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Hand/Peripheral Nerve: Original Articles

Long-Term Outcomes after Surgical Treatment of Radial Sensory Nerve Neuromas: Patient-Reported Outcomes and Rate of Secondary Surgery

Gottlieb, Rachel W. B.Sc.; Westenberg, Ritsaart F. M.D.; Chen, Neal C. M.D.; Coert, J. Henk M.D., Ph.D.; Eberlin, Kyle R. M.D.

Author Information
Plastic and Reconstructive Surgery: January 2021 - Volume 147 - Issue 1 - p 101-111
doi: 10.1097/PRS.0000000000007437

Abstract

A neuroma results from an injured nerve’s attempt at regeneration when there is disorganized axonal sprouting in the absence of a receptive end organ.1 Following nerve injury, neuroma formation may cause neuropathic symptoms, including pain, paresthesias, and hypoesthesia or hyperesthesia.2,3 Not all neuromas are symptomatic, but those that are can cause significant pain and disability.3,4

The radial sensory nerve has been described as particularly prone to development of symptomatic neuroma.5,6 The dorsal radial aspect of the hand and wrist is a common incision site for hand and wrist procedures, which puts the radial sensory nerve at risk for postsurgical injury. In addition, the radial sensory nerve can be adhered proximally as it emerges between the brachioradialis and the extensor carpi radialis longus.7 The formation of a neuroma distal to this can cause additional tension and irritation of the radial sensory nerve as the wrist moves.6

Prior studies evaluating symptomatic neuromas demonstrate that radial sensory nerve neuromas are at higher risk of postoperative pain and appear to have the lowest treatment satisfaction of the upper extremity neuromas.8,9 Although many authors discuss the susceptibility of the radial sensory nerve to symptomatic neuroma formation, there is limited information reporting patient-reported outcomes after treatment of radial sensory nerve neuromas. The aims of this study were to (1) describe the long-term patient-reported outcomes of surgical treatment of symptomatic radial sensory nerve neuromas on upper extremity function, pain, and patient satisfaction; (2) assess which factors were associated with worse upper extremity function, a higher pain intensity, and more pain interference; and (3) describe the secondary surgery rate following neuroma surgery and factors associated with secondary surgery.

PATIENTS AND METHODS

Study Design

After institutional review board approval, we retrospectively identified patients with symptomatic neuromas of the radial sensory nerve from five urban medical centers between January of 2002 and April of 2016. Patients were identified using CPT and International Classification of Diseases, Ninth Revision, and International Classification of Diseases, Tenth Revision, codes related to radial sensory nerve neuroma (n = 7514). (See Appendix, Supplemental Digital Content 1, which shows the complete list of CPT and International Classification of Diseases codes used to identify symptomatic radial sensory nerve neuromas, http://links.lww.com/PRS/E280.) We performed a text search for the word “neuroma” in the pathology and operative notes and identified 1544 patients. We manually reviewed the medical charts of these 1544 patients and identified 75 adult patients who were surgically treated for 80 radial sensory nerve neuromas. We included patients with a clinical diagnosis of symptomatic neuroma of the radial sensory nerve who had a history of traumatic injury or postsurgical nerve injury.

Symptomatic neuroma was defined by clinical criteria: pain, hyperesthesia, hypoesthesia, and/or paresthesia following nerve injury. Presence of symptomatic neuroma was determined by combination of clinical notes with pathology reports or intraoperative description.10 Patients who were treated less than 3 months after sustaining a nerve injury (n = 16), had pathologic findings demonstrating something other than neuroma (n = 1), had inconclusive intraoperative findings for neuroma (n = 1), had no clinical diagnosis for symptomatic neuroma (n = 1), or had insufficient chart documentation (n = 2) were excluded. This resulted in a cohort of 54 patients with 59 radial sensory nerve neuromas. Four patients had neuromas on multiple radial sensory nerve branches: two patients with two neuromas at different locations, one with two neuromas in the same location and one patient with three neuromas in the same location (Fig. 1). We included number of patients instead of number of neuromas to prevent overcounting of patient-specific variables.11 Presence of multiple radial sensory nerve neuromas was included as an explanatory variable. When neuromas developed in different anatomical regions, we included the location of the symptomatic neuroma that underwent the first surgical procedure.

Fig. 1.
Fig. 1.:
Distribution of symptomatic radial sensory nerve neuromas across five anatomical regions.

We collected observational data from a medical chart review for the 54 patients, which included patient factors, neuroma characteristics, and treatment characteristics. Depression and anxiety were defined as any medical history of depression or anxiety preceding neuroma surgery. We defined five regions for neuroma distribution: proximal forearm, up to 8 cm proximal to the wrist; distal forearm and wrist; dorsum of the hand including the carpometacarpal and metacarpophalangeal joints; thumb distal to the metacarpophalangeal joint; and index and radial half of the middle finger distal to the metacarpophalangeal joint (Fig. 1). Neuromas were classified as neuroma-in-continuity, end neuroma with presence of distal nerve target, or end neuroma without presence of distal nerve target. Clinical symptoms were recorded as pain, hyperesthesia, hypoesthesia, and paresthesia. We categorized surgical interventions as follows: excision alone; excision and implantation into bone, muscle, or soft tissue; excision and repair with direct or indirect neurorrhaphy; and neurolysis alone with or without nerve wrapping. The date of last clinical visit was based on the date of the last neuroma-related clinical visit.

