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RATIONALE: Intrathoracic paragangliomas are typically found within the intricate posterior mediastinal region adjacent to the vertebrae, often presenting with substantial volume. Surgical excision of such tumors presents formidable challenges and is conventionally performed via open surgical procedures. PATIENT CONCERNS: In this report, we present the case of a 53-year-old female patient who presented with the discovery of a left intrathoracic mass during a routine physical examination approximately 1 month prior. She complained of chest tightness and chest pain. DIAGNOSES: She complained of chest tightness and chest pain. Magnetic resonance imaging of the chest and brachial plexus revealed a mass adjacent to the left upper lung hilum, measuring approximately 78â ×â 63â ×â 72 mm. The initial suspicion leaned towards a benign lesion. Notably, there was slight compression of the left first thoracic nerve root and mild compression of the middle and lower trunks of the left brachial plexus. Based on the morphological features of the tumor and imaging findings, we suspected its benign nature. INTERVENTIONS: We opted for robot-assisted thoracic surgery to resect the mediastinal tumor. OUTCOMES: Subsequent postoperative pathology confirmed the diagnosis as a paraganglioma. The patient did not experience any notable complications post-surgery, and a 6-month follow-up revealed no signs of recurrence. LESSONS: The successful application of the robot-assisted thoracic surgery surgical technique underscores its efficacy in minimally invasive resection of sizable intrathoracic tumors situated in the posterior mediastinum.
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Procedimientos Quirúrgicos Robotizados , Humanos , Femenino , Persona de Mediana Edad , Procedimientos Quirúrgicos Robotizados/métodos , Neoplasias del Mediastino/cirugía , Neoplasias del Mediastino/patología , Neoplasias del Mediastino/diagnóstico por imagen , Neoplasias del Mediastino/diagnóstico , Imagen por Resonancia Magnética/métodos , Neuroma/cirugía , Neuroma/patología , Neuroma/diagnósticoRESUMEN
CASE: An overall healthy 48-year-old man suffered a left foot mangled crush injury resulting in a post-transmetatarsal amputation and subsequently developing a painful neuroma on the plantar surface of the foot. To avoid the zone of injury, targeted muscle reinnervation was used to treat the neuroma by coapting the tibial nerve to the motor point of the flexor hallucis longus (FHL) muscle. At 1-year follow-up, the patient reported no pain at rest, returned to work, and could ambulate with an orthosis for 30 minutes. CONCLUSION: Rare tibial nerve coaptations to the FHL could serve as a treatment option for patients with neuromas in traumatic postmetatarsal amputation.
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Neuroma , Humanos , Masculino , Persona de Mediana Edad , Neuroma/cirugía , Neuroma/etiología , Músculo Esquelético/cirugía , Músculo Esquelético/inervación , Músculo Esquelético/trasplante , Nervio Tibial/cirugía , Nervio Tibial/lesiones , Amputación Traumática/cirugíaRESUMEN
BACKGROUND: This study analyzed all reported cases of painful traumatic neuromas to better understand their anatomic distribution, etiologies, and surgical treatment. METHODS: PubMed, Embase, Cochrane, and Web of Science were searched in October 2023 for articles describing painful traumatic neuromas. RESULTS: In total, 414 articles reporting 5,562 neuromas were included and categorized into head/neck, trunk, upper extremity, lower extremity, and autonomic nerves. Distribution was as follows: Head/neck: 83 articles reported on 393 neuromas (93.2% iatrogenic) most frequently involving the lingual (44.4%), cervical plexus (15.0%), great auricular (8.6%), inferior/superior alveolar (8.3%), and occipital (7.2%) nerves. Trunk: 47 articles reported on 552 neuromas (92.9% iatrogenic) most commonly involving the intercostal (40.0%), ilioinguinal (18.2%) and genitofemoral (16.2%) nerves. Upper extremity: 160 articles reported on 2082 neuromas (42.2% after amputation) most frequently involving the digital (47.0%), superficial radial (18.3%), and median (7.0%) nerves. Lower extremity: 128 articles reported on 2,531 neuromas (53.0% after amputation) most commonly involving the sural (17.9%), superficial peroneal (17.3%), and saphenous (16.0%) nerves. Autonomic nerves: 17 articles reported on 53 neuromas (100% iatrogenic) most frequently involving the biliary tract (64.2%) and vagus nerve (18.9%). Compared with the extremities, neuromas in the head/neck and trunk had significantly longer symptom duration before surgical treatment and the nerve end was significantly less frequently reconstructed after neuroma excision. CONCLUSION: Painful neuromas are predominantly reported in the extremities yet may occur throughout the body primarily after iatrogenic injury. Knowledge of their anatomic distribution from head to toe will encourage awareness to avoid injury and expedite diagnosis to prevent treatment delay.
