Surgical treatment of painful neuroma in medial antebrachial cutaneous nerve

The branches of the medial antebrachial cutaneous nerve (MACN) are located at the medial site of the elbow. The MACN, especially the posterior branches, may be injured or transected during cubital tunnel surgery or other medial approaches to the elbow. Damage to the nerve can cause a neuroma, which leads to disabling pain and restriction of elbow movement. The initial treatment of the neuroma is nonsurgical, and includes local massage, desensitization, physiotherapy, and systemic medication. If after 6 months of these nonsurgical treatments there is no improvement, surgery is indicated. The authors report their experience with 12 patients treated surgically for painful neuroma by high resection of the proximal end or its implantation into the triceps muscle. After surgery there was a high success rate of pain relief and functional improvement in both elbow movement and handgrip strength.     

Results of treatment of recurrent dorsoradial wrist neuromas

Dorsoradial wrist neuromas diagnosed and treated by traditional techniques remain the most difficult for which to achieve satisfactory pain relief. Between 1981 and 1985, 52 patients with dorsoradial wrist neuromas were treated by neuroma resection and implantation of the nerves innervating the neuroma into the brachioradialis muscle. Critical to this treatment schema was preoperative use of nerve blocks to diagnose overlapping patterns of the cutaneous nerves in this region. Of patients for whom this technique was the first surgical treatment of their neuroma (primary group), 100% achieved good to excellent pain relief. Among patients in whom the neuroma had been operated on once previously (first recurrence group), 88% achieved good to excellent pain relief with the technique described in this article. Of patients treated who had had 3 or more previous "neuroma" operations (multiple recurrence group), this technique resulted in excellent pain relief in 56%. Factors contributing to a poorer result in the multiple recurrence group included duration of pain longer than 24 months and the patient's unemployment. The diagnostic and surgical approach detailed in this article has yielded clinical results that recommend this approach not only as the primary treatment of choice but also as the treatment to help patients with pain from recurrent dorsoradial neuromas. The apparent susceptibility of the superficial branch of the radial nerve (SBRN) to form painful neuromas has been well documented. Once established, the neuroma appears particularly resistant to treatment. Based on experimental and cadaveric studies, we have formulated a treatment plan for patients with dorsoradial wrist neuromas.(ABSTRACT TRUNCATED AT 250 WORDS)     

Pulsed radiofrequency on radial nerve under ultrasound guidance for treatment of intractable lateral epicondylitis

Lateral epicondylitis is a painful and functionally limiting disorder. Although lateral elbow pain is generally self-limiting, in a minority of people symptoms persist for a long time. When various conservative treatments fail, surgical approach is recommended. Surgical denervation of several nerves that innervate the lateral humeral epicondyle could be considered in patients with refractory pain because it denervates the region of pain. Pulsed radiofrequency is a minimally invasive procedure that improves chronic pain when applied to various neural tissues without causing any significant destruction and painful complication. This procedure is safe, minimally invasive, and has less risk of complications relatively compared to the surgical approach. The radial nerve can be identified as a target for pulsed radiofrequency lesioning in lateral epicondylitis. This innovative method of pulsed radiofrequency applied to the radial nerve has not been reported before. We reported on two patients with intractable lateral epicondylitis suffering from elbow pain who did not respond to nonoperative treatments, but in whom the ultrasound-guided pulsed radiofrequency neuromodulation of the radial nerve induced symptom improvement. After a successful diagnostic nerve block, radiofrequency probe adjustment around the radial nerve was performed on the lateral aspect of the distal upper arm under ultrasound guidance and multiple pulsed treatments were applied. A significant reduction in pain was reported over the follow-up period of 12 weeks.     

阿霉素神经干注射联合神经瘤切除或松解治疗痛性神经瘤

目的 介绍一种治疗痛性神经瘤的新方法和初步临床疗效.方法 2002年～2006年,应用阿霉素神经干注射联合神经瘤切除或松解治疗痛性神经瘤患者9例.其中8例切除残端神经瘤后.将神经近端置于正常的软组织内;1例连续性神经瘤仅做神经松解.所有病例均在神经瘤切除或松解后,根据神经干粗细的不同分别用1%的阿霉素0.3～1.0 ml作近端神经干注射.结果 经过24～60个月的临床随访,7例残端神经瘤患者的疼痛明显缓解,1例疼痛减轻,1例无效(仅做神经松解),手术优良率为77.8%.结论 阿霉素神经干注射联合神经瘤切除能有效缓解残端神经痛.     

