Neuroma Excision Research Articles

Middle cranial fossa acoustic neuroma excision: results and complications.

The middle cranial fossa surgical approach has been used for the removal of acoustic neuromas in 43 patients at the University of Iowa since 1974. Hearing was maintained in 50% of patients with tumors 1.5 cm or less outside the porus acusticus. Postoperative hearing, facial nerve function, and complications were similar to reports using the suboccipital or retrosigmoid approach to preserve hearing for this size tumor. The character of the tumor appears to dictate the postoperative outcome rather than the surgical approach.

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.

Preservation of hearing in patients undergoing excision of acoustic neuromas and other cerebellopontine angle tumors.

Microsurgical techniques have made it possible to identify and preserve the cochlear nerve from its origin at the brain stem and along its course through the internal auditory canal in patients undergoing removal of small or medium-sized acoustic neuromas or other cerebellopontine angle (CPA) tumors. In a consecutive series of 100 patients with such tumors operated on between 1975 and 1981, an attempt was made to preserve the cochlear nerve in 23. The decision to attempt to preserve hearing was based on tumor size and the degree of associated hearing loss. In cases of unilateral acoustic neuroma, the criteria for attempted preservation of hearing were tumor size (2.5 cm or less), speech reception threshold (50 dB or less), and speech discrimination score (60% or greater). In patients with bilateral acoustic neuromas or tumors of other types, the size and hearing criteria were significantly broadened. All patients were operated on through a suboccipital approach. Hearing was preserved postoperatively in six (31.6%) of the 19 patients with unilateral acoustic neuromas, although the cochlear nerve was preserved in 16. Of the six patients with postoperative hearing, three retained excellent hearing, and the other three had only sound awareness and poor discrimination. Hearing was preserved in three cases with other CPA tumors, including an epidermoid cyst and small petrous meningiomas in the internal auditory canal. Of the two cases with bilateral tumors, hearing was preserved in one. Of the 23 patients in whom hearing preservation was attempted, nine (39.1%) had some postoperative hearing, which in six was equal to or better than the preoperative level. Thus, it is worthwhile to attempt hearing preservation in selected patients with CPA tumors.

Invasion of the L7 ventral root and spinal pia mater by new axons after sciatic nerve division in kittens

In young kittens the left sciatic nerve was divided followed by nerve suture, distal stump resection, or resection combined with proximal stump capping. The kittens were killed 2 to 3 months postoperatively. In other kittens bilateral L7 ventral rhizotomy or neuroma excision was carried out 80 to 90 days after nerve resection, followed by killing a few days later. Thin sections from the ventral root L7 were examined in the electron microscope. In all animals the average proportion of ventral root unmyelinated axon profiles (UAP) was above normal on the operated side, being highest in capped and resected animals and lower in sutured cases. The proportion of UAP was inversely related to the extent of functional calf muscle reinnervation. In cases with high proportions of UAP, numerous bundles of unmyelinated and small myelinated axons were present in juxtamedullary root fascicles and surrounding pia mater. After L7 ventral rhizotomy in resected animals few intact UAP occurred together with numerous signs of axon degeneration in the proximal root stump on the lesion side. After neuroma excision the proportion of ventral root UAP decreased. Therefore some proportion of the new axons should represent recurrent sprouts from peripheral sources.

The Painful Stump Neuroma and Its Treatment

Successful clinical management of symptomatic neuromas continues to present a challenge to the responsible surgeon. It is unexplained why some patients with neuromas are completely asymptomatic while others exhibit debilitating symptoms. Prevention of neuromas is paramount with precise attention to severed nerves following amputations and other surgical procedures. Once established, treatment of neuromas consists of careful patient counseling, local massage, and desensitization procedures. Sympathetic blockade with guanethidine may be beneficial in some patients. When necessary, surgical excision of the neuroma along with a combination of funiculectomy, epineurial sleeve suture ligation, and silicone capping offers the best chance for eradication. In intractable or recurrent cases and following careful patient selection, neuroma excision followed by nerve grafting combined with sympathetic blockade using guanethidine can be successful in a significant number of cases.

Effects of sciatic nerve resection on L7 spinal roots and dorsal root ganglia in adult cats

The size, distribution, and number of nerve fibers and neuronal perikarya in the L7 spinal roots and ganglia of adult cats were examined 35, 90, and 190 days after ipsilateral sciatic nerve resection. With increasing survival time the size spectra of myelinated ventral root nerve fibers showed a progressive flattening of the alpha peak. In the dorsal roots the myelinated fiber size distribution exhibited a marked shift toward smaller sizes. The reduction in the proportion of large myelinated axons was particularly evident in the dorsal roots. Less clearcut changes were found in the size distribution of spinal ganglion neuronal perikarya. No significant loss of axons could be detected in ventral or dorsal roots. There was, however, a marked reduction in the number of dorsal root ganglion neurons. This discrepancy suggested the possibility that an initial loss of dorsal root axons was concealed by recurrent sprouting of axons from the proximal nerve stump. However, neuroma excision 90 days after nerve resection did not lead to any reduction in dorsal root axon numbers. Thus, any ingrowth of new axons to the dorsal root should occur from levels proximal to the neuroma. In comparison with previous findings in kittens, peripheral nerve resection in adult cats had significantly smaller effects on sizes and numbers of spinal root nerve fibers as well as of dorsal root ganglion neurons. Therefore, the potential for restitution of the peripheral innervation by axon regeneration appeared to be basically greater in mature than in immature animals.

Neuroma formation following digital amputations.

