Noninvasive treatment of cutaneous neurofibromas (cNFs): Results of a randomized prospective, direct comparison of four methods.

BACKGROUND: People with Neurofibromatosis Type 1 (NF1) suffer disfigurement and pain when hundreds to thousands of cutaneous neurofibromas (cNFs) appear and grow throughout life. Surgical removal of cNFs under anesthesia is the only standard therapy, leaving surgical scars. OBJECTIVE: Effective, minimally-invasive, safe, rapid, tolerable treatment(s) of small cNFs that may prevent tumor progression. METHODS: Safety, tolerability, and efficacy of 4 different treatments were compared in 309, 2-4 mm cNFs across 19 adults with Fitzpatrick skin types (FST) I-IV: radiofrequency (RF) needle coagulation, 755 nm alexandrite laser with suction, 980 nm diode laser, and intratumoral injection of 10 mg/mL deoxycholate. Regional pain, clinical responses, tumor height and volume (by 3D photography) were assessed before, 3 and 6 months post-treatment. Biopsies were obtained electively at 3 months. RESULTS: There was no scarring or adverse events > grade 2. Each modality significantly (P < .05) reduced or cleared cNFs, with large variation between tumors and participants. Alexandrite laser and deoxycholate were fast and least painful; 980 nm laser was most painful. Growth of cNFs was not stimulated by treatment(s) based on height and volume values at 3 and 6 months compared to baseline. LIMITATIONS: Intervention was a single treatment session; dosimetry has not been optimized. CONCLUSIONS: Small cNFs can be rapidly and safely treated without surgery.

[Trigeminal neuromas: modern diagnosis and treatment]. / Trigeminal'nye nevrinomy: sovremennaya diagnostika i lechenie.

Trigeminal neuroma (TN) is a benign neoplasm arising from trigeminal nerve sheath. The tumor can grow from any part of the nerve from the root in posterior cranial fossa to peripheral extracranial branches. Symptoms of trigeminal neuroma are variable and usually depend on location and dimensions of tumor. We present a review devoted to the problem of TN. Surgery was the only possible option in patients with TN for a long time. However, radiotherapy became one of the options and sometimes alternative to surgical treatment since the late 1980s. Besides active management of patients with TN, follow-up with regular radiographic control of small asymptomatic tumors also seems to be reasonable. When evaluating treatment outcomes, physicians consider quality of life and return to previous work and activity in addition to resection quality, neurological impairment, relapse-free period and tumor growth control. However, assessment of these indicators after certain treatment is rare. Thus, it is difficult to determine treatment strategy with maximum ratio of effectiveness and quality of life. Therefore, optimization of TN treatment is currently an urgent problem that requires further study.

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.

Current Concepts in Upper-Extremity Amputation.

Advances in motor vehicle safety, trauma care, combat body armor, and cancer treatment have enhanced the life expectancy and functional expectations of patients with upper-extremity amputations. Upper-extremity surgeons have multiple surgical options to optimize the potential of emerging prosthetic technologies for this diverse patient group. Targeted muscle reinnervation is an evolving technique that improves control of myoelectric prostheses and can prevent or treat symptomatic neuromas. This review addresses current strategies for the care of patients with amputations proximal to the wrist with an emphasis on recent advancements in surgical techniques and prostheses.

Dorsal Root Ganglion Stimulation for Complex Regional Pain Syndrome (CRPS) Recurrence after Amputation for CRPS, and Failure of Conventional Spinal Cord Stimulation.

BACKGROUND: Limb amputation is sometimes being performed in long-standing complex regional pain syndrome (CRPS), although little evidence is available guiding management decisions, including how CRPS recurrence should be managed. METHODS: This report details the management of a young soldier with CRPS recurrence 2 years after midtibial amputation for CRPS. RESULTS: Conventional spinal cord stimulation did not achieve paraesthetic coverage, or pain relief in the stump, whereas L4 dorsal root ganglion stimulation achieved both coverage and initially modest pain relief, and over time, substantial pain relief. CONCLUSIONS: Current evidence does not support the use of amputation to improve either pain or function in CRPS. Before a decision is made, in exceptional cases, about referral for amputation, dorsal root ganglion stimulation should be considered as a potentially effective treatment, even where conventional spinal cord stimulator treatment has failed to achieve reliable paraesthetic cover. Furthermore, this treatment may provide pain relief in those patients with CRPS recurrence in the stump after amputation.

Peripheral Neuromodulation for the Treatment of Postamputation Neuroma Pain: A Case Report.

