Nerve Neuroma Research Articles

Excision and Inter-Positional Sural Nerve Graft for Post-Traumatic Non-Conducting Ulnar Nerve Neuroma

Introduction: Ulnar nerve injuries around the wrist resultin paralysis of intrinsic muscles and sensory loss of littlefinger and ulnar half of ring finger. Formation of traumaticneuroma of the ulnar nerve adds pain at the site of nerverepairs.Patients and Methods: 10 patients were included in thisstudy. Clinical, radiological and electrophysiological assessmentindicate surgery in these patients where neuroma wasexcised, identification of sensory and motor fascicles of theulnar nerve was done and cable nerve grafts were used tobridge the nerve defects. Assessment of the outcome was donein patients who finished follow-up for at least one year.Results: Pain at the site of neuroma disappeared aftersurgery. All patients were followed-up and 6 patients neededtendon transfer after one year. Sensory recovery was achievedafter one year. Trophic changes and cold intolerance wasimproved.Discussion: Primary repair of ulnar nerve injuries is thegold standard treatment for such injuries. Claw hand, weaknessof the hand grip and abduction deformities are the main motordefects which can be corrected by tendon transfers. However,sensory defects and cold intolerance affected the outcome ofsurgery. When the diagnosis of non-conducting neuroma ismade, neuroma resection and reconstruction improve theclinical outcome.Conclusion: The unfavorable outcomes of ulnar nerveinjuries can be improved by resection of neuroma in continuityand nerve grafting. Multidisciplinary team is needed to achievethe best clinical outcomes.

Atypical Presentation and Treatment of Large Facial Neuroma: Case Report and Review

Background: Facial nerve neuromas (FNN) are significantly rare brain tumors. Our objective is to report a case of an atypical presentation and treatment of a large facial nerve neuroma. We review current literature and discuss issues pertaining to postoperative outcomes of large facial neuromas.
 Method: We retrospectively reviewed a case of patient who presented in our center with atypical symptoms of a large intracranial facial neuroma (schwannoma), our approach to treatment, outcome and combined it with review of current literature. A review of the current literature was performed by extrapolating data relating to clinical and management details pertaining to FNN, currently listed on the Google scholar, Clinical- Trials.gov database, and PubMed. This information was tabulated and compared with our experience.
 Conclusion: Large facial nerves neuromas (FNN) are very rare brain tumors which may coexist with the patient without debilitating symptoms. When diagnosed, individualized approached to archive maximal resection while preserving surrounding cranial nerves and brain stem function must be the goal. Intraoperative patient positioning, is vital for attaining maximal view, brain relaxation and minimal bleeding.

Facial nerve neuroma mimicking chronic otitis

A 44-year-old male presented with a facial schwannoma extending into both the middle cranial fossa and mastoid processus. Due to hearing loss, facial nerve palsy and inflammatory changes in CT scan, this patient was misdiagnosed as chronic otitis media. Audiogram showed a right mixed hearing loss with 30–40 dB air-bone gap. In MR, features of the facial nerve neuroma were found. The patient was qualified for surgery to remove the tumor via middle fossa approach, with possible conversion to the retroauricular approach. Ossiculoplasty LC was performed. Diagnostic problems and methods of treatment are discussed.

Soft Tissue Contouring at the Time of Osseointegrated Implant Reconstruction for Lower Extremity Amputation.