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Neuroma , Humanos , Neuroma/etiología , Neuroma/cirugía , Neoplasias del Sistema Nervioso Periférico/cirugía , Neoplasias del Sistema Nervioso Periférico/etiologíaRESUMEN
This case report describes the treatment of a postoperative painful neuroma of the tibial nerve using an autologous nerve graft in a dog. The patient presented with sudden non-weight-bearing lameness 10 days after iatrogenic tibial nerve injury during preparation of a reverse saphenous conduit flap. The dog showed severe pain at the surgical site without nerve deficits. A magnetic resonance imaging examination revealed an enlarged tibial nerve at the injury site, consistent with a neuroma. Analgesics were administered over 11 days, but the patient remained in severe pain and non-weight-bearing. Therefore, surgical resection was recommended. The fusiform neuroma was resected microsurgically, and a saphenous nerve graft was transplanted using an epineural nerve repair technique. Histopathological examination was consistent with a neuroma. The dog showed immediate pain relief and weight-bearing the day after surgery with normal motor function. The dog made a full recovery by the last follow-up 6 mo after surgery. If patients develop pain and lameness following surgery or nerve injury, neuroma formation must be considered, even shortly after surgery. Microsurgical resection and autologous nerve transplantation using an epineural nerve repair technique is a viable method to treat painful neuromas and minimize the risk for recurrence in dogs.
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Enfermedades de los Perros , Neuroma , Nervio Tibial , Perros , Animales , Enfermedades de los Perros/cirugía , Neuroma/veterinaria , Neuroma/cirugía , Neuroma/etiología , Nervio Tibial/cirugía , Nervio Tibial/lesiones , Neoplasias del Sistema Nervioso Periférico/veterinaria , Neoplasias del Sistema Nervioso Periférico/cirugía , Trasplante Autólogo/veterinaria , Femenino , MasculinoRESUMEN
BACKGROUND: Targeted muscle reinnervation (TMR) has demonstrated efficacy in reducing neuroma and chronic pain. In this article, we investigated postoperative outcomes in our patient cohort, with a focus on the role of nonmodifiable factors such as patient age and gender. METHODS: Patients who had extremity TMR from April 2018 to October 2022 were reviewed. Outcomes of interest included patient age, gender, cause and type of amputation, delayed versus immediate TMR, as well as postoperative improvement in pain as assessed by numerical rating score (NRS). RESULTS: A total of 40 patients underwent TMR on 47 limbs. Mean age was 46.2 ± 17.0 years. Delayed TMR (27, 57.4%) was most commonly performed, followed by immediate and delayed-immediate at 11 (23.4%) and 9 (19.1%), respectively. Amputation level was most commonly above-knee in 20 (42.6%) patients, followed by below-knee (12, 25.5%), transhumeral (8, 17.0%), transradial (6, 12.8%), and shoulder (1, 2.1%). The median time interval between amputation and TMR was 12 months. The median preoperative NRS assessing residual limb pain (RLP) for patients who underwent delayed TMR was 10. The median postoperative NRS assessing RLP for all patients was 0 (interquartile range25-75: 0-5) and significantly improved compared with preoperative NRS (P < 0.001). At the last follow-up for limbs that had delayed and delayed-immediate TMR (n = 36), 33 (91.7%) limbs had more than 50% resolution of RLP. There was a significant difference in median postoperative NRS by gender (4 in men and 0 in women) (P < 0.05). Postoperative median NRS also favored younger patients (0, <50 years compared with 4.5, >50 years) (P < 0.05). Multiple linear regression analysis showed that, of different variables analyzed, only male gender and older age were predictive of poorer postoperative outcomes. CONCLUSION: TMR showed high efficacy in our cohort, with improved short-term outcomes in women and younger patients.
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Dimensión del Dolor , Humanos , Femenino , Masculino , Persona de Mediana Edad , Adulto , Estudios Retrospectivos , Amputación Quirúrgica/métodos , Músculo Esquelético/inervación , Resultado del Tratamiento , Neuroma/cirugía , Transferencia de Nervios/métodos , Dolor Crónico/cirugía , Anciano , Factores de EdadRESUMEN
BACKGROUND: Many surgical strategies aim to treat the symptomatic neuroma of the superficial branch of the radial nerve (SBRN). It is still difficult to treat despite many attempts to reveal a reason for surgical treatment failure. The lateral antebrachial cutaneous nerve (LACN) is known to overlap and communicate with SBRN. Our study aims to determine the frequency of spreading of LACN fibers into SBRN branches through a microscopic dissection to predict where and how often LACN fibers may be involved in SBRN neuroma. METHODS: Eighty-seven cadaveric forearms were thoroughly dissected. The path of LACN fibers through the SBRN branching was ascertained using microscopic dissection. Distances between the interstyloid line and entry of LACN fibers into the SBRN and emerging and bifurcation points of the SBRN were measured. RESULTS: The LACN fibers joined the SBRN at a mean distance of 1.7 ± 2.5 cm proximal to the interstyloid line. The SBRN contained fibers from the LACN in 62% of cases. Most commonly, there were LACN fibers within the SBRN's third branch (59%), but they were also observed within the first branch, the second branch, and their common trunk (21%, 9.2%, and 22%, respectively). The lowest rate of the LACN fibers was found within the SBRN trunk (6.9%). CONCLUSION: The SBRN contains LACN fibers in almost 2/3 of the cases, therefore, the denervation of both nerves might be required to treat the neuroma. However, the method must be considered based on the particular clinical situation.
