Orthopaedic Jobs

Neuroma


- See: Nerve Injury Menu:

- Discussion
    - occurs following nerve injury;
           - schwann cells at the the site of injury express trophic factors inattempt to regenerate the nerve;
           - neuroma occurs with aberant growth at the nerve injury site;
           - nerve growth factor is a trophic factor that is an integral part of neuroma formation;
    - preoperative considerations: 
           - determine whether there is pain only at neuroma site versus pain down distal distribution of  nerve and/or pain along proximal distribution of nerve;


- Treatment Methods:
    - nerve cauterization:
           - slow cauterization is based on the observation that patients that sustain 4th degree burns never seem to develop neuromas;
    - nerve stirpping:
                  - complete nerve stripping;
           - reference:
                  - Nerve stripping: new treatment for neuromas of plantar cutaneous branch of median nerve.   
    - nerve repair:
           - this is the most reliable method to avoid neuroma formation, even if there is little chance of sensory repair;
           - if necessary consider nerve grafting;
    - vein wrapping:
           - involves wrapping scarred nerves with autogenous vein grafts using a spiral graft technique;
           - in the report by J. Xu MD et al (JHS Vol-25A, 2000. p 93-103), the authors examined the effect of vein wrapping of scarred nerves;
                  - histologic examination revealed absence of scar tissue formation in nerves with vein wrapping (vs nerves w/o vein wrapping);
                  - the authors felt that vein wrapping was a useful technique for the treatment of compression neuropathy;
           - references:
                  - Findings of exploration of a vein-wrapped ulnar nerve: report of a case.
                  - Treatment of recurrent compressive neuropathy of peripheral nerves in the upper extremity with an autologous vein insulator.
                  - Recurrent compressive neuropathy of the median nerve at the wrist: treatment with autogenous saphenous vein wrapping.
                  - Peripheral nerve vein wrapping for intractable lower extremity pain.
                  - Recalcitrant post-surgical neuropathy of the ulnar nerve at the elbow: treatment with autogenous saphenous vein wrapping.

    - nerve transplantation into a vein: 
           - The treatment of painful neuroma on the lower extremity by resection and nerve stump transplantation into a vein.
           - Treatment of painful neuroma by resection and nerve stump transplantation into a vein.
           - Treatment of painful peripheral neuroma by vein implantation.
           - Influence of nerve stump transplantation into a vein on neuroma formation.
           - Treatment of painful peripheral neuromas by vein implantation.
           - Implantation of a nerve ending into a vein.
           - Vein implantation for treatment of painful cutaneous neuromas. A preliminary report.
    - resection and translocation:
           - the goal is to free the nerve from a bed of avascular scar tissue the surrounding abnormal epineurium;
           - there is some anecdotal evidence that slow cautery over a nerve produces a scarring effect that resists neuroma formation;
                  - the motivation for this technique stems from the observation that 4th degree burns rarely produce neuromas;
           - consider use of a conduit and mobilization into muscle; (neuragen.com)
           - removal of distal nerve segments:
                  - indicated for situations in which there is pain throughout the distal distribution of the nerve;
                  - theory is that remnant portion of resected nerve produces pain causing chemical mediators which contribute to a chronic pain syndrome;
                  - this technique involves making multiple incisions over the distal extremity and near complete nerve removal



Pain relief after nerve resection for post traumatic neuralgia

Treatment of superficial and deep peroneal neuromas by resection and translocation of nerves into the anterolateral compartment

Treatment of the painful neuroma by neuroma resection and muscle implantation.  

Neuroma transposition and intramuscular implantation using the Mitek "soft-tissue anchor": a new technique.

Treatment of end-neuromas, neuromas-in-continuity and scarred nerves of the digits by proximal relocation. 

A new operation for the prevention and treatment of amputation neuromas.



Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Thursday, May 24, 2012 11:15 am