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Surgical options if distal nerve end unavailable. Following neuroma excision, options include implantation in muscle, nerve cap, centro-central neurorrhaphy, relocation nerve grafting, "end-to-side" neurorrhaphy, TMR, or use of RPNI.

Surgical options if distal nerve end unavailable. Following neuroma excision, options include implantation in muscle, nerve cap, centro-central neurorrhaphy, relocation nerve grafting, "end-to-side" neurorrhaphy, TMR, or use of RPNI.

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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...

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... branches are not identifiable, given their small size, and in all cases of amputations where the terminal nerve ends are no longer present. In these situations, it is not possible to perform reconstruction of the native nerve in the absence of a distal target, and one must decide the appropriate technique to address the proximal nerve stump (Fig. ...

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... Active techniques for surgical neuroma management include nerve reconstruction with autograft or allograft, targeted muscle reinnervation, and regenerative peripheral nerve interfaces. [3][4][5][6][7] These procedures have been shown to aid in the reduction of pain and opioid use, while improving function and quality of life in patients treated for symptomatic neuromas. 2,[8][9][10][11] Neuromas can sometimes be challenging to locate intraoperatively. ...
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During operative intervention for the treatment of symptomatic neuromas, the authors have observed a hypersensitive "startle" response to stimulation in proximity to the painful nerve. This physiologic sign is an indicator of the specific anatomic localization of the painful stimulus, commonly a symptomatic neuroma, that appears to be reproducible. The aim of this article is to describe this "neuroma startle sign," posit the underlying mechanism for this observation, and propose how this phenomenon could be clinically harnessed for innovation and optimization in both surgery and anesthesia for more effective symptomatic neuroma localization.
... Therefore, new techniques such as targeted muscle reinnervation (TMR) and regenerative peripheral nerve interfaces (RPNI) have been developed and show promising results [7,8]. Their underlying concept of "giving the nerve a new target" seems to be the key factor of success compared to the traditional techniques. ...
... Neuromas are thickened portions of damaged nerves that have uncoordinated axons sprouting surrounded by scar tissue. They consist of axons, Schwann cells, and fibroblasts that are perineurally attached to the surrounding tissue [8]. ...
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Therapy-resistant neuroma pain is a devastating condition for patients and surgeons. Although various methods are described to surgically deal with neuromas, some discontinuity and stump neuroma therapies have anatomical limitations. It is widely known that a neurotizable target for axon ingrowth is beneficial for dealing with neuromas. The nerve needs “something to do”. Furthermore, sufficient soft tissue coverage plays a major role in sufficient neuroma therapy. We aimed, therefore, to demonstrate our approach for therapy of resistant neuromas with insufficient tissue coverage using free flaps, which are sensory neurotized via anatomical constant branches. The central idea is to provide a new target, a new “to do” for the painful mislead axons, as well as an augmentation of deficient soft tissues. As indication is key, we furthermore demonstrate clinical cases and common neurotizable workhorse flaps.
... RPNI is an alternative treatment option for symptomatic neuromas [52][53][54]. In this technique, free muscle grafts are transferred to and wrapped circumferentially around the amputated stump and its transected nerve fascicular units [55,56]. ...
... The practical aspects of TMR are presented in Table 5. TMR is currently suggested to be applied to the following indications; for (i) the reduction of post-amputation PLP and RLP (i.e., the main focus of our review) [18][19][20][21][22][23][24], for (ii) the improvement of fine motor control of upper limb prostheses [51][52][53], and for (iii) prevention of symptomatic neuromas [54,65]. Contraindications include complete sensory loss at the level of the amputation, unstable patient physiology, or severe wound infection when initially undergoing amputation [65]. ...
