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Modified Management of Sensory Nerve Neuroma of the Foot When Implantation into Muscle Is Not Available; Proximal Nerve Stump Capping with Blind-Ended Degradable Nerve Protector
John R. Barbour, MD
Plastic Surgery, Georgetown University, Washington, DC
Introduction: Reconstruction of sensory nerve injuries is critical to prevent painful neuroma formation. Following trauma or surgery to the foot, injured cutaneous nerves are exposed to a number of influences that can lead to unfavorable outcomes. Poor outcomes can be attributed to scar formation within the nerve as well as tethering of the nerve to surrounding tissue. While the events are multi-factorial, a common basis for neuroma formation is disorganized growth of axon cylinders into proliferating granulation tissue. This has been shown to be preventable by an epineural sleeve, implantation into muscle fibers, or neural coaption to adjacent nerve fascicles. Isolation of a nerve from its surrounding environment may prevent scar ingrowth, minimize potential for nerve entrapment, and reduce the impact of aberrantly regenerating nerve fibers. We present an alternate technique for terminal nerve protection to provide an environment resistant to neuroma formation.
Materials and Methods: Seventeen patients underwent exploration for painful neuromas of the foot following trauma or previous surgery. All patients reported a defined focal point of maximal pain in a specific region and all were found to have a surgically identifiable cutaneous neuroma (n=17). Identified nerves were the intermediate or medial dorsal cutaneous nerve (n=8), medial plantar nerve (n=6) or distal sural nerve (n=3). All patients underwent excision of the neuroma, proximal neuroplasty to avoid the area of trauma, and capping of the terminal nerve with a blind-ended degradable nerve protector. Patients were followed for a minimum of nine months (range 9-16 months).
Results: Standardized pain questionnaires were collected on each patient at the time of most recent follow-up. The mean pre-operative pain score on a 0-10 scale for all patients was 6.8±1.4/10, and all patients reported typical nerve entrapment symptoms (Burning, Stabbing, Tingling) on selected descriptive word associations. Mean post-operative pain scores were all reduced and the average reduction was 4.7±0.7 points. All patients reported an immediate reduction and no patients have reported recurrence of the symptoms (n=17, mean pain score 1.7±0.5 points).
Conclusions: Prevention of post-operative neuroma is a major focus for peripheral nerve specialists. Engineered nerve protectors are designed to provide an interface between the nerve and the surrounding tissue, mechanically resist compression from surrounding tissue and exclude scar tissue ingrowth. In selected patients with no expendable or available muscle for implantation, this represents a safe and reasonable option for protection of the distal nerve and prevention of neuroma recurrence or further nerve injury.
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