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Incidence and risk factors of painful neuroma formation following sarcoma resection
Zohra V Aslami, BA1; Christopher R Leland, BS1; Sophie A Strike, MD2; Jonathan A Forsberg, MD, PhD3; Adam S Levin, MD4; Carol D Morris, MD, MS4; Sami H Tuffaha, MD5
1Johns Hopkins School of Medicine, Baltimore, MD; 2Johns Hopkins University, Baltimore, MD; 3Johns Hopkins, Baltimore, MD; 4Johns Hopkins University School of Medicine, Baltimore, MD; 5Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD

Background: When an injured nerve is unrepaired, free nerve endings may form a painful aggregate of aberrant neural growth, called a neuroma. While the incidence and risk factors of symptomatic neuroma formation are well characterized in amputees and other patient populations, these data have not been studied in patients undergoing sarcoma resection. During wide excision for sarcoma, both cutaneous and large-caliber mixed motor-sensory nerves may be sacrificed and left unrepaired. This study aimed to characterize the incidence and risk factors of symptomatic neuroma formation in this population.
Methods: We retrospectively reviewed adult patients undergoing wide excisions for skeletal and soft tissue tumors at a high-volume sarcoma center from 2014-2019. We included wide excisions for an oncologic indication and excluded non-wide excisions, primary amputations, or those with insufficient follow-up (<6 months). This rendered a cohort of 231 patients undergoing 332 wide excisions for primary bone and soft tissue lesions. Patient demographics, oncologic disease and treatment course, resection characteristics, and clinical outcomes were collected, with particular attention to neuropathic indicators of neuroma development. Data are provided as descriptive statistics and multivariable regression modeling was performed.
Results: At the time of surgery, 231 patients (46% female) were a mean 52±19 years old. The most common lesions were sarcomatous (n=302 [91%]) and lipomatous (n=24 [7%]) primary tumors. Most tumors occurred in an extremity (n=255 [77%]). The mean resection size was 12±7 cm (n=332), with 247 subfascial resections (74%). Nerve involvement was documented in 174 excisions (52%), most frequently mixed motor-sensory nerves (n=123 [71%]). Nerve transection was documented in 87 resections (26%). Neuropathic pain was endorsed at 168 (51%) excision sites requiring postoperative neuromodulatory pain medication in 142 (43%) cases. There were 82 symptomatic neuromas (25%) meeting clinical criteria of Tinel’s sign or pain on exam >6 months postoperatively and neuropathy in the distribution of suspected nerve injury. Factors significantly associated with neuroma formation included age <52 years (OR, 2.8; 95% CI, 1.5-5.2; p=0.001) and multiple resections (OR, 2.8; 95% CI, 1.6-4.8; p=0.000).
Conclusion: Following wide excision for skeletal and soft tissue tumors, neuropathic pain was reported at approximately 50% of excision sites and criteria were met for symptomatic neuroma formation after 25% of resections. Younger age at time of surgery and multiple resections were associated with symptomatic neuroma formation. Our results highlight the importance of intraoperative prophylaxis for neuroma prevention following wide excision of tumors, particularly for younger patients with a recurrent tumor burden.


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