Neuroma Resection Research Articles

Pelvic Pain of Pudendal Nerve Origin: Surgical Outcomes and Learning Curve Lessons

When pudendal nerve dysfunction fails to improve after medical and pelvic floor therapy, a surgical approach may be indicated. "Traditional," "posterior," transgluteal nerve decompression fails in an unacceptably high percentage of patients. Insights into pudendal neuroanatomy and pathophysiology offer improved microsurgical outcomes. To evaluate results of a peripheral nerve approach to the pudendal nerve, 55 patients were prospectively evaluated. This cohort included 25 men and 30 women. Surgical approach was posterior, transgluteal if symptoms included rectal pain; or "anterior," inferior pubic ramus approach if symptoms excluded rectal pain. Surgical approach was "resection," if trauma created a neuroma, and "decompression," if there were no neuroma. Effect of comorbidities was analyzed. At 14.3 months postoperatively, untreated anxiety/depression correlated with outcome failure, regardless of surgical approach, p < 0.002. There was no difference in results, men versus women, "anterior" versus "posterior" approach, or neuroma resection versus neurolysis. Success correlated with the "learning curve" of the surgeon. Self-rated success was significantly better (p < 0.0001) for patients operated on during the second year of the study than the first year of the study, and improved again in the final year of the study (p < 0.04), with 86% of the patients in final year achieving an excellent result and 14% achieving a good result. There is hope for surgical relief from pudendal nerve problems by distinguishing neuroma from compression in the diagnosis, and then choosing a site-specific surgical approach related to which pudendal nerve branches are involved.

Results of nerve reconstructions in treatment of obstetrical brachial plexus injuries.

The aim of this study was to evaluate the results achieved using various surgical techniques in patients with partial and total obstetrical brachial plexus palsy. From 2000 to 2013, 33 patients with obstetrical brachial plexus injury underwent surgery. Twenty had follow-up periods greater than 24 months and met the criteria for inclusion in the study. All patients were evaluated using the Active Movement Scale. The outcomes of different nerve reconstructive procedures including nerve transfers, nerve grafting after neuroma resection and end-to-side neurorrhaphy are presented. The overall success rate in upper plexus birth injury was 80 % in shoulder abduction, 50 % in external rotation and 81.8 % in elbow flexion with median follow-ups of 36 months. Success rate in complete paralysis was 87 % in finger and thumb flexion, 87 % in shoulder abduction and 75 % in elbow flexion; the median follow-up was 46 months. Useful reanimation of the hand was obtained in both patients who underwent end-to-side neurotization. Improved function can be obtained in infants with obstetrical brachial plexus injury with early surgical reconstruction.

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.

Bleeding Abdominal Mass in a Patient With Genetic Cutaneous Disorder

A 72-year-oldman presented to the hospital after sustaining a fall, with prior generalized weakness and fatigue.Hehadbeenhaving recurrent gastrointestinal bleeding andmelena during the past year. He reported a 6.75-kgweight loss during the past fewmonths but did not have abdominal pain, nausea, vomiting, fevers, or chills. His surgical history was notable for a coronary artery bypass graft 9months earlier and γ-knife resection of an acoustic neuroma 10 years ago. Physical examination revealed a soft, nontender abdomen without obvious palpable masses. Inspection of the patient’s skin demonstrated multiple fleshy, soft cutaneous nodules (Figure 1A). The patient’s laboratory testing was only notable for anemia with a hemoglobin level of 10.4 g/dL (reference range, 12-16 g/dL). A prior extensive examination, including upper and lower endoscopy, upper gastrointestinal series with small-bowel follow-through, and capsule endoscopy did not reveal a diagnosis. A computed tomography image of the abdomen and pelvis is shown in Figure 1B. A B

What is the best method to treat CSF leaks following resection of an acoustic neuroma?

What is the best method to treat CSF leaks following resection of an acoustic neuroma?

