Phantom Limb Pain and Painful Neuroma After Dysvascular Lower-Extremity Amputation: A Systematic Review and Meta-Analysis.

BACKGROUND: Phantom limb pain (PLP) and symptomatic neuroma can be debilitating and significantly impact the quality of life of amputees. However, the prevalence of PLP and symptomatic neuromas in patients following dysvascular lower limb amputation (LLA) has not been reliably established. This systematic review and meta-analysis evaluates the prevalence and incidence of phantom limb pain and symptomatic neuroma after dysvascular LLA. METHODS: Four databases (Embase, MEDLINE, Cochrane Central, and Web of Science) were searched on October 5th, 2022. Prospective or retrospective observational cohort studies or cross-sectional studies reporting either the prevalence or incidence of phantom limb pain and/or symptomatic neuroma following dysvascular LLA were identified. Two reviewers independently conducted the screening, data extraction, and the risk of bias assessment according to the PRISMA guidelines. To estimate the prevalence of phantom limb pain, a meta-analysis using a random effects model was performed. RESULTS: Twelve articles were included in the quantitative analysis, including 1924 amputees. A meta-analysis demonstrated that 69% of patients after dysvascular LLA experience phantom limb pain (95% CI 53-86%). The reported pain intensity on a scale from 0-10 in LLA patients ranged between 2.3 ± 1.4 and 5.5 ± .7. A single study reported an incidence of symptomatic neuroma following dysvascular LLA of 5%. CONCLUSIONS: This meta-analysis demonstrates the high prevalence of phantom limb pain after dysvascular LLA. Given the often prolonged and disabling nature of neuropathic pain and the difficulties managing it, more consideration needs to be given to strategies to prevent it at the time of amputation.

Symptomatic Neuroma Development following En Bloc Resection of Skeletal and Soft-Tissue Tumors: A Retrospective Analysis of 331 Cases.

BACKGROUND: Although symptomatic neuroma formation has been described in other patient populations, these data have not been studied in patients undergoing resection of musculoskeletal tumors. This study aimed to characterize the incidence and risk factors of symptomatic neuroma formation following en bloc resection in this population. METHODS: The authors retrospectively reviewed adults undergoing en bloc resections for musculoskeletal tumors at a high-volume sarcoma center from 2014 to 2019. The authors included en bloc resections for an oncologic indication and excluded non-en bloc resections, primary amputations, and patients with insufficient follow-up. Data are provided as descriptive statistics, and multivariable regression modeling was performed. RESULTS: The authors included 231 patients undergoing 331 en bloc resections (female, 46%; mean age, 52 years). Nerve transection was documented in 87 resections (26%). There were 81 symptomatic neuromas (25%) meeting criteria of Tinel sign or pain on examination and neuropathy in the distribution of suspected nerve injury. Factors associated with symptomatic neuroma formation included age 18 to 39 [adjusted OR (aOR), 3.6; 95% CI, 1.5 to 8.4; P < 0.01] and 40 to 64 (aOR, 2.2; 95% CI, 1.1 to 4.6; P = 0.04), multiple resections (aOR, 3.2; 95% CI, 1.7 to 5.9; P < 0.001), preoperative neuromodulator requirement (aOR, 2.7; 95% CI, 1.2 to 6.0; P = 0.01), and resection of fascia or muscle (aOR, 0.5; 95% CI, 0.3 to 1.0; P = 0.045). CONCLUSION: The authors' results highlight the importance of adequate preoperative optimization of pain control and intraoperative prophylaxis for neuroma prevention following en bloc resection of tumors, particularly for younger patients with a recurrent tumor burden. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Systematic Review and Meta-Analysis of Global Neuroma Incidence in Upper Extremity Amputees.

BACKGROUND: Neuromas substantially decrease a patient's quality of life and obstruct the use of prosthetics. This systematic review and meta-analysis aimed to determine the global incidence of neuroma formation in upper extremity amputees. METHODS: A literature search was performed using 3 databases: Web of Science, MEDLINE, and Cochrane. Inclusion criteria for the systematic review were those studies investigating only upper extremity amputees and reported postamputation neuroma. A random-effects, inverse-variance analysis was conducted to determine the pooled proportion of neuromas within the upper extremity amputation population. Critical appraisal using the JBI Checklist for Studies Reporting Prevalence Data of each individual article were performed for the systematic review. RESULTS: Eleven studies met the inclusion criteria collating a total of 1931 patients across 8 countries. More than three-fourth of patients are young men (77%; age range, 19-54 years) and had an amputation due to trauma. The random-effects analysis found the pooled combined proportion of neuromas to be 13% (95% confidence interval, 8%-18%). The treatment of neuroma is highly variable, with some patients receiving no treatment. CONCLUSIONS: The pooled proportion of neuroma incidence in the 1931 patients was 13%. With the known global prevalence of upper extremity amputees, this translates to nearly 3 million amputees suffering from a neuroma globally. Increasing training in preventative surgical methods could contribute to lowering this incidence and improving the outcomes of this patient population.

