Search Results (29)

Background and Objectives: Morton’s neuroma is a painful foot condition that can be treated with continuous radiofrequency. However, its efficacy is not always optimal, with failure rates of 15–20%. It has been suggested that these failures may be due to incomplete nerve ablation, allowing for nerve regeneration and persistent pain. So, the aim of this study was to assess the histological effects of continuous radiofrequency on the nerves affected by Morton’s neuroma. Materials and Methods: The effect of continuous radiofrequency was evaluated in two patients with Morton’s neuroma, which required open surgery excision. In both cases, radiofrequency with a standard protocol was applied ex vivo, following the surgical excision of the neuroma. A TLG10 RF generator (90 °C, 90 s) with a monopolar needle with a 0.5 cm active tip was used. Subsequently, the samples were histologically analyzed to determine the degree of nerve ablation. Results: Histological analysis showed homogeneous focal necrosis in both cases, with lesion depths of 2.4 mm and 3.18 mm. However, areas of intact nerve tissue were identified at the periphery of the neuroma, suggesting incomplete ablation. Conclusions: The findings indicate that continuous radiofrequency does not guarantee total nerve ablation, which could explain recurrence in some cases. Intraoperative neurophysiological monitoring could be key to optimizing the procedure, ensuring complete interruption of nerve conduction and improving treatment efficacy. Full article

Background/Objectives: Painful diabetic peripheral neuropathy (pDPN) significantly impacts quality of life, yet its diagnosis remains challenging due to reliance on subjective pain reports and limited objective biomarkers. This meta-analysis evaluated corneal nerve morphology parameters; corneal nerve fibre length (CNFL), corneal nerve fibre density (CNFD), and corneal nerve branch density (CNBD), measured through in vivo confocal microscopy (IVCM), as potential tools for differentiating painful and painless forms of diabetic neuropathy. Methods: A systematic review was performed comparing corneal nerve morphology across four groups: painful diabetic neuropathy (pDPN), non-painful diabetic neuropathy (npDPN), diabetes without neuropathy (DPN-), and healthy controls. Literature search extended over MEDLINE, EMBASE, Web of Science, and Cochrane Library, focusing on studies published since 2000. Study quality was assessed using the Newcastle–Ottawa Scale, while evidence certainly followed GRADE guidelines. Random-effects meta-analyses calculated mean differences (MDs) with 95% confidence intervals (CIs) for CNFL, CNFD, and CNBD. Results: Seven observational studies comprising 803 participants (213 pDPN, 275 npDPN, 99 DPN-, and 216 controls) revealed no significant differences between pDPN and npDPN groups in CNFL (MD = 0.79, 95% CI −0.64 to 2.22), CNFD (MD = 1.67, 95% CI −0.14 to 3.47), or CNBD (MD = 1.84, 95% CI −4.31 to 7.98). However, all metrics were markedly reduced in pDPN compared to DPN- and healthy controls. Conclusions: While effective in identifying diabetic neuropathy, common corneal nerve morphology parameters cannot reliably distinguish pDPN from npDPN. This highlights the need for research into mechanisms like central sensitization, inflammation, and micro-neuromas, which could refine diagnostic and therapeutic approaches for pDPN. Full article

Background: Intermetatarsal bursitis (IMB) is emerging as a diagnostic consideration for patients with forefoot pain. However, few investigations have been conducted into the incidence of IMB among patients with forefoot pain. The symptoms of IMB are described as mimicking those of Morton’s neuroma (MN). Currently, the best method to differentiate between MN and IMB is radiological evaluation. Based on this, the aim of this study was to investigate the incidence of IMB and MN in a prospective cohort of patients with intermetatarsal pain diagnosed with radiological evaluation and compared to a control group. Methods: This study included 26 patients and 13 controls. All participants underwent magnetic resonance imaging (MRI) and ultrasound (US) of one forefoot. Results: Among the 26 patients, 5 (19.2%) had MN and 14 (53.8%) had IMB on MRI compared to US, with which 25 (96.2%) cases of IMB and 0 with MN were identified. In the control group, both modalities found asymptomatic web space pathology in four cases (30.8%), and US identified normal intermetatarsal bursas in five cases. Additionally, our results indicate that MN patients have more severe pain and a longer history of pain compared to IMB patients. Conclusions: Based on our MRI results, we conclude that IMB is frequent in patients with intermetatarsal pain. Differentiation between MN and IMB with US is complex and should be performed with caution and an understanding of both conditions. Normal intermetatarsal bursas are also visible on US as hypoechoic but non-expansive masses. Full article

