Traumatic Neuroma Research Articles

Ultrasound in diagnosis of retroperitoneal femoral nerve injury: A case report

We present a case of retroperitoneal femoral nerve injury after cut wounds at the lower abdomen. Electrodiagnostic tests revealed impaired function of nerve and muscles. A mass was observed at the retroperitoneal part of the femoral nerve by ultrasound, indicating that a traumatic neuroma composed of disordered fascicles was configurated after the injury. Postoperative pathology confirmed hypertrophic and hyperplastic nerve bundles of the mass. Great improvements were shown in the patient's symptoms and electrodiagnostic tests in the subsequent 3 months. This case presented a rare position of neuroma formation by ultrasound.

The Expression of α-SMA in the Painful Traumatic Neuroma: Potential Role in the Pathobiology of Neuropathic Pain

The exact mechanism of neuroma-associated pain is not yet fully understood, thus contributing to the substantial challenge faced in managing patients with painful neuromas. We aimed to observe the expression of alpha smooth muscle actin (α-SMA) in the painful traumatic neuroma and to investigate its possible roles in the cause of neuroma-associated pain. Its expression is considered to be a useful phenotypic marker for myofibroblast, and may contribute to its increased contractile activity. We collected peripheral neuroma specimens prospectively and subsequently divided them into two groups: painful (n=21) and non-painful (n=27) based on blinded preoperative visual analogue scale (VAS) pain scores. We also harvested normal nerve specimens from the discarded limbs as a control group (n=8). We performed immunohistological studies to observe the expression of α-SMA in each group, and calculated the expression level by a high-resolution pathological image analysis system. There was no positive staining of α-SMA observed in the control group, slight positive staining in the non-painful group, and obviously positive staining in the painful group. Pearson correlation analysis demonstrated that VAS scores were significantly associated with the expression intensity of α-SMA (R=0.831; p<0.001). Linear regression analysis indicated that the expression intensity of α-SMA was positively related to the scale of VAS (R(2)=0.691, p<0.001). These findings suggest that: 1) expression of α-SMA may play certain roles in painful traumatic neuroma, either as a direct cause of neuroma-associated pain or as an indirect marker of local mechanical stimuli, and 2) the presence of α-SMA in the painful group may provide rationale for transpositional procedures in the management of traumatic neuroma. The persistent existence of α-SMA in the painful group and the correlation with VAS scores may provide insight into the development of new therapeutic strategies.

Intraoperative and pathological findings of intramedullary amputation neuroma associated with spinal ependymoma

Amputation neuromas typically arise in injured peripheral nerves; rarely, however, they arise in the spinal cord. We report a rare case of intramedullary amputation neuroma associated with ependymoma in the cervical spinal cord. A 73-year-old woman presented with a 5-year history of progressive gait disturbance. Neurological examination revealed complete motor deficit of her hands and legs. Magnetic resonance imaging of the cervical spine revealed an enhancing mass within the spinal cord at the C6/7 level. The patient underwent C5–C7 laminectomy surgery. During resection of the spinal tumor, we found a whitish string resembling an aberrant nerve root or schwannoma with adhesion to the tumor on the ventral side of the spinal cord. After resecting the tumor, the surgical specimen was cut and separated into a soft greyish tumor (spinal tumor) and the tough whitish string. Histopathological and immunohistochemical examination revealed the former was a spinal ependymoma and the latter was a neuroma. An intramedullary amputation neuroma associated with a spinal ependymoma is rare, and this is the first known case in which intraoprerative findings were clearly shown. Neurosurgeons should be aware that spinal ependymomas might coexist with neuromas.

