Recurrent Neuromas Research Articles

Treatment of a patient with chronic causalgia after surgical removal of the neuroma in the second interdigital space

BACKGROUND: Mortons neuroma is a common pathology of the forefoot. Etiopathologically, this disease can be attributed to nerve fibrosis, not a tumor. We now have various therapeutic options for neuromas, the most frequent of which is traction neurectomy. Recurrent pain affects up to 35% of patients with traction neurectomy, and one-third have recurrent stump neuroma produced by the proliferation of fibrous scar tissue around the remaining nerve elements. Conservative treatment methods are more commonly used to treat recurrent neuromas and residual pain, but surgical therapy is required in some cases. Despite the relatively high prevalence, the treatment of such patients is a challenging task for orthopedic traumatologists.
 CLINICAL CASE DESCRIPTION: We show the effective treatment of a patient with stump neuroma and primary Mortons neuroma in two stages. The second interdigital space nerve was transposed, and the deep, transverse metatarsal ligament of the third interdigital space was dissected in the first stage. The second stage consists of removing the sensitive scar, resecting the plantar nerve of the third interdigital space, and performing a Weil osteotomy.
 CONCLUSION: Consistent use of conservative surgical procedures, appropriate revision of the subcutaneous nerve, and excision of a sensitive scar allows for a successful therapeutic outcome, pain alleviation, and the ability to wear normal shoes.

Revision Surgery for Recurrent Morton Neuroma with Use of a Collagen Conduit.

Revision Surgery for Recurrent Morton Neuroma with Use of a Collagen Conduit.

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.

Patient reported outcomes following revision neurectomy through a dorsal approach for recurrent interdigital neuroma

Interdigital neuroma is one of the commonest causes of metatarsalgia. The reported success rate after excision of a primary neuroma is 74%. Recurrent symptoms after neurectomy can be due to a recurrent interdigital neuroma. Recurrent interdigital neuromas can be diagnosed using sound clinical examination and ultrasonography. Surgical excision is the best treatment modality with varying success reported in the literature. We report on the clinical outcome following surgical excision of recurrent interdigital neuromas through a dorsal approach. All patients who had undergone excision of a recurrent interdigital neuroma by a single surgeon between 01/2010 and 12/2019 were identified. Inclusion criteria included patients having a preoperative ultrasound and postoperative histology report. The exclusion criteria were preexisting neuropathy or tarsal tunnel syndrome. Demographic data was collected, and a self-reported foot and ankle score questionnaire (SEFAS) was completed by the patient at their most recent follow-up. Twenty-three patients (25 feet) were included in the study. Mean time of follow-up was 75 (range 14–189) months. The mean age was 49 (range 15–71) years. Eleven (44%) recurrent neuromas were excised from the second webspace and 14 (56%) were excised from the third webspace. All excised masses were confirmed as recurrent neuromas histologically. Regarding the SEFAS score, 17 (73.93%) patients scored as excellent, one (4.34%) as good, three (13.04%) as fair, and two (8.69%) as poor. This long term follow-up study on outcomes after surgery for recurrent interdigital neuroma suggests that excision through a dorsal approach is an effective treatment option with a high patient satisfaction.

Clinical Outcomes of Symptomatic Neuroma Resection and Reconstruction with Processed Nerve Allograft

Background:Neuromas causing sensory disturbance can substantially affect nerve function and quality of life. Historically, passive termination of the nerve end and proximal relocation to muscle or bone has been performed after neuroma resection, but this method does not allow for neurologic recovery or prevent recurrent neuromas. The use of processed nerve allografts (PNAs) for intercalary reconstruction of nerve defects following neuroma resection is reasonable for neuroma management, although reported outcomes are limited. The purpose of this study was to assess the outcomes of pain reduction and functional recovery following neuroma resection and intercalary nerve reconstruction using PNA.Methods:Data on outcomes of PNA use for peripheral nerve reconstruction were collected from a multicenter registry study. The registry database was queried for upper extremity nerve reconstruction with PNA after resection of symptomatic neuroma. Patients completing both pain and quantitative sensory assessments were included in the analysis. Improvement in pain-related symptoms was determined via patient self-reported outcomes and/or the visual analog scale. Meaningful sensory recovery was defined as a score of at least S3 on the Medical Research Council Classification scale.Results:Twenty-five repairs involving 21 patients were included in this study. The median interval from injury to reconstruction was 386 days, and the average nerve defect length was 31 mm. Pain improved in 80% of repairs. Meaningful sensory recovery was achieved in 88% of repairs.Conclusion:Neuroma resection and nerve reconstruction using PNA can reduce or eliminate chronic peripheral nerve pain and provide meaningful sensory recovery.

