Digital Neuroma Research Articles

Management of digital neuromas: an update on current nonoperative and operative interventions

Management of digital neuromas: an update on current nonoperative and operative interventions

Surgical Management of Painful Digital Neuroma: A Systematic Review

Abstract Background Neuromas of the digits can be a mentally and physically disabling condition for patients in this systematic review, the authors discuss a variety of surgical techniques for digital neuroma management. Aim of the Work This systematic review aims to analyze and combine the results of relevant studies on surgical treatment for digital neuroma. It aims to determine the overall success of the surgical procedure and identify which techniques are more effective. Patients and Methods Four databases, including Embase, Scopus, PubMed, and Google Scholar, were searched for relevant studies. The search spans the years 1990 to 2022. Out of 1490 initial studies, 672 remained after removing duplicates. After screening the Abstracts, 647 were excluded for various reasons, leaving 12 eligible studies for inclusion in the systematic review, which included a total of 309 patients. Outcomes reporting included the visual analogue scale (VAS) to report pain, patient satisfaction, the Semmes-Weinstein Monofilament Test, The two-point discrimination test, a non-standard ordinal scale and the mean follow-up duration. Results The studies included neuroma excision, neuroma excision (and implantation into adjacent tissues), centro-central union, proximal relocation, interdigital direct neurorrhaphy, nerve allograft reconstruction, regenerative peripheral interface, dorsal transposition and epineural coaptation, collagen conduits, and muscle-in-vein conduits (MVCs).The results show that a majority of patients achieved pain relief after surgery, with high levels of satisfaction reported in some studies. The most successful surgical approach was not determined since there were no statistically significant differences between the various surgical techniques. However, neuroma excision followed by nerve repair/reconstruction (centro-central union, proximal relocation, direct neurorrhaphy, nerve allograft, regenerative peripheral interface, dorsal transposition and nerve conduit )show magnificent results compared to neuroma excision alone with or without implantation. Factors such as old age, smoking, and high PROMIS Depression scores were found to be independently associated with higher levels of pain interference. Conclusion The results suggest that surgical treatment is effective in reducing pain levels, with most patients reporting complete pain relief or improvement. Neuroma excision followed by nerve repair/reconstruction was found to result in better outcomes compared to neuroma excision alone with or without implantation.

Pronator Quadratus: A Preferable Recipient for Targeted Muscle Reinnervation of Neuromas in the Hand.

Targeted muscle reinnervation (TMR) has emerged as a useful solution to the problem of painful neuromas and is increasingly being applied in many clinical circumstances. Relatively little has been written about TMR for painful neuromas of the hand, and what has been written describes use of the intrinsic muscles as recipients for the nerve transfer. Except in cases of amputation, intrinsic muscle sacrifice carries morbidity. Furthermore, TMR to intrinsic muscles will place the nerve coaptation in areas subject to pressure with loading of the palm. For these reasons, the pronator quadratus may be a preferable target muscle when performing TMR for painful neuromas of the hand. In this report, we describe the rationale for its use and demonstrate the surgical technique and outcomes with case examples.

Dorsal Coaptation for the Treatment of Digital Neuroma

The formation of a symptomatic neuroma after digital tip amputation presents a vexing problem. There is currently no procedure that completely and consistently prevents hypersensitive neuroma formation. This report presents the results of a technique designed to limit axon regeneration and mechanical irritation by neuroma excision, dorsal transposition, and coaptation with the corresponding digital nerve. A retrospective chart review was conducted to assess the effectiveness of neuroma excision with dorsal transposition and epineurial coaptation for postamputation symptomatic digital neuromas. Neuromas were excised using a midlateral fish-mouth incision. Digital nerves were mobilized to the dorsum of the digital tip and coapted using 9-0 nylon epineurial suture. The procedure was modified to salvage viable fingernails or to avoid excessive tension. Mass etal's criteria system was used to evaluate effectiveness. Twenty-four patients with painful neuromas of the radial and ulnar digital nerves after traumatic amputation were included. Thirty-two digits underwent dorsal coaptation. This procedure was associated with a result considered good or excellent in 28 of 32 digits. Twenty-seven of 32 digits registered no pain or stump anesthesia after dorsal coaptation. Twenty-five of 32 digits demonstrated no interference with activities of daily living. Twenty-one of 24 patients returned to work. Neuroma excision with dorsal transposition and epineurial coaptation is an effective treatment for postamputation symptomatic digital neuroma. Therapeutic IV.