We contacted all patients by mail to invite them to participate in a follow-up survey. Patients who did not respond to the letter were contacted by phone. Long-term patient-reported outcome data from the surveys was collected for 25 patients. Of the 29 that did not complete the surveys, seven declined, 18 were unreachable, and four were lost to follow-up. The survey was administered using Research Electronic Data Capture, a secure Web-based data capture tool.12

Study Population

Of the 54 patients, 36 (67 percent) were male. The mean ± SD age was 43.9 ± 11.7 years. Approximately half of the patients were manual laborers [n = 26 (48 percent)], with 18 patients (35 percent) using workers’ compensation insurance. The inciting event for neuroma development was traumatic in 30 patients (56 percent) and postsurgical in 24 patients (44 percent). The most common traumatic injury was laceration [n = 19 (35 percent)] and most common postsurgical injury occurred following de Quervain release [n = 5 (9 percent)]. Patient characteristics are listed in Table 1. The most common location for radial sensory nerve neuromas was the wrist and distal forearm (n = 25) (Fig. 1). At the last clinical visit, 31 patients (57 percent) had at least one neuroma symptom documented in their charts. (See Appendix, Supplemental Digital Content 2, which shows a table of clinical symptoms documented in the medical chart preoperatively and at time of the last clinical visit, http://links.lww.com/PRS/E281.) Median time to last clinical visit for a neuroma was 15.8 months (interquartile range, 2.3 to 45.0 months).

Table 1. - Patient Characteristics
Characteristic Value (%)
Total 54
Mean age ± SD, yr 43.9 ± 11.7
Sex
 Female 18 (33)
 Male 36 (67)
Mean BMI ± SD, kg/m2 28.2 ± 5.0
Race*
 White 37 (69)
 Black 5 (9)
 Hispanic 12 (22)
Laborer 26 (48)
 Workers’ compensation 18 (35)
Smoker 25 (46)
Diabetes 8 (15)
Depression 5 (9)
Anxiety 5 (9)
Dominant side affected
 No 30 (56)
 Yes 24 (44)
Multiple neuromas
 No 50 (93)
 Yes 4 (7)
Zone of injury
 Proximal forearm 3 (6)
 Distal forearm or wrist 25 (46)
 Dorsum of hand 18 (33)
 Thumb 4 (7)
 Index finger 4 (7)
Injury type
 Traumatic 30 (56)
  Laceration 10 (19)
  Laceration and repair 9 (17)
  Amputation 8 (15)
  Other 3 (6)
 Postsurgical 24 (44)
  de Quervain 5 (9)
  Other 19 (35)
Concomitant LABCN injury
 No 6 (11)
 Yes 48 (89)
Neuroma type
 In-continuity 23 (43)
 End without distal nerve target 17 (31)
 End with distal nerve target 14 (26)
Surgical treatment
 Excision 9 (17)
 Excision and repair 13 (24)
 Excision and burial 24 (44)
 Neurolysis with or without wrapping 8 (15)
Time to neuroma surgery, mo
 Median 9.4
 IQR 6.5–15.7
Second neuroma surgery 11 (20)
 Time to second neuroma surgery, mo
  Median 15.2
  IQR 8.8–36.1
Third neuroma surgery 3 (6)
 Time to third operation, mo
  Mean 6.9
  Range 5.1–12.4
BMI, body mass index; LABCN, lateral antebrachial cutaneous nerve; IQR, interquartile range.
*Data unavailable for two subjects.

Of the 25 patients who completed the follow-up surveys, proportionally more patients sustained postsurgical than traumatic injury before neuroma development (p = 0.033). All other explanatory factors were comparable between responders and nonresponders. Mean time to survey completion was 10.7 years (range, 2.8 to 16.5 years).

Patient-Reported Outcomes

At long-term follow-up, we collected Patient-Reported Outcomes Measurement Information System (PROMIS) upper extremity v2.0 computer adaptive testing scores; PROMIS depression v1.0 computer adaptive testing scores; PROMIS pain interference v1.1 computer adaptive testing scores; numerical rating scale scores for pain and satisfaction; global rating scale scores of change; and scores for a questionnaire written by the investigators. (See Appendix, Supplemental Digital Content 3, which shows the investigator-designed questionnaire administered to capture additional information about the current condition, http://links.lww.com/PRS/E282.) The PROMIS upper extremity scale measures upper extremity function. A higher score indicates better function. The PROMIS depression scale measures negative mood, views of self, and social cognition. A higher score indicates a more negative mood. The PROMIS pain interference scale measures consequences of pain on a patient’s life. A higher score indicates more pain interference. For all PROMIS measures, 50 is the mean score for the U.S. general population, with a standard deviation of 10.13 Numerical rating scale scoress for pain and satisfaction are given on a scale of 0 to 10, where a higher score indicates a higher degree of pain intensity or satisfaction. For the global rating scale of change, patients evaluate their current health with respect to their neuroma compared to before their surgery on a seven-point scale from significantly worse (−3) to significantly improved (3).14 Our custom survey targeted current symptoms and medication use.

