Neuroma-in-continuity: a review of pathophysiology and approach to the affected patient.

A neuroma-in-continuity is a neuroma resulting from a nerve injury in which internal neuronal elements are partially disrupted (with a variable degree of disruption to the endoneurium and perineurium) while the epineurium typically remains intact. The portion of injured axons are misdirected and embedded in connective tissue, which may give rise to local neuroma pain and a distal nerve deficit. The lesion may result from a multitude of injury mechanisms, and clinical presentation is often variable depending on the nerve affected. Clinical, electrodiagnostic, and imaging examinations are helpful in assessing the extent and degree of the lesion. If no clear evidence of recovery is identified within 3-4 months post-injury, the patient may benefit from operative exploration. Surgical management options include neurolysis, neuroma resection, nerve grafting, and nerve transfer, or a combination of modalities. A primary consideration of surgery is the possibility of further downgrading nerve function in the pursuit of more, thereby highlighting the need to carefully weigh the advantages and disadvantages prior to surgical intervention. The objective of this review article is to describe the current understanding of the pathophysiology of neuroma-in-continuity lesions, and to review the approach to the affected patient including clinical evaluation, ancillary testing, and intraoperative assessment and treatment options.

[Neuropathic Pain - Differential Diagnosis and Treatment from the Hand Surgeon's Perspective]. / Neuropathische Schmerzen ­ Handchirurgische Differenzialdiagnose und Therapie.

Neuropathic Pain - Differential Diagnosis and Treatment from the Hand Surgeon's Perspective Abstract. Neuropathic pain of the wrist and hand can be caused by a multitude of pathologies, such as trauma, iatrogenic damage, local peripheral nerve compression, nerve tumors and systemic diseases. Neuropathic pain can lead to chronification and disability, severely affecting the patients' quality of life and the ability to work. A precise diagnosis is the key to an adequate therapy with satisfactory functional results. An interdisciplinary and multimodal approach is a prerequisite when treating neuropathic pain. This review article provides an insight into the diagnosis and therapy of pathologies associated with neuropathic pain of the wrist and hand.

Revision surgery for recurrent and persistent carpal tunnel syndrome: Clinical results and factors affecting outcomes.

Thirty-eight hands in 36 patients with recurrent or persistent carpal tunnel syndrome (CTS) were reviewed retrospectively after a mean of 51 months (range 12-86) to identify factors that may lead to poor outcomes after surgical management. Clinical assessment focused on pain and sensitivity recovery, measured with a VAS and Weber's two-point discrimination test, respectively. At the latest follow-up, we found 11 excellent, 15 good, nine fair and three poor results. The risk of fair or poor results was significantly higher in the presence of intraneural fibrosis, severe preoperative sensory deficit, neuroma of the palmar cutaneous branch of the median nerve, workers compensation claims and number of previous surgeries. This last factor also significantly increased the risk of intraneural fibrosis. Despite disappointing outcomes, identification of these factors may improve our prognostic ability for revision surgery in cases of recurrent CTS.

Interest of telemicrosurgery in peripheral nerve tumors: about a series of seven cases.

Surgery of the chronic peripheral nerve lesion should not only limit recurrence after excision, but it should also limit the sensory and motor sequelae. The aim of this work was to study the interest of telemicrosurgery to improve this result. Our series included 7 patients with peripheral nerve neuroma and tumors including two cases of hereditary neurofibromatosis. A Da Vinci S(®) robot equipped with microsurgical instruments was used for intraneural dissection. One case was performed with minimally invasive approach. At last follow-up, the pain decreased from 6/10 preoperatively to 3/10 postoperatively. The sensory deficit was stable except for two patients, whose sensory function was improved. No recurrence was noted. Telemicrosurgery seems to have two interests in the treatment of chronic peripheral nerve lesions: it reduces the size of incisions and increases the accuracy of surgery. These preliminary results suggest that surgical robots could play an essential role in microsurgery.

[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.

[Autologous fat grafting in the surgical management of painful scar: preliminary results]. / Greffe de tissu adipeux autologue dans la prise en charge chirurgicale des cicatrices douloureuses : résultats préliminaires.

The purpose of this study was to report our experience about the effectiveness of autologous fat injections in the management of painful scars. Between 2010 and 2012, all patients with persistent incisional pain despite a well-conduced 6 months medical treatment received an autologous fat graft according to the technique originally described by Coleman. Results interpretation was based on pain improvement thanks to a Visual Analogic Scale (VAS), postoperative patient satisfaction, reduction on analgesics intake and quality of life improvement. Eleven patients were included, the mean quantity of fat injected was 11cm(3). Nine patients (1.5%) benefited from a complete or significant pain decrease, 74.5% reported being very satisfied or satisfied with the result. The mean reduction of VAS was 3.5 points. We did not observe any complication. Autologous fat grafting is an innovative therapeutic approach and appears to be an attractive concept in the management of scar neuromas resistant to drug treatment, by providing an easy effective and safe surgical treatment.