Background/Objectives: Neuropathic pain associated with neuromas is a complex clinical problem to treat. Targeted Muscle Reinnervation (TMR) has been demonstrated to treat pain both as a prophylactic procedure in amputated patients and in patients affected by painful neuromas. It is not clear what its role could be in chronic situations: the literature reports amazing results but also unsuccessful pain relief. Methods: A retrospective analysis was conducted on patients treated with TMR for long-lasting painful neuromas in the upper and lower limbs. Following a clinical and instrumental diagnosis, all patients responded positively to a local anesthetic block. During follow-up visits, the NRS and DN4 questionnaires were used to assess improvement in pain. Results: Three patients were included in this study. TMR was performed 45 months after trauma. Two TMRs involved nerves of the upper extremity, in one case, the tibial nerve. The recipient muscles were the second lumbricalis, pronator quadratus, and flexor digitorum longus of the foot. After surgery, pain decreased for 3 months, but patients experienced a relapse that returned to levels close to the pre-operative period. The types of pain, as reported in DN4 questionnaire, changed slightly compared to those in the pre-surgical period. Follow-up ranged between 12 and 19 months. Conclusions: This small series collected the results of TMR in patients affected by long-lasting symptomatic neuromas in the upper and lower extremities. Despite what is published in other series, this procedure reduced pain for up to 6 months. At final follow-up, the type of pain changed slightly as reported in the DN4 questionnaire, and pain scores reduced by just one point as shown by the NRS. Our experience suggests that TMR might have a slight effect on long-lasting painful neuromas and in these cases, only short-term pain relief could be expected. This suggests using TMR as close as possible to the trauma in order to increase the chances of relieving pain. Full article

Background/Objectives: Tactile gnosis derives from the interplay between the hand’s tactile input and the memory systems of the brain. It is the prerequisite for complex hand functions. Impaired sensation leads to profound disability. Various invasive and non-invasive sensory substitution strategies for providing feedback from prostheses have been unsuccessful when translated to clinical practice, since they fail to match the feeling to genuine sensation of the somatosensory cortex. Methods: Herein, we describe a novel surgical technique for upper-limb-targeted sensory reinnervation (ulTSR) and report how single digital nerves selectively reinnervate the forearm skin and restore the spatial sensory capacity of single digits of the amputated hand in a case series of seven patients. We explore the interplay of the redirected residual digital nerves and the interpretation of sensory perception after reinnervation of the forearm skin in the somatosensory cortex by evaluating sensory nerve action potentials (SNAPs), somatosensory evoked potentials (SEPs), and amputation-associated pain qualities. Results: Digital nerves were rerouted and reliably reinnervated the forearm skin after hand amputation, leading to somatotopy and limb maps of the thumb and four individual fingers. SNAPs were obtained from the donor digital nerves after stimulating the recipient sensory nerves of the forearm. Matching SEPs were obtained after electrocutaneous stimulation of the reinnervated skin areas of the forearm where the thumb, index, and little fingers are perceived. Pain incidence was significantly reduced or even fully resolved. Conclusions: We propose that ulTSR can lead to higher acceptance of prosthetic hands and substantially reduce the incidence of phantom limb and neuroma pain. In addition, the spatial restoration of lost-hand sensing and the somatotopic reinnervation of the forearm skin may serve as a machine interface, allowing for genuine sensation and embodiment of the prosthetic hand without the need for complex neural coding adjustments. Full article

