Update on Upper Limb Neuroma Management

Abstract

Painful terminal neuromas in the upper limb due to nerve injury are common. Neuroma symptoms include a sharp and burning sensation, cold intolerance, dysesthesia, pain, numbness, and paresthesia. These symptoms could have a negative impact on the functional ability of the patient and quality of life. In addition, Prostheses use might be abandoned by amputees due to neuroma-induced pain. Many clinicians face challenges while managing neuromas. Contemporary “active” methods like regenerative peripheral nerve interface (RPNI), targeted muscle reinnervation (TMR), and processed nerve allograft repair (PNA) are replacing the conventional “passive” approaches such as excision, transposition, and implantation techniques. RPNI involves inducing axonal sprouting by transplanting the free end of a peripheral nerve into a free muscle graft. TMR includes reassigning the role of the peripheral nerve by the transfer of the distal end of a pure sensory or a mixed peripheral nerve to a motor nerve of a nearby muscle segment. To give the peripheral nerve a pathway to re-innervate its target tissue, PNA entails implanting a sterile extracellular matrix prepared from decellularized and regenerated human nerve tissue with preserved epineurium and fascicles. Of these, RPNI and TMR appear to hold a promising treatment for nerve-ending neuromas and prevent their relapse. In contrast, PNA may reduce neuroma pain and allow meaningful nerve repair. The aim of this article is to provide an overview of the newer approaches of TMR, RPNI, and PNA and discuss their implications, surgical techniques, and reported consequences.

Patient reported symptoms and disabilities before and after neuroma surgery: a register-based study

“…A neuroma, irrespective of type, can cause pain, paraesthesia, as well as sensory and motor loss 4 – 8 . Neuroma can induce severe disabilities with chronic pain 9 . Treatment of neuroma is complex and challenging, due to the complex mechanisms of chronic pain, why surgically identifying the anatomical origin may be more effective than medication 10 .…”

“…The surgical procedures include active and passive methods, where active methods are used when the distal nerve end is available, and nerve function may recover after surgery. Passive methods are used in the absence of a distal nerve end, where a neuroma can be transposed into another surrounding 4 , 9 . When a nerve trunk is severely trapped in a scar or tethered to the surroundings, an exploration with neurolysis, with or without coverage with flaps, such as muscle or fat, may be indicated 3 , 12 , 13 .…”

Evaluation of Processed Nerve Allograft in Peripheral Nerve Surgery: A Systematic Review and Critical Appraisal

“…Bridging a nerve defect with autologous nerve grafts, such as the sural nerve, the terminal branch of the posterior interosseous nerve or other alternatives, is well established and considered to be the gold standard. [15][16][17][18][19] However, the use of an autologous nerve graft in nerve reconstruction has several possible disadvantages, which may be mainly related to residual problems from donor site [20][21][22] with risks of neuroma formation and subsequent symptoms 23,24 as well as risk for infections. Harvesting an autologous nerve graft prolongs the surgical procedure, implicating an increased need of resources.…”

Nerve Capping Techniques for Neuroma Management

“…Conservative management has proven to be successful in reducing symptoms; however, it is not always sufficient 1,2 . Clinicians should consider surgical intervention in certain situations that are resistant to medicinal treatment 3–5 …”

“…1,2 Clinicians should consider surgical intervention in certain situations that are resistant to medicinal treatment. [3][4][5] Unlike the central nervous system, the peripheral nerve system (PNS) demonstrates a remarkable capacity to regenerate. 6 It is not clear if cranial nerves follow the PNS model, the central nervous system model, or a different regenerative pathway.…”