Epidemiology, risk factors, diagnosis, and treatment of intra-abdominal traumatic neuromas - a narrative review.

Traumatic neuroma (TN) is a disorganized proliferation of injured nerves arising from the axons and Schwann cells. Although TN rarely occurs in the abdominal cavity, the incidence of TN may be underestimated because of the large number of asymptomatic patients. TN can cause persistent pain, which seriously affects quality of life. TN of the biliary system can cause bile duct obstruction, leading to acute cholangitis. It is difficult to differentiate TN from malignancies or recurrence of malignancy, which results in a number of patients receiving aggressive treatment. We collected cases reports of intra-abdominal TN over the past 30 years form PubMed and cases diagnosed in our medical center over the past 20 years, which is the largest case series of intra-abdominal TN to the best of our knowledge. In this review, we discuss the epidemiology, pathophysiology, risk factors, classification, diagnosis, and management of intra-abdominal TN.

Incidence and Nerve Distribution of Symptomatic Neuromas and Phantom Limb Pain after Below-Knee Amputation.

BACKGROUND: Patients with major lower limb amputations suffer from symptomatic neuromas and phantom-limb pain due to their transected nerves. Peripheral nerve surgery techniques, such as targeted muscle reinnervation and regenerative peripheral nerve interface, aim to physiologically prevent this nerve-specific pain. No studies have specifically reported on which nerves most frequently cause chronic pain. The authors studied the nerve-specific incidence of symptomatic neuroma formation and phantom limb pain in patients undergoing a below-knee amputation, to better tailor use of targeted muscle reinnervation and regenerative peripheral nerve interface. METHODS: This was a retrospective review of all patients undergoing a below-knee amputation from January 1, 2013, to December 31, 2018, at MedStar Georgetown University Hospital. All below-knee amputations were performed with a posterior skin flap, myotenodesis, and traction neurectomies of all nerves. Postoperative notes were reviewed for the presence of a symptomatic neuroma, defined as localized pain and a Tinel sign over a known sensory nerve, and nerve-specific phantom limb pain, defined as pain of the missing limb corresponding to a known dermatome. RESULTS: One hundred ninety-eight patients were included in this study. The rate of symptomatic neuroma formation was 14.6 percent (29 of 198), with the superficial peroneal and saphenous nerves most often involved. Diabetes and obesity were protective against symptomatic neuroma formation. The rate of nerve-specific phantom limb pain was 12.6 percent (25 of 198) and highly correlated with the presence of a symptomatic neuroma. CONCLUSION: To optimize outcomes for amputees, it is critical that surgeons best understand what nerves are more likely to form symptomatic neuromas and lead to nerve-specific phantom limb pain, so that surgeons can best tailor primary or secondary management of the major sensory nerves. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

A Systematic Review and Meta-analysis on the Incidence of Patients With Lower-Limb Amputations Who Developed Symptomatic Neuromata in the Residual Limb.

BACKGROUND: Neuromata developed after major extremity amputation can cause pain, limit the use of prosthetics, and negatively affect the quality of life. The frequency of postamputation neuroma varies widely. The objective of this study was to determine the incidence of patients who developed symptomatic neuromata after lower-limb amputation through a systematic review and meta-analysis. METHODS: A systematic review of the literature was performed on 4 major databases. Studies that reported the incidence of symptomatic neuroma in lower-limb amputees were included. A meta-analysis was performed to calculate the pooled incidence of neuromata. RESULTS: Thirteen studies consisting of 1329 patients were included in this meta-analysis. The reported incidence of patients who developed symptomatic neuromata ranged between 4% and 49%. The median duration of follow-up was 8.6 years (interquartile range, 2.0-17.4 years). The pooled percentage (95% confidence interval [CI]) of lower-limb amputees who developed symptomatic neuromata was 19% (12%-29%). In studies with a duration of follow-up at least 3 years, the pooled percentage (95% CI) of lower-limb amputees who developed symptomatic neuromata was 30% (22%-40%). In studies with a follow-up period of fewer than 3 years, the pooled percentage (95% CI) of neuroma incidence was 3% (2%-6%). CONCLUSIONS: In summary, the overall incidence of patients who developed symptomatic neuromata was 19% or approximately 1 in 5 lower-limb amputees. Symptomatic neuromata are more commonly diagnosed when the follow-up period is longer than 3 years. These findings suggest that neuroma after amputation might be underestimated in studies with a short duration of follow-up.