Relocation of neuromas of the lateral antebrachial cutaneous nerve of the forearm into the brachialis muscle

Painful neuromas following injury to the radial side of the wrist can be treated by relocation away from the zone of injury and implantation into muscle. Relocation to the brachialis muscle is useful for isolated neuromas of the lateral antebrachial cutaneous nerve and involves a shorter dissection than relocation to the brachioradialis. It is also useful in patients undergoing multiple procedures to avoid disturbing previous relocations to the brachioradialis. This paper describes the successful relocation of painful neuromas of the lateral antebrachial cutaneous nerve to the brachialis muscle in seven patients.     

Outcome of neurolysis for failed tarsal tunnel surgery

Revision tarsal tunnel surgery was performed on 44 patients (two bilaterally). The surgical procedure included a neurolysis of the tibial nerve in the tarsal tunnel, the medial plantar, lateral plantar, and calcaneal nerves in their respective tunnels, excision of the intertunnel septum, and neuroma resection as indicated. A painful tarsal tunnel scar or painful heel was treated, respectively, by resection of the distal saphenous nerve or a calcaneal nerve branch. Postoperative, immediate ambulation was permitted. Outcomes were assessed with a numerical grading scale that included neurosensory measurements. Outcomes were also assessed by patient satisfaction and their own estimate of residual pain and/or numbness. Mean follow-up time was 2.2 years. Outcomes in terms of patient satisfaction were 54% excellent, 24% good, 13% fair, and 9% poor results. The mean preoperative numerical score was 6.0 and the mean postoperative score was 2.7. There was a significant improvement seen, based on the median difference between scores (P<0.001). Prognostic indicators of poor results in our patient group were coexisting lumbosacral disc disease and/or neuropathy. An approach related to resecting painful cutaneous nerves and neurolysis of all tibial nerve branches at the ankle offers hope for relief of pain and recovery of sensation for the majority of patients with failed previous tarsal tunnel surgery.     

Neuromas of the calcaneal nerves.

A neuroma of a calcaneal nerve has never been reported. A series of 15 patients with heel pain due to a neuroma of a calcaneal nerve are reviewed. These patients previously had either a plantar fasciotomy (n = 4), calcaneal spur removal (n = 2), ankle fusion (n = 2), or tarsal tunnel decompression (n = 7). Neuromas occurred on calcaneal branches that arose from either the posterior tibial nerve (n = 1), lateral plantar nerve (n = 1), the medial plantar nerve (n = 9), or more than one of these nerves (n = 4). Operative approach was through an extended tarsal tunnel incision to permit identification of all calcaneal nerves. The neuroma was resected and implanted into the flexor hallucis longus muscle. Excellent relief of pain occurred in 60%, and good relief in 33%. One patient (17%) had no improvement and required resection of the lateral plantar nerve. Awareness that the heel may be innervated by multiple calcaneal branches suggests that surgery for heel pain of neural origin employ a surgical approach that permits identification of all possible calcaneal branches.     

Painful entrapment of the lateral antebrachial cutaneous nerve at the elbow

PURPOSE: The purpose of this study was to report the diagnosis and management of entrapment neuropathy of the lateral antebrachial cutaneous nerve (LABCN) presenting as lateral elbow pain. METHODS: Twenty-three patients with lateral elbow pain were diagnosed with entrapment of the LABCN. Six patients also had paresthesia of the distal forearm. Diagnosis was made by clinical evaluation and confirmed with diagnostic injection of 1% lidocaine. Electrodiagnostic evaluation was positive in all patients. All patients were treated conservatively. Seven patients improved and 16 patients had surgical decompression of the LABCN at the elbow and distal arm with partial resection of the lateral margin of the biceps tendon. Postoperative follow-up evaluation averaged 45 months. RESULTS: Fourteen patients had complete relief of pain and 2 patients continued to have minimal to mild pain. Of the 6 patients who had preoperative paresthesia only 1 patient had persistent mild paresthesia of the radial side of the distal forearm. Range of motion and grip and pinch strength returned to normal values. All patients returned to their preoperative daily and work activities. CONCLUSIONS: Entrapment neuropathy of the LABCN should be considered in the differential diagnosis of elbow pain. Electrodiagnostic evaluation can be very useful in establishing and confirming the diagnosis. Surgical treatment of patients who do not respond to conservative treatment is simple yet effective in improving the patients' symptoms. Patients who present with paresthesia usually require surgical intervention because paresthesia represents a more progressive stage of the nerve entrapment.     