Statistical Analysis

Dichotomous and categorical data were presented as frequencies with percentages, and continuous data were presented as medians and interquartile ranges or means and standard deviations, based on normality. To assess the influence of our explanatory variables on continuous outcome variables (PROMIS upper extremity and pain interference), we used a t test for dichotomous variables, a one-way analysis of variance for categorical variables, and a Spearman rank correlation coefficient for ordinal or nonnormally distributed continuous variables. The influence of explanatory variables on the numerical rating scale for pain was assessed using a Wilcoxon rank sum test for dichotomous variables, a Kruskal-Wallis test for categorical variables, and a Spearman rank correlation coefficient for continuous or ordinal explanatory variables. To assess the influence of our explanatory variables on revision surgery, we used a t test or a Wilcoxon rank sum test for continuous variables based on normality and a Fisher’s exact for dichotomous or categorical variables. A value of p < 0.05 was considered statistically significant. Data were analyzed using STATA, version 13 (StataCorp LLC, College Station, Texas).

RESULTS

At long-term follow-up, the mean ± SD PROMIS upper extremity scale score was 45.0 ± 12.1, the mean ± SD PROMIS depression scale score was 49.9 ± 10.2, and the mean ± SD PROMIS pain interference scale score was 55.5 ± 10.3. This is close to the average score of the general U.S. population, which is 50, with a standard deviation of 10 for all PROMIS measures.13 Patients reported a median pain intensity of 3 of 10 (interquartile range, 1 to 6) for neuroma pain over the last week on the numerical rating scale for pain, with 80 percent of the patients (n = 20) completing surveys reporting some degree of pain. Pain patterns and pain intensity after specific trigger mechanisms are listed in Table 2. On the global rating scale, 17 patients (68 percent) described themselves in the range of minimally to significantly improved (Table 3).

Table 2. - Pain Patterns and Trigger Mechanisms for Neuroma Pain
Value (%)
No. 25
Pattern of pain
 Continuous, steady, constant 7 (28)
 Rhythmic, periodic, intermittent 7 (28)
 Brief, momentary, transient 6 (24)
 No pain 5 (20)
NRS pain by trigger mechanism
 Temperature
  Median 1.0
  IQR 0.0–7.0
 Mean movement ± SD 3.6 ± 3.2
 Mean touch or pressure ± SD 4.8 ± 3.8
 Mean spontaneous ± SD 3.1 ± 3.3
NRS, numerical rating scale; IQR, interquartile range.

Table 3. - Patient-Reported Outcomes at Time of Follow-Up
Value (%)
No. 25
Measure
 Mean PROMIS UE score ± SD 45.0 ± 12.1
 Mean PROMIS depression ± SD 49.9 ± 10.2
 Mean PROMIS PI ± SD 55.5 ± 10.3
 NRS
  Pain
   Median 3
   IQR 1–6
  Satisfaction
   Median 10
   IQR 7–10
 GRS of change
  Median 2
  IQR 0–3
  Significantly improved (+3) 9 (36)
  Improved (+2) 4 (16)
  Minimally improved (+1) 4 (16)
  Unchanged (0) 3 (12)
  Minimally worse (−1) 2 (8)
  Worse (−2) 1 (4)
  Significantly worse (−3) 2 (8)
 Choose to repeat treatment 20 (87)
 Current nerve medication use 2 (4)
 Current opioid use 2 (4)
 Mean time to survey follow-up ± SD, yr 10.7 ± 4.3
UE, upper extremity; PI, pain interference; NRS, numerical rating scale; IQR, interquartile range; GRS, global rating scale.

On the numerical rating scale for satisfaction, patients scored their satisfaction with treatment with a median of 10 (interquartile range, 7 to 10) of 10. When asked whether, given a choice, they would choose the same treatment again, 87 percent (n = 20) said yes, 5 percent (n = 3) said no, and 4 percent (n = 2) did not provide a response. All patient-reported outcomes are listed in Table 3.

On bivariate analysis, older patients (p = 0.002) and patients with higher pain interference (p < 0.001), higher numerical rating scale score for pain (p = 0.012), and lower global rating scale score (p = 0.01) had worse upper extremity function (Tables 4 and 5). Patients with their dominant side affected (p = 0.02) and neuroma symptoms at their last clinical visit (p = 0.04) had higher PROMIS pain interference scale score. Patients with a history of anxiety (p = 0.04), a history of depression (p = 0.04), and their dominant hand affected (p = 0.04) had more pain intensity on the numerical rating scale for pain.