Neuroma pain can be severe, persistent, and treatment resistant. We present a case of a 37-year-old female amputee who suffered from severe neuroma pain, which had proved resistant to pharmacologic treatment, glycerol injections, spinal cord stimulation, radiofrequency thermocoagulation, and repeated surgical removals. After treatment with peripheral nerve stimulation, using a St. Jude Medical Octrode lead implanted percutaneously under ultrasound guidance close to her painful neuroma, her ongoing pain dramatically decreased from 8 to 3 on a numeric rating scale (0-10). Peripheral neuromodulation is a promising relatively new treatment that can be used for neuroma pain.

Outcomes of Ultrasound-Guided Extracorporeal Shock Wave Therapy for Painful Stump Neuroma

OBJECTIVE: To investigate the effect of extracorporeal shock wave therapy (ESWT) on painful stump neuroma. METHODS: Thirty patients with stump neuroma at the distal end of an amputation site were assigned randomly to the ESWT group (n=15) and the transcutaneous electrical nerve stimulation (TENS)+desensitization+pharmacological treatment group (n=15). For 3 weeks, the ESWT group received a weekly session involving 1,500 pulses at 0.10 mJ/mm2, while the control group was treated 10 times each, 40 minutes per day with TENS and desensitization treatment, and daily medication for 3 weeks. ESWT stimulation was given by focusing on the area at the neuroma site clearly identified by ultrasound. RESULTS: The changes in the McGill pain questionnaire were 38.8+/-9.0 prior to treatment and 11.8+/-3.1 following the treatment. The corresponding values for the control group were 37.2+/-7.7 and 28.5+/-10.3. The changes between groups were significantly different (p=0.035). The change in visual analog scale prior to and after treatment was 7.0+/-1.5 and 2.8+/-0.8 in the ESWT group, respectively, and 7.2+/-1.4 and 5.8+/-2.0 in the control group. These changes between the groups were also significantly different (p=0.010). The outcome in the pain rating scale also showed significant differences between groups (p0.05). CONCLUSION: The study findings imply that ESWT for stump neuroma is superior to conventional therapy.

Serious axillary nerve injury caused by subscapular artery compression resulting from use of backpacks.

A palsy of the brachial plexus elements caused by carrying a heavy backpack is a very rare injury usually occurring in soldiers or hikers, and recovery is usually spontaneous. We describe here the case of male civilian presenting with an isolated serious axillary nerve palsy associated with chronic backpack use. During the surgery, a dumbbell-shaped neuroma-in-continuity was found which was caused by direct pressure from the subscapular artery. After resection of the neuroma, a nerve graft from the sural nerve was used to reconstruct the nerve. Reinnervation was successful and the patient was able to abduct his arm to its full range, with full muscle strength, within 24 months.

Ultrasound-guided radiofrequency ablation in the management of interdigital (Morton's) neuroma.

OBJECTIVE: To identify the benefits of ultrasound-guided radiofrequency ablation of Morton's neuroma as an alternative to surgical excision. MATERIALS AND METHODS: We studied a consecutive cohort of surgical candidates for Morton's neurectomy who we referred, instead, for radiofrequency ablation (RFA). Under local anaesthetic, RFA was performed under ultrasound guidance, by a single radiologist. This out-patient procedure was repeated after 4 weeks if necessary. We followed patients for a minimum of 6 months to assess their change in visual analogue pain scores (VAS), symptom improvement, complications and progression to surgical excision. RESULTS: Thirty feet in 25 patients were studied. There were 4 men and 21 women with an average age of 55 years (range 33-73 years). All had tried previous methods of conservative management. Forty percent presented with 2nd space neuromas and 60% with 3rd space ones. The average number of treatment sessions was 1.6 (range 1-3, mode 1). Prior to treatment, all patients had pain on activity (VAS average: 6.0, range 3-9). Post-treatment there was a statistically significant reduction in pain scores (post-RFA VAS average: 1.7, range 0-8, p < 0.001). The average overall symptom improvement was 76%. There was one minor complication of temporary nerve irritation. Three neuromas (10%) have progressed to surgical excision; 1 patient has ongoing, unchanged pain with no obvious cause. At 6 months, 26 out of 30 feet had a satisfactory outcome. CONCLUSION: Ultrasound-guided RFA has successfully alleviated patients' symptoms of Morton's neuroma in >85% of cases. Only 10% have proceeded to surgical excision in the short term.

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.