The Negative Effect of Unsupervised Exercises on Patients with Facial Paresis

Objectives: Compare facial function at onset of skilled facial rehabilitation of patients with facial paresis performing unsupervised facial exercise routine and patients with no previous intervention. Methods: Retrospective chart review at a tertiary referral center including all patients from our institution who had &gt;1/6 House Brackman score and were referred to physical therapy for facial retraining from 2012 to 2013. Patients were excluded from the study if they had a facial reanimation procedure or electrical stimulation prior to onset of physical therapy. The study used House Brackman (HB) and Facial Grading System (FGS) with 3 subscales: resting symmetry (rFGS), voluntary movement (mFGS), and synkinesis (sFGS). Results: Fourteen patients were referred to facial retraining therapy and met the specified inclusion and exclusion criteria. The medical diagnoses included postoperative acoustic neuroma resection, Bell’s palsy, and Ramsay Hunt Syndrome. Eight patients did not participate in exercise prior to physical therapy evaluation and 6 patients were issued unsupervised facial exercise prior to therapy. Patients who participated in an unsupervised facial exercise program had a significantly higher sFGS score of 6.83 ± 2.23 at initial physical therapy evaluation than those who did not participate in exercises, with a score of 3.75 ± 2.61 ( P = .038). There were no significant differences between HB, FGS, rFGS, or mFGS. Conclusions: Patients who participated in unsupervised facial exercises had more synkinesis than those patients who did not. Generic facial exercises prior to formal individualized facial retraining therapy may be counterproductive. Further investigation is necessary to determine if initial synkinesis score impacts overall patient outcomes following intervention.

The use of multimedia as an adjunct to the informed consent process for Morton's neuroma resection surgery.

The purpose of this study was to assess if a computer-based multimedia education module (MEM) improved patients' comprehension when used as an adjunct to the standard verbal consent process for Morton's neuroma resection surgery. Nineteen patients (15 females and 4 males) considered candidates for Morton's neuroma resection surgery were prospectively recruited. A standardized verbal discussion was had with each patient regarding risks and benefits of surgery, alternative treatments, and the usual postoperative course. Patient understanding was then assessed with a questionnaire. Each patient subsequently viewed the MEM and the questionnaire was repeated. Patients also rated ease of understanding and satisfaction with both methods of patient education. Patients answered a significantly greater proportion of correct answers after viewing the MEM module (85%), compared to verbal discussion alone (61%) (P = .002). Patients rated both the ease of understanding of the module and amount of information provided by the module as a mean of 9.3 cm on a 10 cm Visual Analog Scale (VAS). The majority of patients (76%) rated the multimedia tool as having answered their questions about surgery as well or better than the treating surgeon. An interactive multimedia educational tool was a useful adjunct to the informed consent process for patients considering Morton's neuroma resection surgery. Level II, prospective cohort study.

Case Scenario: Postoperative Brachial Plexopathy Associated with Infraclavicular Brachial Plexus Blockade

Case Scenario: Postoperative Brachial Plexopathy Associated with Infraclavicular Brachial Plexus Blockade

Masseter-to-facial nerve transfer: a novel effective technique for facial functional reconstruction after acoustic neuroma resection

Objective To determine the effects of masseter-to-facial nerve transfer for patients who acquired a proximal injury to the facial nerve and to analyze the associated morbidities after the operation.Methods A total of 16 patients underwent tumor resection in cerebellopontine angle (CPA) received the masseter-to-facial nerve transfer from November 2010 to February 2013 in our center with continuously follow-up.Terzis's smile grading and Metha's synkinetic movements scales were used to evaluate the preoperative and postoperative mimetic muscle function.The periods between the operation and the onset of mimetic muscle contraction were also documented.A questionnaire was introduced to assess the donor-site morbidity and the ability to smile without biting.Results All patients had restored the smile function with biting(P ＜0.05).9 of 16 patients had excellent or good results,5 had moderated results and 2 had poor results.4 patients complained about moderate degree of masseter atrophy and required further revision.The synkinetic movements were observed in all patients and were rated as mild.Conclusions Masseter-facial nerve transfer was a highly efficient technique to reanimate the paralytic muscle in patients who acquired intracranial facial nerve injury with minor deformities.After continued physical therapy,some patients were able to regain a symmetrical and effortless smile with mild synkinetic movements. Key words: Facial nerve; Neuroma,acoustic; Nerve transfer; Masseter nerve