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.

Prevalence of residual limb pain and symptomatic neuromas after lower extremity amputation: a systematic review and meta-analysis.

ABSTRACT: Residual limb pain (RLP) is associated with (partial) extremity amputations and is defined as pain felt in the remaining part of the amputated limb. A common cause of RLP is neuroma formation after nerve transections. Neuromas can be very painful and severely debilitating pathologies, preventing prosthetic use, reducing quality of life, and requiring medication. Residual limb pain and symptomatic neuromas are often not properly recognized by physicians explaining the varying prevalence in the literature. This systematic review and meta-analysis aim to provide a comprehensive overview of published literature on the prevalence of RLP and symptomatic neuroma after lower extremity amputation. Studies reporting the prevalence of RLP and symptomatic neuroma pain in patients who have had a lower extremity amputation published between 2000 and 2020 were identified in PubMed and Embase. Random-effects meta-analyses of proportions were performed to quantify the prevalence of RLP and symptomatic neuroma. Subgroups were identified and analysed. For RLP, the pooled prevalence was 59% (95% CI: 51-67). For symptomatic neuromas, the pooled prevalence was 15% (95% CI: 7-28). Residual limb pain subgroup analysis showed statistically significant higher prevalence in patients aged >50 years, follow-up >2 years, and in studies using a self-administered questionnaire for data collection. The prevalence of RLP and symptomatic neuroma in patients who have had a lower extremity amputation is 59% and 15%, respectively. Knowledge of their high prevalence may result in better awareness among physicians, in turn providing timely and adequate management.

Sex Correlation to the Prevalence of Pedal Neuromas in Various Interspaces: A Retrospective Study.

BACKGROUND: Morton's neuromas are abnormalities of the common digital nerve branch located between the lesser metatarsal heads. Historically, interdigital (Morton's) neuromas have been characterized as being most common in the third interspace and in females. The principal investigator observed Morton's neuromas commonly in the second and third interspaces in both sexes. To our knowledge, no literature exists to evaluate Morton's neuroma location with a focus on each sex independently. The present study evaluates Morton's neuroma interspace location and whether there is a variation by sex. METHODS: In this retrospective study, 582 deidentified magnetic resonance imaging reports with a diagnosis code for Morton's neuroma were evaluated for patients scanned from January 2, 2015, through April 19, 2016. Incomplete records and those with radiologist findings inconsistent with Morton's neuroma were eliminated. For the remaining 379 patients, data were collected on sex, laterality, history of trauma, plantar plate tear, age, and interspace location. Special focus was given to second and third interspace Morton's neuromas. Data were evaluated using the Pearson χ2 and independent-samples Mann-Whitney U tests, with P < .05 indicating statistical significance. RESULTS: No statistically significant distribution between sex and second and third interspace Morton's neuromas was noted. Right vs left foot, age, and history of trauma did not vary statistically significantly between sexes. There was a statistically significant difference between the presence of plantar plate tears between sexes. Male patients with Morton's neuromas were found to have a higher rate of plantar plate tears (P = .01). CONCLUSIONS: This study found that there were no statistically significant differences between sexes and Morton's neuromas location, laterality, or age.

Description and classification of postpartum chronic pain: A multicentric prospective study.