Patients with lower extremity amputations using a classic socket prosthesis face many challenges related to the socket-limb interface. The adaptation of osseointegration has allowed for the attachment of a prosthesis directly to bone, eliminating this interface and providing mechanical benefits. Contrary to the socket prosthesis, the osseointegrated prosthesis requires reducing and minimizing the soft tissue envelope. Studies have shown that patients who have undergone placement of these implants have high rates of reoperation for soft tissue redundancy. The purpose of our study was to evaluate complication rates and need for revisional surgery using our technique of soft tissue closure around the prosthesis at the time of implant placement. An institutional review board-approved, retrospective chart review was performed on all patients who underwent implantation of an osseointegrated prosthesis for lower extremity amputation with concomitant plastic surgery closure at our institution during a 2-year period from June 2017 to June 2019. Patient demographics, health status descriptors, operative data, length of admission, and rates of postoperative complications were gathered from the electronic medical record and coded into a HIPAA-compliant database. Specific outcomes tracked included minor and major infection, osteomyelitis, implant failure, hematoma, seroma, delayed wound healing, and rates of reoperation and readmission. There were a total of 14 patients who underwent osseointegrated implant placement with concomitant plastic surgical coverage of the prosthesis during the study period. The average patient age was 50 years (range, 26-70 years), and average body mass index was 32.2 kg/m (range, 19.7-44.8 kg/m). Average follow-up time was 28 weeks (range, 10-73 weeks). There were 2 cases of local infection resolved with a course of oral antibiotics. There were no instances of infection requiring procedural intervention or hospital admission, nor any cases of osteomyelitis. Two patients required outpatient surgery for exchange of implant abutment, one required revision of a prosthesis for hardware loosening, and one required targeted muscle reinnervation of a sciatic nerve neuroma. There were no patients who required revisional surgery for soft tissue redundancy and no cases of delayed wound healing. Adequate planning of incisions and soft tissue contouring is important in the care of osseointegrated patients. Plastic surgery involvement can decrease soft tissue complications and lead to improved patient outcomes.

Chronic Pain Due to Bilateral Neuroma Mimicking Complex Regional Pain Syndrome on an Amputated Finger Stump: A Case Report

A 62-year-old man presented with chronic pain with an exacerbation for the last 15 days. His left index finger was surgically amputated and the pain was around the base of his index finger which was referred to forearm and other fingers too. A couple of years ago, he sustained an injury to the left index finger and started having pain once the wound was healed. Subsequently exploration was done to relive pain which did not reduce and for some unknown reason the finger was amputated surgically later. Although the symptoms and signs were mimicking complex regional pain syndrome (CRPS), the other possible causes for the pain such as nerve entrapment and neuromas on the course of the nerve were considered. The surgical exploration was done at the stump and multiple neuromas were found. The neuromas were removed and the wound was closed by carefully burying the nerve endings. Patient had a complete pain relief at the second postoperative day and he had been followed for the next couple of weeks.

Management of Sural Nerve Neuromas with Targeted Muscle Reinnervation.

Summary:Neuromas are a debilitating peripheral nerve problem due to aberrant axon sprouting and inflammation after nerve injury. The surgical management of neuromas has for a long time been up for debate, largely due to lack of consistent, reliable outcomes with any one technique. We have found success utilizing targeted muscle reinnervation, a technique originally described in amputees that re-routes the proximal ends of cut sensory nerve stumps into the distal ends of motor nerves to nearby muscles. In doing so, the sensory nerve ending can regenerate along the length of the motor nerve, giving it a place to go and something to do. In this report, we describe our technique specifically for targeted muscle reinnervation of sural nerve neuromas that is applicable to both amputees and to patients with intact limbs. Sural nerve neuromas can occur after sural nerve harvest for reconstructive procedures and particularly after lateral malleolar incisions for orthopedic access to the calcaneus. By re-routing the sural nerve into a motor nerve of the lateral gastrocnemius muscle, we are able to manage a variety of sural nerve neuromas presenting anywhere along the course of the sural nerve and in a variety of clinical settings.