Targeted Muscle Reinnervation as a Solution for Nerve Pain.

After reading this article, the participants should be able to: 1. List current nonsurgical and surgical strategies for addressing postamputation neuroma pain and discuss their limitations. 2. Summarize the indications and rationale for targeted muscle reinnervation. 3. Develop an operative plan for targeted muscle reinnervation in an acute or delayed fashion for upper and lower extremity amputations. 4. Propose a management algorithm for treatment of symptomatic neuromas in an intact limb. 5. Discuss the risk of neuroma development after primary revision digital amputation or secondary surgery for a digital neuroma. 6. Compare and contrast targeted muscle reinnervation to the historical gold standard neuroma treatment of excision and burying the involved nerve in muscle, bone, or vein graft. 7. Interpret and discuss the evidence that targeted muscle reinnervation improves postamputation neuroma and phantom pain when performed either acutely or in a delayed fashion to treat existing pain. Symptomatic injured nerves resulting from amputations, extremity trauma, or prior surgery are common and can decrease patient quality of life, thus necessitating an effective strategy for management. Targeted muscle reinnervation is a modern surgical strategy for prevention and treatment of neuroma pain that promotes nerve regeneration and healing rather than neuroma formation. Targeted muscle reinnervation involves the transfer of cut peripheral nerves to small motor nerves of adjacent, newly denervated segments of muscle and can be easily performed without specialized equipment. Targeted muscle reinnervation strategies exist for both upper and lower extremity amputations and for symptomatic neuromas of intact limbs. Targeted muscle reinnervation has been shown in a prospective, randomized, controlled trial to result in lower neuroma and phantom pain when compared to the historical gold standard of burying cut nerves in muscle.

Digital Pacinian corpuscle neuroma complicated by glomus tumor

Digital Pacinian corpuscle neuroma complicated by glomus tumor

Regenerative Peripheral Nerve Interfaces for the Management of Symptomatic Hand and Digital Neuromas.

Summary:Painful neuromas result from traumatic injuries of the hand and digits and cause substantial physical disability, psychological distress, and decreased quality of life among affected patients. The regenerative peripheral nerve interface (RPNI) is a novel surgical technique that involves implanting the divided end of a peripheral nerve into a free muscle graft for the purposes of mitigating neuroma formation and facilitating prosthetic limb control. The RPNI is effective in treating and preventing neuroma pain in major extremity amputations. The purpose of this study was to determine if RPNIs can be used to effectively treat neuroma pain following partial hand and digital amputations. We retrospectively reviewed the use of RPNI to treat symptomatic hand and digital neuromas at our institutions. Between November 2014 and July 2019, we performed 30 therapeutic RPNIs on 14 symptomatic neuroma patients. The average patient follow-up was 37 weeks (6–128 weeks); 85% of patients were pain-free or considerably improved at the last office visit. The RPNI can serve as a safe and effective surgical solution to treat symptomatic neuromas after hand trauma.

Digital pacinian neuroma in a patient with myeloma

Digital pacinian neuroma in a patient with myeloma

Nerve allograft reconstruction of digital neuromata

Objective: A symptomatic digital neuroma may have a devastating impact on a person's life. There is no gold standard method of treatment. We hypothesise that the reconstruction of neuroma with nerve allograft will reduce the sensitisation and cortical reorganisation associated with peripheral nerve injury. In this study, we aim to assess the effect of neuroma reconstruction with nerve allograft on patient-reported pain and satisfaction. Methods: We conducted a retrospective review of patients who underwent nerve allograft reconstruction for painful digital neuroma at our unit, from July 2015 to July 2018. We measured pre- and post-operative visual analogue scale (VAS) pain scores, patient satisfaction and patient evaluation measure (PEM) scores. Results: In 10 patients, we reconstructed 12 neuromata. In nine of these patients (11 neuromata), we demonstrated a post-operative reduction in pain, with a change in median VAS score from 7.5 to 1. Patients were satisfied with their operation, with a median satisfaction score of 10/10. The procedure was unsuccessful in two patients, one with a static VAS score and one with a satisfaction score of