Pacinian Neuroma on the Tips of Fingers / 대한피부과학회지

Pacinian neuroma, also known as hyperplasia and/or hypertrophy of pacinian corpuscles is a rare skin condition usually occurring in the hand. Although it is known to cause pain and tenderness on the affected skin, asymptomatic cases have also been reported. We report a 46-year-old male monk who presented with asymptomatic skin lesions of paler color than the adjacent normal skin on the tips of the fingers of both hands. The 3 mm punch biopsy conducted on the lesion showed an increased number of onion bulb-like structures with a nerve fiber in each center. The patient was diagnosed with pacinian neuroma and has been under regular follow up without treatment.

Sea urchin injuries to the hand: a case report and review of the literature.

Sea urchin injuries to the hand are uncommon. A variety of home remedies can be found on the internet and other sources for dealing with this problem in the acute setting. Many long term complications such as granulomas, arthritis, and tenosynovitis can result from a neglected sea urchin injury. We report an unusual case of a patient with a remote sea urchin injury who presented with ulnar digital nerve paresthesias. A traumatic neuroma was found on surgical exploration. We review the literature on injuries to the hand caused by sea urchins and their management. Management of sea urchin injuries to the hand with retained spines requires surgical debridement in order to prevent significant long term complications including stiffness, tenosynovitis, granulomas, and arthritis.

[Effects of lycium barbarum polysaccharide on formation of traumatic neuroma and pain after transection of sciatic nerve in rats].

OBJECTIVE: To investigate the effects of lycium barbarum polysaccharide (LBP) on the formation of traumatic neuroma and pain after transection of sciatic nerve in rats. METHODS: Forty Sprague-Dawley (SD) rats, weighing 200-220 g, half male and half female, were allocated into 2 groups randomly: LBP group and control group (n = 20 per group). The right sciatic nerves were transected and 2 cm sciatic nerve were removed in all rats of the 2 groups. LBP were intraperitoneally injected in a volume of 10 mg/(kgd) in the LBP group, while the same volume normal saline (NS) in the control group for 28 days. The deficiency of toenail and toe were observed to estimate the autophagy of the operated limb. Light microscope and transmission electron microscope were used to observe the formation of traumatic neuroma after transection of sciatic nerve. RESULTS: Autophagy was observed in 5 rats (25%) of LBP group and in 12 rats (60%) of control group at 4 weeks, showing significant difference (P < 0.05). Neuroma formed in 8 rats (40%) of LBP group and in 16 rats (80%) of control group, showing significant difference (P < 0.05). The observation of light microscope showed that there were unorganized growth cells in the neuroma, infiltrated muscle cells, the regeneration of axons and ensheathing cells to form small patch and funicular structure in the control group, while in the LBP group there were less proliferation of nerve fibers with a regular arrangement. Transmission electron microscope showed that there were lots of axons in nerve tumour, more fusoid fibroblasts, more collagen fiber, and hyperplasia and degenerated myelin sheath in the control group, while in the LBP group there were less myelin sheath in the proximal end of injuring nerves, less Schwann cells and fibroblasts, and sparsed collagen fibers. CONCLUSION: LBP can inhibit autophagy and the formation of traumatic neuroma after transection of sciatic nerve in rats.

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.

Mirror therapy in patients with causalgia (complex regional pain syndrome type II) following peripheral nerve injury: two cases.

OBJECTIVE: To describe the use of mirror therapy in 2 patients with complex regional pain syndrome type II following traumatic nerve injury. DESIGN: Two case reports. SUBJECTS: Two patients with complex regional pain syndrome type II. METHODS: Two patients received mirror therapy with the painful hand hidden behind the mirror while the non-painful hand was positioned so that, from the perspective of the patient, the reflection of this hand was "superimposed" on the painful hand. Pain was measured with a visual analogue scale. RESULTS: The first case had developed a severe burning and constant pain in the hand due to a neuroma. In this patient, a strong reduction in pain was found during and immediately after mirror therapy. As a result, the patient was able to perform active exercises that were previously too painful. However, despite the pain relief during and directly after the exercises, the overall level of pain did not decrease. The second patient also had severe burning pain following a glass injury. In this patient, repeated mirror therapy for a 3-month period strongly decreased pain due to causalgia. CONCLUSION: The presented cases demonstrate that the use of mirror therapy in patients with causalgia related to a neuroma is worthy of further exploration as a potential treatment modality in patients with causalgia.

Vein grafts used as nerve conduits for obstetrical brachial plexus palsy reconstruction.