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Cadáver , Neuroma , Nervio Radial , Humanos , Neuroma/cirugía , Nervio Radial/anatomía & histología , Nervio Radial/cirugía , Femenino , Masculino , Anciano , Persona de Mediana Edad , Antebrazo/inervación , Antebrazo/cirugía , Anciano de 80 o más Años , Fibras Nerviosas , Neoplasias del Sistema Nervioso Periférico/cirugía , Disección/métodosRESUMEN
Targeted muscle reinnervation (TMR) and regenerative peripheral nerve interface (RPNI) are used to prevent or treat neuromas in amputees. TMR for above-the-knee amputation (AKA) is most commonly performed through a posterior incision rather than the stump wound because recipient motor nerves are primarily located in the proximal third of the thigh. When preventative TMR is performed with concurrent AKA, a posterior approach requires intraoperative repositioning and an additional incision. The purpose of this study was to evaluate feasibility of TMR and operative times for nerve management performed through the wound compared to a posterior approach in AKA patients to guide surgical decision-making. Patients who underwent AKA with TMR between 2018-2023 were reviewed. Patients were divided into two groups: TMR performed through the wound (Group I) and TMR performed through a posterior approach (Group II). If a nerve was unable to undergo coaptation for TMR due to the lack of suitable donor motor nerves, RPNI was performed. Eighteen patients underwent AKA with nerve management were included from Group I (8 patients) and Group II (10 patients). TMR coaptations performed on distinct nerves was 1.5 ± 0.5 in Group I compared to 2.6 ± 0.5 in Group II (p = 0.001). Operative time for Group I was 200.7 ± 33.4 min compared to 326.5 ± 37.1 min in Group II (p = 0.001). TMR performed through the wound following AKA requires less operative time than a posterior approach. However, since recipient motor nerves are not consistently found near the stump, RPNI may be required with TMR whereas the posterior approach allows for more TMR coaptations.
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Amputación Quirúrgica , Transferencia de Nervios , Humanos , Masculino , Femenino , Amputación Quirúrgica/métodos , Persona de Mediana Edad , Adulto , Transferencia de Nervios/métodos , Estudios Retrospectivos , Tempo Operativo , Muñones de Amputación/inervación , Muñones de Amputación/cirugía , Regeneración Nerviosa/fisiología , Estudios de Factibilidad , Anciano , Neuroma/cirugía , Muslo/inervación , Muslo/cirugía , Músculo Esquelético/inervación , Músculo Esquelético/trasplanteRESUMEN
INTRODUCTION: Interdigital neuroma (IN) is a benign enlargement of tissue surrounding the common plantar digital nerve. Although the standard surgical treatment of IN remains debated, recent attention has been given to less-invasive surgical decompression by intermetatarsal ligament (IML) release with neurolysis. This study aimed to compare the outcomes of IML release with neurolysis with standard interdigital neurectomy. METHODS: A retrospective chart review was conducted on 350 consecutive patients who underwent surgical treatment of IN. Patients who satisfied our inclusion and exclusion criteria were categorized into two groups based on the surgical treatment received: IML release with neurolysis or interdigital neurectomy. Outcomes assessed included recurrence of symptoms, rate of revision surgery, and postoperative wound infection. RESULTS: Of the total sample, 40 patients (31.5%) reported recurrence of symptoms within a 12-month follow-up period. Patients who underwent IML release with neurolysis had a markedly higher recurrence rate (47.50%) than those who underwent interdigital neurectomy (24.14%). The rate of postoperative wound infection was similar between the two groups. Binary logistic regression revealed that only the surgical technique was associated with the recurrence of symptoms. Despite the higher rate of symptom recurrence in the IML release with neurolysis patient group, the rate of revision surgery in those with symptom recurrence was similar between both groups. DISCUSSION: IML release with neurolysis seems to have a higher risk of symptom recurrence than interdigital neurectomy. No patient-specific factors were identified as being associated with symptom recurrence. However, patients who did experience symptom recurrence in either surgical group had similar rates of revision surgery, which may be due to mild recurrent symptom severity in the IML release group that does not warrant revision surgery in these patients. Future studies should consider objective symptom recurrence severity and patient satisfaction. LEVEL OF EVIDENCE: Level III.