経口的胆管内視鏡にて観察した,非手術例の総胆管・胆嚢管に発生したt r a u m a t i c n e u r o m a の1 例

経口的胆管内視鏡にて観察した,非手術例の総胆管・胆嚢管に発生したt r a u m a t i c n e u r o m a の1 例

Letter to the Editor

To the Editor: Recently, an interesting research article by Romanos et al1 was published that related the frequency, and the importance, of the mandibular incisive canal (MIC) and its nerve in preoperative planning for implant surgery. For most surgeons, the anatomy and content of the MIC are controversial,2–5 and in many books or articles, there is no reference to its existence,6–8 whereby the anterior mandible region is considered a safe area for implant placement. However, the high rate of incidence reported in anatomical and imaging studies conclude that the MIC (and its nerve) corresponds to a constant anatomical structure rather than an anatomical variation,5,8 with an origin at the level of mental foramen, term at the apex of the mandibular lateral incisor, and an average diameter between 1.8 (±0.5)5,9 and 1.48 (±0.57) mm.1 Neurosensory disorders have been reported after installation of implants in the anterior region of the mandible.6,10,11 Other complications such as bruising and swelling during or after surgical procedures, or even a traumatic neuroma,10 can arise due to direct7,10 or indirect6,9 trauma of the canal or it's nerve. Another complication is the failure of osseointegration because of the migration of soft tissue around the implant.7 The high detection rate of MIC by cone beam computed tomography indicates the high value of the analysis for preoperative surgical procedures in the anterior mandibular area.3 Current evidence has described the microsurgical approach by endoscopic visualization of neurovascular structures in oral surgery and implantology, including MIC and its nerve,2,3,12 as we can see in Figure 1, which uses an immersion endoscopic technique for precise location and removal of the mandibular incisive nerve after implant placement. Mandibular incisive nerve and other nerves of the maxillofacial area have rarely been seen with this quality and amplification.Fig. 1: A, Evaluation of the visibility and the course of the mandibular incisive canal using cone-beam computed tomography. B, Intraoperative visualization by immersion endoscopy (Karl Storz 1.9mm diameter) of mandibular incisive nerve (terminal branch) prior to resection in the area of implant placement. Red arrow indicates the osseous border of the mandibular incisive canal and white arrow its nerve.The presence, and anatomy, of the MIC and its nerve should not be ignored in the planning of implants and other surgical procedures in the anterior mandible. This could play a fundamental role in avoiding any risk of neurovascular damage and obtaining successful osseointegration. We agree with Romanos et al1 that there is no doubt that orthopantomographs underestimate the real presence of MIC and a more precise examination should be taken into consideration when surgical procedures in this anatomical area have to be performed. Cone beam computed tomography is recommended to identify these structures before any surgical procedure in this region, along with the use of intraoperative endoscopy for a successful outcome (see Fig. 1 A and B).

Interest of the ultrasonography in the diagnoses and treatment of traumatic neuroma after limb amputation

Interest of the ultrasonography in the diagnoses and treatment of traumatic neuroma after limb amputation

Time dependency of traumatic neuroma development: Comments on “reduction of osttraumatic neuroma and epineural scar formation in rat sciatic nerve by application of microcrystallic chitosan”

Time dependency of traumatic neuroma development: Comments on “reduction of osttraumatic neuroma and epineural scar formation in rat sciatic nerve by application of microcrystallic chitosan”

The Effects of Targeted Muscle Reinnervation on Neuromas in a Rabbit Rectus Abdominis Flap Model

A targeted muscle reinnervation (TMR) model was created using a pedicled rabbit rectus abdominis (RA) flap to receive the input from previously amputated forelimb neuromas. We hypothesize that a segmental muscle flap can undergo TMR and that it is possible to differentiate the signal from 3 independent nerves. In addition, by virtue of the nerve coaptation, the morphology of the previous amputation neuroma would become more like that of an in-continuity neuroma. Five New Zealand white rabbits had a forelimb amputation. In a second-stage surgery, an RA flap was transposed onto the chest wall. After neuroma excision, 3 neurorrhaphies were made between the median nerve, radial nerve, and ulnar nerves, and 3 motor nerves of the RA. After 10 weeks, the electrophysiologic properties of the reinnervated flap were tested. Nerve specimens from the median, radial, and ulnar nerves were harvested before and after TMR to quantify the histomorphometric changes effected by TMR on the mixed nerve neuromas. Of the 12 nerve coaptations performed in the 4 viable flaps, all 12 were grossly successful. Muscle surface EMG data demonstrated that the RA retained its segmental innervation pattern after TMR. Similarly, prolonged stimulation of 1 nerve reinnervating the RA resulted in the depletion of glycogen specific to the territory of the muscle stimulated by that nerve. TMR was found to favorably alter the histomorphometric characteristics of the neuroma by decreasing myelinated fiber counts and increasing fascicle diameter in the transferred nerves. This study demonstrates that 1 segmented muscle having TMR by multiple nerve ingrowth and in turn generate discrete EMG signals. During this process, the previous amputation neuroma undergoes favorable morphologic alteration. Based on these preclinical results, this technique might be useful in upper extremity amputees to recruit target muscles to have reinnervation to drive myoelectric prostheses and to treat symptomatic neuromas.