Table 4. - Factors Associated with PROMIS Upper Extremity: Bivariate Analysis
Factor No. PROMIS UE (Mean ± SD) p
Sex 0.86
 Female 9 45.5 ± 13.1
 Male 16 44.7 ± 11.9
Diabetes 0.09
 No 21 46.8 ± 11.4
 Yes 4 35.5 ± 12.3
Smoke 0.57
 No 15 46.1 ± 13.1
 Yes 10 43.3 ± 10.8
Laborer 0.84
 No 13 45.5 ± 14.2
 Yes 12 44.5 ± 9.9
Workers’ compensation 0.52
 No 16 46.2 ± 12.0
 Yes 9 42.8 ± 12.6
Anxiety 0.30
 No 23 45.7 ± 12.2
 Yes 2 36.4 ± 9.1
Depression 0.30
 No 23 45.7 ± 12.2
 Yes 2 36.4 ± 9.1
Injury type 0.50
 Traumatic 10 47.0 ± 12.3
 Postsurgical 15 43.6 ± 12.1
Concomitant LABCN injury 0.67
 No 22 45.4 ± 12.8
 Yes 3 42.1 ± 5.2
Postsurgical injury at OSH 0.28
 No 21 46.1 ± 12.1
 Yes 4 38.8 ± 11.6
Multiple
 No 23 44.6 ± 12.0 0.63
 Yes 2 49.0 ± 16.9
Zone 0.46
 Forearm or wrist 12 43.4 ± 11.0
 Dorsum of hand 9 47.0 ± 11.5
 Thumb 3 40.0 ± 18.8
 Index 1 61.0 ± 0.0
Neuroma type 0.46
 In-continuity 10 45.3 ± 13.8
 End without distal nerve target 9 48.0 ± 12.1
 End with distal nerve target 6 39.9 ± 8.6
Surgical treatment 0.28
 Excision 3 41.8 ± 14.7
 Excision and repair 8 41.8 ± 8.7
 Excision and burial 11 50.2 ± 13.3
 Neurolysis with or without wrapping 3 37.6 ± 10.0
Pain 0.48
 No 1 53.5 ± 0.0
 Yes 24 44.6 ± 12.2
Preoperative sensory symptoms 0.94
 No 7 45.3 ± 11.3
 Yes 18 44.9 ± 12.7
Hypersensitivity 0.84
 No 17 45.3 ± 11.6
 Yes 8 44.2 ± 13.9
Hyposensitivity 0.15
 No 19 47.0 ± 13.0
 Yes 6 38.7 ± 5.4
Positive Tinel sign 0.96
 No 16 45.1 ± 12.2
 Yes 9 44.8 ± 12.5
Symptoms at last clinical follow-up 0.11
 No 11 49.3 ± 9.3
 Yes 14 41.5 ± 13.2
Second neuroma surgery 0.27
 No 19 43.4 ± 11.5
 Yes 6 49.8 ± 13.6
Third neuroma surgery 0.23
 No 23 44.1 ± 12.1
 Yes 2 55.0 ± 8.5
Current nerve medication 0.91
 No 23 44.9 ± 12.6
 Yes 2 45.9 ± 4.4
Current opioid medication 0.33
 No 23 45.7 ± 11.8
 Yes 2 36.9 ± 17.1
Choose to repeat the treatment 0.18
 No 2 36 ± 8.6
 Yes 20 46.6 ± 2.7
UE, upper extremity; LABCN, lateral antebrachial cutaneous nerve; OSH, outside hospital.

Table 5. - Factors Associated with PROMIS Upper Extremity: Bivariate Analysis
Factor PROMIS UE Correlation Coefficient p
PROMIS depression −0.21 0.39
Age −0.73 <0.01*
Time to neuroma surgery −0.05 0.08
PROMIS PI −0.84 <0.01*
PROMIS depression −0.21 0.39
NRS pain −0.49 0.01*
GRS 0.48 0.01*
PI, pain interference; NRS, numerical rating scale; GRS, global rating scale.
*Statistically significant.

Eleven patients (20 percent) underwent a second operation for their neuroma at a median of 15.2 months (interquartile range, 8.8 to 36.1 months) after initial neuroma surgery. Three patients had a third operation at 5.1, 6.9, and 12.4 months after their second operation. The presence of multiple neuromas was associated with secondary surgery (p = 0.001) (Table 6).

Table 6. - Factors Associated with Secondary Surgery: Bivariate Analysis
Factors No Secondary Surgery (%) Secondary Surgery (%) P
No. 43 11
Mean age ± SD, yr 44.0 ± 12.1 43.7 ± 10.5 0.96
Sex 1.00
 Female 14 (33) 4 (36)
 Male 29 (67) 7 (64)
Mean BMI ± SD, kg/m2 27.8 ± 5.1 30.2 ± 4.4 0.22
Race 0.87
 White 30 (70) 7 (64)
 Black 4 (9) 1 (9)
 Hispanic 9 (21) 3 (27)
Laborer 1.00
 No 22 (51) 6 (55)
 Yes 21 (49) 5 (45)
Workers’ compensation 0.076
 No 30 (71) 4 (40)
 Yes 12 (29) 6 (60)
Smoker 0.31
 No 25 (58) 4 (36)
 Yes 18 (42) 7 (64)
Diabetes 0.34
 No 38 (88) 8 (73)
 Yes 5 (12) 3 (27)
Depression 1.00
 No 39 (91) 10 (91)
 Yes 4 (9) 1 (9)
Anxiety 1.00
 No 39 (91) 10 (91)
 Yes 4 (9) 1 (9)
Dominant side affected 0.74
 No 23 (53) 7 (64)
 Yes 20 (47) 4 (36)
Multiple neuromas 0.001*
 No 43 (100) 7 (64)
 Yes 0 (0) 4 (36)
Zone of injury 0.49
 Proximal forearm 3 (7) 0 (0)
 Distal forearm or wrist 21 (49) 4 (36)
 Dorsum of hand 14 (33) 4 (36)
 Thumb 3 (7) 1 (9)
 Index 2 (5) 2 (18)
Concomitant LABCN injury 0.67
 No 39 (91) 9 (82)
 Yes 4 (9) 2 (18)
Injury type 0.74
 Traumatic 23 (53) 7 (64)
 Postsurgical 20 (47) 4 (36)
Neuroma type 0.90
 In-continuity 18 (42) 5 (45)
 End neuroma without distal target 13 (30) 4 (36)
 End neuroma with distal target 12 (28) 2 (18)
Surgical treatment 0.61
 Excision 8 (19) 1 (9)
 Excision and repair 11 (26) 2 (18)
 Excision and burial 19 (44) 5 (45)
 Neurolysis with or without wrapping 5 (12) 3 (27)
Mean PROMIS UE ± SD 43.4 ± 11.5 49.8 ± 13.6 0.27
Mean PROMIS PI ± SD 56.3 ± 10.1 53.1 ± 11.7 0.52
NRS
 Pain
  Median 2 4.5
  IQR 1–5 0–6 0.70
 Satisfaction
  Median 10 9.5
  IQR 5–10 7–10 0.80
LABCN, lateral antebrachial cutaneous nerve; UE, upper extremity; PI, pain interference.
*Statistically significant.

