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Topic: Peripheral Nerve Repair and Regeneration

The management of neuropathic pain

from neuromas in the upper limb: surgical

techniques and future directions

Tereze Laing , Aftab Siddiqui , Manu Sood 1,2
1,2
1,2
1 Department of Hand Surgery, St. Andrew’s Centre for Plastic Surgery and Burns, Broomfield Hospital, Chelmsford, Essex CM4 9QZ, UK.
2 Department of Plastic Surgery Research, St. Andrew’s and Anglia Ruskin Research Unit, Bishop Hall Lane, Chelmsford, Essex CM1 1SQ, UK.
Address for correspondence: Ms. Tereze Laing, St. Andrew’s Centre for Plastic Surgery and Burns, Broomfield Hospital, Chelmsford, Essex
CM4 9QZ, UK. E-mail: terezelaing@yahoo.com

ABSTRACT
Neuropathic pain of the upper limb results from damage or disease of the upper limb somatosensory
system caused by wide range of pathologies including peripheral neuromas. Treatment strategies depend
on making an accurate diagnosis, recognizing co-existing pathologies, and formulating an individualized
treatment plan that commonly involves multiple modalities. A long list of nonsurgical and surgical
methods acting peripherally (neuromodulation, nerve blocks, surgical manipulation of the nerve) and
centrally (medications, spinal cord, and deep brain stimulation) has been described and it is clear that no
one treatment is wholly reliable. In this article, we briefly review the pathophysiology of pain caused by
neuromas, the current treatment options and the latest research in therapeutic developments.
Key words:
Nerve, neuroma, neuromodulation, pain, relocation

INTRODUCTION due to the wealth of research pain secondary to peripheral
neuromas is reasonably well‑understood.
The international association for the study of pain defines
neuropathic pain as pain resulting from a lesion or disease PATHOPHYSIOLOGY OF THE
in the central or peripheral nervous system. [1‑3] This PERIPHERAL NEUROMA
categorization is broad and includes a range of etiologies
such as trauma, lesions of the central nervous system, A neuroma is formed with when a nerve is transected and
diabetic peripheral neuropathy, multiple sclerosis, and is not surgically repaired successfully. The word neuroma
herpetic nerve lesions. When the upper limb is involved, means “nerve tumor” and accurately describes the bulbous
it also includes chronic nerve compression, neuritis and mass of regenerating axons that grow in an uncoordinated
complex regional pain syndrome. A significant proportion fashion from the proximal nerve end. This tissue consists of
of pain in the upper limb results from neuroma formation. Schwann cells, fibroblasts, blood vessels, and regenerating
Currently, our knowledge of the underlying mechanisms axons. Neuromas may be further defined by the integrity
is limited for pain resulting from complex regional pain of the nerve components. An end neuroma occurs
syndrome and diabetic peripheral neuropathy. However, following complete nerve transection or neurotmesis by
Sunderland’s classification. The term partial neuroma or
neuroma‑in‑continuity (Sunderland grade 4‑6 injury) is used
Access this article online
Quick Response Code: to describe nerves that are partly intact.
Website: Persisting pain arising from a terminal neuroma is
www.parjournal.net
relatively uncommon, estimated to occur in 3‑5% of
peripheral nerve injuries. In general, complete nerve
[4]
DOI: transections do not result in major pain. Two main
10.4103/2347-9264.160879 processes are believed to be responsible that of persistent
abnormal peripheral nerve stimulation and central

Plast Aesthet Res || Vol 2 || Issue 4 || Jul 15, 2015 165