Characteristic Ultrasound Feature of Traumatic Neuromas After Neck Dissection: Direct Continuity with the Cervical Plexus

Traumatic neuroma may be easily confused with recurrent lymphadenopathy in the neck, causing patient anxiety, need for fine-needle aspiration (FNA), and even surgery. The purpose of this study was to evaluate the ultrasound (US) features that differentiate traumatic neuroma from recurrent lymphadenopathy after lateral neck dissection (LND), focusing on direct continuity with the involved nerve. This study compared US features of 56 traumatic neuromas in 36 consecutive patients, with 56 recurrent lymphadenopathies in 34 consecutive patients who had a previous history of total thyroidectomy and LND for thyroid cancer. Direct continuity of a nerve with a nodule and other US factors of a nodule (the short axis diameter, short-to-long axis ratio, location, shape, margin, echogenicity, vascular flow, hilar line, cystic portion, and echogenic dots) were evaluated in the two groups. Traumatic neuromas after LND had a prevalence of 17.8% (36/202) on US. Direct continuity with the involved nerve was visible in 98.2% (55/56) of the traumatic neuromas. The involved nerves in these traumatic neuromas were either terminal type (4/55, 7.3%) or spindle type (51/55, 92.7%). The short axis diameters, short-to-long axis ratio, location, shape, margin, and echogenicity were significantly different (p<0.001) in these two groups. None of the traumatic neuromas had a hilar line, vascular flow, or cystic portion. Direct continuity with the cervical plexus may be a characteristic US feature of traumatic neuroma after LND. This feature, along with ancillary findings, may prevent unnecessary surgery as well as painful FNA.

Characteristic Ultrasound Feature of Traumatic Neuromas after Neck Dissection: Direct Continuity with the Cervical Plexus

Characteristic Ultrasound Feature of Traumatic Neuromas after Neck Dissection: Direct Continuity with the Cervical Plexus

Traumatic neuroma in a patient with breast cancer after mastectomy: a case report and review of the literature

The incidence of traumatic neuroma is extremely low, especially in those patients with breast cancer after mastectomy. There are only 10 cases reported in the literature. We report a patient who developed a palpable nodular mass near the mastectomy scar. The result of excisional biopsy was traumatic neuroma. Review of the literature reveal 10 cases with breast cancer of traumatic neuromas after mastectomy. Traumatic neuroma is a benign lesion and a reparative response of the nerve to injury, either direct/indirect trauma or chronic inflammation. Benign lesions as traumatic neuromas are more rarely seen after mastectomy. However, in order to manage patients' treatment, the most critical problem is to distinguish it from recurrent breast carcinoma. Although assistant examination methods such as ultrasound and computed tomography are valuable to a certain extent, the final diagnosis can only be confirmed on pathologic examination.

Clinicopathologic and immunohistochemical features of oral neurofibroma

Objective. The purposes of this study were to assess clinical, histopathological and immunohistochemical features of 22 oral neurofibromas (NFs) and discuss with previously described literature, addressing the main aspects regarding the differential diagnosis. Materials and methods. Immunohistochemical reactions included S-100, CD34, GLUT-1, EMA, Ki-67, p53 and Collagen IV and histochemical reactions for Alcian blue. Results. Clinically, the preferential location was the maxillary bones, tongue and buccal mucosa. Microscopically, widely spread spindle-shaped cells with scant cytoplasm and elongated nuclei were observed. Immunostaining revealed that the tumor cells weakly expressed GLUT-1, Collagen IV, Ki-67 and p53. They were variably positive for CD34, S-100 protein and membrane epithelial antigen (EMA). Conclusions. The different types of nerve sheath cells observed in the present series reinforce the presence of heterogeneous population in NFs. The strong positivity for S-100 suggests that the lesions were more composed by S-100-positive Schwann cells than other cells. Besides, the high number of CD34-positive cells suggests that this marker can be useful for the differential diagnosis of NFs against PEN, traumatic neuromas and Schwannomas. Finally, the low immunostaining for p53 and Ki-67 may indicate that NFs massively composed by S-100-positive Schwann cells present low potential of aggressiveness and malignant transformation.