Surgical Management of Genitofemoral Neuralgia

Video Objective This video reviews the etiology, diagnosis, and management of genitofemoral neuralgia which is defined as pain along the distribution of the genitofemoral nerve. Setting The patient in this video began having symptoms of genitofemoral neuralgia following a laparotomy. A common mechanism of iatrogenic injury to this nerve is crush injury from poorly placed self-retaining retractors during abdominopelvic surgery. A neurectomy can be offered because the genitofemoral nerve has only sensory function and no motor function. Interventions We review the surgical technique for resection of the genital branch of the genitofemoral nerve. This technique involves retroperitoneal dissection over the psoas muscle, identification of the bifurcation of the nerve into its femoral and genital branches, isolation of the nerve, resection of the nerve, and implantation of the proximal nerve ending into the psoas muscle for nerve regeneration and neuroma prevention. Conclusion This technique is 66-100% in successful in relieving symptoms including the case of this patient.

Clinical outcome and ultrasonographic evaluation of treatment using polyglycolic acid-collagen tube for chronic neuropathic pain after peripheral nerve injury

BackgroundA novel polyglycolic acid (PGA)-collagen tube has been available in Japan since March 2013, and the development of high-resolution ultrasonography has recently allowed detailed evaluation of nerves. The purpose of this study was to report the clinical outcomes and evaluations of in-vivo changes under high-resolution ultrasonography for treatment using PGA-collagen tube for painful chronic nerve injury. MethodsFour patients underwent surgical management of peripheral nerve neuroma, with nerve defects after neuroma resection reconstructed using PGA-collagen tube. Mean duration of follow-up was 30 months. Patients were surveyed to determine visual analog scale scores for pain before surgery and at final follow-up. At final follow-up, sensory function was evaluated using the Semmes–Weinstein test, static 2-point discrimination (2PD), and moving 2PD. Furthermore, we performed ultrasonography for all patients every 1 month after surgery. ResultsIn all cases, resting pain, radicular pain, and dysesthesia were improved immediately after the operation and remained improved until the last follow-up. At the time of final follow-up, the Semmes–Weinstein test was red in 2 cases and blue in 2 cases. Mean static 2PD was 15.5 ± 5.3 mm and mean moving 2PD was 11.5 ± 5.3 mm. Ultrasonography revealed that the PGA outer wall had disappeared by 3 months postoperatively, and a hypoechoic linear shadow bridged the proximal and distal stumps. Swelling of the junction between nerve and nerve conduits was revealed at 4 months after surgery and remained until last follow-up. ConclusionsAll patients were very satisfied with pain relief, but recovery of sensory function was insufficient. Ultrasonographic evaluation after using PGA-collagen tube for painful chronic peripheral nerve injury was useful for observing in-vivo changes. Type of study/level of evidenceTherapeutic IV.

Morphological changes of the nerve after restorative treatment using electric welding technology (experimental study)

Objective – to study morphological features regenerative nerve neuroma after a complete intersection and restorative surgery with the use of electric welding technology.Materials and methods. The experimental model of operative intervention on injured peripheral nerve by immediate nerve stump’s epineurium welding and partial hindlimb immobilization was developed. The study was performed on 66 white, non-breeding male rats aged 5–7 months with a body weight of 350–450 g of vivarium breeding in Institute of Neurosurgery named after acad. A.P. Romodanov NAMS of Ukraine. Animals were divided into four experimental groups: 1 – surgical animals that included access to the sciatic nerve and its full intersection (n = 21), 2 – animals that were surgically intervened, which included access to the sciatic nerve, its intersection and the restoration of anatomical integrity by the application of an epineural suture (n = 18), 3 – animals that were operated surgically, which included access to the sciatic nerve, its intersection and the restoration of anatomical integrity by electric welding of the epineurium of the ends (n = 21), 4 – sham group, who were given access to the transverse nerve without its intersection (n = 6). In the experimental group of electric welding, the operation was performed using the apparatus EKWZ-300, «Patonmed» in the automatic mode dA2, with variable high-frequency (440 kHz) modulated current up to 0,3 A, the voltage at the 34 V pincer shield, the duration of the rectangular exposure pulse 0.8 s. Formated 5–6 electric weld point connections along the perimeter of the intersection with a complete alignment of the ends. The neurohistological method of study was used to study the morphological picture of the peripheral nerve in the region of the regenerative neurology and the distal segment in 1 and 3 months after surgical intervention. Results. It was established that simultaneous use of the technique of welded epineural joint of parts and partial immobilization of the limb in the postoperative period leads to uniform maturation of the neuro-connective tissue and its more complete neuroticisation.Conclusions. Recovery processes in the injured peripheral nerve occur better with the simultaneous formation of an immediate welded epineural joint of the ends and partial immobilization of the limb.

