True Neuroma Research Articles

D61. Management of Recurrent Morton’s Neuromas with Targeted Muscle Reinnervation

PURPOSE: Morton’s interdigital neuroma is a common cause of severe foot pain that is detrimental to quality of life. Current operative interventions for this condition include neurolysis, decompression, or neurectomy, which may result in true neuroma formation, with failure rates reported up to 49%. The objective of this study was to evaluate the efficacy of targeted muscle reinnervation (TMR) for the treatment of Morton’s neuromas that have failed previous surgeries. METHODS: A retrospective chart review was performed between March 2018 and April 2021. Eight patients underwent TMR of the medial plantar nerve (MPN), lateral plantar nerve (LPN), and/or sensory plantar common digital nerves. All patients were non-amputees who had previously undergone surgery for Morton’s neuroma and now had recurrent symptoms. The operative techniques employed for TMR of neuromas in the foot were described, along with post-operative outcomes. RESULTS: Of the 8 patients reviewed receiving TMR for neuroma pain in the foot, all of whom had previously undergone excisions of digital nerve neuromas: 7 patients had complete or near complete resolution of their pain; 1 patient had no improvement upon follow-up. Of the successfully treated group, 4 had complete or near complete resolution of paresthesia, dysesthesia, and other neuropathic signs in the relevant nerve distribution. The remaining 3 had partial improvement of these symptoms. The mean follow-up period was 395 days. CONCLUSION: This study is the first to investigate TMR as a treatment and prevention option for the recurrence of Morton’s neuroma. Our technique revealed good clinical outcomes and no procedure-specific complications.

Morton's neuroma as a surgical example of entrapment syndrome

Morton's neuroma is a misnomer in the sense that the digital nerve lesion in question is not a true neuroma of a nerve, but rather, perineural fibrosis. Nonetheless, for many decades, optimal treatment for its metatarsalgia was nerve resection due to the fact it was an identifiable anatomical mass. Dellon 1 Dellon A.L. Treatment of morton's neuroma as a nerve compression. The role for neurolysis.. J Am Podiatr Med Assoc. 1992; 82: 399-402 Crossref PubMed Scopus (55) Google Scholar in 1992 popularized the theory that the pain derived in fact from digital nerve compression by the deep transverse intermetatarsal ligament. Then it stood to reason pain caused by nerve entrapment could be relieved with a decompressive neurolysis without resecting the nerve, eliminating the risk of (stump) neuroma pain as well as preserving sensory function. This is often best done from the dorsal aspect of the foot, given the appropriate exposure of the ligament can be reliably achieved with a perceived shorter time to postoperative weight-bearing. What has been unclear to date is the long-term effectiveness of this the dorsal decompressive approach by Dellon, and Mischitz et al. 2 Mischitz M. Zeitlinger S. Michlinger J. Rab M Nerve decompression according to A.L. Dellon in Morton neuroma - A retrospective analysis.. J Plastic Reconstr Aesthet Surg. 2020; Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar show in their article that it does afford very favorable pain, foot function, and skin sensibility outcomes years after surgery. Nerve decompression according to A.L. Dellon in Morton's neuroma - A retrospective analysisJournal of Plastic, Reconstructive & Aesthetic SurgeryVol. 73Issue 6PreviewFirst reported by Dellon et al. in 1992, nerve decompression by dissecting the deep transversal intermetatarsal ligament through a dorsal incision appears to be a reliable method for treating Morton's neuroma by addressing its underlying pathomechanism, since it should rather be considered as Morton's entrapment. As there are no current studies dealing with Dellon's surgical technique, we carried out a retrospective analysis with the aim of showing that nerve decompression is an effective method to treat Morton's neuroma, and one that considers its true pathology. Full-Text PDF