Medial acoustic neuromas: clinical and surgical implications

Medial acoustic neuroma is a rare entity that confers a distinct clinical syndrome. It is scarcely discussed in the literature and is associated with adverse features. This study evaluates the clinical and imaging features, pertinent surgical challenges, and treatment outcome in a large series of this variant. The authors postulate that the particular pathological anatomy with its arachnoidal rearrangement has a profound implication on the surgical technique and outcome. The authors conducted a retrospective analysis of 52 cases involving 33 women and 19 men who underwent resection of medial acoustic neuromas performed by the senior author (O.A.) over a 20-year period (1993-2013). Clinical, radiological, and operative records were reviewed, with a specific focus on the neurological outcomes and facial nerve function and hearing preservation. Intraoperative findings were analyzed with respect to the effect of arachnoidal arrangement on the surgeon's ability to resect the lesion and the impact on postoperative function. The average tumor size was 34.5 mm (maximum diameter), with over 90% of tumors being 25 mm or larger and 71% being cystic. Cerebellar, trigeminal nerve, and facial nerve dysfunction were common preoperative findings. Hydrocephalus was present in 11 patients. Distinguishing intraoperative findings included marked tumor adherence to the brainstem and frequent hypervascularity, which prompted intracapsular dissection resulting in enhancement on postoperative MRI in 18 cases, with only 3 demonstrating growth on follow-up. There was no mortality or major postoperative neurological deficit. Cerebrospinal fluid leak was encountered in 7 patients, with 4 requiring surgical repair. Among 45 patients who had intact preoperative facial function, only 1 had permanent facial nerve paralysis on extended follow-up. Of the patients with preoperative Grade I-II facial function, 87% continued to have Grade I-II function on follow-up. Of 10 patients who had Class A hearing preoperatively, 5 continued to have Class A or B hearing after surgery. Medial acoustic neuromas represent a rare subgroup whose site of origin and growth patterns produce a distinct clinical presentation and present specific operative challenges. They reach giant size and are frequently cystic and hypervascular. Their origin and growth pattern lead to arachnoidal rearrangement with marked adherence against the brainstem, which is critical in the surgical management. Excellent surgical outcome is achievable with a high rate of facial nerve function and attainable hearing preservation. These results suggest that similar or better results may be achieved in less complex tumors.

Intratemporal Traumatic Neuromas of the Facial Nerve

To describe 2 patients with traumatic neuromas of the intratemporal facial nerve in the absence of trauma. Retrospective case review. Tertiary care referral center. Patients included underwent resection of an intratemporal facial nerve mass. Upon pathologic evaluation, the patients were found to have traumatic neuromas of the facial nerve. Patients underwent resection of an intratemporal facial traumatic neuroma. Histopathologic evaluation was performed including an immunohistochemistry evaluation. Two patients were identified with intratemporal facial nerve traumatic neuromas. The patients had no significant history of trauma or chronic inflammatory process. Pathologic evaluations, including immunohistochemistry, of the excised masses were consistent with traumatic neuromas. All tumors were noted to have a disorganized collection of axons and were not consistent with the expected diagnosis of schwannoma. Tumors involved the tympanic and vertical segments of the facial nerve. A cavernous angioma was found within one mass and is thought to be the etiology of neuroma formation. Traumatic neuromas are possible in the intratemporal facial nerve in the absence of trauma. A cavernous angioma of the facial nerve is a newly described possible cause of traumatic neuroma formation.