Forefoot disorders and conservative treatment.

Forefoot disorders are often seen in clinical practice. Forefoot deformity and pain can deteriorate gait function and decrease quality of life. This review presents common forefoot disorders and conservative treatment using an insole or orthosis. Metatarsalgia is a painful foot condition affecting the metatarsal (MT) region of the foot. A MT pad, MT bar, or forefoot cushion can be used to alleviate MT pain. Hallux valgus is a deformity characterized by medial deviation of the first MT and lateral deviation of the hallux. A toe spreader, valgus splint, and bunion shield are commonly applied to patients with hallux valgus. Hallux limitus and hallux rigidus refer to painful limitations of dorsiflexion of the first metatarsophalangeal joint. A kinetic wedge foot orthosis or rocker sole can help relieve symptoms from hallux limitus or rigidus. Hammer, claw, and mallet toes are sagittal plane deformities of the lesser toes. Toe sleeve or padding can be applied over high-pressure areas in the proximal or distal interphalangeal joints or under the MT heads. An MT off-loading insole can also be used to alleviate symptoms following lesser toe deformities. Morton’s neuroma is a benign neuroma of an intermetatarsal plantar nerve that leads to a painful condition affecting the MT area. The MT bar, the plantar pad, or a more cushioned insole would be useful. In addition, patients with any of the above various forefoot disorders should avoid tight-fitting or high-heeled shoes. Applying an insole or orthosis and wearing proper shoes can be beneficial for managing forefoot disorders.

Traumatic neuroma of buccal nerve

Background: Traumatic neuromas (TN) are non-neoplastic proliferations of a nerve arising in response to an injury, in most of the cases after direct trauma or surgical manipulation. The most common intraoral TN are found in the mental foramen, lower lip and tongue. We describe the case of extraosseous TN in the alveolar gum.

Pathogenesis, clinical evaluation and non-surgical management of symptomatic neuromas: A literature review

Neuromas are an often-underdiagnosed cause of chronic pain resulting from a peripheral nerve injury. There are two main sub-types as follows: end neuromas result from nerve transection caused by transection of a nerve due to trauma, iatrogenic injury, following amputation or oncological resection and neuroma-in-continuity where axonal injury with loss of internal neural architecture following direct trauma, compression or traction results in disorganised neural regeneration with no loss of physical continuity of the nerve sheath. Pharmacological symptom control is often inadequate. A comprehensive, structured assessment and multi-modality management regimen is required to achieve favourable outcomes in neuroma management. Strategies include peripheral neuromodulation, neurorehabilitation interventions, psychological support, peripheral nerve blockade, radiofrequency ablation and surgery. Surgical interventions are aimed at restoration of nerve continuity when possible, modification of the nerve environment and neuroma relocation or capping. This review will discuss diagnostic techniques and management strategies of peripheral neuromas.

Ultrasound, Clinical, and Electrophysiological Findings in Persistent Carpal Tunnel Syndrome.