Background: Targeted muscle reinnervation (TMR) was originally developed to enhance prosthetic control in amputees. However, it has also serendipitously demonstrated benefits in reducing phantom pain and neuromas. As a result, it has emerged as a secondary treatment for chronic neuromas in amputees and holds promise for managing neuropathic pain in non-amputee patients, particularly those with neuromas. This review synthesizes the current literature on TMR indications for non-amputee patients, highlighting its potential to address chronic peripheral nerve pain and neuromas beyond its original application in amputation. Methods: A thorough search of the PubMed and Cochrane databases up to January 2024 was conducted following the PRISMA guidelines. Inclusion criteria comprised case series, cohort studies, and randomized controlled trials reporting TMR outcomes in non-amputees. Results: Of 263 articles initially identified, 8 met the inclusion criteria after screening and full-text assessment. The articles were all case series with varied sample sizes and mainly focused on neuroma treatment (n = 6) and neuropathic pain management (n = 2) for both upper and lower extremities. Clinical studies included TMR efficacy for sural nerve neuromas in the lower extremities and hand neuromas, showing pain relief and improved function. Key findings were encouraging, showing successful pain relief, patient satisfaction, and psychosocial improvement, with only rare occurrences of complications such as motor deficits. Conclusions: In non-amputee patients, TMR appears to be a promising option for the surgical management of neuropathic pain, demonstrating favorable patient satisfaction and psychosocial outcomes along with low morbidity rates. Although functional improvements in gait recovery and range of motion are encouraging, further research will be important to confirm and expand upon these findings. Full article

Background: Neuropathic pain results from a defect in the somatosensory nervous system caused by a diversity of etiologies. The effect of current treat-ment with analgesics and surgery is limited. Studies report the therapeutic use of adipose tissue-derived components to treat neuropathic pain as a new treatment modality. Objective: The aim of this systematic review was to investigate the therapeutic clinical efficacy of adipose tissue-derived components on neuro-pathic pain. Methods: PubMed, Medline, Cochrane and Embase databases were searched until August 2023. Clinical studies assessing neuropathic pain after autologous fat grafting or the therapeutic use of adipose tissue-derived com-ponents were included. The outcomes of interest were neuropathic pain and quality of life. Results: In total, 433 studies were identified, of which 109 dupli-cates were removed, 324 abstracts were screened and 314 articles were excluded. In total, ten studies were included for comparison. Fat grafting and cellular stromal vascular fraction were used as treatments. Fat grafting indications were post-mastectomy pain syndrome, neuromas, post-herpetic neuropathy, neuro-pathic scar pain and trigeminal neuropathic pain. In seven studies, neuropathic pain levels decreased, and overall, quality of life did not improve. Conclusions: The therapeutic efficacy of adipose tissue-derived components in the treatment of neuropathic pain remains unclear due to the few performed clinical trials with small sample sizes for various indications. Larger and properly designed (randomized) controlled trials are required. Full article

Neuroma, a pathological response to peripheral nerve injury, refers to the abnormal growth of nerve tissue characterized by disorganized axonal proliferation. Commonly occurring after nerve injuries, surgeries, or amputations, this condition leads to the formation of painful nodular structures. Traditional treatment options include surgical excision and pharmacological management, aiming to alleviate symptoms. However, these approaches often offer temporary relief without addressing the underlying regenerative challenges, necessitating the exploration of advanced strategies such as tissue-engineered materials for more comprehensive and effective solutions. In this study, we discussed the etiology, molecular mechanisms, and histological morphology of traumatic neuromas after peripheral nerve injury. Subsequently, we summarized and analyzed current nonsurgical and surgical treatment options, along with their advantages and disadvantages. Additionally, we emphasized recent advancements in treating traumatic neuromas with tissue-engineered material strategies. By integrating biomaterials, growth factors, cell-based approaches, and electrical stimulation, tissue engineering offers a comprehensive solution surpassing mere symptomatic relief, striving for the structural and functional restoration of damaged nerves. In conclusion, the utilization of tissue-engineered materials has the potential to significantly reduce the risk of neuroma recurrence after surgical treatment. Full article