INTRODUCTION: To classify persistent perineal and pelvic postpartum pain using the classification usually employed in chronic pelvic pain. MATERIAL AND METHOD: Prospective observational study including all women who have consulted an algologist or gynecologist at one of the six French centers for a chronic pain (superior or equal to 3 months) spontaneous linked by the mother with her childbirth were included. During semi-directed interviews, a questionnaire regarding sociodemographic factors and detailed questions about pain were collected. Then, pelvic and perineal pain were classified into 7 pain syndromes: pelvic sensitization (Convergences PP criteria), complex regional pain syndrome (Budapest criteria), pudendal or cluneal neuralgia (Nantes criteria), neuroma, thoraco-lumbar junction syndrome, myofascial pain (muscle trigger zone), fibromyalgia (American College of Rheumatology criteria). The principal objective of this study is to assess the prevalence of each painful disorder. The secondary aims were the description of socio-demographic factors and clinical characteristics of this population, identify the related symptoms and the impact on daily function associated with the chronic pelvic or perineal postpartum pain. RESULTS: 40 women with chronic pelvic or perineal pain spontaneously linked with childbirth were included. 78 % experienced pain for more than 12 months. A large majority had a vaginal birth (95 %) with perineal suture (90 %) and severe acute pain within the first week postpartum (62 %). Postpartum pain impacted participant's sexual activity (80 %), micturition (28 %) and defecation (38 %). In the sample, 17 cases of neuroma, 6 patients with pudendal or cluneal neuralgia, 13 patients with pelvic sensitization and 2 cases of fibromyalgia were identified. Complex regional pain syndrome was diagnosed in 8 patients, and myofascial pain in 11 women, and only 1 patient had thoraco-lumbar junction syndrome. Neuropathic pain was found in 31 participants (77.5 %) according to DN4 criteria. DISCUSSION: The classification scheme proposed in this study may be a very useful tool to investigate postpartum pelvic and perineal pain and to propose a treatment.

Prophylactic Regenerative Peripheral Nerve Interfaces to Prevent Postamputation Pain.

BACKGROUND: Postamputation pain affects a large number of individuals living with major limb loss. Regenerative peripheral nerve interfaces are constructs composed of a transected peripheral nerve implanted into an autologous free muscle graft. The authors have previously shown that regenerative peripheral nerve interfaces can be used to treat symptomatic end neuromas that develop after major limb amputation. In this study, they investigated the potential of prophylactic interfaces to prevent the formation of symptomatic neuromas and mitigate phantom limb pain. METHODS: Patients who underwent limb amputation with and without prophylactic regenerative peripheral nerve interface implantation were identified. A retrospective review was performed to ascertain patient demographics, level of amputation, and postoperative complications. Documentation of symptomatic neuromas and phantom limb pain was noted. RESULTS: Postoperative outcomes were evaluated in a total of 90 patients. Forty-five patients underwent interface implantation at the time of primary amputation, and 45 control patients underwent amputation without interfaces. Six control patients (13.3 percent) developed symptomatic neuromas in the postoperative period compared with zero (0.0 percent) in the prophylactic interface group (p = 0.026). Twenty-three interface patients (51.1 percent) reported phantom limb pain, compared with 41 control patients (91.1 percent; p < 0.0001). CONCLUSIONS: Prophylactic regenerative peripheral nerve interfaces in major limb amputees resulted in a lower incidence of both symptomatic neuromas and phantom limb pain compared with control patients undergoing amputation without regenerative peripheral nerve interfaces, suggesting that prevention of peripheral neuromas following amputation may diminish the central pain mechanisms that lead to phantom limb pain. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Incidence and associations of painful neuroma in a contemporary cohort of lower-limb amputees.

BACKGROUND: The painful post amputation neuroma significantly impairs the prosthesis-wearing lower-limb amputee. It remains poorly understood, with literature limited to cohorts of traumatic amputees. This paper reports the incidence and associations of painful neuroma in a modern tertiary centre with a case load of amputations performed for both traumatic and non-traumatic indications. METHOD: This retrospective cohort study analysed the records of 304 patients who underwent all-cause lower-limb amputation at The Alfred Hospital between January 2002 and March 2012. Patients were included in our analysis if they completed 1-year follow-up at our Amputee Rehabilitation Clinic, producing a final cohort of 96 patients. In order to identify a painful neuroma post-operatively, both clinical suspicion, and either histopathological or radiological evidence were required. RESULTS: The overall incidence of symptomatic neuromas was 4.17%. There was no significant difference between patients who underwent amputation for a traumatic indication (6.25% (2/32) versus 3.13% (2/64); P = 0.59) compared to non-traumatic indication (P = 0.59). Visual analogue score at discharge and the presence of phantom limb pain at follow-up showed significant associations with the formation of painful neuroma. Dose of opioid on discharge, history of depression and current smoking did not reach statistical significance. CONCLUSION: This study presents a lower incidence of painful post-amputation neuroma to those published in the literature. This may be attributed to improved methodology. The described associations require further investigation into central factors leading to neuroma sensitization.

[Incidence of painful neuroma after end-to-end nerve suture wrapped into a collagen conduit. A prospective study of 185 cases]. / Incidence des douleurs névromateuses après manchonnage par un tube de collagène des sutures nerveuses directes. Étude prospective de 185 cas.