Painful Nodules and Cords in Dupuytren Disease

The etiology of Dupuytren disease is unclear. Pain is seldom described in the literature. Patients are more often disturbed by impaired extension of the fingers. We recently treated a series of patients who had had painful nodules for more than 1 year, and we therefore decided to investigate them for a possible anatomical correlate. Biopsies were taken during surgery from patients with Dupuytren disease and stained to enable detection of neuronal tissue. We treated 17 fingers in 10 patients. Intraoperatively, 10 showed tiny nerve branches passing into or crossing the fibrous bands or nodules. Of 13 biopsies, 6 showed nerve fibers embedded in fibrous tissue, 3 showed perineural or intraneural fibrosis or both, and 3 showed true neuromas. Enlarged Pacinian corpuscles were isolated from 1 sample. All patients were pain free after surgery. Although Dupuytren disease is generally considered painless, we treated a series of early stage patients with painful disease. Intraoperative inspection and histological examination of tissue samples showed that nerve tissue was involved in all cases. The pain might have been due to local nerve compression by the fibromatosis or the Dupuytren disease itself. We, therefore, suggest that the indication for surgery in Dupuytren disease be extended to painful nodules for more than 1 year, even in the early stages of the disease in the absence of functional deficits, with assessment of tissue samples for histological changes in nerves.

True neuroma of the appendix: a case report and literature review

The differential diagnosis of stromal tumours of the appendix includes leiomyoma, gastrointestinal stromal tumour and neuro-genic lesions. Terminology of neurogenic tumours is confusing in the literature. The term ‘neuroma' of the appendix includes the common obliterative fibrosis of the appendix. However, true neuroma of the appendix occurring as a circumscribed nodular tumour, like all appendiceal stroma tumours is extremely uncommon. We report a true neuroma of appendix in a healthy 3 year old boy, who presented with symptoms of appendicitis.

Alcohol Injections for Morton Neuroma

Morton neuroma — an entrapment neuropathy with fibrosis and edema, rather than a true neuroma — is a frequent cause of pain in the toes and distal foot. Most commonly, the interdigital nerve between the third and fourth …

Neural spectrum: palisaded encapsulated neuroma and verocay body poor dermal schwannoma.

We examined 25 palisaded encapsulated neuromas (PEN) of the skin and used peripherin antibody as an immunohistochemical label for axons. Quantitative analysis of the axon to schwann cell nuclear ratio for each PEN was determined by examining cross-sectioned neuroid fascicles. This revealed that 120 of the 253 cross-sectioned fascicles in PEN lacked axon and only 5% of the fascicles had an axon to schwann cell nuclear ratio greater than 1:2. In contrast, all fascicles in 40 dermal nerves adjacent to PENs as well as 35 traumatic neuromas in surgical scars had an axon to schwann cell nuclear ratio of at least 1:2 and the majority a ratio of 1:1 or higher. These results suggest that there is a spectrum between PENs which are axon rich to a form of schwannoma with an identical histopathology which lacks significant axonal content and that not all PENs are true neuromas.

Preoperatively Diagnosed Utricular Neuroma Treated by Selective Partial Labyrinthectomy

Unlike the acoustic neuroma that occupies the internal acoustic meatus and extends into the cerebellopontine angle, the true intralabyrinthine neuroma is an extremely uncommon finding. The majority of the published cases were found at autopsy or during destructive labyrinthectomy for uncontrollable Meniere's syndrome. To the best of our knowledge, we present the smallest exclusively intrautricular neuroma that has ever been diagnosed preoperatively. Detailed magnetic resonance imaging studies allowed the detection of this tumor, measuring only 3.5 mm in diameter. The tumor was removed via atticomastoidectomy and partial labyrinthectomy. The diagnostic workup, radiographic characteristics, and surgical treatment are discussed, together with a review of the literature.