Adding robotic surgery to bionic reconstruction might open a new dimension. The objective was to evaluate if a robotically harvested rectus abdominis (RA) transplant is a feasible procedure to improve soft-tissue coverage at the residual limb (RL) and serve as a recipient for up to three nerves due to its unique architecture and to allow the generation of additional signals for advanced myoelectric prosthesis control. A transradial amputee with insufficient soft-tissue coverage and painful neuromas underwent the interventions and was observed for 18 months. RA muscle was harvested using robotic-assisted surgery and transplanted to the RL, followed by end-to-end neurroraphy to the recipient nerves of the three muscle segments to reanimate radial, median, and ulnar nerve function. The transplanted muscle healed with partial necrosis of the skin mesh graft. Twelve months later, reliable, and spatially well-defined Hoffmann–Tinel signs were detectable at three segments of the RA muscle flap. No donor-site morbidities were present, and EMG activity could be detected in all three muscle segments. The linear discriminant analysis (LDA) classifier could reliably distinguish three classes within 1% error tolerance using only the three electrodes on the muscle transplant and up to five classes outside the muscle transplant. The combination of these surgical procedure advances with emerging (myo-)control technologies can easily be extended to different amputation levels to reduce RL complications and augment control sites with a limited surface area, thus facilitating the usability of advanced myoelectric prostheses. Full article

The infrapatellar branch of the saphenous nerve (SN) is a widely described anatomic and functional structure; however, its relevance in daily clinical practice is underestimated. All surgical procedures performed on the anteromedial aspect of the knee are associated with a risk of iatrogenic injury to this nerve, including knee arthroscopy, knee arthroplasty, tibial nailing, etc. We present the case of a saphenous nerve neuroma after treatment with radiofrequency thermal ablation due to a knee pain problem. After conducting an anaesthetic suppression test, we decided to perform a denervation of the medial saphenous nerve in Hunter’s canal. We performed surgery on the anteromedial aspect of the knee. The distal end of the medial SN was coagulated with a bipolar scalpel. The proximal end of the nerve was released proximally, and a termino-lateral suture was made at the free end of the nerve after creating an epineural window to inhibit its growth. A double crush was produced proximally to the suture site to create a grade II-III axonal injury. Autologous plasma rich in growth factors (PRGF) was used to reduce potential post-surgical adhesions and to stimulate regeneration of the surgical lesions. One year after surgery, the patient was living a completely normal life. Full article

Morton’s neuroma (MN) is a compressive neuropathy of the common plantar digital nerve, most commonly affecting the third inter-digital space. The conservative approach is the first recommended treatment option. However, other different approaches have been proposed, offering several options of treatments, where, several degrees of efficacy and safety have been reported. We treated five consecutive patients affected by MN through three indirect ultrasound-guided injections of type I porcine collagen at weekly intervals. All patients were assessed before the treatment, after the treatment and up to 6 months after the last injection via AOFAS and VNS scores for pain, in which the function and pain were evaluated, respectively. In all patients, both analyzed variables progressively ameliorated, with benefits lasting until the last follow-up. The trend of the scores during the follow-up showed significant statistical differences. No side effects occurred. To our knowledge, this is the first study on injections of type I porcine collagen for the treatment of Morton’s neuroma. Future research is needed to confirm the positive trend achieved in this MN mini-series. Full article

Background: Traumatic neuroma is a common sequela of peripheral nerve injury or amputation, which often leads to severe neuropathic pain. The present study investigated the effect of local lidocaine administration on preventing the formation of traumatic neuroma. Methods: Forty-eight male Sprague–Dawley rats were randomly assigned to two groups. The lidocaine group underwent sciatic nerve transection, followed by an injection of lidocaine (0.5%) around the proximal of a severed sciatic nerve under ultrasound-guidance 2–7 days after neurectomy. In the control group, rats received an injection of saline following neurectomy. The autotomy score, mechanical allodynia, thermal hyperalgesia, histological assessment, expression of neuroma, and pain-related markers were detected. Results: Lidocaine treatment reduced the autotomy score and attenuated mechanical allodynia and thermal hyperalgesia. The mRNA expression of α-SMA, NGF, TNF-α, and IL-1β all significantly decreased in the lidocaine group in comparison to those in the saline control group. The histological results showed nerve fibers, demyelination, and collagen hyperplasia in the proximal nerve stump in the saline control group, which were significantly inhibited in the lidocaine group. Conclusions: The present study demonstrated that local lidocaine administration could inhibit the formation of painful neuroma due to traumatic nerve injury. Full article

