Incidence, Diagnosis, and Management of Neuromas Following Radiofrequency Ablation Treatment: a Narrative Review.

OBJECTIVE: To determine the epidemiology of neuroma formation as a complication following radiofrequency ablation for chronic pain conditions as well as reviewing the diagnosis and management of neuromas. DESIGN: Evidence-based narrative review and critical appraisal of literature. RESULTS: A comprehensive review of the literature generated one case report describing neuroma formation following lumbar facet medial branch radiofrequency denervation. The rare incidence may be explained by neuroma pathophysiology and peripheral nerve injury produced by radiofrequency ablation, in combination with its asymptomatic nature. Diagnosis of neuromas is predominantly confirmed by clinical history and physical exam with potential for nerve blocks or imaging. Ultrasound has been suggested as a primary imaging modality with magnetic resonance imaging as a secondary option. Neuroma management ranges from conservative therapy to surgery with varying success rates. CONCLUSIONS: Neuroma formation following radiofrequency ablation procedures is exceedingly rare and could be a hypothetical concern in clinical practice. However, the true incidence may be inaccurate given the asymptomatic nature of neuromas.

Painful Complications After Cosmetic Surgery: Management of Peripheral Nerve Injury.

BACKGROUND: Aesthetic procedures are among the most common surgeries performed by plastic surgeons. The prevalence of persistent pain remains unknown and underappreciated in the plastic surgery literature. OBJECTIVES: The purpose of this article was to increase awareness of this problem while describing the diagnostic and management strategies for patients with postoperative pain after aesthetic plastic surgery. METHODS: A literature review was performed utilizing the PubMed database to identify painful complications of brachioplasty, blepharoplasty, rhytidectomy, abdominoplasty, breast augmentation, mastopexy, and breast reduction. A treatment algorithm was described to guide plastic surgeons presented with patients reporting pain after aesthetic surgery. RESULTS: Title and abstract review followed by application of inclusion and exclusion criteria resulted in 20 clinical studies for this review, including lateral femoral cutaneous nerve, iliohypogastric nerve, and intercostal nerves after abdominoplasty; median antebrachial cutaneous nerve after brachioplasty; supraorbital, supratrochlear, and infratrochlear nerves after blepharoplasty; greater auricular nerve, auriculotemporal nerve, and zygomaticofacial nerve after rhytidectomy; and intercostobrachial nerve after breast surgery. CONCLUSIONS: Neuromas can be the source of pain following aesthetic surgery. The same clinical and diagnostic approach used for upper and lower extremity neuroma pain can be employed in patients with persistent pain after aesthetic surgery.

Pain Phenotypes and Associated Clinical Risk Factors Following Traumatic Amputation: Results from Veterans Integrated Pain Evaluation Research (VIPER).

OBJECTIVE: To define clinical phenotypes of postamputation pain and identify markers of risk for the development of chronic pain. DESIGN: Cross-sectional study of military service members enrolled 3-18 months after traumatic amputation injury. SETTING: Military Medical Center. SUBJECTS: 124 recent active duty military service members. METHODS: Study subjects completed multiple pain and psychometric questionnaires to assess the qualities of phantom and residual limb pain. Medical records were reviewed to determine the presence/absence of a regional catheter near the time of injury. Subtypes of residual limb pain (somatic, neuroma, and complex regional pain syndrome) were additionally analyzed and associated with clinical risk factors. RESULTS: A majority of enrolled patients (64.5%) reported clinically significant pain (pain score ≥ 3 averaged over previous week). 61% experienced residual limb pain and 58% experienced phantom pain. When analysis of pain subtypes was performed in those with residual limb pain, we found evidence of a sensitized neuroma in 48.7%, somatic pain in 40.8%, and complex regional pain syndrome in 19.7% of individuals. The presence of clinically significant neuropathic residual limb pain was associated with symptoms of PTSD and depression. Neuropathic pain of any severity was associated with symptoms of all four assessed clinical risk factors: depression, PTSD, catastrophizing, and the absence of regional analgesia catheter. CONCLUSIONS: Most military service members in this cohort suffered both phantom and residual limb pain following amputation. Neuroma was a common cause of neuropathic pain in this group. Associated risk factors for significant neuropathic pain included PTSD and depression. PTSD, depression, catastrophizing, and the absence of a regional analgesia catheter were associated with neuropathic pain of any severity.

What factors predict the need for further intervention following corticosteroid injection of Morton's neuroma?