Palisaded Encapsulated Neuromas

Reed et al described the clinical and light-microscopic findings of palisaded encapsulated neuromas in 1972, but few cases have been reported since. We have studied 81 consecutive tumors. Clinically, these were solitary, asymptomatic, 2- to 6-mm, flesh-colored papules, usually located on the face of middle-aged patients. The correct diagnosis was rarely made; the lesion was most often mistaken for a basal cell epithelioma, melanocytic nevus, or other benign tumor. Light microscopy revealed single or multiple encapsulated dermal lobules composed of interlacing Schwann cells. Variable numbers of fine axons and myelin sheath remnants were present. Palisading of nuclei was not a prominent feature. Electron microscopy demonstrated substantial numbers of class C fibers (mostly nonmyelinated) only partially enveloped by Schwann cell cytoplasm. Pathologically, palisaded encapsulated neuromas are distinctive true neuromas resembling those seen in the multiple mucosal neuroma syndrome. Electron-microscopic findings are similar to those seen in peripheral nerve regeneration, suggesting that palisaded encapsulated neuromas may be traumatic in origin, and could represent regeneration following local minor injury to the skin.

Prevention of neuroma formation by Neodym Yag laser--experimental observations.

The influence of Laser radiation on neuroma formation was investigated in rat sciatic nerves. Peripheral nerve trunks were divided by focused Neodym Yag Laser and compared with those transected by microscissors. The nerves were re-exposed at different time intervals up to 240 days after initial operation. True neuroma formation could not be observed after laser transection. Sharp division resulted in widespread amputation neuromas consisting of regenerating axons and connective tissue. Neodym Yag laser radiation by its scattering effect may cause deep coagulation necrosis and thrombosis of vasa nervorum thus sealing the dome of the divided nerve trunk. The formation of amputation neuromas may be suppressed by laser application.

Palisaded encapsulated neuromas: a clinicopathological study

Palisaded encapsulated neuromas (PFN) are uncommon benign neural neoplasms of the skin, first described by Reed, Fine and Meltzer (1972). Sixty consecutive cases of PEN were reviewed. Clinically these asymptomatic lesions appeared as shiny, dome-shaped, flesh- coloured, firm, 2–6 mm papules that were present for a few months to several years. Only twice was the correct diagnosis made, the usual clinical impression being basal cell carcinoma or melanocytic naevus. All lesions were solitary, most occurring on the central face, nose or lips, of middle-aged individuals of both sexes. Less than 10% occurred outside the facial area. By light microscopy, well-demarcated single or multiple nodules composed of fascicles of spindle cells were seen in the dermis. No mast cells were present and there were no areas resembling Antoni type B tissue. By electron microscopy (EM) the tumour consists of interlacing bundles of Schwann cells admixed with many non-myelinated C fibres. Only a few axons are myelinated. PEN should be included in the differential diagnosis of fiesh-coloured papules on the face. These are true neuromas that are distinctive pathologically and can be easily differentiated from neurilemmomas and neurofibromas. They most closely resemble traumatic neuromas but lack fibrosis surrounding the nerve bundles. They also are similar to neuromas in the multiple mucosal neuromata syndrome (Williams & Pollock, 1966; Reed et al., 1972). We speculate that minor injury to facial skin damages small peripheral nerve fascicles leading to proliferation of axons in a fashion similar to traumatic neuroma formation. As the lesion matures many of the small bundles of nerve regress, leaving either single or multiple lobules of axonal and Schwannian proliferation to produce the true neuroma seen on EM.

Tenth Annual Report of the Giza Memorial Ophthalmic Laboratory, Cairo, 1935.

The tenth annual report records the administration and scientific work of the laboratory during 1935 under the following four headings: Postgraduate Education.—The usual postgraduate course in medical and surgical ophthalmology was given during April and October. Twenty candidates for admission to the ophthalmic section of the department of public health attended the course given in April and fourteen the course given in May. Pathologic Section.—Five hundred and twenty-eight pathologic specimens and 16,064 smears from the eyes of patients with purulent ophthalmia were submitted for examination. Among the 139 blind eyes received, the sight in 89, or 64 per cent, had been destroyed through acute ophthalmia. Among the interesting specimens studied were 1 showing xeroderma pigmentosum, 2 showing uveal tuberculosis, 1 showing involvement of the eyelid with an infection due to filaria Bancrofti, 2 showing neurofibroma and 1 showing a true neuroma believed to have arisen from the sympathetic