Three to 5% of the nerves directly and correctly sutured evolve towards significant neuropathy pain. The psychological, social and economic impact of such a consequence is very important. The purpose of this retrospective study was to evaluate the incidence of the occurrence of a trigger zone or a neuroma, at 6months of maximum follow-up after direct nervous suture bushed in a type 1 collagen tube. Every patient taken care for a traumatic nervous injury from November 2008 to March 2012 was included in the study. The exclusion criteria were any replantation, nervous tissue defect and any distal nervous stump which could not technically be wrapped around. The only conduct used was made of collagen type 1 (Revolnerv(®), Orthomed™). All patients were examined after one, three and sixmonths for a clinical evaluation made by the same surgeon. The apparition of a trigger zone or a real neuroma was clinically assessed. One hundred and seventy-four patients for a total of 197 sutured nerves were included in the study. At the 6 months follow-up, 163 patients were evaluated for a total of 185 nerves. No patient suffered from a neuroma at this time. As the treatment of neuroma is very difficult, considering the cost and the results, wrapping direct end-to-end sutures by a collagen type 1 tube seems helping to prevent the appearance of a neuroma.

Morphology of plantar interdigital neuroma: a comparative cadaveric study of elderly Finnish and Japanese individuals.

To examine morphological differences in Morton's interdigital neuroma between two elderly human populations, we conducted comparative study using 40 Japanese (27 males, 13 females; mean age, 81.2 years) and 21 Finnish (6 males, 15 females; mean age, 80.5 years) cadavers. We defined the neuroma as a thickening of the nerve of at least two-fold relative to the non-pathological proximal part. The incidence of this neuroma was 25% (10/40) in the Japanese and 33.3% (7/21) in the Finnish cadavers. Moderate or severe hallux valgus (with an angle of more than 20 degrees) was seen in half of the 40 Japanese cadavers (7 males, 13 females), but was absent in the Finnish cadavers. Such hallux valgus was present in 7 (5 males, 2 females) of the 10 Japanese cadavers with neuroma. Moreover, in 2 Japanese cadavers, a paper-like, specialized type of neuroma was associated with the deformity. Pathogenesis of Morton's neuroma might be different between human populations with or without hallux valgus.

The incidence of symptomatic neuroma in amputation and neurorrhaphy patients.

PURPOSE: The incidence of symptomatic neuroma in finger nerve injuries varies widely in the literature. In this retrospective study, we evaluated the incidence of symptomatic neuroma after repair of digital nerve injuries (neurorrhaphy) and after amputation of one or more fingers. We also determined the need for re-operation on symptomatic neuroma patients. METHODS: In a retrospective study, we collected data from medical files. All patients who were treated for a hand trauma in the emergency department during the last 10 years were included. We gathered data on the presence of symptomatic neuroma and re-operation of the patients. RESULTS: In our database, 583 people had a peripheral nerve injury of whom 177 people had an amputation. The incidence of digital nerve injury without amputation followed by neurorrhaphy was 1%. In digital nerve injuries with amputation the incidence was 7.8%, which is significantly higher than after digital nerve injuries without amputation. CONCLUSIONS: People with an amputation injury have significantly more symptomatic neuroma than people who undergo neurorrhaphy. People who have a symptomatic neuroma after digital nerve injuries have been operated significantly more than people who have a non-symptomatic neuroma or no neuroma at all. This information can be of help when treating digital nerve injuries. TYPE OF STUDY/LEVEL OF EVIDENCE (LOE): Prognostic.

Fibroproliferative neuromas may occur after iatrogenic injury for lipomatosis of nerve.

BACKGROUND: Lipomatosis of nerve (LN) is a condition associated with nerve-territory overgrowth. We have noted a unique type of neuroma at sites of LN injury; the neuroma extends beyond the epineurium, enhances, and appears to enlarge over time. OBJECTIVE: We sought to understand the relationship between fibroproliferative scarring and surgery performed on the nerve. METHODS: A review of the searchable records for LN at our institution found 52 cases, confirmed by pathology or pathognomonic appearance on magnetic resonance imaging (MRI). Clinical histories were reviewed to categorize the surgeries performed by the degree of iatrogenic injury to the nerve. Postoperative MRI was performed in 22 of the 46 patients who had surgery, which was then retrospectively reviewed for fibroproliferative neuromas. RESULTS: Complex and masslike neuromas were found on MRI, correlating with the degree of iatrogenic injury to the nerve. These fibrous neuromas proliferated beyond the epineurium, disrupted fascicular architecture, were contrast enhancing when contrast was administered, indicative they were unique and unlike stump or traction neuromas. Of the 8 patients who underwent surgery involving nerve decompression alone, none developed fibroproliferative neuromas. Of the 7 patients who underwent surgery involving nerve debulking, fibroproliferative neuromas developed in 4. Of the 11 patients who underwent surgery involving nerve transection, all developed fibroproliferative neuromas (P < .001). There was also a high incidence of hypertrophic scarring of the skin incision (21.3%). CONCLUSION: Surgical injury of LN appears to be strongly associated with the development of fibroproliferative neuromas. It is possible that the pathological overgrowth stimulus associated with LN promotes exuberant scar formation.

