We analyzed factors associated with reoperation of symptomatic neuroma. In this study, 641 surgically treated neuromas were identified, 96 percent of which occurred in the extremities. Neuromas were secondary to traumatic injury in 50 percent and surgery in 38 percent, and it was found that initial surgery for neuroma was performed at a median of 9 months after the inciting event.
In this study, neuroma excision and nerve implantation was the most commonly performed technique, followed by excision and neurorrhaphy with or without nerve graft. Reasons for this choice of treatment may include the presence of more neuromas in continuity, or the presence of stump neuromas without an available distal target. The rate of secondary surgery after primary neuroma surgery was 7.8 percent. If a neuroma was treated by excision followed by neurorrhaphy with or without nerve graft, the secondary surgery rates were lower compared to excision alone or excision and implantation.
This study should be considered in light of its strengths and limitations. First, the patients in this study were identified retrospectively using chart review, making the selection dependent on correct coding. Second, the diagnosis of neuroma was based on a combination of patient history and physical examination, and there is no gold standard for diagnosis. In this study, the majority of the patients had histologic confirmation (n = 362) or intraoperative findings corresponding with a neuroma (n = 201). Third, this study did not account for the patients who underwent treatment (1) at a pain clinic or (2) performed by a different surgeon outside our institution. Fourth, newer surgical techniques such as targeted muscle reinnervation and regenerative peripheral nerve interface were not evaluated given the timeframe of this study, although they are increasingly used in the senior author’s (K.R.E.) practice. Lastly, this study did not investigate patient psychosocial factors related to surgery or outcomes.
However, this study may underestimate the surgical failure rate, as secondary surgery is an imperfect proxy for patient outcome. If one neuroma surgery has “failed,” some surgeons may not offer the patient a second operation. It has been reported that patients who have undergone more than three previous operations for neuroma have 66 percent good/excellent pain relief after excision and implantation, compared with 90 percent good/excellent results after initial surgery.29 In patients with persistent pain after initial surgery, central sensitization may have occurred, influencing surgical outcomes when addressing the peripheral impetus.46 Centralization of pain may impact the success of peripheral nerve intervention, although the surgical impact on this phenomenon is not currently well understood.
We also report the anatomical distribution of surgically treated neuromas. Neuromas treated operatively were most common in the upper and lower extremities. In the upper extremities, the digital nerves were predominantly affected as a result of (nonamputation) trauma (65 percent) or amputation (21 percent). In the lower extremity, Morton neuroma (25 percent) was most common, followed by peroneal neuroma (23 percent) and sural neuroma (22 percent); the latter was most often caused by prior surgery (70 percent). A previous study reported that the lower extremity was the most commonly involved anatomical region (54 percent), which is similar to the rate identified in this study.47 It is likely that surgically treated neuromas are most common in the extremities, as they are prone to trauma and often have a thin subcutaneous cover.
Many surgical techniques to treat neuroma have been described. Techniques involving neuroma excision and implantation/burying have historically been the most commonly used, and were the most commonly performed techniques in this study.11,15,29,40,48 In a comparative meta-analysis, Poppler et al. concluded that 77 percent of all patients with neuroma had meaningful improvement of pain regardless of the surgical method used.49 In this study, we identified a lower rate of secondary operation after neuroma excision with nerve reconstruction (direct neurorrhaphy or neurorrhaphy with a nerve graft) compared to other interventions. This is similar to the finding by Pet et al., in which patients treated with traction neurectomy had a relatively high rate of symptomatic recurrence.34 This is also in line with the findings of Guse and Moran, who found that nerve repair had the highest rate of success.50 This study’s finding of lower rates of secondary neuroma surgery in patients undergoing neurorrhaphy with or without nerve graft compared to those undergoing implantation techniques is most likely the result of active treatment of the nerve ending.51 Newer techniques such as targeted muscle reinnervation and use of a regenerative peripheral nerve interface have provided promising results.36,39,52–54 Of the patients treated with primary targeted muscle reinnervation at the time of traumatic amputation, 92 percent were free of pain at follow-up.55
The secondary neuroma surgery rate of 7.8 percent identified in this study is similar to prior studies. Dellon and Mackinnon evaluated 78 neuromas in 60 patients that were treated by resection and implantation into muscle and reported a secondary surgery rate of 6.4 percent.29 Vlot et al. described a secondary surgery rate of 23 percent for digital neuromas and found that avulsion injury and neuroma of the index finger were associated with higher rates of secondary surgery.13 In another study, Decrouy-Duruz et al. evaluated secondary surgery in 231 patients that had neuropathic pain after nerve injury, of which 44 percent were classified as neuroma and were treated with resection and transposition in soft tissue. The remainder were neuroma in continuity or scarred nerves and were treated with neurolysis alone. Their overall reoperation rate was 16 percent; however, because of the different cohort of patients, direct comparison with this study is difficult.47 A retrospective study of 67 patients surgically treated by excision and burying the proximal end of the nerve in the muscle reported a secondary surgery rate of 21 percent.34
The decision for secondary neuroma surgery is complex and based on many factors, including patient symptoms, surgeon experience, and available techniques for reconstruction. Some surgeons are reluctant to offer secondary surgery for neuroma if the first intervention was unsuccessful. In this study, we found that patients undergoing initial neuroma surgery performed by surgeons trained in microsurgery were more likely to undergo secondary surgery. This may be because nerve-trained microsurgeons have more surgical options available for treatment of neuroma compared with nonmicrosurgeons and may be more willing to attempt additional surgical intervention.
Patients with symptomatic neuroma may undergo surgical intervention in an attempt to ameliorate symptoms. Surgical treatment of neuroma may improve quality of life for these patients, and most patients will not undergo secondary neuroma surgery. Further investigation into the optimal timing and type of surgical technique is needed to help inform surgical decision-making.
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