We present the clinical, electrophysiological, and nerve ultrasound findings in cases of persistent carpal tunnel syndrome (PCTS). Eighteen PCTS patients underwent evaluation with the Boston Carpal Tunnel Syndrome Questionnaire (BCTSQ), electrophysiology, and nerve ultrasound with a mean of 3.5 months (SD ±1.4) after open surgery. PCTS patients showed a mean symptom severity scale score of 3.1 (SD ±1.1) and functional severity scale score of 3.2 (SD ±0.9) in BCTSQ. Nerve conduction studies revealed axonal affection of the median nerve in 13/18 patients, ultrasound showed disturbed echogenicity in all patients, a pathological wrist to forearm ratio in 16/18 patients, and cross-sectional area enlargement of the median nerve at the distal wrist crease in 12/18 patients. Ultrasound documented scar tissue formation (in 12/18 patients), incomplete release of retinaculum flexorum (in 4/18 patients), and neuroma of the median nerve (in 2/18 patients) as PCTS cause. Our data show significant functional disability, axonal nerve damage, and scar tissue formation as common PCTS causes.

Amputation neuroma of the vagal nerve simulating celiac lymph node enlargement: diagnosis with EUS-FNA

Amputation neuroma of the vagal nerve simulating celiac lymph node enlargement: diagnosis with EUS-FNA

Anatomic Pyrocarbon Hemiarthroplasty for Thumb Carpometacarpal Osteoarthritis in Patients under 65 Years: Mid Term Results.

To assess the midterm outcome of patients under 65 who underwent anatomic pyrocarbon hemiarthroplasty for thumb carpometacarpal (CMC) osteoarthritis. A prospective analysis was performed of a consecutive series of active patients, less than 65 years of age, with symptomatic osteoarthritis who had undergone a CMC hemiarthroplasty using a stemmed metacarpal based, anatomic pyrolytic carbon resurfacing with an additional one third flexor carpi radialis (FCR) tendon transfer to maintain stability. The Wrightington Hand Score, Disability Arm Shoulder and Hand (DASH) Score, and the Patient Rated Wrist Evaluation Score (PRWE) were utilised. Clinical data was obtained for grip strength, pinch strength, and range of motion. The MEAN age was 57.6 years. MEAN follow up was 6.5 years. All patients had improvement in pain, grip strength and function. There was no significant difference in grip and pinch strengths between the individual's left and right hand. All patients stated that they would undergo the procedure again. There was one revision following a traumatic trapezium fracture. One patient underwent a neurolysis of a superficial radial nerve neuroma associated with an impinging trapezial osteophyte. Active patients, under 65 years of age with Eaton-Littler stage III osteoarthritis of the thumb CMC joint who are treated with anatomic pyrolytic carbon resurfacing hemiarthroplasty and stabilisation may achieve sustained improvement in pain and hand function for up to 6.5 years.

Procedural Ultrasound Location of Pectoral Nerve Neuroma Prior to Breast Reconstruction Surgery

Chronic pain from breast surgery seems to be relatively commensurate with the increase in number of breast surgeries itself. There have been many improvements in surgery as well as anesthesia technique. These novel techniques have shown promising results in both decreasing post operative pain, opioid use along with the cascade of undesirable side effects, and even cancer recurrence. Ultrasound seems to play an integral part in the development of these analgesic techniques and furthers our understanding of relevant anatomy. We present a case where ultrasound correctly identified a chronic pain causing neuroma during the pre-procedural analgesic employment. The offending neuroma was subsequently reported to the surgeon pre procedurally, and resected under direct vision during the surgical reconstruction. This finding altered the course of the surgery and yielded positive results post operatively.

A systematic review to assess the effectiveness and safety of nerve reconstruction using absorbable synthetic nerve conduit

This study aimed to assess the effectiveness and safety of absorbable synthetic nerve conduit through systematic review. The search strategy was embodied according to PICO (patient, intervention, comparison, and outcome). The patients were with peripheral nerve damage and neuroma. The intervention was nerve reconstruction with absorbable synthetic nerve conduit. Comparisons were autologous nerve graft and end-to-end suturing. The safety outcome was procedure-related complications. The effectiveness outcomes were nerve function tests, procedure failure rate, and subjective assessment. A total number of 434 papers were searched, five studies included. The safety outcomes reported higher in the intervention group in clinical trial including wound healing problems and debridement of the wound. The effectiveness results were improved in the intervention group, but not significant in comparative study. In case series and case reports, the efficacy outcomes were different among articles. Nerve reconstruction using absorbable synthetic nerve conduit was needed further study, nevertheless it is expected to be clinically useful.