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Neuroma , Humanos , Estudios Retrospectivos , Femenino , Persona de Mediana Edad , Masculino , Neuroma/cirugía , Adulto , Anciano , Reoperación , Descompresión Quirúrgica/métodos , Recurrencia , Resultado del TratamientoRESUMEN
Surgical procedures, including nerve reconstruction and end-organ muscle reinnervation, have become more prominent in the prosthetic field over the past decade. Primarily developed to increase the functionality of prosthetic limbs, these surgical procedures have also been found to reduce postamputation neuropathic pain. Today, some of these procedures are performed more frequently for the management and prevention of postamputation pain than for prosthetic fitting, indicating a significant need for effective solutions to postamputation pain. One notable emerging procedure in this context is the Regenerative Peripheral Nerve Interface (RPNI). RPNI surgery involves an operative approach that entails splitting the nerve end longitudinally into its main fascicles and implanting these fascicles within free denervated and devascularized muscle grafts. The RPNI procedure takes a proactive stance in addressing freshly cut nerve endings, facilitating painful neuroma prevention and treatment by enabling the nerve to regenerate and innervate an end organ, i.e., the free muscle graft. Retrospective studies have shown RPNI's effectiveness in alleviating postamputation pain and preventing the formation of painful neuromas. The increasing frequency of utilization of this approach has also given rise to variations in the technique. This article aims to provide a step-by-step description of the RPNI procedure, which will serve as the standardized procedure employed in an international, randomized controlled trial (ClinicalTrials.gov, NCT05009394). In this trial, RPNI is compared to two other surgical procedures for postamputation pain management, specifically, Targeted Muscle Reinnervation (TMR) and neuroma excision coupled with intra-muscular transposition and burying.
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Neuralgia , Neuroma , Humanos , Amputación Quirúrgica , Neuroma/cirugía , Nervios Periféricos/cirugía , Nervios Periféricos/fisiología , Ensayos Clínicos Controlados Aleatorios como Asunto , Estudios RetrospectivosRESUMEN
Robotic microsurgery is an emerging field in reconstructive surgery, which provides benefits such as improved precision, optimal ergonomics, and reduced tremors. However, only a few robotic platforms are available for performing microsurgical procedures, and successful nerve coaptation is still a challenge. Targeted muscle reinnervation (TMR) is an innovative reconstructive procedure that rewires multiple nerves to remnant stump muscles, thereby reducing neuroma and phantom limb pain and improving the control of bionic prostheses. The precision of surgical techniques is critical in reducing axonal sprouting around the coaptation site to minimise the potential for neuroma formation. This study reports the first use of a microsurgical robotic platform for multiple nerve transfers in a patient undergoing TMR for bionic extremity reconstruction. The Symani robotic platform, combined with external microscope magnification, was successfully used, and precise handling of nerve tissue and coaptation was easily feasible even in anatomically challenging environments. While the precision and stability offered by robotic assistance may be especially useful for nerve surgery, the high economic costs of robotic microsurgery remain a major challenge for current healthcare systems. In conclusion, this study demonstrated the feasibility of using a robotic microsurgical platform for nerve surgery and transfers, where precise handling of tissue is crucial and limited space is available. Future studies will explore the full potential of robotic microsurgery in the future.
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Biónica , Microcirugia , Transferencia de Nervios , Procedimientos Quirúrgicos Robotizados , Humanos , Microcirugia/métodos , Transferencia de Nervios/métodos , Masculino , Regeneración Nerviosa/fisiología , Miembro Fantasma/cirugía , Miembros Artificiales , Muñones de Amputación/inervación , Muñones de Amputación/cirugía , Músculo Esquelético/inervación , Músculo Esquelético/trasplante , Procedimientos de Cirugía Plástica/métodos , Neuroma/cirugíaRESUMEN
BACKGROUND: This study investigated the relative cost utility of three techniques for the management of symptomatic neuromas after neuroma excision: (1) implantation of nerve into muscle, (2) targeted muscle reinnervation (TMR), and (3) regenerative peripheral nerve interface (RPNI). METHODS: The costs associated with each procedure were determined using Common Procedural Terminology codes in combination with data from the Centers for Medicaid and Medicare Services Physician and Facility 2020 Fee Schedules. The relative utility of the three procedures investigated was determined using changes in Patient-Reported Outcomes Measurement Information System (PROMIS) and Numeric Rating Scale (NRS) pain scores as reported per procedure. The relative utility of each procedure was reported in terms of quality-adjusted life years (QALYs), as is standard in the literature. RESULTS: The least expensive option for the surgical treatment of painful neuromas was nerve implantation into an adjacent muscle. In contrast, for the treatment of four neuromas, as is common postamputation, TMR without a microscope was found to cost $50,061.55 per QALY gained, TMR with a microscope was found to cost $51,996.80 per QALY gained, and RPNI was found to cost $14,069.28 per QALY gained. While RPNI was more expensive than nerve implantation into muscle, it was still below the standard willingness-to-pay threshold of $50,000 per QALY, while TMR was not. CONCLUSION: Evaluation of costs and utilities associated with the various surgical options for the management of painful neuromas suggest that nerve implantation into muscle is the least expensive option with the best improvement in QALY, while demonstrating comparable outcomes to TMR and RPNI with regard to pain symptoms.