The role of processed nerve allograft in peripheral nerve surgery

Objective: Peripheral nerve surgery involves the direct repair of peripheral nerves after trauma, reconstruction of nerve gaps and the management of painful nerve conditions such as end neuroma. There are a variety of situations where direct microsurgical repair is not possible or not the preferred option. Processed nerve allograft (PNA) offers a bespoke solution in the management of nerve gaps without the morbidity associated with autografts. Methods: A prospective database was populated for patients having nerve allograft implantation in the management of peripheral nerve injury. Results: Between July 2015 and November 2018 (40 months), 62 nerves in 45 patients were treated with AVANCE® PNA at the Birmingham Hand Centre at the Queen Elizabeth Hospital, Birmingham, UK. The mean age at implantation was 43 (range 16–77). Digital nerve reconstruction formed 50% of the total nerve repairs. Indications were 20 digital neuroma reconstructions, 13 neuromas after amputation, 20 traumatic injuries with nerve tissue loss, 8 delayed presentation after trauma, 3 contraindications to general anaesthesia, 4 insufficient autografts, 1 failed autograft and 3 tumour reconstructions. Conclusion: AVANCE® PNA is a useful tool in the reconstruction of peripheral nerve injury and the management of painful neuromas. An absolute indication is the management of painful neuromas in sensitised patients where avoidance of an additional site of neuropathic pain at a donor site is an important consideration. In digital neuroma management, there is good evidence to support use with equivalent efficacy to autologous sensory nerve grafts of a similar length.

Transient morton’s toe: An uncommon presentation of a common clinical condition

Herpes zoster (Shingles) is a result of reactivation of the Varicella-zoster virus (VZV) in dorsal root ganglia (DRG) after a long latency period following a primary infection (chickenpox). A Morton's toe or neuroma is an enlarged common plantar nerve, usually in the third web space. Our patient, a 52 year old male, presented with an initial clinical and radiological picture of Morton’s toe. He however went on to develop characteristic vesicular rash of Herpes zoster over L5 dermatome within 48 hours of onset of forefoot pain signifying a temporal association which responded dramatically to antiviral medication. The clinical features mimicking Morton’s toe were probably due to the already compromised/ scarred inter digital space secondary to an old injury. This peculiar case, depicting a clinical presentation of Herpes zoster in the prodromal phase, has not been reported in literature till date. Knowledge of such an association would help clinicians in anticipating Herpes zoster as one of the differential diagnoses in a case of Morton’s toe and manage it accordingly. The rapid and substantial recovery in the patient’s forefoot symptomatology along with skin lesion following the initiation of antiviral therapy highlights the fact that the clinically apparent Morton’s toe was a manifestation of underlying Herpes zoster rather than a true inter digital neuroma.

New Surgical Approach to Common Digital Neuroma with Combined Technique of Nerve Decompression, Dorsal Nerve Transposition and Nerve Wrap in the Foot

New Surgical Approach to Common Digital Neuroma with Combined Technique of Nerve Decompression, Dorsal Nerve Transposition and Nerve Wrap in the Foot

Interdigital direct neurorrhaphy for treatment of painful neuroma due to finger amputation.

