The management of neuropathic pain from neuromas in the upper limb: surgical techniques and future directions

Abstract

Neuropathic pain of the upper limb results from damage or disease of the upper limb somatosensory system caused by wide range of pathologies including peripheral neuromas. Treatment strategies depend on making an accurate diagnosis, recognizing co-existing pathologies, and formulating an individualized treatment plan that commonly involves multiple modalities. A long list of nonsurgical and surgical methods acting peripherally (neuromodulation, nerve blocks, surgical manipulation of the nerve) and centrally (medications, spinal cord, and deep brain stimulation) has been described and it is clear that no one treatment is wholly reliable. In this article, we briefly review the pathophysiology of pain caused by neuromas, the current treatment options and the latest research in therapeutic developments.

Targeted Muscle Reinnervation to Improve Pain, Prosthetic Tolerance, and Bioprosthetic Outcomes in the Amputee

“…In 1984, Dellon et al demonstrated that excision of the neuroma and burial of the cut nerve in muscle improved neuroma pain in a large number of patients. 17 Other options described include crushing the distal nerve stump, 18 burying the nerve stump within a cortical window cut into a nearby bone, 19 and sewing two distal nerve stumps directly together into a loop. 20 Despite numerous methods and advances, none have proven consistent enough to set a standard of management for both preventing and treating NPLP in amputee populations.…”

Cutaneous nerve-conscious surgical repair of vascular access-related aneurysm assisted by anatomical ultrasonography in hemodialysis patients

“…If the trunk were transected, we recommend nerve suture or proximal nerve-end translocation to a local muscle under loupe magnification based on recommendations from orthopedic and neurosurgical articles. [9][10][11][23][24][25][26] Our study has some limitations. First, the number of enrolled patients was small.…”

“…The focus is on the education of nerve anatomy to avoid injury and the management of painful neuromas caused by the injuries. 7,[9][10][11] In addition to very few reports on nerve injuries after VA surgery, severe nerve lesions are also considered rare despite their proximity to vessels in VA surgery of the upper limb. 1,3 However, Brittinger reported that 5% to 20% of patients with radiocephalic AVF at the wrist suffered from the lesions of the SRN or LACN.…”

“…Other techniques, including aneurysmal resection without exposing the nerve, dissecting the subcutaneous tissue deliberately and longitudinally so as to not cross the nerve path, and avoiding electrocautery that caused thermal nerve damage, may help reduce nerve lesions. 1,9,11 Medical devices such as pneumatic tourniquet could help increase the visibility of the cutaneous nerve in bloodless operative fields, in addition to loupe magnification. 4,11 The clinical significance of preventing cutaneous nerve injury is to avoid postoperative neuropathies, including sensory deficits and potential neuropathic pain caused by neuroma formation at an injured nerve.…”

“…23,24 The most important step in their prevention is to avoid intraoperative nerve injury because even minor damage to the most peripheral nerves in the digits could lead to neuropathic pain. 9,23,25 VA surgery should ensure the preservation of the SRN, LACN, and MACN trunks to avoid the risk of extensive sensory blunting and potential neuropathic pain. If the trunk were transected, we recommend nerve suture or proximal nerve-end translocation to a local muscle under loupe magnification based on recommendations from orthopedic and neurosurgical articles.…”