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Análisis Costo-Beneficio , Neuroma , Humanos , Neuroma/cirugía , Neuroma/economía , Años de Vida Ajustados por Calidad de Vida , Regeneración Nerviosa/fisiología , Masculino , Femenino , Transferencia de Nervios/métodos , Transferencia de Nervios/economía , Músculo Esquelético/inervación , Nervios Periféricos/cirugía , Persona de Mediana Edad , Dimensión del Dolor , Estados UnidosRESUMEN
Peripheral trigeminal neuropathies are assessed by MR neurography for presurgical mapping. In this clinical report, we aimed to understand the utility of MR neurography following nerve-repair procedures. We hypothesized that postoperative MR neurography assists in determining nerve integrity, and worsening MR neurography findings will corroborate poor patient outcomes. Ten patients with peripheral trigeminal neuropathy were retrospectively identified after nerve-repair procedures, with postsurgical MR neurography performed from July 2015 to September 2023. Postsurgical MR neurography findings were graded as per postintervention category and subcategories of the Neuropathy Score Reporting and Data System (NS-RADS). Descriptive statistics of demographics, inciting injury, injury severity, NS-RADS scoring, and clinical outcomes were obtained. There were 6 women and 4 men (age range, 25-73 years). Most injuries resulted from third molar removals (8/10), with an average time from the inciting event to nerve-repair surgery of 6.1 (SD, 4.6) months. In Neuropathy Score Reporting and Data System-Injury (NS-RADS I), NS-RADS I-4 injuries (neuroma in continuity) were found in 8/10 patients, and NS-RADS I-5 injuries were found in the remaining patients, all confirmed at surgery. Surgeries performed included microdissection with neurolysis, neuroma excision, and nerve allograft with Axoguard protection. Three patients with expected postsurgical MR neurography findings experienced either partial improvement or complete symptom resolution, while among 7 patient with persistent or recurrent neuropathy on postsurgical MR neurography, one demonstrated partial improvement of sensation, pain, and taste and one experienced only pain improvement; the remaining 5 patients demonstrated no improvement. Postsurgical MR neurography consistently coincided with clinical outcomes related to pain, sensation, and lip biting and speech challenges. Lip biting and speech challenges were most amenable to recovery, even with evidence of persistent nerve pathology on postsurgical MR neurography.
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Neuroma , Enfermedades del Nervio Trigémino , Masculino , Humanos , Femenino , Adulto , Persona de Mediana Edad , Anciano , Imagen por Resonancia Magnética/métodos , Estudios Retrospectivos , Neuroma/cirugía , DolorRESUMEN
OBJECTIVE: Chronic foot pain, a common cause of forelimb lameness, can be treated by palmar digital neurectomy (PDN). Complications include neuroma formation and lameness recurrence. In humans, neuroanastomoses are performed to prevent neuroma formation. The aim of the study was to evaluate the outcome of horses undergoing dorsal-to-palmar branch neuroanastomosis following PDN. STUDY DESIGN: Retrospective case series. ANIMALS: Eighty-five horses with PDN and dorsal-to-palmar branch neuroanastomosis. METHODS: Medical records for horses undergoing this procedure at two hospitals between 2015 and 2020 were reviewed. Palmar and dorsal nerve branches of the PDN were transected and end-to-end neuroanastomosis was performed by apposition of the perineurium. Follow-up was obtained from medical records and telephone interviews. Success was defined as resolution of lameness for at least one year. RESULTS: Lameness resolved following surgery in 81/85 (95%) horses with 57/84 (68%) sound at one year. Postoperative complications occurred in 19/85 (22%) cases. The main limitations of the study were an incomplete data set, inaccurate owner recall, and variations in procedure. CONCLUSION: Compared to previous studies, this technique resulted in similar numbers of horses sound immediately after surgery, a comparable rate of postoperative neuroma formation but a higher recurrence of lameness rate at 1 year postoperatively. CLINICAL SIGNIFICANCE: End-to-end neuroanastomosis of the dorsal and palmar branches of the PDN does not reduce the rate of neuroma formation in horses. Long-term outcome was less favorable compared to previously reported PDN techniques.