痛性神经瘤33例治疗分析

目的 通过对痛性神经瘤不同的治疗比较,分析痛性神经瘤的疗效及预后.方法 对33例不同受伤机制而导致的39处痛性神经瘤,进行单纯神经瘤体高位切除（8例）,瘤体切除伴屈肌腱鞘植入（1例）、伴骨内植入（5例）、神经断端吻合（2例）、神经原位移植（10例）、皮瓣覆盖（7例）等进行不同手术的治疗比较.结果 术后随访2～30年,按患者疼痛的主观意见来改善评定：优11例,良20例,差2例,优良率93%.结论 不同的受伤机制导致不同部位形成的痛性神经瘤行不同的手术治疗,其疗效无明显差异,而与受伤机制、首次术后局部血运、是否感染、瘢痕增生情况、神经处理方式、患者心理状况等有明显差异.     

Entrapment of the Posterior Interosseous Nerve

48 patients, 20 men and 28 women, were examined because of pain radially-proximally in the forearm, in 2 patients bilaterally. 31 patients, representing 32 elbows, had previously been treated for chronic lateral epicondylitis with local steroid injections, antiphlogistic drugs, immobilization and/or surgery one or several times, without any relief of the symptoms. The affected arm was in 44 instances the most loaded one during work. The duration of the symptoms varied from 6 months to about 10 years, on average 2 years. The main complaint was pain at night, which was reported by 43 patients. Other complaints were pain during work, radiating pain, numbness, and weakness. The main preoperative findings were intense local tenderness about 5 cm distal to the lateral epicondyle, present in all 50 forearms, and indirect pain induced by supination against resistance, present in 43 forearms. The complaints were interpreted as being caused by entrapment of the posterior interosseous nerve at its entrance into the supinator muscle. Decompression of the nerve was performed in all instances. The length of follow-up varied from about 2 months to 3 years, on average 2 years. Results: excellent 33, good 9, fair 6 and poor 2. The preoperative symptoms and findings are discussed, as well as the site and severity of nerve entrapment and the main differential diagnosis: lateral epicondylitis.     

Entrapment of the lateral antebrachial cutaneous nerve exiting through the forearm fascia

Isolated lateral antebrachial cutaneous nerve entrapment syndromes are uncommon. This report describes the compression of the lateral antebrachial cutaneous nerve of the forearm at the level of its passage through the superficial antebrachial fascia, distal to the elbow crease. Numbness and a painful dysesthesia over the radial aspect of the volar forearm were documented. Failure of conservative treatment necessitated surgical decompression.     

Nerve stripping: new treatment for neuromas of the palmar cutaneous branch of the median nerve

We present a new method for the treatment of painful neuromas of the palmar cutaneous branch of the median nerve. A preliminary cadaver study was done to investigate the extraneural and intraneural course of the palmar cutaneous branch of the median nerve with respect to the main trunk of the median nerve. Seven patients presented with a painful neuroma following previous surgery on the palmar aspect of the wrist. The neuroma was dissected and excised by stripping the whole of the palmar cutaneous branch from the main trunk of the median nerve. In all cases complete relief from pain and discomfort was achieved. The resulting area of numbness in the palm did not represent a significant problem.     

改良体表定位前臂近段掌侧切口治疗桡骨近段骨折的安全性研究

目的用肱二头肌腱桡侧缘与桡侧屈腕肌肌腱的连线作为前臂近段掌侧切口术前体表定位线,探讨该体表定位方法的临床安全性。 方法回顾性分析自2012年1月至2016年4月期间,21例桡骨近侧1/3骨折患者的手术资料。术前体表定位切口的方法采用肱二头肌腱桡侧缘与桡侧屈腕肌肌腱连线,行切开复位钢板内固定术。其中男16例,女5例;年龄19~52岁,平均34岁。致伤原因：跌伤15例,交通伤3例,高处坠落伤2例,打架致伤1例。左侧12例,右侧9例。均为单纯桡骨干骨折、闭合性损伤、术前无神经损伤症状。受伤至手术时间为1~9 d,平均4 d。术后根据Grace和Eversmann标准对患者前臂旋转功能进行评价,并评价其前臂外侧皮神经支配区域的感觉情况。 结果本组患者术后获11~24个月（平均14个月）随访,所有骨折均获得骨性愈合,愈合时间均<6个月。根据末次随访时前臂功能评价的Grace和Eversmann标准：优15例、良4例、可2例,优良率为90.5%。无感染、内固定失败及神经或血管损伤等并发症发生,没有患者发生桡神经及前臂外侧皮神经损伤的症状。 结论通过改良体表定位前臂掌侧入路的方法,手术切开时能有效避免医源性前臂外侧皮神经损伤。术中以肱二头肌腱为参照,并确保在肱二头肌腱的桡侧进行操作。肱二头肌腱是安全可靠的定位标记。     