One hundred consecutive patients with 144 digital amputations performed at the University of Colorado Health Sciences Center between 1978 and 1980 were retrospectively reviewed. In this group, four patients demonstrated painful amputation stumps. Two of these were treated by surgical excision of neuromas and two patients, who had more vague complaints, were treated by desensitization which decreased the sensitivity of their stumps and allowed them to return to work. It is felt that this low incidence of painful neuromas and amputation stumps is due to the positive postoperative effort to send patients back to work as soon as possible, allowing them to perform their own therapy and thereby minimizing their disability and tendency to develop pain problems.

Facial nerve preservation in patients with large acoustic neuromas treated by a combined middle fossa transtentorial translabyrinthine approach.

With large acoustic neuromas, the primary goal of surgery is safe total removal of the tumors, and the secondary goal is preservation of nearby neural structures, including the facial nerve. In a series of 15 consecutive patients with large cerebellopontine angle tumors, all of which were more than 2.5 cm in diameter, tumor excision was performed by a one-stage combined middle fossa-translabyrinthine approach. There were 13 acoustic neuromas, 10 of which were more than 4 cm in diameter, one petrous apex meningioma 4 cm in diameter, and one facial neuroma 3 cm in diameter. The tumors were totally removed in all 15 patients. The facial nerve was preserved in 12 of 13 evaluable patients. In the 14th patient the nerve had been transected in a previous suboccipital procedure with incomplete removal, and in the 15th patient the nerve was sutured following excision of a facial neuroma. Thus, the nerve was lost at surgery in only one patient. This combined approach provided very clear visualization of the cerebellopontine angle, including the brain stem and the lower cranial nerves. It enabled identification of both the origin of the facial nerve at the brain stem and the lateral segment of the nerve in the internal auditory canal. Anterior extensions of tumor growing through the tentorial hiatus were easily removed. The results in these 15 patients show that this approach is excellent for total removal of large acoustic neuromas with preservation of the facial nerve. It is especially suitable for large tumors with anterior extensions.

Allescheria boydii Osteomyelitis Following Multiple Steroid Injections and Surgery

This is a report of a 46-year-old male who developed an Allescheria boydii infection secondary to excision of an interdigital neuroma. Previously reported cases of infection occurred in an immunosuppressed patient and in patients on systemic corticosteroid therapy, but not associated with a surgical wound. This patient received multiple local corticosteroid injections which may have produced local as well as systemic immunosuppression. Fungal cultures were not taken for many months and thus the true etiology of the infection was not discovered until late. The importance of obtaining fungal cultures particularly in patients receiving corticosteroid therapy, either local infiltration or systemic, cannot be overemphasized.

Zur Klinik und Pathogenese der Morton'schen Krankheit

From experience with 58 own cases the authors found that Morton's metatarsalgia due to a sclerosing neuroma of the plantar digital nerve is very often not recognised for many years. As this painfull affection easily can be cured, the clinical symptoms and histological findings, the diagnostic steps and treatment are described and the etiology discussed. For the excision of the plantar digital neuroma, situated generally between 3rd and 4th metatarsal head, the dorsal web-splitting approach is preferred because of better scars and immediate weigt-bearing. The operation is performed on outdoor patients. There were no complications. The results of 35 operations two or more years back show immediate and complete relief of pain in 31 cases and significant but incomplete relief in 4 cases.

Laparoscopic diagnosis of abdominal wall hematoma

The exact location of a mass palpable in the ventral abdomen is sometimes difficult to define. Uncertainty may exist whether it lies in the peritoneal cavity or is situated within the abdominal wall. Laparoscopy is a safe and readily available method to clarify such a diagnostic dilemma,' thus avoiding an exploratory laparotomy. CASE REPORT A 42-year-old white woman was admitted to Beth Israel Medical Center for elective excision of a Morton's neuroma. On the fourth postoperative day she manifested clinical signs suggestive of a pulmonary embolus, and physical examination disclosed left calf tenderness with a Homan's sign. The patient was put at bed rest, and heparin was given in doses sufficient to maintain the partial thromboplastin time at twice normal levels. Six days after commencement of anticoagulant therapy, she complained of right lower quadrant pain and nausea. Examination revealed a temperature of 1OO.4°F and a tender, non-fluctuant mass measuring 6 cm x 8 cm in the right lower quadrant of the abdomen close to an appendectomy scar. Abdominal scout films showed a normal gas pattern. A presumptive diagnosis of an intramural or pericecal hematoma was suggested by a surgical consultant. Heparin therapy was immediately discontinued. The mass remained tender and did not change in size or consistency over the next 5 days. At laparoscopy, requested to clarify the nature of the mass, no intra-abdominal abnormality was found. It was quite apparent that the large mass in the right lower quadrant lay within the abdominal wall itself, producing marked bulging into the peritoneal cavity on its inner aspect. Manual pressure on the anterior abdominal wall moved the mass toward the telescope. The diagnosis of a hematoma within the anterior abdominal wall was made. The patient's further course was uneventful, and the hematoma eventually resolved spontaneously. DISCUSSION Hematoma formation within the rectus sheath is not uncommon, with many cases on record. Interest stems chiefly from its mimicking of intra-abdominal disease. Sometimes the diagnosis is correctly made only by laparotomy.2 In the great majority of instances, abdominal wall hematomas are situated below the level of the umbilicus and are on the right side twice as often as the left.3The commonest source of the bleeding is a ruptured inferior epigastric vein.The mechanism of this condition is quite variable with direct trauma being most frequent. Spastic muscular contractions such as may occur during seizures, severe coughing, and sexual intercourse have been described.sCollagen disorders, degenerative vascular diseases, and blood dyscrasias may also be predisposing factors,3 and the entity has been associated with pregnancy.In the postoperative patient an improperly placed suture injuring the inferior epigastric vessels shou Id be considered.