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Enfermedades de los Caballos , Cojera Animal , Neuroma , Animales , Caballos , Enfermedades de los Caballos/cirugía , Estudios Retrospectivos , Neuroma/veterinaria , Neuroma/cirugía , Cojera Animal/cirugía , Masculino , Femenino , Miembro Anterior/cirugía , Miembro Anterior/inervación , Anastomosis Quirúrgica/veterinaria , Anastomosis Quirúrgica/métodos , Resultado del Tratamiento , Enfermedades del Pie/veterinaria , Enfermedades del Pie/cirugía , Procedimientos Neuroquirúrgicos/veterinaria , Procedimientos Neuroquirúrgicos/métodos , Procedimientos Neuroquirúrgicos/efectos adversosRESUMEN
BACKGROUND: Shoulder internal rotation contracture and subluxation in the first year of life has long been recognized in some patients with brachial plexus birth injury (BPBI). Surgical management of shoulder pathology has traditionally been undertaken following nerve reconstruction as necessary. In some patients; however, shoulder pathology may impair or obscure functional neuromuscular recovery of the upper extremity. As a proof of concept, we report a highly selected subset of patients with BPBI in whom shoulder surgery undertaken before one year of age obviated the need for neuroma resection and nerve grafting. METHODS: A retrospective review was performed of all patients with upper trunk BPBI who underwent shoulder surgery before one year of age from 2015 to 2018. Upper extremity motor function was evaluated with preoperative and postoperative Active Movement Scale scores, Cookie tests, and the requirement for subsequent neuroma resection and nerve grafting. RESULTS: Fifteen patients with BPBI meeting the inclusion criteria underwent shoulder surgery (including a subscapularis slide and tendon transfers of the teres major and latissimus dorsi muscles) before 1 year of age. Preoperatively, no patients of the appropriate age passed the Cookie test for elbow flexion. Thirteen patients either passed the Cookie test or scored Active Movement Scale score 7 for elbow flexion at or before the last available follow-up undertaken at a median age of 3.4 [1.4, 5.2] years. One of those 13 patients underwent single fascicular distal nerve transfer to improve elbow flexion before subsequently passing the Cookie test. Two patients did not have sufficient follow-up to assess elbow flexion. CONCLUSION: Although the exact role of shoulder surgery in infancy for BPBI remains to be defined, the findings from this study provide proof of concept that early, targeted surgical treatment of the shoulder may obviate the need for brachial plexus nerve reconstruction in a highly selected group of infants with BPBI.
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Traumatismos del Nacimiento , Neuropatías del Plexo Braquial , Plexo Braquial , Contractura , Neuroma , Lactante , Humanos , Neuropatías del Plexo Braquial/cirugía , Plexo Braquial/lesiones , Neuroma/cirugía , Rango del Movimiento Articular , Resultado del TratamientoRESUMEN
BACKGROUND: Phantom limb pain (PLP) and symptomatic neuroma can be debilitating and significantly impact the quality of life of amputees. However, the prevalence of PLP and symptomatic neuromas in patients following dysvascular lower limb amputation (LLA) has not been reliably established. This systematic review and meta-analysis evaluates the prevalence and incidence of phantom limb pain and symptomatic neuroma after dysvascular LLA. METHODS: Four databases (Embase, MEDLINE, Cochrane Central, and Web of Science) were searched on October 5th, 2022. Prospective or retrospective observational cohort studies or cross-sectional studies reporting either the prevalence or incidence of phantom limb pain and/or symptomatic neuroma following dysvascular LLA were identified. Two reviewers independently conducted the screening, data extraction, and the risk of bias assessment according to the PRISMA guidelines. To estimate the prevalence of phantom limb pain, a meta-analysis using a random effects model was performed. RESULTS: Twelve articles were included in the quantitative analysis, including 1924 amputees. A meta-analysis demonstrated that 69% of patients after dysvascular LLA experience phantom limb pain (95% CI 53-86%). The reported pain intensity on a scale from 0-10 in LLA patients ranged between 2.3 ± 1.4 and 5.5 ± .7. A single study reported an incidence of symptomatic neuroma following dysvascular LLA of 5%. CONCLUSIONS: This meta-analysis demonstrates the high prevalence of phantom limb pain after dysvascular LLA. Given the often prolonged and disabling nature of neuropathic pain and the difficulties managing it, more consideration needs to be given to strategies to prevent it at the time of amputation.
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Neuroma , Miembro Fantasma , Humanos , Miembro Fantasma/diagnóstico , Miembro Fantasma/epidemiología , Miembro Fantasma/etiología , Estudios Retrospectivos , Estudios Transversales , Calidad de Vida , Estudios Prospectivos , Resultado del Tratamiento , Amputación Quirúrgica/efectos adversos , Neuroma/diagnóstico , Neuroma/epidemiología , Neuroma/cirugía , Extremidades , Extremidad InferiorRESUMEN
BACKGROUND: Nerve conduits are either used to bridge nerve gaps of up to 3 cm or to protect nerve coaptations. Biodegradable nerve conduits, which are currently commercially available, include Chitosan or collagen-based ones. As histological aspects of their degradation are highly relevant for the progress of neuronal regeneration, the aim of this study was to report the histopathological signs of such nerve conduits, which were removed during revision surgery. MATERIALS AND METHODS: Either Chitosan (n = 2) or collagen (n = 2) nerve conduits were implanted after neuroma resection and nerve grafting (n = 2) or traumatic nerve lesion after cut (n = 1) or crush injury (n = 1) in two females and two men, aged between 17 and 57 years. Revision surgery with removal of the nerve conduits was indicated due to persisting neuropathic pain and sensorimotor deficits, limited joint motion, or neurolysis with hardware removal at a median time of 17 months (range: 5.5-48 months). Histopathological analyses of all removed nerve conduits were performed. RESULTS: A scar neuroma was diagnosed in one out of four patients. Mechanical complication occurred in one patient after nerve conduit implantation bridged over finger joints. Intraoperatively no or only initial signs of degradation of the nerve conduits were observed. Chitosan conduits revealed largely unchanged shape and structure of chitosan, and coating of the conduit by a vascularized fibrous membrane. The latter contained deposits taken up by macrophages, most likely representing dissolved chitosan. Characteristic histopathologic features of the degradation of collagen conduits were a disintegration of the compact collagen into separate fine circular strands, No foreign body reaction was observed in all removed nerve conduits. CONCLUSIONS: Both Chitosan nerve conduits have not been degraded. The collagen nerve conduits showed a beginning degradation process. Furthermore, wrapping the repaired nerve with a nerve conduit did neither prevent adhesions nor improved nerve gliding. Therefore, biodegradation in time should be particularly addressed in further developments of nerve conduits.