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Background Targeted muscle reinnervation (TMR) has been shown to reduce phantom limb pain (PLP) and residual limb pain (RLP) in amputee patients, improving the quality of life. This systematic review aimed to evaluate the quality of data and determine the efficacy of TMR on pain reduction and functional outcomes in amputees. Methods The protocol was registered and published a priori on PROSPERO (CRD42021285083). Medline, Embase, CENTRAL, Science Citation Index, and PsycINFO databases were searched until June 2022, retrieving 10 studies (n = 943). Selected outcomes were pain scores, improvement in limb function, complication rates, pain medication, and resubmission rates. Results Ten studies (1 RCT and 9 observational studies) were included (n = 1099 limbs). The mean follow-up was 17.9 months (range 9.6–24.0). For NRS, the pooled mean difference was − 2.68 (95% CI: − 3.21, − 2.14; p < 0.0001) for RLP and − 2.17 (95% CI: − 2.70, − 1.63; p < 0.0001) for PLP, in favor of the TMR group, respectively. Pooled mean differences were significantly lower for all domains (all p < 0.0001) of the PROMIS score, in favor of the TMR group. Complication rates ranged from 0 to 16%. All studies showed a reduction in PLP and RLP following TMR. Three studies, assessing functional outcomes, showed an increase following TMR. The RCT was graded high quality and observational studies were moderate to very low quality. Conclusions Despite varying study quality, pooled analysis shows a significant reduction in RLP and PLP across all PROMIS domains and significant reduction in NRS scores in the TMR group. Additionally, TMR demonstrated improved functional outcomes for amputees. Systematic review registration. PROSPERO CRD42021285083. Level of evidence: Not gradable
... [14] (Figure 1). The simplest way is to retract the nerve and transect proximally (traction neurectomy) so that the nerve will retract between muscles in the stump, far from the skin; even if a neuroma occurs, it would not be painful [15,16] . The limitation of this treatment is that one does not have control of the nerve end and pain can appear, hence, the patient will be limited in wearing prosthesis or sitting in a wheelchair [17] . ...
... Different synthetic materials or vein can be used to cap the end of the nerve so that painful regrowth of the nerve can be reduced. More recent studies have been focused on nerve capping and selecting a conduit for treatment of neuroma in continuity, not for endneuroma [16] . ...
... End-to-end nerve coaptation Depending on the level of amputation and the nerves involved, nerve coaptation can be done between different nerves epineurally or between fascicles in the same nerve (centrocentral neurorrhaphy) [16] . Therefore, it is expected that repairing "like to like" tissue as a basic principle in plastic surgery, the nerve stump covered with regenerated epineurium will return the nerve to its physiological state [32][33] . ...
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... In cases of no available distal nerve stump, as often seen in endneuroma, "passive" or "ablative" options such as intraosseous implantation or nerve capping, which do not facilitate functional recovery, have to be considered. Neuromain-continuity, however, may be subject to nerve reconstruction in cases of two stumps after neuroma resection [4]. In accordance with primary nerve repair, reconstructive techniques aim for the tensionless restoration of nerve continuity. ...
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Background: Considering the debilitating burden of neuroma resulting in a significant loss of function and excruciating pain, the use of muscle-in-vein conduits (MVCs) for the reconstruction of painful neuroma of sensory nerves of the fingers was assessed. Methods: We retrospectively analyzed 10 patients who underwent secondary digital nerve repair by MVCs. The recovery of sensibility was evaluated by static and moving two-point discrimination (2PDs, 2PDm) and Semmes-Weinstein monofilament testing (SWM). The minimum follow-up was set 12 months after the operation. Results: The median period between trauma and nerve repair was 13.4 weeks (IQR 53.5). After neuroma resection, defects ranged from 10-35 mm (mean 17.7 mm, SD 0.75). The successful recovery of sensibility was achieved in 90% of patients after a median follow-up of 27.0 months (IQR 31.00). The mean 2PDs and 2PDm was 8.1 mm (SD 3.52) and 5.2 mm (SD 2.27), respectively. Assessment by SWM resulted in a mean value of 3.54 (SD 0.69). Reduction in pain was achieved among all patients; eight patients reported the complete relief of neuropathic pain. There was no recurrence of neuroma in any patient. Conclusions: Muscle-in-vein conduits provide an effective treatment for painful neuroma of digital nerves, resulting in satisfactory restoration of sensory function and relief of pain.
... 1,2 Patients with amputations often experience intense, pathological pain that can be neuropathic in nature or can occur secondarily to neuromas and phantom limb pain (pain in the absent extremity). [3][4][5] The pathophysiology of amputation-induced pain is not yet fully understood; however, multiple factors play a key role in its development that include changes in both the peripheral and central nervous systems. Given the higher risk of anxiety and depression in this population, 6,7 effective treatment is, therefore, imperative for both physical health and mental health. ...
... 87 The primary goal of surgical resection is removal of pathologic, disorganized swellings of terminal nerve axons, with various methods employed to reduce recurrence. 3,87,88 Methods utilized can vary from ligation, relocation into bone or muscle, and nerve capping, for example, but all have notable issues with recurrence as well as clinically significant resolution of pain in the majority of study participants long term. 3,87,88 These shortcomings could be theorized to be secondary to a failure to address the underlying cause of the pain, namely neuronal hyperexcitability and aberrant signaling, resulting from a loss of end-organ innervation following amputation. ...
