Surgical Algorithm for Neuroma Management: A Changing Treatment Paradigm

Abstract

Successful treatment of the painful neuroma is a particular challenge to the nerve surgeon. Historically, symptomatic neuromas have primarily been treated with excision and implantation techniques, which are inherently passive and do not address the terminal end of the nerve. Over the past decade, the surgical management of neuromas has undergone a paradigm shift synchronous with the development of contemporary techniques aiming to satisfy the nerve end. In this article, we describe the important features of surgical treatment, including the approach to diagnosis with consideration of neuroma type and the decision of partial versus complete neuroma excision. A comprehensive list of the available surgical techniques for management following neuroma excision is presented, the choice of which is often predicated upon the availability of the terminal nerve end for reconstruction. Techniques for neuroma reconstruction in the presence of an intact terminal nerve end include hollow tube reconstruction and auto- or allograft nerve reconstruction. Techniques for neuroma management in the absence of an intact or identifiable terminal nerve end include submuscular or interosseous implantation, centro-central neurorrhaphy, relocation nerve grafting, nerve cap placement, use of regenerative peripheral nerve interface, “end-to-side” neurorrhaphy, and targeted muscle reinnervation. These techniques can be further categorized into passive/ablative and active/reconstructive modalities. The nerve surgeon must be aware of available treatment options and should carefully choose the most appropriate intervention for each patient. Comparative studies are lacking and will be necessary in the future to determine the relative effectiveness of each technique.

Targeted Muscle Reinnervation: Outcomes in Treating Chronic Pain Secondary to Extremity Amputation and Phantom Limb Syndrome

“…Minimal human studies exist comparing these modalities, and no strong conclusions have been made. [27][28][29][30] Others have felt that this technique failed and trialed neurectomy with proximal transposition with good results but small patient numbers and short follow-up. 31…”

Relocation Nerve Grafting: A Technique for Management of Symptomatic Digital Neuromas

“…Several techniques have been described for the management of terminal neuromas and can be divided into active and passive interventions. 20 Passive techniques following neuroma excision include relocation of the distal end (muscle, bone, or vein), traction neurectomy, centro-central neurorrhaphy, and nerve capping. Active management strategies include hollow-tube, allograft, or autograft reconstruction, "end-to-side" neurorrhaphy, targeted muscle reinnervation (TMR) and regenerative peripheral nerve interface (RPNI).…”

“…However, none of the aforementioned techniques are perfectly effective in preventing recurrence of symptoms, particularly in more distal injuries in the hand. 20 In the setting of digital ray amputations, RNG may be preferable to TMR and RPNI because of the limited soft tissue coverage in the hand. Relocation of the nerve end to a deeper anatomical location prevents both the frequency and magnitude of mechanical stimulation.…”

Risk Factors for Neuropathic Pain Following Major Upper Extremity Amputation

“…5,7,8 Active treatment of nerve ends following amputation or neuroma excision has recently been advocated for the prevention and treatment of neuropathic pain. 9,10 Nerve repair or nerve reconstruction of the nerve ends following neuroma excision has shown to reduce secondary operations and improves outcomes. [11][12][13] Additionally, over the past decade, targeted muscle reinnervation (TMR) and regenerative peripheral nerve interfaces (RPNIs) have been increasingly utilized to prevent and treat symptomatic neuroma and phantom limb pain.…”

“…[11][12][13] Additionally, over the past decade, targeted muscle reinnervation (TMR) and regenerative peripheral nerve interfaces (RPNIs) have been increasingly utilized to prevent and treat symptomatic neuroma and phantom limb pain. 10,14 Both techniques aim to provide a functional distal target for the regenerating axons, mitigating phantom limb pain and the development of symptomatic neuromas. [15][16][17] Upper extremity amputations are performed by a variety of surgical subspecialties, including general trauma surgeons, orthopaedic surgeons, plastic surgeons, and vascular surgeons.…”