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Quitosano , Neuroma , Masculino , Femenino , Humanos , Adolescente , Adulto Joven , Adulto , Persona de Mediana Edad , Quitosano/uso terapéutico , Quitosano/química , Regeneración Nerviosa/fisiología , Colágeno/uso terapéutico , Colágeno/metabolismo , Prótesis e Implantes , Neuroma/etiología , Neuroma/prevención & control , Neuroma/cirugía , Nervio Ciático/lesionesRESUMEN
BACKGROUND/AIM OF THE STUDY: Nerve capping is a method of neuroma treatment or prevention that consists of the transplantation of a proximal nerve stump into an autograft or other material cap, after surgical removal of the neuroma or transection of the nerve. The aim was to reduce neuroma formation and symptoms by preventing neuronal adhesions and scar tissue. In this narrative literature review, we summarize the studies that have investigated the effectiveness of nerve capping for neuroma management to provide clarity and update the clinician's knowledge on the topic. METHODS: A systematic electronic search following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria was performed in the PubMed database combining "neuroma," "nerve," "capping," "conduit," "treatment," "management," "wrap," "tube," and "surgery" as search terms. English-language clinical studies on humans and animals that described nerve capping as a treatment/prevention technique for neuromas were then selected based on a full-text article review. The data from the included studies were compiled based on the technique and material used for nerve capping, and technique and outcomes were reviewed. RESULTS: We found 10 applicable human studies from our literature search. Several capping materials were described: epineurium, nerve, muscle, collagen nerve conduit, Neurocap (synthetic copolymer of lactide and caprolactone, which is biocompatible and resorbable), silicone rubber, and collagen. Overall, 146 patients were treated in the clinical studies. After surgery, many patients were completely pain-free or had considerable improvement in pain scores, whereas some patients did not have improvement or were not satisfied after the procedure. Nerve capping was used in 18 preclinical animal studies, using a variety of capping materials including autologous tissues, silicone, and synthetic nanofibers. Preclinical studies demonstrated successful reduction in rates of neuroma formation. CONCLUSIONS: Nerve capping has undergone major advancements since its beginnings and is now a useful option for the treatment or prevention of neuromas. As knowledge of peripheral nerve injuries and neuroma prevention grows, the criterion standard neuroprotective material for enhancement of nerve regeneration can be identified and applied to produce reliable surgical outcomes.
Asunto(s)
Neuroma , Traumatismos de los Nervios Periféricos , Animales , Humanos , Muñones de Amputación , Colágeno , Neuroma/prevención & control , Neuroma/cirugía , Traumatismos de los Nervios Periféricos/cirugía , Nervios Periféricos/cirugíaRESUMEN
BACKGROUND: Although symptomatic neuroma formation has been described in other patient populations, these data have not been studied in patients undergoing resection of musculoskeletal tumors. This study aimed to characterize the incidence and risk factors of symptomatic neuroma formation following en bloc resection in this population. METHODS: The authors retrospectively reviewed adults undergoing en bloc resections for musculoskeletal tumors at a high-volume sarcoma center from 2014 to 2019. The authors included en bloc resections for an oncologic indication and excluded non-en bloc resections, primary amputations, and patients with insufficient follow-up. Data are provided as descriptive statistics, and multivariable regression modeling was performed. RESULTS: The authors included 231 patients undergoing 331 en bloc resections (female, 46%; mean age, 52 years). Nerve transection was documented in 87 resections (26%). There were 81 symptomatic neuromas (25%) meeting criteria of Tinel sign or pain on examination and neuropathy in the distribution of suspected nerve injury. Factors associated with symptomatic neuroma formation included age 18 to 39 [adjusted OR (aOR), 3.6; 95% CI, 1.5 to 8.4; P < 0.01] and 40 to 64 (aOR, 2.2; 95% CI, 1.1 to 4.6; P = 0.04), multiple resections (aOR, 3.2; 95% CI, 1.7 to 5.9; P < 0.001), preoperative neuromodulator requirement (aOR, 2.7; 95% CI, 1.2 to 6.0; P = 0.01), and resection of fascia or muscle (aOR, 0.5; 95% CI, 0.3 to 1.0; P = 0.045). CONCLUSION: The authors' results highlight the importance of adequate preoperative optimization of pain control and intraoperative prophylaxis for neuroma prevention following en bloc resection of tumors, particularly for younger patients with a recurrent tumor burden. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.