BACKGROUND: This study investigated factors that may predict the need for Morton's neuroma (MN) to undergo further treatment within 2 years of a single ultrasound-guided corticosteroid injection. METHODS: A retrospective study was undertaken over a three-year period. The data was stratified into two groups: Group A - did not receive further intervention and Group B - received further treatment. We investigated age, gender, neuroma size and presence of other forefoot pathology or ipsilateral neuromas. RESULTS: 54 patients (57 feet) were reviewed. 29 feet (51%) required further treatment within 2 years (11 repeat injections, 18 surgical excisions). Binary logistic regression showed that larger neuromas (p=0.011) and younger patients (p=0.007) predicted the need for further intervention but not gender (p=0.272). The distribution of concomitant forefoot pathology and ipsilateral neuromas were similar between the two groups. CONCLUSION: Size and age appear to be predictors for further treatment of MN within 2 years of corticosteroid injection.

Entrapment neuropathy about the foot and ankle: an update.

Occurrences of entrapment neuropathies of the lower extremity are relatively infrequent; therefore, these conditions may be underappreciated and difficult to diagnose. Understanding the anatomy of the peripheral nerves and their potential entrapment sites is essential. A detailed physical examination and judicious use of imaging modalities are also vital when establishing a diagnosis. Once an accurate diagnosis is obtained, treatment is aimed at reducing external pressure, minimizing inflammation, correcting any causative foot and ankle deformities, and ultimately releasing any constrictive tissues.

Strategies for Treating Traumatic Neuromas with Tissue-Engineered Materials.

Neuroma, a pathological response to peripheral nerve injury, refers to the abnormal growth of nerve tissue characterized by disorganized axonal proliferation. Commonly occurring after nerve injuries, surgeries, or amputations, this condition leads to the formation of painful nodular structures. Traditional treatment options include surgical excision and pharmacological management, aiming to alleviate symptoms. However, these approaches often offer temporary relief without addressing the underlying regenerative challenges, necessitating the exploration of advanced strategies such as tissue-engineered materials for more comprehensive and effective solutions. In this study, we discussed the etiology, molecular mechanisms, and histological morphology of traumatic neuromas after peripheral nerve injury. Subsequently, we summarized and analyzed current nonsurgical and surgical treatment options, along with their advantages and disadvantages. Additionally, we emphasized recent advancements in treating traumatic neuromas with tissue-engineered material strategies. By integrating biomaterials, growth factors, cell-based approaches, and electrical stimulation, tissue engineering offers a comprehensive solution surpassing mere symptomatic relief, striving for the structural and functional restoration of damaged nerves. In conclusion, the utilization of tissue-engineered materials has the potential to significantly reduce the risk of neuroma recurrence after surgical treatment.

A small painful neuroma of the transverse cervical nerve treated with pulsed radiofrequency: A case report.

BACKGROUND: Neck pain is a common complaint seen amongst patients from all ages. When common causes of neck pain have been ruled out, it is important to investigate further. A careful physical exam can help identify the painful structures. An ultrasound of the area can also be helpful to identify possible structures involved. Neuromas can be treated with oral medications as well as more invasive techniques, such as pulsed radiofrequency (PRF). CASE DESCRIPTION: In this case report, we discuss a 67-year-old female who presented with left anterior neck pain after developing a cervical mass who was later diagnosed as non-Hodgkin lymphoma. A small neuroma of the left transverse cervical nerve was found on ultrasound and ultimately was treated with PRF with a complete resolution of her symptoms at two months follow-up. CONCLUSION: PRF seems to be a useful tool for controlling neuropathic pain caused by a neuroma.

Ultrasound guided alcohol ablation of Morton's neuroma.

BACKGROUND: Morton's neuroma is a common cause of metatarsalgia. This study evaluated the efficacy of ultrasound guided alcohol injection as a treatment for this condition. METHOD: Data from 87 treatment courses were included in this study with a mean follow of 14.3 months. RESULTS: Technical success was 100%. One patient developed symptoms consistent with an allergic reaction to the injection and one patient declined further injection because of periprocedural pain. Partial or total treatment response was achieved in 66%, with 32% of patients having complete resolution of pain. The median visual analogue score (VAS) decreased from 8 pre-procedure to 4 post-procedure (p < 0.0001). Procedural success was greater in patients under 55 years old and in those with solitary neuromas. Seventeen patients (20%) went on to have surgery due to continuing pain. CONCLUSION: Ultrasound guided alcohol ablation for the treatment of Morton's neuroma was a safe procedure that significantly reduced pain and may offer an alternative therapy to surgery.