DISCUSSION

In this study, we describe long-term patient-reported outcomes of patients surgically treated for symptomatic neuromas of the radial sensory nerve. In addition, we describe patient and injury characteristics, and the rate of and factors associated with secondary surgery. We report observational data for 54 patients with 59 symptomatic radial sensory nerve neuromas and patient-reported outcome data for 25 patients at a mean ± SD of 10.7 ± 4.3 years. The mean ± SD PROMIS upper extremity score was 45.0 ± 12.1 and the median numerical rating scale for pain score was 3 (interquartile range, 1 to 6). Patients were satisfied with their treatment, reporting a median numerical rating scale score for satisfaction of 10 (interquartile range, 7 to 10), indicating high satisfaction. On the global rating scale, 68 percent describe themselves as improved after surgery. The rate of revision surgery was 11 of 54 patients (20 percent).

In this long-term study, the mean ± SD PROMIS upper extremity scale score was 45.0 ± 12.1. This score is similar to the PROMIS upper extremity scale score reported for digital neuromas15 and is 0.5 SD lower than that for the general population.13 Recent publications set the minimum clinically important difference for PROMIS upper extremity scale score between 4.2 and 8.0 for carpal tunnel syndrome.16,17 The five-point difference between our cohort and the general population exceeds the lower limit of this established minimum clinically important difference. The PROMIS upper extremity scale categorizes symptoms as severe (<30), moderate (30 to 40), mild (40 to 45), and within normal limits (>45). In our cohort, 64 percent of patients had mild or no functional deficit. Although we are unable to compare preoperative and postoperative patient-reported outcomes, previous studies demonstrate that surgical treatment for neuromas improves pain, depression, and quality of life.18,19 We see at long-term follow-up that patients’ upper extremity functional deficit is mild on average after surgical treatment for radial sensory nerve neuromas.

Bivariate analysis showed that patients who were older, who had increased numerical rating scale score for pain, or increased pain interference more frequently had worse upper extremity function. Upper extremity function is known to decrease with age.20,21 PROMIS pain interference is an effective measure of patient coping strategies in response to pain,22 and its association with PROMIS upper extremity scale score is well established across upper extremity conditions.23–25 More pain interference, but not worse function, was more frequently seen in patients with the dominant side affected. The association between hand dominance and PROMIS pain interference was also found after surgery for hypothenar hammer syndrome and digital neuromas.15,26 This finding and prior studies suggest that teaching patients coping strategies and increasing factors such as mindfulness, self-efficacy, and resilience through psychological interventions may aid in reducing pain interference and improving physical function.27–30 In addition, documentation of neuroma symptoms at last clinical visit was associated with higher PROMIS pain interference.

At long-term follow-up, 80 percent of patients still experienced pain from their neuroma, with a median pain intensity of 3 (interquartile range, 1 to 6) on the numerical rating scale for pain. Insufficient pain relief, as defined by numerical rating scale score for pain greater than 3, was reported in 52 percent of patients.8 Bivariate analysis showed that patients with a history of anxiety or depression, the dominant side affected, and documentation of neuroma symptoms at the last clinical visit had more pain. The median numerical rating scale score for pain in our study is comparable, with the mean ± SD numerical rating scale score for pain for upper or lower extremity neuromas of 3.8 ± 2.7 at 2-year follow-up and for digital neuromas of 3 (interquartile range, 1 to 5) at 7.6-year follow-up.18 Prior studies showed that depression and anxiety disorders are associated with greater pain intensity and more opioid use.31,32 Of the survey respondents, two currently take opioids for pain management and two take neuropathic pain medications, such as gabapentin or nortriptyline. A similar opioid use rate was reported at follow-up for surgically managed upper extremity neuromas 22 months after surgery.8 Opioids have the potential risk of misuse in patients with neuropathic pain.33,34 A multidisciplinary approach and use of drugs such as pregabalin, gabapentin, and nortriptyline are considerations in the treatment of neuroma pain.33 The association of anxiety and depression with worse surgical outcomes and increased opioid use suggest that patients should undergo appropriate diagnostic workup and intervention for anxiety and depression before surgical treatment for their neuroma. Tools such as the PROMIS depression and pain interference scales can be used to help identify patients who may benefit from additional support.35,36

The secondary surgery rate was 20 percent, indicating that in some cases, initial surgical treatment did not yield satisfactory results. The secondary surgery rate of this cohort is twice the secondary surgery rate of all upper extremity neuromas treated at our institution over the same timeframe and three times the secondary surgery rate of digital neuroma after amputation treated at our institution.4,10 The presence of multiple neuromas was associated with secondary surgery (p = 0.001), and there were no differences in patient-reported outcomes between patients who did and did not undergo revision. The revision rate supports the overall consensus that radial sensory nerve neuromas are challenging to treat.