Surgical treatment of patients with facial neuromas--a report of 26 consecutive operations.

OBJECTIVE: To analyze surgical treatment and outcome in patients with facial neuromas at a tertiary referral hospital. STUDY DESIGN: A chart review of 26 patients treated between 1971 and 2006, with questionnaire follow-up ranging from 2 to 19 years. All patients except one were operated with radical tumor removal approaches. RESULTS: Approximately 54% of the patients presented with symptoms related to the VIIth cranial nerve (facial palsy and facial spasm), 58% with symptoms related to the VIIIth cranial nerve (hearing deficit, tinnitus, and vertigo), and 8% related to the Vth cranial nerve (facial pain and facial sensory deficit). Approximately 39% presented with no facial symptoms. Twenty-one patients received a facial nerve graft from the greater auricular nerve or the sural nerve; 1 patient had an accessory-facial anastomosis. One patient had a subtotal tumor removal preserving the facial nerve. Three patients were not grafted. Most tumors (88%) affect the geniculate ganglion. Approximately 82% of the grafted patients regained a House-Brackmann facial nerve function (HB) grade III; 14% regained HB grades IV to V. No serious morbidity or mortality was reported. No recurrences have been reported where a total tumor removal was performed. CONCLUSION: Surgical removal of facial neuroma is a safe procedure with a low complication rate and a low recurrence rate. First symptoms are diverse and are predominantly derived from the facial and vestibulocochlear nerve. Facial nerve grafting is reliable, giving the patient an acceptable facial nerve function (HB III).

Tumour and tumour-like conditions of peripheral nerve origin: ten years' experience.

BACKGROUND: There are four major lesions which may arise in the peripheral nerve, namely neuroma, schwannoma, neurofibroma and malignant peripheral nerve sheath tumor. OBJECTIVE: In the present study we look into the spectrum of peripheral neural tumors including their age distribution site distribution and histopathology. MATERIALS AND METHODS: This is retrospective study conducted in the Dept of Pathology, Manipal Teaching Hospital, Pokhara. All histopathologically diagnosed cases of primary lesions of peripheral nerve during the period Jan 2000 to Nov 2009 were reviewed and the data were analysed. RESULT: A total of 114 cases of peripheral neural lesions were reported in the same period. Total number of nonmalignant cases was 106 (93%) while malignant cases were 8 (7%). Among the nonmalignant cases neurofibroma was the commonest (51 cases, 45% of all) closely followed by schwannoma (39 cases, 34% of all). Among the neurofibroma cases only 2 cases had multiple neurofibromatosis while others were solitary. Among the schwannoma cases 4 were diagnosed as ancient schwannoma with presence of bizarre cells with hyperchromatic nuclei. The commonest site involved for both schwannoma and neurofibroma was scalp-face-neck followed by back. The age range for schwannoma was 16 to 75 years whereas the same for the neurofibroma cases was 2 to 82 years. MPNST cases were seen in the age range of 40 to 72 with 3 cases in upper extremity, 3 in lower extremity and 1 each in lip and cheek. 1 case was diagnosed as cellular neurofibroma with atypia in tongue and was confirmed by S100. CONCLUSION: The majority of the tumor are benign and the commonest benign tumor was neurofibroma of sporadic type, closely followed by schwannoma. In our study the commonest site was scalp-face-neck unlike other studies. This may be due to more compliance of the patients due to cosmetic reason.

Disorders of the lesser toes.

Lesser toe disorders are an often under-appreciated source of pain and disability in athletes. Patients may have significant symptoms from corns, hammertoe and mallet toe deformities, and metatarsalgia resulting from neuromas and metatarsophalangeal joint instability. Although patients may present with vague symptoms, a careful history and physical examination will point a clinician to an accurate diagnosis. Treatment of these lesser toe disorders is straightforward and leads to predictably good results.

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.