[Clinical vignette for the medical school student: jugular foramen syndrome]. / La vignette diagnostique de l'etudiant. Syndrome du trou déchiré postérieur (foramen jugulaire).

Cranial neuropathies are frequent and their semiological analysis is the basis of the diagnostic workup. This is even more true in the case of multiple cranial neuropathies. We here propose a diagnostic exercise in the case of a simultaneous cranial nerves IX (glossopharyngeal), X (vagus) and XI (spinal) deficit. This case exemplifies that knowledge of nervous anatomy and physiology is the basis of the semiology of the nervous system.

Musical therapy attenuates neuroma pain by modifying leptin expression.

BACKGROUND: Accumulating evidence reveals that music therapy appears to help patients with pain. However, there is a limited understanding of the underlying mechanisms. Several studies indicate that leptin level has a crucial relationship with acute and chronic pain. Herein, we evaluated the effects of music stimulation and the potential roles of adipokines (leptin) in pain behaviors. METHODS: We used a tibial neuroma transposition (TNT) rat model to mimic neuroma pain. Adult male Sprague-Dawley rats were randomly assigned to one of the three groups (n = 6):group 1 (GC), TNT with white noise; group 2(GM), TNT with music; and group 3(GH), TNT. White noise and music stimulation was given once a day following surgery until the end of the study (42nd day). Pain behavioral tests were carried out before surgery and on the 3rd, 10th, 14th, 21st, 28th, 35th, and 42nd days after surgery. At the end of the observation period, we analyzed the histological samples of blood, spinal cord, and prefrontal cortex to investigate the role of leptin in pain behaviors modulated by white noise and sound stimulation. RESULT: Music therapy might improve the pain of TNT rats. Music stimulation ameliorated paw withdrawal thermal latency (PWTL) from the 3rd day after the surgery while the mechanical pain was improved 21 days after the operation.Music stimulation also increased leptin expression in the spinal cord, prefrontal cortex.White noise had no obvious effect. CONCLUSION: Music therapy might improve the pain of TNT rats. Besides, music stimulation ameliorated TNT-induced pain behaviors and affected leptin expression.

Spinal cord stimulation for recurrent painful neuromas of the foot.

The authors report the case of a patient affected by recurrent neuromas of the interdigital nerves of the left foot that appeared after surgery for Morton's disease. Implantation of spinal cord stimulation (SCS) system was performed after three unsuccessful surgical revisions, which demonstrated the presence of multiple neuromas growing at endings of the stumps of the nerves and fasciculi. The patient developed chronic neuropathic pain localized within the third metatarsal region of the left foot. Conservative treatments failed and autonomous gait became impossible. SCS immediately abolished pain and the patient was able to perform her normal daily activities within 1 month. At our knowledge, this is the first report in literature of SCS successfully employed for recurrent and refractory pain due to Morton's neuroma.

Alcohol sclerosing therapy is not an effective treatment for interdigital neuroma.

BACKGROUND: Alcohol sclerosing therapy has been reported as a safe and effective means of treating interdigital neuromas, both with or without ultrasound. The use of ultrasound introduces beside the ultrasound device, increased cost, and the need for skilled technicians and may reduce usability, especially in the outpatient clinic. We report a series of patients with interdigital neuroma treated using ethanol sclerosing therapy in a clinic setting without the use of ultrasound. MATERIALS AND METHODS: We retrospectively reviewed charts of 32 consecutive patients who were enrolled to receive a series of sclerosing ethanol injections from June 2009 to April 2010 for the treatment of a painful interdigital neuroma. Plain radiographs and MRI scans were obtained if clinically indicated to assistance with the diagnosis. Duration and quality of symptoms were recorded and current pain levels were evaluated on a visual analog pain scale. Previous treatments, including orthotic use, corticosteroid injection, or prior neuroma resection were reported. A solution of 1 ml consisting of 20% ethanol and 0.25% bupivacain solution was injected without the use of ultrasound into the affected webspace. The mixture was provided by the local pharmacy. Technical success was confirmed by the temporary resolution of pain following local anesthetic infiltration. If still symptomatic, an injection was repeated every 2 weeks, with most patients receiving a series of four injections. Pain was evaluated on a visual analog pain scale at each visit. Treatment success was defined as resolution of pain as expressed by the patient. RESULTS: Of the 32 patients successful relief of symptoms was only achieved in seven patients, while 25 showed no significant reduction of symptoms and considered or underwent a surgical excision. CONCLUSION: Alcohol sclerosing therapy administered in the clinic setting without alcohol is not an effective treatment in the nonoperative management of painful interdigital neuromas and has been abandoned in our clinic.