Asunto(s)
Neuroma , Neoplasias de los Tejidos Blandos , Neoplasias de la Columna Vertebral , Adulto , Humanos , Femenino , Persona de Mediana Edad , Adolescente , Adulto Joven , Estudios Retrospectivos , Resultado del Tratamiento , Neoplasias de la Columna Vertebral/cirugía , Recurrencia Local de Neoplasia/patología , Neoplasias de los Tejidos Blandos/epidemiología , Neoplasias de los Tejidos Blandos/etiología , Neoplasias de los Tejidos Blandos/cirugía , Neuroma/epidemiología , Neuroma/etiología , Neuroma/cirugía , DolorRESUMEN
BACKGROUND: Targeted muscle reinnervation (TMR) is an effective technique for the prevention and management of phantom limb pain (PLP) and residual limb pain (RLP) among amputees. The purpose of this study was to evaluate symptomatic neuroma recurrence and neuropathic pain outcomes between cohorts undergoing TMR at the time of amputation (ie, acute) versus TMR following symptomatic neuroma formation (ie, delayed). METHODS: A cross-sectional, retrospective chart review was conducted using patients undergoing TMR between 2015 and 2020. Symptomatic neuroma recurrence and surgical complications were collected. A subanalysis was conducted for patients who completed Patient-Reported Outcome Measurement Information System (PROMIS) pain intensity, interference, and behavior scales and an 11-point numeric rating scale (NRS) form. RESULTS: A total of 105 limbs from 103 patients were identified, with 73 acute TMR limbs and 32 delayed TMR limbs. Nineteen percent of the delayed TMR group had symptomatic neuromas recur in the distribution of original TMR compared with 1% of the acute TMR group ( P < 0.05). Pain surveys were completed at final follow-up by 85% of patients in the acute TMR group and 69% of patients in the delayed TMR group. Of this subanalysis, acute TMR patients reported significantly lower PLP PROMIS pain interference ( P < 0.05), RLP PROMIS pain intensity ( P < 0.05), and RLP PROMIS pain interference ( P < 0.05) scores in comparison to the delayed group. CONCLUSIONS: Patients who underwent acute TMR reported improved pain scores and a decreased rate of neuroma formation compared with TMR performed in a delayed fashion. These results highlight the promising role of TMR in the prevention of neuropathic pain and neuroma formation at the time of amputation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
Asunto(s)
Transferencia de Nervios , Neuralgia , Neuroma , Miembro Fantasma , Humanos , Estudios Retrospectivos , Estudios Transversales , Transferencia de Nervios/métodos , Amputación Quirúrgica , Miembro Fantasma/etiología , Miembro Fantasma/prevención & control , Miembro Fantasma/cirugía , Neuroma/etiología , Neuroma/prevención & control , Neuroma/cirugía , Neuralgia/etiología , Neuralgia/prevención & control , Neuralgia/cirugía , Músculos , Músculo Esquelético/cirugía , Muñones de Amputación/cirugíaRESUMEN
BACKGROUND: Neuromas substantially decrease a patient's quality of life and obstruct the use of prosthetics. This systematic review and meta-analysis aimed to determine the global incidence of neuroma formation in upper extremity amputees. METHODS: A literature search was performed using 3 databases: Web of Science, MEDLINE, and Cochrane. Inclusion criteria for the systematic review were those studies investigating only upper extremity amputees and reported postamputation neuroma. A random-effects, inverse-variance analysis was conducted to determine the pooled proportion of neuromas within the upper extremity amputation population. Critical appraisal using the JBI Checklist for Studies Reporting Prevalence Data of each individual article were performed for the systematic review. RESULTS: Eleven studies met the inclusion criteria collating a total of 1931 patients across 8 countries. More than three-fourth of patients are young men (77%; age range, 19-54 years) and had an amputation due to trauma. The random-effects analysis found the pooled combined proportion of neuromas to be 13% (95% confidence interval, 8%-18%). The treatment of neuroma is highly variable, with some patients receiving no treatment. CONCLUSIONS: The pooled proportion of neuroma incidence in the 1931 patients was 13%. With the known global prevalence of upper extremity amputees, this translates to nearly 3 million amputees suffering from a neuroma globally. Increasing training in preventative surgical methods could contribute to lowering this incidence and improving the outcomes of this patient population.