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Topic: Peripheral Nerve Repair and Regeneration

Painful scar neuropathy: principles of

diagnosis and treatment

Pierluigi Tos , Alessandro Crosio , Pierfrancesco Pugliese , Roberto Adani ,
1
2
1
1
Francesca Toia , Stefano Artiaco 1
3
1 Department of Orthopedics, Reconstructive Microsurgery Unit, City of Health and Sciences of Turin, Trauma Hospital, 10100 Torino, Italy.
2 Department of Hand Surgery and Microsurgery, University Hospital of Verona, 37126 Verona, Italy.
3 Plastic and Reconstructive Surgery, Department of Surgical, Oncological and Oral Sciences, University of Palermo, 90127 Palermo, Italy.
Address for correspondence: Dr. Pierluigi Tos, Department of Orthopedics, Reconstructive Microsurgery Unit, City of Health and Sciences of
Turin, Trauma Hospital, 10100 Torino, Italy. E-mail: pierluigi.tos@unito.it

ABSTRACT
Nerve-tissue interactions are critical. Peripheral nerve injuries may involve intraneural and
extraneural scar formation and affect nerve gliding planes, sometimes leading to complex clinical
presentations. All of these pathological entities involve pain as the main clinical symptom and
can be subsumed under the term “painful scar neuropathy”. The authors review the literature on
treatment approaches to peripheral nerve scar neuropathy and the outcomes of neurolysis-associated
procedures and propose a simple classification and a therapeutic approach to scar neuropathy. The
search retrieved twenty-one papers, twenty of which reported pain reduction or resolution with
various techniques. There is no consensus on the best therapeutic approach to neuropathic pain
due to scar tethering. Most authors report good or excellent results with different techniques, from
nerve wrapping with anti-adhesion devices to nerve coverage or wrapping with vascularized tissue.
The authors’ classification of and therapeutic approach to peripheral nerve scar lesions aims at
promoting a logical approach based on the analysis of lesion type (perineural, or endoneural and
perineural), pain type (due to traction or external trauma, pain at rest), and number of previous
operations. Patients need to be informed that multiple procedures may be required, that outcomes
may be partial, and that surgery can potentially worsen preoperative conditions. The review found
no evidence for the best therapeutic approach to scar neuropathy, but there is consensus on a
multidisciplinary approach.

Key words:
Complex regional pain syndrome type II, painful neuropathy, painful scar neuropathy, scar neuritis,
traction neuropathy

INTRODUCTION nerve that provides for elongation during movement.
Small nutritional vessels entering the epineurium from
Peripheral nerves have the ability to adapt to different surrounding muscles are among the principal connections
positions during limb and joint movements. Such between nerves and soft tissue.
flexibility is enabled by a gliding apparatus around the
A peripheral nerve subjected to elongation stress can
extend a few millimeters compared to its length at rest.
Access this article online Elongation is enabled by a conjunctiva‑like structure
[1]
Quick Response Code: constituting the outermost layer of the nerve trunk
Website: that Millesi et al. designated paraneurium. The inner
[2]
www.parjournal.net
nerve structure can also undergo elongation, and gliding
planes have been detected between deep epineurium
[3]
DOI: and perineurium as well as between individual fascicles.
10.4103/2347-9264.160878 Joint excursion, therefore, involves complete epineurial
and intraneural movement, where nerve elongation

156 Plast Aesthet Res || Vol 2 || Issue 4 || Jul 15, 2015