Painful neuroma following amputation is a disabling condition for which treatments are not usually satisfactory. The aim of this study is to retrospectively evaluate the results of interdigital neurorrhaphy after neuroma resection as an option for the surgical treatment of painful digital neuroma. We retrospectively analyzed data from seven patients submitted to interdigital neurorrhaphy for treatment of digital neuroma. For evaluation of the results, the visual analog scale (VAS) for pain assessment, measurements with Simmens-Weinstein filaments and a handgrip dynamometer, and quantification of the Disabilities of the Arm, Shoulder and Hand (DASH) score were all performed. The mean improvements on the VAS and DASH scores were calculated. The mean follow-up was 28.3 months. All patients presented some degree of improvement in upper limb functionality and pain, and handling the affected finger was possible in all cases. The mean improvement on the VAS and DASH scores was 29.8 and 55.5 %, respectively. No patients presented long-term complications. Although this study was based on a small number of patients, it indicates that interdigital neurorrhaphy seems to be a feasible surgical treatment for painful digital neuroma.

Comparative analysis of curative effect of different surgeries for painful digital proper neuroma

This paper aims to investigate the curative effect of different surgeries for painful digital proper neuroma. There were 30 patients with painful digital proper neuroma, among whom 11 patients underwent arched double end-to-side neuroanastomosis, 10 patients underwent nerve graft with end-to-end neuroanastomosis, while other 9 patients underwent directly end-to-end neuroanastomosis. The results showed that the two-point discrimination (2-PD) was (5.01 ± 0.71) mm in arched double end- to-side neuroanastomosis, which was significantly lower than that in nerve graft with end-to-end neuroanastomosis [(7.30 ± 1.21) mm] and directly end-to-end neuroanastomosis [(6.10 ± 1.10) mm; F = 3.144, P = 0.022]. According to Burchiel's efficacy, there were 9 excellent and 2 good fingers in arched double end-to-side neuroanastomosis; 4 excellent, 3 good and 3 fair fingers in nerve graft with end-to-end neuroanastomosis; 4 excellent, 4 good and one fair fingers in directly end-to-end neuroanastomosis. The efficacy of the first group was significantly better than those of the other 2 groups ( Z = -1.927, P = 0.041). The arched nerves of double end-to-side neuroanastomosis is a valuable surgical method for painful digital proper neuroma, which can quickly restore the sensation of fingers, and have better outcome than the other two methods. doi: 10.3969/j.issn.1672-6731.2014.09.014

Bilaterally innervated dorsal digital flap for sensory reconstruction of digits

BackgroundProviding sensory coverage in digits continues to be a challenging problem. This study reports the sensory reconstruction of digits with bilaterally innervated dorsal digital flaps and compares the results between dual- and single-innervated flaps. MethodsOver 7 years, a retrospective study was conducted with 73 patients who had soft-tissue defect of the digit treated with the bilaterally innervated dorsal digital flap. There were 73 soft-tissue defects in 73 digits. The size of the defects ranged from 1.8 to 2.7cm in length (mean, 2.2cm) and from 1.6 to 2.2cm in width (mean, 1.9cm). The bilateral dorsal branches of the digital nerves were attached with the flap for the sensory reconstruction of digits. Reconstructive techniques included the cross-finger flap in 35 cases, the dorsal digital island flap in 24 cases, and the dorsal digital free flap in 14 cases. To objectively evaluate the efficacy of the bilaterally innervated flaps, we selected a comparison group that included 42 patients treated with the single-innervated flap. ResultsA significant difference was found between the dual- and single-innervated flaps in two-point discrimination, pain, Tinel's sign, and patient satisfaction results. By comparison, the dual-innervated flap presented better discriminatory sensation on the flap, lower incidence of pain and Tinel's sign, and a larger degree of satisfaction than the single-innervated flap. Of the dual-innervated flap group, the mean joint motion of the donor finger was similar to that of the opposite side. ConclusionsThe bilaterally innervated dorsal digital flap is a reliable alternative for the sensory reconstruction of digits. Performing double neurorrhaphies can improve flap sensation and reduce digital neuroma incidence when reconstructing a soft-tissue defect associated with both transected digital nerves.