Nonsurgical Approaches to Neuroma Management.

Symptomatic neuromas and chronic neuropathic pain are significant problems affecting patients' quality of life and independence that are challenging to treat. These symptoms are due to structural and functional changes that occur peripherally within neuromas, as well as alterations that occur centrally within the brain and spinal cord. A multimodal approach is most effective, with goals to minimize opioid use, to capitalize on the synergistic effects of nonopioid medications and to explore potential benefits of novel adjunctive treatments.

Effects of 4% Ethanol Sclerosing Injection on Morton's Neuroma: A Histologic Study.

BACKGROUND: Nonoperational treatments for Morton's neuroma remain controversial because it is believed that sclerosing injections do not change nerve fibers on a cellular level. Up to 80% success rates with 4% ethanol sclerosing have been documented, and the remainder required operational removal of the painful nerve. We sought to evaluate the histologic characteristics of Morton's neuromas treated with 4% ethanol sclerosing injection versus corticosteroid injection alone in patients who required removal of the nerve for pain relief. METHODS: A retrospective histologic review was performed of 23 consecutive patients who were treated with either sclerosing injection or nonsclerosing injection and underwent nerve removal between September 1, 2012, and February 28, 2015. RESULTS: Of 19 patients who met the inclusion criteria, eight received sclerosing injections and 11 received nonsclerosing injections. Intraneural fibrosis was more severe in the nonsclerosing injection group (P = .008). CONCLUSION: Histologic changes are seen in Morton's neuroma with the use of 4% ethanol sclerosing injection, contrary to findings from previous studies.

A case series of pulsed radiofrequency treatment of myofascial trigger points and scar neuromas.

INTRODUCTION: Pulsed radiofrequency (PRF) current applied to nerve tissue to treat intractable pain has recently been proposed as a less neurodestructive alternative to continuous radiofrequency lesioning. Clinical reports using PRF have shown promise in the treatment of a variety of focal, neuropathic conditions. To date, scant data exist on the use of PRF to treat myofascial and neuromatous pain. METHODS: All cases in which PRF was used to treat myofascial (trigger point) and neuromatous pain within our practice were evaluated retrospectively for technique, efficacy, and complications. Trigger points were defined as localized, extremely tender areas in skeletal muscle that contained palpable, taut bands of muscle. RESULTS: Nine patients were treated over an 18-month period. All patients had longstanding myofascial or neuromatous pain that was refractory to previous medical management, physical therapy, and trigger point injections. Eight out of nine patients experienced 75-100% reduction in their pain following PRF treatment at initial evaluation 4 weeks following treatment. Six out of nine (67%) patients experienced 6 months to greater than 1 year of pain relief. One patient experienced no better relief in terms of degree of pain reduction or duration of benefit when compared with previous trigger point injections. No complications were noted. DISCUSSION: Our review suggests that PRF could be a minimally invasive, less neurodestructive treatment modality for these painful conditions and that further systematic evaluation of this treatment approach is warranted.

Traumatic neuroma of extrahepatic bile ducts after orthotopic liver transplantation.

Traumatic neuromas (TN) of the biliary tree causing strictures have only occasionally been described after liver transplantation. Herein, we have reported 15 cases of TN that were detected between 1 and 17 months after transplantation (median: 4 months) during surgery for obstructive jaundice (12 cases), after alterations of liver function tests (two cases), or incidentally discovered after retransplantation (n = 1) we resected the lesion and the biliary anastomosis. Pathological examination and immunostaining for S-100 protein were performed to study the nerve fascicles. After a median follow-up time of 64 months (range = 0-127), 10 patients are alive without any complication related to the previous biliary TN. We propose the following classification: type I: TN originating from and located in the main biliary tract wall, and type II: TN arising from the surrounding tissues next to the main biliary tract. We conclude that TN are not uncommon after liver transplantation and that they are sometimes symptomatic, causing a biliary stricture that requires surgical treatment. We propose a classification to help patient selection for surgery. In our opinion, resection of the TN is the operation of choice, together with resection of the involved biliary tract in type I TN.

Heel neuroma: a case study.