GANGLIOGLIONEUROMA OF THE SPINAL CORD ASSOCIATED WITH PSEUDOSYRINGOMYELIA

Of the intramedullary tumors of the spinal cord, true neuroma, consisting of ganglion cells, glia cells and large numbers of nerve fibers, is rare. Though common in the sympathetic nervous system, this tumor is rare in the cerebrospinal nerves, the spinal ganglia and the brain itself. Only one instance was reported by Foerster 1 in which such a tumor was restricted to the spinal cord. In two other cases the tumor extended from the medulla into the upper cervical portion of the spinal cord, reaching the second segment, in the case reported by Pick and Bielschowsky, 2 and the third segment, in that recorded by Foerster and Gagel. 3 Unfortunately, this tumor has been described under a variety of names, such as ganglionic neuroma, neuroglioma, ganglionic glioma, neuroganglioma and ganglioglioneuroma. The most commonly used term, ganglioneuroma, is inaccurate, in that it names only one of the cellular constituents of this

Tumors of the Peripheral Nerves

The individual fiber of a peripheral nerve is composed of an axon or neurite, which is usually encased in a myelin sheath. Surrounding this is a protoplasmic envelope, the sheath of Schwann. These elements, the neurite, the myelin sheath, and sheath of Schwann, are neurogenic in origin (Fig. 1). The neurite is a prolongation of an individual nerve cell, while the sheath of Schwann is composed of a syncytium of cells which migrate out from the neural crest in early embryonic life (Harrison). The myelin sheath is supposedly a product of the nerve cell. The individual nerve fibers are embedded in connective tissue, the endoneurium, and are gathered into bundles enclosed by fibrous tissue, the perineurium. The entire nerve, consisting of these bundles of individual fibers, is overlaid by connective tissue, referred to as epineurium (Fig. 2). Tumors of the peripheral nerves were divided by Virchow, in 1863, into false neuromas, which include tumors of the nerve sheath, and true neuromas including growths arising from nerve fibers or nerve cells. Among the true neuromas are ganglioneuromas of the peripheral, spinal, and sympathetic nerves, and amputation neuromas, which are a combination of nerve fiber and sheath regeneration following the severing of a nerve trunk. Sporadic examples of neuro-epitheliomas of the peripheral nerves have been reported.

THE GANGLIONEUROMAS OF THE CENTRAL NERVOUS SYSTEM

Among the confused group of tumors described as neuromas, one subclass stands out in well defined relief. This is the class that has been variously described as ganglioneuroma (Bailey and Cushing), ganglioglioma (Perkins) and ganglioglioneuroma (Bielschowsky). Despite the difference in conception, which seems to be indicated by the varied terminology, these tumors constitute a well defined group with well defined characteristics. They are found in the cerebrospinal nerves and ganglia, in the sympathetic system, and most rarely in the central nervous system. In the latter situation only a few such tumors have been reported. We here record a typical ganglioneuroma, the only one in a large series of cases of tumor of the brain in the series of Dr. C. H. Frazier in the University Hospital, Philadelphia. CLASSIFICATION The first satisfactory attempt to classify the neuromas was made by Virchow 1 who differentiated between false and true neuromas. In the

THE NATURE OF VON RECKLINGHAUSEN'S DISEASE AND THE TUMORS ASSOCIATED WITH IT

Multiple neurofibromatosis is a condition which has long proved a fascinating study because of its bizarre and varied clinical manifestations, its familial characteristics, its rarity and the large number of unsuspected lesions of the nervous system usually disclosed by necropsy. The of von Recklinghausen's disease to be described is one of the rare examples of this condition involving both the peripheral and central nervous system and the meninges. It is reported not merely to add one more interesting case to the already large literature of the subject, but because it affords an opportunity to study the disease process itself. Further, it provides an opportunity to study the nature of the tumors which under other conditions arise from the nerves, meninges and central nervous system. REVIEW OF THE LITERATURE Virchow1divided neuromas into true and false types. He considered that a true neuroma must contain nerve tissue and nerve