BACKGROUND: Limited availability of donor nerve grafts along with donor-site morbidity has stimulated research toward other alternatives for the repair of severe nerve injuries. The authors provide a comprehensive review of "tubulization" biology and share with the readers their experience with two cases of obstetrical brachial plexus paralysis where they used vein grafts with "minced" nerve tissue, to accomplish connectivity of proximal donors with distal targets. Usage of vascular tissue as conduits for nerve regeneration was first reported more than 100 years ago. It has been suggested that the vein's wall allows diffusion of the proper nutrients for nerve regeneration, acts as a barrier against ingrowth of scar, and prevents wastage of regenerating axons. METHODS: In this report, vein grafts of 2.4, 3.5, and 22 cm in length filled with minced peripheral nerve tissue were used as bridges in two cases of obstetrical brachial plexus paralysis. RESULTS: By filling the vein lumen with small pieces of nerve tissue suspended in a heparinized saline solution, a potential problem associated with vein collapse caused by compression was solved. CONCLUSION: The authors suggest that tubulization techniques should be kept in mind in clinical practice when autologous nerve grafts are insufficient for distal target connectivity or as an alternative to conventional nerve grafts for bridging certain nerve defects.

Neurectomy of Nerve Branch to Medial Gastrocnemius Muscle for Calf Reduction

In Orientals, hypertrophy of calves frequently found. In 1990, Mladick and Watanabe presented extensive and specific operative techniques for reduction of calves and ankles. however, they cautioned that liposuction should be restricted in the muscular type of calf because their anatomic characteristics led easily to complications and low satisfaction rate. the chief reason for this problem is due to hypertrophy of lower legs that is caused by muscular hypertrophy. In preoperative considerations for the patient selection, most patients have hypertrophy of the gastrocnemius muscles. Calf muscles composed of the medial, lateral gastrocnemius and soleus muscles. To identify the muscle hypertrophy clinically, the patient should stand on toe-tip posture and check out the pinch test for the measurement of fat thickness. Muscular hypertrophy of the calves is divided into 3 types, such as medial upper half, lateral upper half and total hypertrophy with or without excess fat of lower legs. The indications of calves reduction depends on the excess fat of lower leg, calf muscle hypertrophy and combined excess fat and muscle hypertrophy. The methods of calves reduction are as follows weight control, liposuction, calf muscle resection and combined procedures. But the postoperative results are not as dramatic as abdomen and have low satisfaction rate because there are many postoperative complications, such as surface irregularities, asymmetrical shape, scars with hyperpigmentation and infection. I reported that the neurectomy of medial gastrocnemius muscle is the new ideal method on calf muscle hypertrophy with medial bulging by the contraction of medial gastrocnemius muscle on toe tip stance especially in 1993. Recently this method are popular but the procedure needs expert skill. So muscular disuse atrophy by botox injection to medial gastrocnemius muscle is introduced temporarily. Other method such as muscle reduction by RF, denervation method by RF or alcohol injection to the area near nerve branches to medial gastrocnemius below popliteal fossa are also introduced but they are effected temporarily due to reinnervation of neurotization and neuroma in conduits. The surgical procedure is simple, easy and safe method and it can be done under the local anesthesia with sedation. The transverse incision 2 cm in length was done over the distal crease of popliteal fossa, and divided fascia and exposed the tibial nerve. and identify and confirm the 4 branches of medial gastrocnemius, sural, soleus and lateral gastrocnemius with nerve stimulation by electric current and then the nerve branch to medial gastrocnemius muscle has to be divided and removed above 3 cm in length. Skin closure was done with meticulous hemostasis. The postoperative care is simple. The wound was dressed with mild compression and changed daily. The patients can walk and go home immediately after surgery. We recommended early exercise and wearing the pressure garments to support shrinkage and smooth contouring of medial bulging area on calves during 3 months. The postoperative results are very satisfied from 1 to 3 month and there are no functional deficit and no edema, indurations and irregularity. The calf reduction rate was about 10% shrinkage(34cm in diameter on the superior 1/3 calves portion was reduced to 31cm in diameter, mean reduction is 2.5-3cm in diameter.) due to the muscular atrophy caused by neurectomy of medial gastrocnemius. In this report, I described that neurectomy of nerve branch to medial gastrocnemius muscle is a new ideal method for calf reduction and this procedure induce the superior results than the other procedures on calf muscle hypertrophy with 13 years long term follow up. I think my procedure is more rational and also effective, simple, easy, and safe for significant reduction of calves circumference and improvement of cosmesis on hypertrophy of lower leg.