Etiology, diagnosis, and management of facial palsy: 2000 patients at a facial nerve center

To evaluate the range and incidence of facial palsy etiologies in cases presenting to a tertiary facial nerve center, and to review the broad and evolving spectrum of diagnostic and management approaches to the condition. Retrospective chart review. Records of patients referred for facial weakness between 2003 and 2013 were reviewed for cases of facial palsy. Cases of muscle dysfunction and primary hemifacial spasm were excluded. The remainder were analyzed by age, sex, and diagnosis. Diagnostic and treatment strategies were reviewed. There were 1,989 records that met inclusion criteria. Bell's palsy accounted for 38% of cases, acoustic neuroma resections 10%, cancer 7%, iatrogenic injuries 7%, varicella zoster 7%, benign lesions 5%, congenital palsy 5%, Lyme disease 4%, and other causes 17%. Sixty-one percent of patients were female. Mean age at presentation was 44.5 years (±18.6 years). Diagnoses were revealed primarily by history, though serial physical examinations, radiography, and hematologic testing also contributed. Management strategies included observation, physical therapy, pharmacological therapy, chemodenervation, facial nerve exploration, decompression, repair, and the full array of static and dynamic surgical interventions. Bell's palsy remains the most common facial palsy; females present more often for evaluation. Comprehensive diagnostic investigation is mandatory in atypical cases, and thorough management must be multidisciplinary. The algorithms presented herein outline a single center's approach to the facial palsy patient, providing a framework that clinicians caring for these patients may adapt to their specific settings. 2b.

Retractorless translabyrinthine approach for resection of a large acoustic neuroma: operative video and technical nuances

Large acoustic neuromas, greater than 3 cm, can be technically challenging tumors to remove because of their intimate relationship with the brainstem and surrounding cranial nerves. Successful tumor resection involves functional preservation of the facial nerve and neurovascular structures. The translabyrinthine approach is useful for surgical resection of acoustic neuromas of various sizes in patients with poor preoperative hearing. The presigmoid surgical corridor allows direct exposure of the tumor in the cerebellopontine angle without any fixed cerebellar retraction. Early identification of the facial nerve at the fundus facilitates facial nerve preservation. Large acoustic tumors can be readily removed with a retractorless translabyrinthine approach using dynamic mobilization of the sigmoid sinus. In this operative video atlas report, the authors demonstrate their operative nuances for resection of a large acoustic neuroma via a translabyrinthine approach using a retractorless technique. Facial nerve preservation is achieved by maintaining a plane of dissection between the tumor capsule and the tumor arachnoid so that a layer of arachnoid protects the blood supply to the facial nerve. Multilayered closure is achieved with a fascial sling technique in which an autologous fascia lata graft is sutured to the dural defect to suspend the fat graft in the mastoidectomy defect. We describe the step-by-step technique and illustrate the operative nuances and surgical pearls to safely and efficiently perform the retractorless translabyrinthine approach, tumor resection, facial nerve preservation, and multi-layered reconstruction of the skull base dural defect to prevent postoperative cerebrospinal fluid leakage. The video can be found here: http://youtu.be/ros98UxqVMw .

Retrosigmoid craniotomy for resection of acoustic neuroma with hearing preservation: a video publication

In this publication, video format is utilized to review the operative technique of retrosigmoid craniotomy for resection of acoustic neuroma with attempted hearing preservation. Steps of the operative procedure are reviewed and salient principles and technical nuances useful in minimizing complications and maximizing efficacy are discussed. The video can be found here: http://youtu.be/PBE5rQ7B0Ls .

A stepwise illustration of the retrosigmoid approach for resection of a cerebellopontine meningioma

The retrosigmoid approach is a work-horse approach to the cerebellopontine angle (CPA), providing access from the foremen magnum to the tentorium. Indications for this approach are variable such as resection of meningiomas, acoustic neuromas and epidermoid tumors, treatment of vascular lesions of vertebrobasilar system, vascular decompression of cranial nerves (V, VII, IX, X), cranial nerve neurectomies, and intrinsic lesions of the cerebellum and brainstem. In this video, we demonstrate the use of retrosigmoid craniotomy for resection of a large CPA meningioma, delineating all steps including positioning, mapping. The video can be found here: http://youtu.be/kISkYS16Brk .