... 3,87,88 Methods utilized can vary from ligation, relocation into bone or muscle, and nerve capping, for example, but all have notable issues with recurrence as well as clinically significant resolution of pain in the majority of study participants long term. 3,87,88 These shortcomings could be theorized to be secondary to a failure to address the underlying cause of the pain, namely neuronal hyperexcitability and aberrant signaling, resulting from a loss of end-organ innervation following amputation. ...
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Despite advancements in surgical and rehabilitation strategies, extremity amputations are frequently associated with disability, phantom limb sensations, and chronic pain. Investigation into potential treatment modalities has focused on the pathophysiological changes in both the peripheral and central nervous systems to better understand the underlying mechanism in the development of chronic pain in persons with amputations. Methods: Presented in this article is a discussion outlining the physiological changes that occur in the peripheral and central nervous systems following amputation. In this review, the authors examine the molecular and neuroplastic changes occurring in the nervous system, as well as the state-of-the-art treatment to help reduce the development of postamputation pain. Results: This review summarizes the current literature regarding neurological changes following amputation. Development of both central sensitization and neuronal remodeling in the spinal cord and cerebral cortex allows for the development of neuropathic and phantom limb pain postamputation. Recently developed treatments targeting these pathophysiological changes have enabled a reduction in the severity of pain; however, complete resolution remains elusive. Conclusions: Changes in the peripheral and central nervous systems following amputation should not be viewed as separate pathologies, but rather two interdependent mechanisms that underlie the development of pathological pain. A better understanding of the physiological changes following amputation will allow for improvements in therapeutic treatments to minimize pathological pain caused by amputation.
... Symptomatic terminal neuromas develop when the transected axons of an injured nerve fail to reestablish connections with their end organs, which are no longer present following amputation. Exuberant regeneration of these axons occurs, forming disorganized, hyperexcitable, painful masses of Schwann cells, axonal sprouts, blood vessels, and connective tissue [36,37] . Although multiple surgical interventions have been proposed for symptomatic neuroma treatment, such as traction neurectomy, these conventional methods have yielded unsatisfactory results including failed pain resolution and neuroma recurrence [38][39][40] . ...
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Despite significant advancements in neuroprosthetic control strategies, current peripheral nerve interfacing techniques are limited in their ability to facilitate accurate and reliable long-term control. The regenerative peripheral nerve interface (RPNI) is a biologically stable bioamplifier of efferent motor action potentials with demonstrated long-term stability. This innovative, straightforward, and reproducible surgical technique has shown enormous potential in improving prosthetic control for individuals with upper limb amputations. The RPNI consists of an autologous free muscle graft secured around the end of a transected peripheral nerve or individual fascicles within a residual limb. This construct facilitates EMG signal transduction from the residual peripheral nerve to a neuroprosthetic device using indwelling bipolar electrodes on the muscle surface. This review article focuses on the development of the RPNI and its use for intuitive and enhanced prosthetic control and sensory feedback. In addition, this article also highlights the use of RPNIs for the prevention and treatment of postamputation pain.
... Burying the proximal end of an injured nerve in muscle can provide moderate benefits; however, innervated muscle will not accept additional innervation from an injured nerve implanted within it, and this approach results in neuroma recurrence within the muscle. 5 Based on an improved understanding of axonal regeneration and nerve physiology, more recent techniques have focused on the use of denervated muscle sources as a potential reinnervation target for the axons regenerating from the injured proximal nerve stump. ...