This may be attributable to many factors, including the anatomy of the radial sensory nerve and failure of initial surgical treatment. The radial sensory nerve is fixed proximally as it emerges between the brachioradialis and the extensor carpi radialis longus 8 cm proximal to the wrist. It runs on top of the first extensor compartment and crosses the wrist joint on the radial dorsal side. Thus, the radial sensory nerve stretches with ulnar deviation of the wrist. Stretching may increase when scar tissue fixes the nerve distally after injury.6 Neuromas of the radial sensory nerve may therefore be more susceptible to irritation and pain than other neuromas. In addition, the radial sensory nerve lies superficially close to the abductor pollicis longus and extensor pollicis brevis tendons and radius with minimal padding from soft tissue. In most cases, the branches of the lateral antebrachial cutaneous nerve and radial sensory nerve overlap in the radial dorsal side of the hand and distal forearm. A prior study suggested that there is a high probability of lateral antebrachial cutaneous nerve injury when the radial sensory nerve is injured, which may lead to unsatisfactory results if, during treatment of the radial sensory nerve, a lateral antebrachial cutaneous nerve injury is missed and not treated.37,38 Another theory is that if a nerve is injured, adjacent uninjured nerves sprout and populate the neurosomes of the injured nerve. Pain induced from the injured radial sensory nerve may therefore be transmitted by the lateral antebrachial cutaneous nerve and vice versa.37,38 Concomitant lateral antebrachial cutaneous nerve injury was reported for 11 percent of patients (n = 6) in our cohort. Patients with concomitant injury of the lateral antebrachial cutaneous nerve appear to have higher surgical revision rates. Initial surgical treatment may fail when concomitant nerve injuries are not treated or if the surgical method used is not best suited for the injury. Using a diagnostic nerve block to help identify all involved nerves and nerve branches, and choice of initial procedure, is critical in managing these challenging injuries.37 A prior study cautions against nerve grafting in such a mobile area as that of the radial sensory nerve and suggests that excision and burial may be the preferred treatment for such neuromas.39 Another study suggests the use of targeted muscle reinnervation to manage symptomatic radial sensory nerve neuromas.40 Because of the small sample size, our study is underpowered to analyze the effects of surgical method on outcome. Future research should investigate the effects of treatment method on patient outcomes.

Our data demonstrate that 32 percent of patients had no improvement or worsened symptoms following their final neuroma surgery. However, 50 percent of patients who did not improve stated they would make the same decision again and 38 percent were completely satisfied with their treatment (numerical rating scale for satisfaction, 10). This reflects the difficulty of treating radial sensory nerve neuromas and that some patients were satisfied with the attempted treatment even if it did not yield good results. Radial sensory nerve neuromas have been reported as some of the most challenging to treat of upper extremity neuromas, with 33 percent satisfaction following radial sensory nerve neuroma surgery.8 Overall, 87 percent of patients reported that they would undergo surgery again if faced with the same decision. This reflects that despite the difficulties of treating these injuries, patients generally agree that attempting surgical treatment was worthwhile.

Our results must be considered in light of the study’s limitations. First, there are no specific International Classification of Diseases and CPT codes for radial sensory nerve neuromas, which increases the chance of selection bias. We minimized this bias by identifying patients using a large set of CPT and International Classification of Diseases codes that may be used for these injuries and reviewed the charts manually. Second, the outcomes of this study are limited to surgically treated patients at an academic medical center with expertise in management of trauma and peripheral nerve surgery. It may be possible that there are differences in symptom improvement or coping style between patients who elect surgery versus conservative treatment. In addition, certain patients with mild neuroma pain may not seek additional medical care. Third, because of the selected timeframe and sample size, we were unable to assess the comprehensive effect of newer techniques such as targeted muscle reinnervation, regenerative peripheral nerve interface, and nerve allograft reconstruction—considered active management of the terminal nerve end, for which early results are encouraging.3,19,41 Fourth, 54 percent of subjects did not participate in long-term follow-up, which could result in selection bias. However, the majority of patients who did not participate [22 of 29 (76 percent)] were unreachable. Prior studies using similar methodologies demonstrate a range of long-term follow-up survey response rates between 32.6 and 67.9 percent and found that patients farther out from treatment are less frequently reached by phone, e-mail, or mail.15,26,42 This may be because patient contact information becomes less accurate over time.43 In our cohort, a higher proportion of patients with postsurgical compared to traumatic nerve injury participated. Thus, our results may be more applicable to patients who develop neuromas of the radial sensory nerve following surgical intervention. However, retrospectively, there was no difference in revision rate between the two groups, which suggests that outcomes may be comparable regarding neuroma surgery. Fifth, the global rating scale of change is subject to recall bias, as we ask patients to retrospectively evaluate improvement of their symptoms years after treatment. Sixth, our analysis counted patients rather than neuromas. We therefore may underestimate or overestimate the effect of neuroma location by including only one neuroma in patients with multiple neuromas. To account for excluded neuromas, we included in our analysis whether patients had multiple neuromas. Lastly, because of the small sample size, we are not able to study the independent association of our explanatory variables using a multivariable analysis and are underpowered to show equivalence of surgical methods. If we compared excision and burial to the averaged outcomes of the remaining methods with 80 percent power, we could detect a minimum difference of 14.0 points in PROMIS upper extremity scale scores or a three-fold increase in revision rate, which are large effect sizes. This study would therefore be underpowered to evaluate the best surgical method with the available data. Although our sample size is small, our study screens which factors may be important to consider during treatment and in future studies. Future studies should assess the independent association of our explanatory variables on the outcome of radial sensory nerve neuroma surgery and which surgical treatment is superior for this type of neuroma.

