic hand surgeons, and neurosurgeons (categorized as trained in nerve microsurgery) as well as other surgeons (considered to be untrained in nerve microsurgery). It is unknown whether the specialty training of the treating surgeon has an effect on outcome, but surgeons with a dedicated interest in neuroma management continue to perform the majority of these operations at our institution and have myriad surgical options in their armamentarium. We agree with the commenting authors that timing of intervention is important in the management of symptomatic neuromas; we found that this interval was longer in patients with a traumatic etiology compared with a surgical etiology. Timely treatment of symptomatic neuromas is important, because surgical intervention before central sensitization takes place may improve outcomes.9 Prospective, comparative studies are needed to define the optimal surgical intervention for symptomatic neuromas in all anatomic locations. There is great contemporary interest in this problem, which hopefully will help facilitate additional outcome studies and continued surgical innovation in this arena. DISCLOSURE Dr. Lans has no financial interests to disclose. Dr. Eberlin is a consultant for AxoGen and Integra. No funding was received for this communication.