Muscle herniation of the lower extremity, such as tibialis anterior muscle herniation (TAMH), is not a rare cause of leg pain in athletes. However, a few studies have reported surgical treatment for TAMH, and the optimal surgical procedure remains controversial. Fasciotomy was reported to be effective for patients with TAMH. However, this procedure would be associated with a risk of intraoperative injury to the superficial peroneal nerve (SPN), although no previous literature has reported this complication. This case report aimed to report a case of bilateral TAMHs in which a traumatic neuroma of the SPN developed after fasciotomy. A 16-year-old baseball player presented with painful swelling lesions of the bilateral lower extremities (1 lesion on the right, 3 lesions on the left) after sports activities. An ultrasonographic evaluation showed swelling lesions of the anterolateral parts of the bilateral lower extremities in the standing position after dashing, while these lesions were not detected in the supine position. A fasciotomy of the crural fascia was performed after conservative treatment failed. Several days after surgery, the patient presented with weakened touch sensation over the dorsal area of the left foot. At the three-month follow-up examination, a swelling lesion with hard elasticity was identified. The palpation of this lesion caused a radiating sensation in the area supplied by the SPN. He was able to return to playing baseball six months after surgery. The patient was asymptomatic without palpation of the traumatic neuroma of the SPN at the latest follow-up examination. In conclusion, the present case report suggests that orthopedic surgeons need to consider the risk of iatrogenic injury to the SPN during fasciotomy for the treatment of TAMHs. However, there may be a risk of injuring the SPN because of the many variants of the course of the SPN within the compartment of the lower extremities. Full article

Therapy-resistant neuroma pain is a devastating condition for patients and surgeons. Although various methods are described to surgically deal with neuromas, some discontinuity and stump neuroma therapies have anatomical limitations. It is widely known that a neurotizable target for axon ingrowth is beneficial for dealing with neuromas. The nerve needs “something to do”. Furthermore, sufficient soft tissue coverage plays a major role in sufficient neuroma therapy. We aimed, therefore, to demonstrate our approach for therapy of resistant neuromas with insufficient tissue coverage using free flaps, which are sensory neurotized via anatomical constant branches. The central idea is to provide a new target, a new “to do” for the painful mislead axons, as well as an augmentation of deficient soft tissues. As indication is key, we furthermore demonstrate clinical cases and common neurotizable workhorse flaps. Full article

Focal vibration therapy seeks to restore the physiological function of tissues and the nervous system. Recommendations for vibration settings, e.g., that could improve residual limb health and prosthesis acceptance in people with amputation, are pending. To establish a physiological connection between focal vibration settings, clinical outcomes, and molecular and neuronal mechanisms, we combined the literature on focal vibration therapy, vibrotactile feedback, mechanosensitive Piezo ion channels, touch, proprioception, neuromodulation, and the recovery of blood vessels and nerves. In summary, intermittent focal vibration increases endothelial shear stress when applied superficially to blood vessels and tissues and triggers Piezo1 signaling, supporting the repair and formation of blood vessels and nerves. Conversely, stimulating Piezo1 in peripheral axon growth cones could reduce the growth of painful neuromas. Vibrotactile feedback also creates sensory inputs to the motor cortex, predominantly through Piezo2-related channels, and modulates sensory signals in the dorsal horn and ascending arousal system. Thus, sensory feedback supports physiological recovery from maladaptations and can alleviate phantom pain and promote body awareness and physical activity. We recommend focal vibration of phantom limb maps with frequencies from ~60–120 Hz and amplitudes up to 1 mm to positively affect motor control, locomotion, pain, nerves, and blood vessels while avoiding adverse effects. Full article