Traumatic Neuroma - An unforeseen lesion subsequent to simple extraction

Traumatic Neuroma - An unforeseen lesion subsequent to simple extraction

A Case of IgG4-related Sclerosing Cholangitis with a Normal Serum IgG4 Level: Report of a Case

Although hilar cholangioma is the most common cause of stricture of the hilar bile duct, several diseases can contribute to stenosis. Here, we report on a patient with immunoglobulin (Ig) G4-related sclerosing cholangitis (IgG4-SC) of the hilar bile duct arising from obstructive jaundice. The patient had undergone laparoscopic cholecystectomy for the removal of gallstones. The differential diagnosis for icterus included hilar cholangiocarcinoma, primary sclerosing cholangitis, IgG4 sclerosing cholangitis, ischemic bile duct stenosis, a complication of cholecystitis, amputation neuroma, and iatrogenic stenosis. Numerous examinations were performed, but a definite diagnosis remained elusive. Because cholangiocarcinoma could not be ruled out, we proposed surgical resection. The patient subsequently underwent extended right liver lobectomy and intrahepatic cholangiojejunostomy. Pathological examination revealed numerous inflammatory cell infiltrates resembling IgG4-positive antibody plasma cells in the stromal layer of the stenotic bile duct walls. Hypertrophy of the nerve fiber fascicles was not observed. The serum IgG4 level of the patient was within the normal range. Few reports of IgG4-SC with a normal serum IgG4 level have been published. When this condition presents as it did in the present case, establishing a definite diagnosis can be difficult.

A Case Report of Traumatic Neuroma of the Cervical Spinal Cord in a Dog

Traumatic neuroma of the cervical spinal cord was diagnosed in a 14-year-old male mixed-breed dog. A gross view showed two intradural extramedullary masses, measuring 1 and 0.6 cm in length and 0.7 and 0.4 cm in diameter, attached to the left side of the spinal cord at the level of the sixth and seventh cervical vertebrae. Microscopically, the cervical spinal masses comprised interlacing fascicles of axons and Schwann cells surrounded by collagenous stroma. Immunohistochemically, the fascicles were stained positively for neurofilament and S-100 proteins. Ultrastructurally, variably sized myelinated fibers and onion bulb-like structures were observed. To our knowledge, this is the first report of a traumatic neuroma in the cervical spinal cord of a dog.

Identification of Continuity of Transected Nerve on Sonography After Neck Dissection: Direct Sign of Traumatic Neuroma

Traumatic neuroma can be confused with a metastatic lymph node after neck dissection for malignancy, thereby increasing patient anxiety and necessitating fine needle aspiration (FNA). To date, however, there have been no reports showing a direct ultrasonographic (US) sign of traumatic neuroma that could help distinguish it from a metastatic lymph node after neck dissection. Here, we describe a patient with traumatic neuroma who showed a direct US sign after total thyroidectomy with modified radical neck dissection (MRND). A 61-year-old man who had undergone total thyroidectomy with bilateral MRND for papillary thyroid carcinoma was found to have an oval-shaped nodule in his right lateral neck by US examination, which was first suspected of being a metastatic lymph node. However, when the position of the US transducer was changed to the oblique plane, a thin, cord-like, hypoechoic structure was found to be connected to the nodule. This structure passed between the longus capitis and scalenus medius muscles in an upward direction, and was ultimately located in the groove of the right transverse process of the C4 vertebra. Based on this anatomic relation, we concluded that the nodule was a traumatic neuroma and did not perform an unnecessary FNA. The detection of a mass in the line of the transected nerve may be a direct US indication of traumatic neuroma after neck dissection.

Traumatic Neuroma in Continuity Injury Model in Rodents

Traumatic neuroma in continuity (NIC) results in profound neurological deficits, and its management poses the most challenging problem to peripheral nerve surgeons today. The absence of a clinically relevant experimental model continues to handicap our ability to investigate ways of better diagnosis and treatment for these disabling injuries. Various injury techniques were tested on Lewis rat sciatic nerves. Optimal experimental injuries that consistently resulted in NIC combined both intense focal compression and traction forces. Nerves were harvested at 0, 5, 13, 21, and 65 days for histological examination. Skilled locomotion and ground reaction force (GRF) analysis were performed up to 9 weeks on the experimental (n=6) and crush-control injuries (n=5). Focal widening, disruption of endoneurium and perineurium with aberrant intra- and extrafascicular axonal regeneration and progressive fibrosis was consistently demonstrated in 14 of 14 nerves with refined experimental injuries. At 8 weeks, experimental animals displayed a significantly greater slip ratio in both skilled locomotor assessments, compared to nerve crush animals (p<0.01). GRFs of the crush- injured animals showed earlier improvement compared to the experimental animals, whose overall GRF patterns failed to recover as well as the crush group. We have demonstrated histological features and poor functional recovery consistent with NIC formation in a rat model. The injury mechanism employed combines traction and compression forces akin to the physical forces at play in clinical nerve injuries. This model may serve as a tool to help diagnose this injury earlier and to develop intervention strategies to improve patient outcomes.