CONCLUSIONS

Radial sensory nerve neuromas remain difficult to treat and have a high secondary surgery rate (20 percent), with only 68 percent of patients reporting improvement after surgical intervention. Most patients who undergo surgery for radial sensory nerve neuromas have mild functional deficits at long-term follow-up after surgery; however, the range of outcomes is wide. The presence of multiple neuromas was associated with secondary surgery. Risk factors for a less satisfactory result include age, higher PROMIS pain interference scale score, involvement of the dominant hand, and history of anxiety or depression.

REFERENCES

1. Sunderland S. Consequences of disruption of the endoneurium and perineurium: Neuroma formation. Fibre interaction and the artificial synapse. In: Nerves and Nerve Injuries. 1968:Edinburgh: E & S Livingstone; 180–193.
2. Arnold DMJ, Wilkens SC, Coert JH, Chen NC, Ducic I, Eberlin KR. Diagnostic criteria for symptomatic neuroma. Ann Plast Surg. 2019;82:420–427.
3. Eberlin KR, Ducic I. Surgical algorithm for neuroma management: A changing treatment paradigm. Plast Reconstr Surg Glob Open. 2018;6:e1952.
4. Vlot MA, Wilkens SC, Chen NC, Eberlin KR. Symptomatic neuroma following initial amputation for traumatic digital amputation. J Hand Surg Am. 2018;43:86.e1–86.e8.
5. Watson J, Gonzalez M, Romero A, Kerns J. Neuromas of the hand and upper extremity. J Hand Surg Am. 2010;35:499–510.
6. Dellon AL, Mackinnon SE. Susceptibility of the superficial sensory branch of the radial nerve to form painful neuromas. J Hand Surg Br. 1984;9:42–45.
7. Dellon AL, Mackinnon SE. Radial sensory nerve entrapment in the forearm. J Hand Surg Am. 1986;11:199–205.
8. Stokvis A, van der Avoort DJ, van Neck JW, Hovius SE, Coert JH. Surgical management of neuroma pain: A prospective follow-up study. Pain. 2010;151:862–869.
9. Stokvis A, Coert JH, van Neck JW. Insufficient pain relief after surgical neuroma treatment: Prognostic factors and central sensitisation. J Plast Reconstr Aesthet Surg. 2010;63:1538–1543.
10. Wolvetang NHA, Lans J, Verhiel SHWL, Notermans BJW, Chen NC, Eberlin KR. Surgery for symptomatic neuroma: Anatomic distribution and predictors of secondary surgery. Plast Reconstr Surg. 2019;143:1762–1771.
11. Bryant D, Havey TC, Roberts R, Guyatt G. How many patients? How many limbs? Analysis of patients or limbs in the orthopaedic literature: A systematic review. J Bone Joint Surg Am. 2006;88:41–45.
12. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)—A metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42:377–381.
13. Liu H, Cella D, Gershon R, et al. Representativeness of the Patient-Reported Outcomes Measurement Information System internet panel. J Clin Epidemiol. 2010;63:1169–1178.
14. Kamper SJ, Maher CG, Mackay G. Global rating of change scales: A review of strengths and weaknesses and considerations for design. J Man Manip Ther. 2009;17:163–170.
15. Lans J, Baker D, Castelein R, Sood R, Chen NC, Eberlin KR. Patient reported outcomes following surgical treatment of symptomatic digital neuromas. Plast Reconstr Surg. 2020;145:563e–573e.
16. Bernstein DN, Houck JR, Mahmood B, Hammert WC. Minimal clinically important differences for PROMIS physical function, upper extremity, and pain interference in carpal tunnel release using region- and condition-specific PROM tools. J Hand Surg Am. 2019;44:635–640.
17. Beleckas CM, Gerull W, Wright M, Guattery J, Calfee RP. Variability of PROMIS scores across hand conditions. J Hand Surg Am. 2019;44:186–191.e1.
18. Domeshek LF, Krauss EM, Snyder-Warwick AK, et al. Surgical treatment of neuromas improves patient-reported pain, depression, and quality of life. Plast Reconstr Surg. 2017;139:407–418.
19. Dumanian GA, Potter BK, Mioton LM, et al. Targeted muscle reinnervation treats neuroma and phantom pain in major limb amputees: A randomized clinical trial. Ann Surg. 2019;270:238–246.
20. Janssen MM, Hendriks JC, Geurts AC, de Groot IJ. Variables associated with upper extremity function in patients with Duchenne muscular dystrophy. J Neurol. 2016;263:1810–1818.
21. Beks RB, Mellema JJ, Menendez ME, Chen NC, Ring D, Vranceanu AM. Does mindfulness correlate with physical function and pain intensity in patients with upper extremity illness? Hand (N Y). 2018;13:237–243.