UNLABELLED: This article reviews the diagnosis, pathology, and treatment of plantar heel neuroma, an entity that has previously been described and recognized, yet one that we feel warrants further review because of the prevalence of plantar heel pain that does not respond to the usual array of treatments. We feel that neuroma of the medial calcaneal nerve often goes undiagnosed, and may progress to a severely painful condition that requires surgical intervention. In this article, we describe another case of heel neuroma in an otherwise healthy patient with a history of chronic plantar heel pain that was unresponsive to a wide array of nonsurgical treatments. LEVEL OF CLINICAL EVIDENCE: 4.

Traumatic neuroma in mastectomy scar: Two case reports and review of the literature.

RATIONALE: Traumatic neuroma is a reparative proliferative response of the nerve after trauma or surgery, which rarely occurs in the breast. However, it must be distinguished from tumor recurrence. PATIENT CONCERNS: A 78-year-old woman underwent left-sided modified radical mastectomy for invasive carcinoma, 7 years before this case. Two painless nodules near the mastectomy scar were discovered in regular follow-up physical examination. A 62-year-old woman had received right-sided modified radical mastectomy for intraductal carcinoma, 4 years before this case. An asymptomatic nodule near the mastectomy scar was detected during follow-up ultrasound (US) examination. DIAGNOSIS: The lesions in both patients were diagnosed as traumatic neuroma. INTERVENTIONS: The first patient underwent excisional biopsy. The second patient underwent US guided core-needle aspiration, followed by conservative therapy. OUTCOMES: Neither patient complained of any discomfort, nor both exhibited normal physical and US findings during follow-up examinations. LESSONS: Newly discovered nodules with the benign imaging features near the mastectomy site of a patient, especially with the tail sign, traumatic neuromas should be taken into consideration. Routine US examination is important for follow-up of breast cancer patients who have undergone mastectomy.

Practical experience with sonographically guided phenol instillation of stump neuroma: predictors of effects, success, and outcome.

OBJECTIVE: Phantom limb pain and stump pain frequently occur after limb amputation, and stump neuromas play an important role in generation of the pain. The purpose of this study was to evaluate the effects of a previously described optimized procedure for sclerosis of painful stump neuromas under real-time high-resolution sonographic guidance. SUBJECTS AND METHODS: In this prospective study, neurosclerosis was performed on 82 patients by means of high-resolution sonographically guided injection of up to 0.8 mL of 80% phenol solution according to a standardized protocol. RESULTS: During treatment all patients had marked improvement in terms of reduction of pain measured with a visual analog scale. Twelve (15%) of the subjects were pain free after one to three treatments, nine of the 12 achieving relief with the initial instillation. At 6-month follow-up evaluation, 52 patients assessed their present pain quantity with a simplified three-step score. Twenty (38%) of the 52 patients reported almost unnoticeable pain, and 33 (64%) reported pain equal to the minimum reached during therapy. In 18 (35%) of the 52 patients, the incidence of painful periods had markedly decreased. The neurosclerosis procedure had a low complication rate (5% rate of minor complications, 1.3% rate of major complications). CONCLUSION: The high-resolution sonographically guided neurosclerosis procedure had a significantly better outcome than other documented treatments. Sonographically guided neurosclerosis should be included in the management of chronic phantom limb and stump pain.

[Multifrequency vestibular study after vestibular neurotomy and chemical labyrinthectomy]. / Etude vestibulaire multifréquentielle après neurotomie vestibulaire et labyrinthectomie chimique.

OBJECTIVES: Vestibular neurotomy (VN) and chemical labyrinthectomy (CL) are the two most common techniques of vestibular deafferention to treat patients with intractable vertigo. A long-term evaluation of vestibular function has been performed with a variety of vestibular tests to find out whether there persisted any residual vestibular function after each technique. METHODS: We called in all patients who have been treated for the last 10 years and have no known vestibular disease in the non treated ear. Low frequencies were analyzed with caloric tests, medium frequencies with the head-shaking test and head-impulse test, and high frequencies with the skull vibration test. The otolithic function was explored with the subjective vertical visual analysis and otolithic myogenic evoked potentials. Nine patients treated with VN and 12 with CL presented to our department. We were thus able to compare VN and CL patients with a group of 10 normal patients and another group of nine patients that had had a translabyrinthine approach for an acoustic neuroma. RESULTS: We found out that vestibular responses did persist in seven out of nine (78 %) patients after VN and 11 out of 12 (92 %) patients after CL. On the other hand, no vestibular response was detected following resection of vestibular schwannoma through a translabyrinthine approach. CONCLUSION: We came to the conclusion that the two latter techniques, unlike vestibulocochlear nerve section via the translabyrinthine approach, are only incomplete methods of vestibular deafferention.