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Purpose Neuroma formation following upper-extremity peripheral nerve injury often results in persistent, debilitating neuropathic pain with a limited response to medical management. Vascularized, denervated muscle targets (VDMTs) offer a newly described surgical approach to address this challenging problem. Like targeted muscle reinnervation and regenerative peripheral nerve targets, VDMTs are used to redirect regenerating axons from an injured nerve into denervated muscle to prevent neuroma formation. By providing a vascularized muscle target that is reinnervated via direct neurotization, VDMTs offer some theoretical advantages in comparison with the other contemporary surgical options. In this study, we followed the short-term pain outcomes of patients who underwent VDMT surgery for neuroma prevention or treatment. Methods We performed a retrospective chart review of 9 patients (2 pediatric and 7 adult) who underwent VDMTs either for symptomatic upper-extremity neuromas or as a prophylactic measure to prevent primary neuroma formation. In-person and/or telephone interviews were conducted to assess their postoperative clinical outcomes, including the visual analog pain scale simple pain score. Results Of the 9 patients included in this study, 7 underwent VDMT surgery as a prophylactic measure against neuroma formation, and 2 presented with symptomatic neuromas that were treated with VDMTs. The average follow-up was 5.6 ± 4.1 months (range, 0.5–13.2 months). The average postoperative pain score of the 7 adult patients was 1.1 (range, 0–8). Conclusions This study demonstrated favorable short-term outcomes in a small cohort of patients treated with VDMTs in the upper extremity. Larger, prospective, and comparative studies with validated patient-reported and objective outcome measures and longer-term follow-ups are needed to further evaluate the benefits of VDMTs in upper-extremity neuroma management and prevention. Type of study/level of evidence Therapeutic III.
... A more proactive, comprehensive approach would clearly be in the patient's best interest. 46 Recent literature has suggested the use of psychological questionnaires in addition to Quick DASH scores in assessing the patients' posttraumatic outcomes. 47 This is certainly an excellent recommendation but does not replace direct surgeon-to-patient verbal dialogue regarding both their physical and mental health during the postamputation rehabilitation period. ...
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Major limb amputation is a devastating potential outcome of trauma, tumor, or disease. Much has been written about the physical, functional, economic, and psychological consequences of major limb loss. In contradistinction, considerably less has been written concerning the consequences of "minor" limb loss, specifically single partial digit amputations. Are minor limb (partial single digit) amputations associated with symptoms of psychological disorder similar to those reported for major limb amputations? Methods: We conducted a clinical research study through interview and examination of 25 adult patients (average age: 45 years) who had suffered a single partial digit amputation to determine if symptoms of depression, anxiety, anger, or posttraumatic stress disorder newly occurred, and if such symptoms correlated with the surgical outcome. Questionnaires for Quick-DASH, Michigan Hand Score, and Diagnostic and Statistical Manual of Mental Disorders-5 Psychological Profile testing were completed. Results: All but one of the patients suffered from psychological symptoms for a minimum of 3 months. Symptom resolution time averaged 6 months for seven of the 25 patients. For 18 of the 25 patients, both psychological disturbance and neuroma pain were ongoing. The Psychological Profile scores suggesting pathology were inversely related to the scores on the Quick-Dash and Michigan Hand (somatic) questionnaires indicating wellness (P < 0.03). Conclusions: (1) Even minor partial amputations of single digits can trigger significant psychological disturbance; the study hypothesis is validated. (2) Psychological and somatic outcomes are directly correlative. (3) Mitigating neuroma pain and verbally offering psychological support services early in the postamputation period should improve the clinical outcome of digital amputations.
... The concept of repairing a nerve to reconnect it with their end organs allowing for an active physiological regeneration to reduce neuropathic pain is also a paradigm shift in current existing symptomatic neuroma treatments (37). An example of that is targeted muscle reinnervation (TMR) which actively directs regenerating axons into a distal adjacent motor branch. ...
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Full-text available
Introduction : Post-traumatic neuropathic pain is a major factor affecting quality of life after finger trauma and is reported with considerable variance in literature. This can partially be attributed to the different methods of determining neuropathic pain. The Douleur Neuropathique 4 (DN4) has been validated to be a reliable and non-invasive tool to assess the presence of neuropathic pain. This study investigated the prevalence of neuropathic pain after finger amputation or digital nerve repair using the DN4-questionnaire. Methods : Patients with finger amputation or digital nerve repair were identified between 2011 and 2018 at our institution. After a minimal follow-up of 12 months the short form DN4 (S-DN4) was used to asses neuropathic pain. Results : A total of 120 patients were included: 50 patients with 91 digital amputations and 70 patients with 87 fingers with digital nerve repair. In the amputation group, 32% of the patients had pain, and 18% had neuropathic pain. In the digital nerve repair group, 38% of the patients had pain, and 14% had neuropathic pain. Secondly, of patient-, trauma- and treatment specific factors, only the time between trauma and surgery had significant negative influence on the prevalence of neuropathic pain in patients with digital nerve repair. Conclusion : This study shows that persistent pain and neuropathic pain are common after finger trauma with nerve damage. One of the significant prognostic factors in developing neuropathic pain is treatment delay between trauma and time of digital nerve repair, which is of major clinical relevance for surgical planning of these injuries.