Fractures Around the Lateral Cortical Hinge After a Medial Opening-Wedge High Tibial Osteotomy: A New Classification of Lateral Hinge Fracture

The purpose of this study was to determine the frequency of lateral hinge fractures after opening-wedge high tibial osteotomy and investigate the patterns of fracture and their clinical outcome. We analyzed 104 knees in 93 patients with a mean age of 68 ± 7 years. Of the knees, 74 were diagnosed as having primary osteoarthritis and 30 with osteonecrosis. The mean follow-up period was 41 months. Lateral hinge fractures were classified as follows: type I, the fracture reaches just proximal to or within the tibiofibular joint; type II, the fracture reaches the distal portion of the proximal tibiofibular joint; and type III, a lateral plateau fracture. A standard postoperative rehabilitation protocol was used for type I fractures, 3 of 5 patients with type II fractures were treated with non-weight bearing, and type III fractures were treated with non-weight bearing until visible callus formation. The Knee Society scores for the knee and for function showed improvement from 49 ± 11 to 91 ± 7.7 points and from 62 ± 13 to 95 ± 8.2 points, respectively. Lateral cortex fractures were observed in 26 knees (25%): 19 type I, 5 type II, and 2 type III. In the type II fracture group, 2 of 5 patients were judged to have a delayed bone union. There were 2 cases of infection (2%) and 1 case of traumatic neuroma (1%) but no instances of implant failure, nonunion, or deep vein thrombosis among our patient cohort. High tibial osteotomy patients treated with a combination of TomoFix (Synthes, Bettlach, Switzerland) and bone substitute were able to walk with full weight bearing 2 weeks after surgery. No complications were seen in 19 patients with type I fractures. Of 5 patients with type II fractures, 2 had delayed unions with a correction loss of 3° and 7°, respectively. Level IV, therapeutic case series.

Neuroma traumático palatino: presentación de un caso

Traumatic neuroma is a reactive tumor of the peripheral neural tissue produced after an injury. This entity appears in the oral cavity usually after a trauma or surgical procedures such as tooth extraction. We report a case of traumatic neuroma in the palate of a 71-year-old man and review the most important clinicopathological features of this tumor.

Hepatobiliary and Pancreatic: Traumatic bile duct neuroma

A man, aged 76, was recovering after surgery for a perforated rectosigmoid cancer. His past history included a cholecystectomy for gallstones, 17 years previously. A computed tomography scan of the abdomen showed a small enhancing nodule in the mid-bile duct. Liver function tests were normal but the serum carbohydrate antigen, 19.9 (CA19.9) level was elevated at 302 U/mL (reference <37 U/mL). A magnetic resonance cholangiogram showed eccentric wall thickening of the mid-bile duct (arrow) consistent with a bile duct neoplasm (Figure 1). At surgery, he had a hard mass, 1 cm in diameter, in the mid-bile duct and had a segmental resection with a Roux-en-Y hepaticojejunostomy. Histological examination revealed hyperplastic and disorganised nerve fibers surrounded by fibrous connective tissue (H&E x200, Figure 2). Immunohistochemical stains were positive for S100 (inset Figure 2). The diagnosis was that of a post-operative (traumatic) neuroma of the bile duct. A neuroma or traumatic neuroma is an exuberant but non-neoplastic proliferation of a nerve that occurs after injury or surgery. After biliary surgery, neuromas can occur in the cystic duct stump but neuromas involving the bile duct are rare. Macroscopically, they are small white-gray nodules that develop at the proximal end of the injured or transected nerve. Histologically, there is a haphazard proliferation of nerve tissue that includes axons, Schwann cells and fibroblasts surrounded by a fibrous capsule. Cystic duct neuromas may be a cause of biliary-type pain after cholecystectomy and, historically, one surgical option was shortening of the cystic duct stump. The results of this procedure remains unclear. More recently, an interesting case report described three patients with pain after cholecystectomy whose symptoms were aggravated by pushing on cystic duct clips with a needle guided by endoscopic ultrasound. Symptoms improved after an injection of local anesthetic and steroid into the region and 2 of 3 patients had resection of the cystic duct stump (Am J Gastroenterol, 2005; 100: 491). Whether neuromas of the bile duct cause pain remains unclear but these nodules can result in extra-hepatic obstruction. In the latter setting, the differential diagnosis can include post-operative strictures, retained stones, benign tumors and bile duct cancer. A pre-operative diagnosis of bile duct neuroma is likely to be difficult and most patients have been treated by surgery, usually with an hepaticojejunostomy. Contributed by