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Diagnostic Criteria for Symptomatic Neuroma

Arnold, Denise M. J., MD*; Wilkens, Suzanne C., MD*; Coert, J. Henk, MD; Chen, Neal C., MD*; Ducic, Ivica, MD, PhD; Eberlin, Kyle R., MD§

doi: 10.1097/SAP.0000000000001796
Peripheral Nerve Surgery and Research

Introduction After nerve injury, disorganized or incomplete nerve regeneration may result in a neuroma. The true incidence of symptomatic neuroma is unknown, and the diagnosis has traditionally been made based on patient history, symptoms, physical examination, and the anatomic location of pain, along with response to diagnostic injection. There are no formally accepted criteria for a diagnosis of neuroma.

Materials and Methods A literature search was performed to identify articles related to neuroma: Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed and Pubmed, Embase, and the Cochrane Library were searched for all relevant articles pertaining to neuroma. Articles were screened by title and abstract for relevance. If an article was considered potentially relevant, the full article was reviewed. After consideration, 50 articles were included in this systematic review.

Results No previous articles directly addressed diagnostic criteria for symptomatic neuroma. Factors related to neuroma diagnosis gleaned from previous studies include pain and cold intolerance (patient history), positive Tinel sign or diminished 2-point discrimination (physical examination findings), response to diagnostic nerve block, and presence of neuroma on diagnostic imaging (ultrasound or magnetic resonance imaging). Based on literature review, the importance and number of references, as well as clinical experience, we propose criteria for diagnosis of symptomatic neuroma. To receive a diagnosis of symptomatic neuroma, patients must have (1) pain with at least 3 qualifying “neuropathic” characteristics, (2) symptoms in a defined neural anatomic distribution, and (3) a history of a nerve injury or suspected nerve injury. In addition, patients must have at least 2 of the following 4 findings: (1) positive Tinel sign on examination at/along suspected nerve injury site, (2) tenderness/pain on examination at/along suspected nerve injury site, (3) positive response to a diagnostic local anesthetic injection, and (4) ultrasound or magnetic resonance imaging confirmation of neuroma.

Conclusions The diagnosis of neuroma is based on a careful history and physical examination and should rely on the proposed criteria for confirmation. These criteria will be helpful in more precisely defining the diagnosis for clinical and research purposes.

From the *Hand Surgery Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA;

Department of Surgery, University Medical Center, Utrecht, the Netherlands;

Washington Nerve Institute, McLean, VA; and

§Hand Surgery Service, Division of Plastic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA.

Received July 15, 2018, and accepted for publication, after revision November 7, 2018.

Conflicts of interest and sources of funding: none declared.

K.R.E. serves as a consultant for AxoGen and Integra. N.C.C. serves as a consultant for Miami Device Solutions. I.D. serves as the Medical Director for AxoGen.

Reprints: Kyle R. Eberlin, MD, Division of Plastic Surgery, Massachusetts General Hospital, Wang 435, 55 Fruit St, Boston, MA 02114. E-mail:

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