Fore Foot Pain: Morton Neuroma Surgery—Tips for Surgeons

Morton’s neuroma is a mechanical neuropathy of plantar interdigital nerve. It is one of the most common causes of forefoot pain. One of the most undesirable complications of Morton’s neuroma surgery is recurrent neuroma. Excision level of Morton’s neuroma is important to prevent recurrence. In this study, we aimed to figure out preferred excision levels of orthopedic surgeons by evaluating pathological samples. Pathological specimens of 192 patients were prepared and examined by the same pathologist. One hundred thirty-nine patients were women (72.3%) and 53 were men (27.6%). The most common interspace affected was the third at 171 (89%) patients, followed by the second at 21 (11%). Mean age was 45.8 years (between 23 and 73). Twenty-two of them were left foot and the other 170 were right foot. Recurrent neuromas, pathological sample more than one piece from one surgical site, were excluded from the study. Pathological specimens were prepared and examined by the same pathologist. Gross pathological appearance and histopathological findings were recorded. Mean sample length was 2.05 cm (between 0.8 and 6 cm). One hundred forty-five samples were smaller (75.5%) than 3 cm, and only 47 samples (24.5%) were bigger than 3 cm. Our database results showed that majority of surgeons excise the nerve shorter than it should be. One of the reasons for high recurrence rates in Morton neurinoma may be inadequate excision of the nerve.

Use of poly dl-lactide-ε-caprolactone (Neurolac) conduit for enveloping traumatic neuromas

Neuroma is a common benign neoplasm that occurs at nerve repair sites causing morbidity to the patients. There are various methods available in literature to treat neuromas and recurrence of neuromas. Poly dl-lactide-e-caprolactone conduits are normally used to treat the nerve defects and help regeneration of the nerve. This case study describes a novel method with Neurolac conduits for the management of recurrent neuromas with promising results. This will open a new horizon for the clinicians to manage difficult and recurrent neuromas. We have described the technique with illustrations, which will help the reader to understand the steps involved in the procedure. Level of Evidence: Level V, therapeutic study.

Spinal cord stimulation for recurrent painful neuromas of the foot

The authors report the case of a patient affected by recurrent neuromas of the interdigital nerves of the left foot that appeared after surgery for Morton's disease. Implantation of spinal cord stimulation (SCS) system was performed after three unsuccessful surgical revisions, which demonstrated the presence of multiple neuromas growing at endings of the stumps of the nerves and fasciculi. The patient developed chronic neuropathic pain localized within the third metatarsal region of the left foot. Conservative treatments failed and autonomous gait became impossible. SCS immediately abolished pain and the patient was able to perform her normal daily activities within 1 month. At our knowledge, this is the first report in literature of SCS successfully employed for recurrent and refractory pain due to Morton's neuroma.

Rates of Recurrence, Residual Tumor, and Reoperation and SRS in a Consecutive Series of 540 Patients with Acoustic Neuroma, 1988 to 2005

Introduction: Presently there are several options available to patients with acoustic tumors. Information concerning recurrences following treatment of acoustic tumors is important to the decision-making process and informed consent. A consecutive series of 540 patients with acoustic tumors who underwent resection as primary treatment were followed for a mean of 7.5 years. Results with regard to residual and recurrent tumors are reported and analyzed. Methods: In addition to maintaining a database (Microsoft Access) concerning this group of patients, additional follow-up visits, telephone questionnaires, correspondence from referring physicians, and 1-, 3-, and 6-year MRI scans were used to obtain results. Results: Of 540 patients analyzed, we were able to document 8 recurrent or residual tumors, 3 of which were re-resected. Conclusions: There continues to be a paucity of literature documenting the frequency of residual or recurrent tumors requiring treatment following attempted complete microsurgical resection. A low incidence of tumor recurrence was noted after successful microresection of acoustic tumors in this series. Enhancing lesions in the distal internal auditory canal (IAC) on MRI at 1 year postop are predictive of growing recurrent acoustic neuromas at 3 years. A negative MRI at 1 year postop is highly predictive of no recurrence at 3 and 6 years.

Transcranial magnetic stimulation for diagnosis of residual limb neuromas

Paysant J, André J-M, Martinet N, Beis J-M, Datié A-M, Henry S, Dap F. Transcranial magnetic stimulation for diagnosis of residual limb neuromas. Arch Phys Med Rehabil 2004;85:737–42. Objective To analyze the mechanism and examine the potential diagnostic contribution of transcranial magnetic stimulation (TMS) in diagnosing painful, clonic, and/or autonomic manifestations in amputees’ residual limbs. Design Prospective study. Setting Regional rehabilitation institute at a medical school in France. Participants Thirty-four amputees (24 with myoclonus, stump pain, or trophic skin disorders; 10 controls with no stump symptoms). Interventions Not applicable. Main Outcomes Measures TMS performed before and after correcting prosthesis adaptation. Results TMS induced pain in 12 amputees, clonic manifestations in 4, and autonomic manifestations in 2. Twelve patients underwent magnetic resonance imaging that showed neuromas in all 12. After neuroma resection in 9 amputees, TMS no longer provoked abnormal manifestations. TMS did provoke abnormal manifestations after resection in 3 patients who had postoperative recurrent neuromas. The response to TMS was negative in subjects with a clinically silent neuroma (n=7). The response was also negative in all patients with other stump anomalies whose clinical manifestations fully regressed after conservative treatment. There was a highly significant correlation between the presence of a pathologic neuroma and TMS-induced abnormal manifestations ( P<.0001). Conclusions TMS can provoke symptoms in patients who experience spontaneous or evoked symptoms related to a neuroma. Induced symptoms are proportional to spontaneous symptoms. Removing the neuroma can stop stump symptoms and reverse the TMS effect. The response to TMS was negative in the control subjects with clinically silent neuromas; conservative treatment was successful in these cases. TMS-induced abnormal manifestations underlying mechanisms are discussed (ephaptic transmission in neuromas).