Clinical audit of the surgical management of plantar digital neuroma

Thirty two patients (34 neuromata) were reviewed postoperatively by hospital notes and interview. Eighty-eight per cent had undergone some form of conservative care prior to surgery and the average duration of symptoms before seeking help was 27 months (range 2–96 months). Ninety-four per cent were satisfied with their postoperative outcomes. Sensory impairment in the affected intermetatarsal space, as detected by the log monofilament, was observed in 59%. Only 25% of these considered this a problem. Forty-four per cent of patients required some form of postop rehabilitation.This audit shows that neurectomy can be a safe and effective procedure for the treatment of plantar digital neuroma, although 100% symptomatic relief is not guaranteed. Patients should be made aware of post-op outcomes such as hypoaesthesia.

The use of vein grafts in upper extremity nerve surgery

Vein grafts have been used to cope with several problems in peripheral nerve surgery, including vein wrapping of scarred nerves involved in chronic pain syndromes, vein caps for recurrent end-stump neuromas, vein conduits for nerve gaps after resection of neuromas-in-continuity, and following trauma. From 1993–1997, 30 vein grafts were performed in 28 patients. Five chronic peripheral nerve pain syndromes were treated by vein wrapping for two ulnar, two median and one radial sensory nerve, with significant pain resolution in all cases. Two recurrent digital neuromas were treated with vein caps, with pain resolution in each case. Nine patients with neuromas-in-continuity underwent neuroma resection and nerve repair with vein conduits. Twelve patients (14 nerves) underwent primary or delayed repair with vein conduits for nerve gaps following trauma. Sensory return measured by two point discrimination after repair of nerve gaps, following either neuroma-in-continuity resections or trauma, was 5–10 mm in 17 digital or common digital nerve injuries, and greater than 10 mm in three radial sensory nerve injuries.

Rapid Relief Of A Painful, Long-Standing Posttraumatic Digital Neuroma Treated By Transcutaneous Vibratory Stimulation (TVS)

A case of a patient with a painful posttraumatic digital neuroma that had been present for 13 years is presented. Treatment for the painful neuroma was twice a week for one month using transcutaneous vibratory stimulation (TVS). The patient was assessed using various tests before and after this period of treatment. There was a reduction in pain, and dexterity and strength improved. The method of treatment and the assessment techniques are described. In this case, the therapeutic benefit of the method could be clearly differentiated from the natural healing course, since no significant improvement had occurred spontaneously over many years.

Indications and results of skin flaps in painful digital neuroma

Of the many procedures for treating painful neuromas, resection and proximal translocation are the most usual techniques, but these can decrease distal sensibility increasing deafferentation pain. In cases of intricate pain (nociception plus deafferentation), certain types of flaps allow the treatment of both components of the pain. We have used 30 such flaps in 28 patients: local flaps (exchange, advancement or lasso island flaps) and distant flaps (free “custom-made” toe flaps).The results of the different techniques provides 86.6% excellent or good results.

Treatment of the painful neuroma by neuroma resection and muscle implantation.

The successful treatment of the painful neuroma remains an elusive surgical goal. This report evaluates one approach to the management of this problem which entails neuroma excision and placement of the proximal end of the nerve away from denervated skin, away from tension, and into a well-vascularized environment: muscle. Seventy-eight neuromas in 60 patients with a mean follow-up of 31 months (range 18 to 43 months) were evaluated. Sixty-seven percent of these patients involved Workmen's Compensation and 57 percent had had at least one previous operation to treat their pain. The results demonstrated good to excellent results in 82 percent of the treated nerves in the entire group. Factors that were predictive of a poorer outcome were (1) digital neuroma (p less than 0.0005), (2) Workmen's Compensation (p less than 0.01), and (3) three or more previous operations for pain (p less than 0.01). Transposition of nerves into small superficial muscles or muscles with significant excursion resulted in treatment failures. The etiology and histopathology of treatment failures are reviewed. Treatment of radial sensory neuromas by transposition of the radial sensory nerve into the brachioradialis muscle when any associated injury to the lateral antebrachial cutaneous nerve was also treated, gave good to excellent relief of pain, and improved hand function in 88 percent of the patients.