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Neuroma resection and reconstruction CONCLUSION
With a neuroma‑in‑continuity, there is an option to resect
the neuroma and reconstruct the nerve. Again the same Pain following traumatic peripheral nerve injury falls into
factors as mentioned previously will be considered (the the category of neuropathic pain as defined by the
functional importance of the nerve, the patient’s desires, international association for the study of pain yet these
occupation, age). For noncritical nerves, we prefer to injuries are not frequently included in the neuropathic
relocate the nerve as any loss of the remaining function is pain literature. Although there are several epidemiological
well‑compensated for by relief of pain. and quality of life studies relating to neuropathic pain,
very few of these studies include peripheral nerve
Neuroma resection and relocation injuries. [48‑51] This lack of knowledge was highlighted
As discussed above, we now routinely relocate painful in a review by Novak and Katz. They concluded that
[52]
nerves as a primary procedure. Although yet to be there is very little information on incidence and severity
published, our unit recently reviewed outcomes for of neuropathic pain, the associated disability, impact on
relocation in this subset of patients who nerves were quality of life or health status of patients with traumatic
determined clinically or intraoperatively to be intact, that peripheral nerve injuries. Most studies report only on
is, neuromas‑in‑continuity or tethered in surrounding scar the physical impairment related to motor and/or sensory
tissue. Pain completely resolved in 21 of 23 patients. In recovery. There are, however, a large number of reports
the others pain reduced significantly in severity. Just detailing intervention outcomes that shows the enormity
2 patients experienced mild pain at the site of relocation. of the problem and the lack of a single reliable solution.
The technique of relocation is the same as that for
terminal neuromas as described previously. Determining the cause of postinjury pain is the key to
success in treatment and can often be achieved by a
FUTURE DIRECTIONS thorough clinical evaluation alone. Injury of a sensory
nerve may result in altered sensation or anesthesia in
Our treatment of choice in cases of neuromas involving the distribution of the nerve. Unless accurate coaptation
the median and ulnar nerves refractory to nonsurgical of the epineurium is achieved, neuroma formation is
means is neurolysis and wrapping the critical nerve in local inevitable but is not in the majority of cases painful.
vascularized fascia. It is usually easy to raise an adequate The two main processes believed to be responsible for
sized flap for this purpose based on the ulnar or radial neuroma‑mediated pain are local persistent mechanical
arteries in the previously unscarred forearm. However, or chemical stimulation of the nerve ending and
following multiple procedures the local tissue may be central stimulation of dorsal ganglion, spinal cord and
central nervous system pathways. This understanding has
of substandard quality. Del Pinal et al. have reported led to the development of techniques to wrap the nerve
[40]
the use of free vascularized adipofascial flaps in scarred or move the nerve to a site where it is less irritated.
beds in the forearm and hand to improve tendon gliding.
The technique of free tissue transfer has been described A multitude of surgical techniques has been described in
previously to address scarred nerve beds of the brachial cases that fail conservative measures. Indeed, such a wide
plexus. [41,42] We are not aware of its application at more array of treatments suggests that there is no single way of
distal sites, and it is an avenue for future development. completely and effectively managing peripheral neuromas
with surgery. There are some general principles, which
Free fat grafting is one of the new ways to treat guide the surgical choice. If the nerve injury is recent,
neuromas. This technique is minimally invasive and can we explore immediately with the aim to primarily repair
[43]
be repeated. It has been shown to be valuable in treating the nerve if possible or resect the injury and reconstruct
Dupuytren’s contracture and Raynaud’s disease. Currently, with autologous nerve grafts. In the case of established
we have no experience of this technique. We believe that neuromas‑in continuity, where the nerve provides a distal
there is a greater benefit from transferring vascularized critical function such as in the case of the median or ulnar
fat attached to a fascial flap as it avoids the risk of fat nerves, every effort is made to preserve the functional
necrosis seen with transferring aspirated fat. elements. Our procedure of choice is neurolysis and
Recently, there has been an introduction of biological and wrapping the nerve in a local vascularized fascial flap.
synthetic polymers to the field of nerve reconstruction. When the smaller cutaneous nerves or digital nerves
Excellent outcomes in terms of sensory recovery have are involved, we generally opt for relocation to a site
been demonstrated using some of these materials determined by the nerve injured and the level of injury.
as alternatives to autologous nerve grafts. [44,45] The End‑neuromas of these smaller cutaneous nerves are
limitations include the length of the defect that can be managed similarly with relocation to local muscle or bone.
treated (which is not longer than 2 cm). The importance of
the alignment in nerve guide conduits has been recently REFERENCES
revealed, and the designers of the conduits are taking
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[46]
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Loeser JD, Treede RD. The Kyoto protocol of IASP basic pain terminology.
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