Ultrasonographic diagnosis of recurrence after excision of an interdigital neuroma.

We retrospectively reviewed the records of 20 patients (21 feet) with previous interdigital neuroma resections and symptoms suggestive for, but not diagnostic of, recurrent neuroma. Sonography was performed when clinical findings supplemented by local anesthetic block did not conclusively confirm the presence of recurrent neuroma. Studies performed in 13 patients (14 feet) were positive for recurrent neuromas. Three studies were indeterminate. The remaining four studies were negative for recurrent neuroma. The ultrasound studies were performed at an average of 19.2 months (range, 2-82 months) after the resection. Nine patients with 11 previous interdigital neuromas underwent ultrasonographic examination of the forefoot and subsequent revision neuroma resection. At surgery, gross and histologic findings were consistent with recurrent neuroma in 10 of 11 cases; one patient was found to have metatarsal-phalangeal synovitis. Ultrasonography appears to be a useful means for confirming neuroma recurrence in patients with symptoms after interdigital neurectomy when the diagnosis is not clear on physical examination.

Cervical neuromas with extradural components: surgical management in a series of 57 patients.

Cervical neuromas with extradural components (intraextradural or strictly extradural forms) are rare. Their resection raises the problems of nerve root preservation, vertebral artery (VA) control, and spinal stability. A series of 57 patients with neuromas (29 neurofibromas, 23 schwannomas, 4 neurofibrosarcomas, and 1 plexiform neurofibroma) was treated during the period of 1980 to 1995, using one of the lateral approaches (antero- or posterolateral approach). The VA was always controlled before resection of the tumor. In cases of intraextradural forms, the intradural component was removed by a complementary laminectomy (three patients) in the early period and then by an oblique corpectomy through the same lateral approach (five patients) in the late period. A laminectomy had been performed in 15 other patients (11 patients with intraextradural neuromas) before they were referred to us. These patients included seven with recurrent neuromas, occurring after an average period of 4.1 years (1-9 yr). Complete resection was achieved in all except two patients, in whom the nerve root reacted positively to intraoperative stimulation and could not be separated from the tumor. One of the patients was subsequently operated on after 2 years. Another recurrence was observed in another patient at 1 year. The four patients with sarcomas died from recurrence within 2 years. The rate of root preservation included an average of 28%, including 43.5% for schwannomas, 18% for neurofibromas, 44% for lower cervical neuromas (C4-C8), and 4.5% for upper cervical neuromas (C1-C3). Worsening of preoperative neurological deficits was observed in only two patients. The VA was always preserved, except in one patient with a sarcoma that was preoperatively occluded. No instability was observed in any of the patients. Complete resection with good neurological results can be achieved in most patients harboring cervical neuromas each with an extradural component by using a lateral approach and VA control. If the root cannot be separated from the tumor, especially in patients with neurofibromas, intraoperative stimulation can help decide whether the root may be divided without incurring postoperative deficit. The lateral approach permits the resection of the extradural as well as the intradural component by a complementary oblique corpectomy. There was no morbidity in relation to VA control as well as no postoperative instability.

Etiology of symptomatic recurrent interdigital neuromas

Morton's neuroma is a common disease entity of the foot that is often treated with surgical resection. A complication of neuroma resection is recurrence of symptoms as a result of the formation of an amputation neuroma. The authors offer an anatomical and biomechanical explanation for the location of symptomatic amputation neuromas. The neuromas are found on the plantar surface proximal to the condyles of the metatarsal and medial to the interspace where the nerve is resected. The theory is based on intraoperative observations during surgery for recurrent neuromas and on cadaver dissections and offers a method based on this theory to reduce the number of recurrences.

Surgical treatment of interdigital neuroma

Morton's neuroma or interdigital neuroma may represent an entrapment of the plantar interdigital nerves in the forefoot. Interdigital neuromas are found in the second and third interspaces. Complaints include plantar pain, pain on ambulation, pain relieved by shoe removal, and pain radiating into the toes. Physical findings include plantar pain between 2nd and 3rd or 3rd and 4th metatarsals, which may radiate to the toe. Conservative treatment can yield up to 75% satisfactory results with metatarsal pads and cortisone injections being most effective. Surgical removal of the neuroma yields 80% to 85% satisfactory results. Recurrent neuromas, if excised, also have an approximately 85% success rate after surgery, and the excision can be either from the dorsal or plantar aspect of the foot. Complications in primary or recurrent procedures include wound infection, persistent discomfort, and formation of bulb neuromas.