Neurolysis alone as the treatment for neuroma-in-continuity with more than 50% conduction in infants with upper trunk brachial plexus birth palsy

The debate addressed in this article is that of surgical treatment methods for a neuroma-in-continuity. The authors of this study chose to test the hypothesis that more severe nerve injuries, as distinguished by < 50% conduction across a neuroma-in-continuity, could be treated with neuroma resection and grafting, whereas less severe nerve injuries, with > 50% conduction across the neuroma, could be treated with neurolysis alone. The goal of this study was to compare preoperative and postoperative Active Movement Scale (AMS) scores in children with upper trunk brachial plexus birth injuries treated with neurolysis alone if the neuroma's conductivity was > 50% on intraoperative nerve testing. Seventeen patients (7 male, 10 female) met the criteria for inclusion in this study. Surgery was done when the patients were an average of 10 months old (range 6-19 months). The authors analyzed AMS scores from the preoperative assessment, 1-year postoperative follow-up visit, and subsequent follow-up assessment as close to 3 years after surgery as possible (referred to in this paper as > 2-year postoperative scores). Comparison of preoperative and 1-year follow-up data showed significant improvement in shoulder abduction, flexion, external rotation, and internal rotation; elbow flexion and supination; and wrist extension. Comparison of preoperative findings and results of assessment at > 2-year follow-up showed significant improvement in shoulder abduction, flexion, external rotation; and elbow flexion and supination. At final follow-up, useful function (AMS score of 6 or 7) was achieved for elbow flexion in 14 of 16 patients, shoulder flexion in 11 of 15 patients, shoulder abduction in 11 of 16 patients, and shoulder external rotation in 5 of 15 patients. This report indicates that there is a subgroup of patients who can benefit clinically, with functional improvement of shoulder and elbow function, from treatment with neurolysis alone for upper trunk lesions demonstrating more than 50% conduction across the neuroma on intraoperative nerve testing. Patients with less than 50% conduction, indicating more severe disease, are treated with nerve resection and grafting in the authors' treatment algorithm.

Standing balance tests for screening people with vestibular impairments

To improve the test standards for a version of the Romberg test and to determine whether measuring kinematic variables improved its utility for screening. Healthy controls and patients with benign paroxysmal positional vertigo, postoperative acoustic neuroma resection, and chronic peripheral unilateral weakness were compared. Subjects wore Bluetooth-enabled inertial motion units while standing on the floor or medium-density, compliant foam, with eyes open or closed, with head still or moving in pitch or yaw. Dependent measures were time to perform each test condition, number of head movements made, and kinematic variables. Patients and controls did not differ significantly with eyes open or with eyes closed while on the floor. With eyes closed, on foam, some significant differences were found between patients and controls, especially for subjects older than 59 years. Head movement conditions were more challenging than with the head still. Significantly fewer patients than controls could make enough head movements to obtain kinematic measures. Kinematics indicated that lateral balance control is significantly reduced in these patients compared to controls. Receiver operator characteristics and sensitivity/specificity analyses showed moderately good differences with older subjects. Tests on foam with eyes closed, with head still or moving, may be useful as part of a screening battery for vestibular impairments, especially for older people. 3b.

Free anterolateral thigh flap with vascularized lateral femoral cutaneous nerve for the treatment of neuroma‐in‐continuity and recurrent carpal tunnel syndrome after carpal tunnel release

Treatment of recurrent carpal tunnel syndrome (CTS) is challenging, especially in a case with recurrent CTS and a neuroma formation. Resection of the neuroma causing the syndrome, reconstruction of the nerve gap of the median nerve, and covering up the reconstructed median nerve with well-vascularized soft tissue for prevention of CTS re-recurrence are the essential procedures. We report a case of recurrent CTS with severe pain due to a neuroma-in-continuity successfully treated using a free anterolateral thigh (ALT) flap with a vascularized lateral femoral cutaneous nerve (LFCN). A 2 cm neuroma existed in the median nerve and was resected. The nerve gap was repaired using a vascularized LFCN included in the ALT flap. The ALT flap was transferred to the wrist to cover the median nerve. The severe pain disappeared completely and the sensory and motor impairment of the median nerve improved 5 months after the free flap surgery, as the Tinel's sign moved distally away from the wrist and disappeared. The result of the Semmes-Weinstein test improved from 5.08 to 4.31 and she was able to flex and extend the right wrist and fingers without pain. CTS did not recur 15 months after the surgery. A free ALT flap with vascularized LFCN allows nerve reconstruction for the median nerve gap created after neuroma resection and coverage of the median nerve with well-vascularized soft tissue to prevent adhesion and CTS recurrence.