22. Kortlever JT, Janssen SJ, van Berckel MM, Ring D, Vranceanu AM. What is the most useful questionnaire for measurement of coping strategies in response to nociception? Clin Orthop Relat Res. 2015;473:3511–3518.
23. Kazmers NH, Hung M, Rane AA, Bounsanga J, Weng C, Tyser AR. Association of physical function, anxiety, and pain interference in nonshoulder upper extremity patients using the PROMIS platform. J Hand Surg Am. 2017;42:781–787.
24. Hermanussen HH, Menendez ME, Chen NC, Ring D, Vranceanu AM. Predictors of upper-extremity physical function in older adults. Arch Bone Jt Surg. 2016;4:359–365.
25. Döring AC, Nota SP, Hageman MG, Ring DC. Measurement of upper extremity disability using the Patient-Reported Outcomes Measurement Information System. J Hand Surg Am. 2014;39:1160–1165.
26. Demetri L, Lans J, Gottlieb R, Dyer GSM, Eberlin KR, Chen NC. Long-term patient-reported outcomes after surgery for hypothenar hammer syndrome. Hand (N Y). 2020;15:407–413.
27. Westenberg RF, Zale EL, Heinhuis TJ, et al. Does a brief mindfulness exercise improve outcomes in upper extremity patients? A randomized controlled trial. Clin Orthop Relat Res. 2018;476:790–798.
28. Verhiel SHWL, Greenberg J, Zale EL, Chen NC, Ring DC, Vranceanu AM. What role does positive psychology play in understanding pain intensity and disability among patients with hand and upper extremity conditions? Clin Orthop Relat Res. 2019;477:1769–1776.
29. Ring D. More pain than expected after losing a finger. J Hand Surg Am. 2018;43:e1.
30. Jayakumar P, Overbeek CL, Lamb S, et al. What factors are associated with disability after upper extremity injuries? A systematic review. Clin Orthop Relat Res. 2018;476:2190–2215.
31. Vranceanu AM, Jupiter JB, Mudgal CS, Ring D. Predictors of pain intensity and disability after minor hand surgery. J Hand Surg Am. 2010;35:956–960.
32. Bot AG, Bekkers S, Arnstein PM, Smith RM, Ring D. Opioid use after fracture surgery correlates with pain intensity and satisfaction with pain relief. Clin Orthop Relat Res. 2014;472:2542–2549.
33. Wright ME, Rizzolo D. An update on the pharmacologic management and treatment of neuropathic pain. JAAPA. 2017;30:13–17.
34. Els C, Jackson TD, Kunyk D, et al. Adverse events associated with medium- and long-term use of opioids for chronic non-cancer pain: An overview of Cochrane Reviews. Cochrane Database Syst Rev. 2017;10:CD012509.
35. Crijns TJ, Bernstein DN, Ring D, Gonzalez RM, Wilbur D, Hammert WC. Depression and pain interference correlate with physical function in patients recovering from hand surgery. Hand (N Y). 2019;14:830–835.
36. Beleckas CM, Prather H, Guattery J, Wright M, Kelly M, Calfee RP. Anxiety in the orthopedic patient: Using PROMIS to assess mental health. Qual Life Res. 2018;27:2275–2282.
37. Mackinnon SE, Dellon AL. The overlap pattern of the lateral antebrachial cutaneous nerve and the superficial branch of the radial nerve. J Hand Surg Am. 1985;10:522–526.
38. Poublon AR, Walbeehm ET, Duraku LS, et al. The anatomical relationship of the superficial radial nerve and the lateral antebrachial cutaneous nerve: A possible factor in persistent neuropathic pain. J Plast Reconstr Aesthet Surg. 2015;68:237–242.
39. Dellon AL, Mackinnon SE. Pain after radial sensory nerve grafting. J Hand Surg Br. 1986;11:341–346.
40. Daugherty THF, Bueno RA Jr, Neumeister MW. Novel use of targeted muscle reinnervation in the hand for treatment of recurrent symptomatic neuromas following digit amputations. Plast Reconstr Surg Glob Open. 2019;7:e2376.
41. Woo SL, Kung TA, Brown DL, Leonard JA, Kelly BM, Cederna PS. Regenerative peripheral nerve interfaces for the treatment of postamputation neuroma pain: A pilot study. Plast Reconstr Surg Glob Open. 2016;4:e1038.
42. Westenberg RF, Nierich J, Lans J, Garg R, Eberlin KR, Chen NC. What factors are associated with response rates for long-term follow-up questionnaire studies in hand surgery? Clin Orthop Relat Res. E-published ahead of print May 20, 2020.
43. London DA, Stepan JG, Goldfarb CA, Boyer MI, Calfee RP. The (in)stability of 21st century orthopedic patient contact information and its implications on clinical research: A cross-sectional study. Clin Trials. 2017;14:187–191.

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