Surgical management of neuroma pain: A prospective follow-up study

Abstract

Painful neuromas can cause severe loss of function and have great impact on the daily life of patients. Surgical management remains challenging; despite improving techniques, success rates are low. To accurately study the success of surgical neuroma treatment and factors predictive of outcome, a prospective follow-up study was performed. Between 2006 and 2009, pre- and post-operative questionnaires regarding pain (VAS, McGill), function (DASH), quality of life (SF-36), symptoms of psychopathology (SCL-90), epidemiologic determinants and other outcome factors were sent to patients surgically treated for upper extremity neuroma pain. Pain scores after diagnostic nerve blocks were documented at the outpatient clinic before surgery. Thirty-four patients were included, with an average follow up time of 22 months. The mean VAS score decreased from 6.8 to 4.9 after surgery (p<0.01), 19 (56%) of patients were satisfied with surgical results. Upper extremity function improved significantly (p=0.001). Neuroma patients had significantly lower quality of life compared to a normal population. Employment status, duration of pain and CRPS symptoms were found to be prognostic factors. VAS scores after diagnostic nerve block were predictive of post-operative VAS scores (p=0.001). Furthermore, smoking was significantly related to worse outcome (relative risk: 2.10). The results could lead to improved patient selection and treatment strategies. If a diagnostic nerve block is ineffective in relieving pain, patients will most likely not benefit from surgical treatment. Patients should be encouraged to focus on activity and employment instead of their symptoms. Smoking should be discouraged in patients who will undergo surgical neuroma treatment.

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

“…7 There is no consensus on the optimal management of painful neuromas, with up to 150 various recommendations cited to control neuroma formation. 8,[15][16][17][18][19][20] This is likely attributed a lack of understanding of the pathophysiology of persistent neuromaassociated pain. 2,21-23 ).…”

“…5 Nonetheless, mechanical entrapment of regenerated unhealthy nerve fibers by surrounding scar tissues is generally considered to be the most plausible cause of painful neuromas, and serves as the rationale for treatment modalities that transfer the nerve stump into muscles, veins, or bone. 8 In addition to serving as a phenotypic marker of myofibroblast activity, the expression of a-SMA may also contribute to the increased contractile activity of the myofibroblast. 9,10 In view of the self-contraction ability of the myofibroblast and its role in the development of scar contracture in wound healing, 11,12 we hypothesize that scar tissue within the neuroma may also crush the regenerated nerve fibers (internal compression), especially when contractile myofibroblasts are present, leading to the persistent neuroma-associated pain.…”

Regenerative Peripheral Nerve Interfaces for the Treatment of Postamputation Neuroma Pain: A Pilot Study

“…7 The neuroma’s afferent fibers develop ectopic activity, mechanical sensitivity, and chemosensitivity to catecholamines. 8 The altered expression of transduction molecules, upregulation of sodium channels, downregulation of potassium channels, and development of nonfunctional connections between axons all contribute to the hyperexcitability and spontaneous discharge witnessed within injured nerves.…”

Interventional management of neuropathic pain: NeuPSIG recommendations

“…In certain rare instances (e.g., if pain is experienced within the sensory territory of a single nerve and that nerve is both distal and purely sensory in function or if a neuroma has formed as a result of nerve injury) ablative procedures of a peripheral nerve may be considered as a treatment for chronic NP [9,120]. Dorsal root entry zone (DREZ) lesioning is considered by some to be the procedure of choice for the treatment of NP due to brachial or lumbosacral plexus nerve root avulsion [6].…”