Scleral Contact Lenses as an Alternative to Tarsorrhaphy for the Long-Term Management of Combined Exposure and Neurotrophic Keratopathy

Most ophthalmologists are unaware of the therapeutic applications of gas-permeable scleral contact lenses for the prevention and treatment of ocular complications in patients with facial nerve palsy and concomitant neuroparalysis. The case reports refer to 3 patients who developed unilateral lagophthalmos and corneal anesthesia after an acoustic neuroma or intracranial tumor resection. Two patients explicitly requested a tarsorrhaphy to be opened because they were incapacitated by the limited visual acuity and visual field. Tarsorrhaphy was not an acceptable aesthetic solution for the third patient. Fluid-ventilated scleral lenses were fitted because they protect the cornea by creating a precorneal fluid reservoir while optimizing visual acuity. The follow-up periods were 3, 17, and 18 years. Two patients wear the contact lenses full time, but the wearing time is limited to 10 hours per day for the third patient. All patients were instructed not to wear their lenses while sleeping. Two eyes required a corneal transplant, but lens wear could be resumed 4 to 6 weeks after transplantation. The learning curve for the insertion and removal of this large-diameter lens is the main obstacle for a patient, especially when there is loss of corneal sensation. Scleral lens wear is a valid long-term alternative to standard treatment options such as tarsorrhaphy for patients with corneal exposure and corneal anesthesia as a consequence of postsurgery facial nerve paralysis. Scleral contact lenses provide these patients with effective protection of the ocular surface in an aesthetically acceptable way while optimizing visual function.

Use of Collagen Conduits in Management of Painful Neuromas of the Foot and Ankle

Painful neuromas of the foot and ankle frequently pose a treatment dilemma due to persistent pain or recurrence after resection. The purpose of this survey was to evaluate the clinical and functional outcomes in patients in which collagen nerve conduits were used as an adjunct to the resection of a painful neuroma. Our prior experience with vein conduits for this purpose suggested that we might have similar success with the use of these devices. Chart reviews and telephone surveys were performed on patients operated by the senior surgeon (JSG) at our medical center from June 2006 to June 2011. A total of 50 patients underwent excision of painful single or multiple neuromas with the end of the resected nerve sutured into the collagen conduit. Each patient preoperatively was asked to describe the amount of pain he or she was experiencing on a scale from 1 to 10, with 10 indicating the most severe pain. In the telephone interview conducted during this study, the same question was asked of each patient following revision. Patient ages ranged from 16 to 77 years, with a mean of 54 years. In all, 30 right and 20 left sides were operated, and 1 patient had bilateral involvement. Mean follow-up was 36 months (6-55 months). There were a total of 69 nerves that underwent conduit procedures. Of 69 nerve conduit constructs, 30 (43%) were painless at final outcome, 23 (33%) had pain scores of 1 to 4, 6 (9%) had pain scores of 5 to 7, and 10 (15%) had severe symptoms with pain scores of 8 to 10. Satisfactory outcomes in which patients stated that they were significantly improved with the procedure and now functional occurred in 59/69 (85%). In all, 24 (48%) patients were completely symptom free, 13 (26%) had a pain score of 1 to 4, 6 (12%) had scores of 5 to 7, and 10 (15%) had severe pain with scores of 8 to 10. Three patients had superficial infections (stitch abscesses): 2 resolved with oral antibiotics and 1 resolved spontaneously. Three patients developed complex regional pain syndrome. One patient responded to a dorsal column stimulator and 2 responded to sympathetic blocks. No other complications were reported. Collagen conduits were safe and generally successful adjuncts to simple excision in the management of painful neuromas of the foot and ankle. Level IV, retrospective case series.