Facial nerve neuroma in the geniculate ganglion extending into the internal auditory canal: A case report

Facial nerve schwannoma is a very rare benign tumor representing less than 1% of intrapetrous lesions. Our patient is a forty-one year old female who has suffered from recurrent right facial palsy for the last six years. She was first misdiagnosed as having Bell’s palsy and received corticosteroids which resulted in little improvement. She then had facial nerve decompression surgery which resulted in a partial improvement. Since then, she has suffered from recurrent attacks of facial palsy. Two years ago, she came to our hospital seeking further treatment options. The final diagnosis made by MRI was a possible facial nerve tumor. To obtain a better facial outcome, total tumor removal was performed through the middle cranial fossa approach along with facial-hypoglossal nerve end-to-side anastomosis through transmastoid approach. Her hearing was preserved, and she obtained a better facial outcome than that of her preoperative level. In conclusion, facial nerve schwannoma has the potential to be misdiagnosed as Bell’s palsy which might lead to a delay in diagnosis, and end-to-side neurorrhaphy may be an effective alternative in a selected case.

P 99 Additional diagnostic benefit of high resolution ultrasound of the peripheral nerv in addition to classical ENG 2 case reports of posttraumatic nerve injury from an interdisciplinary consultancy

Posttraumatic/post-surgery nerve injury is a frequent problem in surgical departments and has a grave impact on patients recovery and functionality. Exact diagnosis of nerve function and severity of the injury is often a demanding task for electrophysiology laboratories. Classical neurophysiological exams like EMG and ENG occasionally have limited only value in establishing the location and etiology of nerve injury. High resolution ultrasound is a valuable additional tool to plan further treatment. We report two cases of post-surgery peripheral nerve damage from our interdisciplinary consultancy. Case 1 58 year old female presenting after fracture and surgery of the right distal radius with severe local pain of distal forearm and paresthesia of dig. II and III. An external ENG had suggested a mild atypical posttraumatic CTS. High resolution ultrasound revealed a grossly enlarged median nerve 3 cm proximal of the wrist with partial loss of intraneural fascicle-signal. A posttraumatic neuroma of median nerve with partially remaining continuity could be diagnosed. Case 2 23 year old female presenting with complete palsy of foot elevation after polytrauma and knee surgery 3 month prior. EMG and ENG showed complete denervation of fibular nerve. High resolution ultrasound showed a foreign body splitting the fibular nerv proximal to fibula head. Reexploration was decided and intraoperatively tendon graft penetrating the nerve could be confirmed and removed. Clinical follow-up showed gradual recovery of nerve function. Interdisciplinary consultancy consisting of neurosurgeon, neurologist and anesthetist and use of high resolution ultrasound in addition to ENG/EMG can help to establish a timely diagnosis of cause and location of nerve damage and therefore might lead to early treatment and improved clinical outcome.

Endoscopic Interdigital Neurectomy of the Foot

Morton's neuroma is a compressive neuropathy resulting in perineural fibrosis rather than a neuroma of the plantar digital nerve. Surgical treatment is indicated for patients with a clear diagnosis of Morton's neuroma and no improvement with nonsurgical treatment. The surgical options include isolated intermetatarsal ligament division, isolated interdigital nerve excision, and interdigital nerve excision with intermetatarsal ligament division, with or without submuscular transposition. This can be performed via dorsal or plantar approach. The open approaches require long incisions and extensive soft-tissue dissection. The purpose of this Technical Note is to describe the surgical details of endoscopic interdigital neurectomy. This is an endoscopic approach involving interdigital nerve excision with intermetatarsal ligament division and submuscular transposition.