Treatment of recurrent lingual nerve end‐neuroma: A case report

A neuroma is a collection of disorganized nerve sprouts emanating from an interruption of axonal continuity, forming within a collagen scar as the nerve attempts to regenerate. Lingual neuroma formation secondary to iatrogenic trauma to the tongue is likely not uncommon; however, we could not find a report in the literature of treatment of a distal tongue end‐neuroma treated by resection and implantation into muscle. Here we describe a patient who experienced debilitating chronic tongue pain after excision of a benign mass. After failing conservative management, the patient was taken to the operating room where an end‐neuroma of the lingual nerve was identified and successfully treated by excision and burying of the free proximal stump in the mylohyoid muscle. At 17 months postoperatively, she remains pain free without dysesthesias. © 2013 Wiley Periodicals, Inc. Microsurgery 33:575–577, 2013.     

Treatment of recurrent neuroma of the interdigital nerve by implantation of the proximal nerve into muscle in the arch of the foot

A prospective study was done to evaluate the results of treating recurrent "Morton's" neuroma by a technique that combined resecting the interdigital neuroma through a plantar approach and implantation of the proximal end of the nerve into an intrinsic muscle in the arch of the foot. As a part of this study, quantitative sensory testing was done for the medial plantar and medial calcaneal nerves. Seventeen recurrent interdigital neuromas were resected in 13 patients. Pain was identified on physical examination as being due to neuromas located in the first (one), second (six), third, (eight) and fourth (two) web spaces. Seven of the 13 patients were found to have, by quantitative sensory testing and physical examination, an associated tarsal tunnel syndrome responsible for symptoms related to numbness in the foot in addition to the pain of the recurrent neuroma. These patients had tarsal tunnel decompression at the time of the neuroma resection. At a mean follow-up time of 33.8 months (range 24-42 months), done by direct physician interview and examination, 80% of the patients had excellent relief of symptoms, returned to their regular job, and wore usual footwear. Twenty percent of the patients had good relief of symptoms, worked at a different job, and had to change their footwear. It is concluded that recurrent pain after a dorsal interdigital neurectomy can be treated successfully through a plantar approach with implantation of the proximal end of the nerve into an intrinsic muscle. This study also identified an association of tarsal tunnel syndrome in 54% of this series of patients with recurrent Morton's neuroma.     

经皮微创钢板固定治疗肱骨干骨折的疗效分析

目的探讨经皮微创钢板内固定术治疗肱骨干骨折的方法及疗效。 方法2014年5月至2017年5月,应用锁定加压钢板经皮微创固定治疗肱骨干骨折患者26例,男18例、女8例;平均年龄42.6岁（19~72岁）;右侧19例,左侧7例。致伤原因：交通伤11例,平地摔伤8例,高处坠落伤4例,扭伤3例。根据AO分型：A型6例,B型15例,C型5例。其中1例合并桡神经麻痹,1例合并同侧尺桡骨干骨折,1例合并同侧桡骨远端骨折,1例合并对侧肱骨髁间骨折,1例合并同侧股骨粗隆间骨折。受伤距手术时间为3~12 d（平均7.2 d）。其中20例采用前侧入路,6例采用后外侧入路进行经皮微创钢板内固定术。术后患者每2周复查记录功能恢复情况,每4周摄X线片了解骨折愈合情况。 结果经过12~35个月的随访（平均16.4个月）,所有骨折均获得骨性愈合,平均愈合时间14.8周（10~22周）。末次随访时,患者美国加州大学肩关节评分（the university of California at Los Angeles shoulder rating scale,UCLA）为24~35分（平均34.1分）,肘关节Mayo功能评分为91~100分（平均93.3分）。1例患者术后出现桡神经麻痹,3个月后症状消失;另1例术前即合并桡神经损伤患者,术中未显露探查桡神经,神经功能亦于术后2个月恢复。 结论采用经皮微创钢板固定的方式治疗复杂肱骨干骨折,手术创伤更小,操作简单安全,骨折愈合率高,临床疗效满意。     

The role of the extensor digitorum communis muscle in lateral epicondylitis

A common finding in tennis elbow is pain in the region of the lateral epicondyle during resisted extension of the middle finger (Maudsley's test). We hypothesized that the pain is due to disease in the extensor digitorum communis muscle, rather than to compression of the radial nerve or disease within extensor carpi radialis brevis. Thirteen human forearm specimens were examined. It was found that the extensor digitorum communis was separable into four parts. The part to the middle finger originated from the lateral epicondyle, but the muscle slips to the other fingers originated more distally. Pain ratings were measured in ten patients diagnosed with lateral epicondylitis during isometric finger and wrist extension tests. The results confirmed the high prevalence of a positive Maudsley's test in lateral epicondylitis, and also that the patients with tenderness at the site of origin of the extensor digitorum communis slip to the middle finger had the greatest pain during middle finger extension. These anatomical and clinical findings clarify the anatomy of extensor digitorum communis, and suggest that this muscle forms the basis for the Maudsley's test. The muscle may play a greater role in tennis elbow than previously appreciated.     

肘部和前臂段桡神经解剖特征及损伤修复

目的 观察肘部和前臂段桡神经的解剖学特征及损伤修复的方法.方法 36侧成人上肢标本,于肘外侧做"S"形切口,从肱肌和肱桡肌间隙内解剖出桡神经肘段,沿桡神经干向远端追踪,找出桡神经深支出旋后肌的各个分支,测量深支各肌支的发出点、入肌点距肱骨髁上水平的距离和长度.逆行分离各分支,观察各分支的神经纤维在桡神经干内的分布定位特征.对12例肘部桡神经损伤的患者,采用桡神经定位缝合和不定位缝合的方法进行修复.结果 12例获得平均2.4年的随访.根据桡神经深支支配的运动区肌腱肌力恢复情况,神经定位缝合6例,术后有效率为83.3%.非定位缝合6例,有效率为50.0%.桡神经定位缝合组的有效率明显高于不定位缝合组.结论 前臂背侧距肱骨外上髁10～15cm范围内的锐器伤,伸拇困难者应考虑有骨间背神经肌支的损伤.运动支的神经纤维在桡神经干的内侧,对肘部桡神经断裂伤修复时重点应缝合内侧部分.显微定位缝合技术修复肘部和前臂段桡神经损伤是有效的方法.     

Endoscopic decompression of the ulnar nerve at the elbow

PURPOSE: The ideal operative treatment for cubital tunnel syndrome, the second most common form of peripheral compression neuropathy, remains controversial. We therefore reviewed our series of endoscopically assisted ulnar nerve decompression at the elbow to determine the effectiveness of the procedure, which was intended to minimize perioperative morbidity and scar discomfort. METHODS: In 36 patients (ages 22-76 years) with clinical McGowan grade I (4 patients), II (21 patients), and III (11 patients) and electrophysiologic signs of cubital tunnel syndrome (35 primary, 1 recurrent), 20 cm of the ulnar nerve was released through a 3.5-cm-long skin incision above the medial epicondyle. A 4-mm, 30 degrees standard endoscope and custom-made guiding-dissecting tool were utilized during the procedure, and the mean postoperative follow-up examination was 14 months (range 6-19). RESULTS: No macroscopically visible nerves and vessels were injured during the procedure. The only postoperative complication was hematoma in one patient that resolved after conservative management. One case was converted from endoscopic to open because of a ganglion that surrounded the nerve in the forearm. There was no scar discomfort (ie, painful neuroma, impaired sensibility, or burning sensation) or elbow extension deficit after surgery, and surgical wounds all healed within a week. Outcomes were excellent in 21 of 36 cases and good in 12 of 36 cases. All patients improved electrophysiologically after surgery, were satisfied with the procedure, returned to full activities within 3 weeks, and would have the procedure again. CONCLUSIONS: By using a safe and reliable endoscopic technique characterized by a short incision, minimum soft tissue dissection, and early postoperative mobilization, we were able to preserve the benefits of conventional approaches (namely, complete release and good visualization), while avoiding problems such as painful scarring and elbow contracture.     

Surgical treatment of resistant lateral epicondylitis. Follow-up study of 19 patients after excision,release and repair of proximal common extensor tendon origin

BACKGROUND: Lateral epicondylitis resistant to conservative treatment is a rare yet disabling condition. When diagnosed, it should be treated surgically. The appropriate surgical treatment relies on a precise diagnosis, usually based on physical examination. Exclusion of other pathologies in the lateral elbow area is essential. METHODS: We report on an outcome in a group of 19 consecutive patients treated by excision, release, reattachment and repair of the common extensor origin. These patients were followed clinically for at least 2 years. RESULTS: Eighteen patients reported recovery from pain and a satisfactory subjective gaining of strength in their forearm on average 3 and 4 months after the surgery, respectively. CONCLUSIONS: The presented treatment method is highly effective in the treatment of resistant lateral epicondylitis.