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Yang H, Dong Y, Wang Z, Lai J, Yao C, Zhou H, Alhaskawi A, Hasan Abdullah Ezzi S, Kota VG, Hasan Abdulla Hasan Abdulla M, Lu H. Traumatic neuromas of peripheral nerves: Diagnosis, management and future perspectives. Front Neurol 2023; 13:1039529. [PMID: 36712443 PMCID: PMC9875025 DOI: 10.3389/fneur.2022.1039529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 12/19/2022] [Indexed: 01/12/2023] Open
Abstract
Traumatic neuromas are infrequent in clinical settings but are prevalent following trauma or surgery. A traumatic neuroma is not a true malignancy, rather, it is a hyperplastic, reparative nerve reaction after injury and typically manifests as a nodular mass. The most common clinical manifestations include painful hypersensitivity and the presence of a trigger point that causes neuralgic pain, which could seriously decrease the living standards of patients. While various studies are conducted aiming to improve current diagnosis and management strategies via the induction of emerging imaging tools and surgical or conservative treatment. However, researchers and clinicians have yet to reach a consensus regarding traumatic neuromas. In this review, we aim to start with the possible underlying mechanisms of traumatic neuromas, elaborate on the diagnosis, treatment, and prevention schemes, and discuss the current experiment models and advances in research for the future management of traumatic neuromas.
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Affiliation(s)
- Hu Yang
- Department of Orthopedics, The First Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang, China
| | - Yanzhao Dong
- Department of Orthopedics, The First Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang, China
| | - Zewei Wang
- Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Jingtian Lai
- Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Chenjun Yao
- Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Haiying Zhou
- Department of Orthopedics, The First Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang, China
| | - Ahmad Alhaskawi
- Department of Orthopedics, The First Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang, China
| | | | | | | | - Hui Lu
- Department of Orthopedics, The First Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang, China,Alibaba-Zhejiang University Joint Research Center of Future Digital Healthcare, Zhejiang University, Hangzhou, Zhejiang, China,*Correspondence: Hui Lu ✉
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Bowen JB, Wee CE, Kalik J, Valerio IL. Targeted Muscle Reinnervation to Improve Pain, Prosthetic Tolerance, and Bioprosthetic Outcomes in the Amputee. Adv Wound Care (New Rochelle) 2017; 6:261-267. [PMID: 28831329 DOI: 10.1089/wound.2016.0717] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Accepted: 01/17/2017] [Indexed: 12/12/2022] Open
Abstract
Scope and Significance: There are ∼185,000 amputations each year and nearly 2 million amputees currently living in the United States. Approximately 25% of these amputees will experience chronic pain issues secondary to localized neuroma pain and/or phantom limb pain. Problem: The significant discomfort caused by neuroma and phantom limb pain interferes with prosthesis wear, subjecting amputees to the additional physical and psychological morbidity associated with chronic immobility. Although numerous neuroma treatments are described, none of these methods are consistently effective in eliminating symptoms. Translational Relevance: Targeted muscle reinnervation (TMR) is a surgical technique involving the transfer of residual peripheral nerves to redundant target muscle motor nerves, restoring physiological continuity and encouraging organized nerve regeneration to decrease and potentially prevent the chaotic and misdirected nerve growth, which can contribute to pain experienced within the residual limb. Clinical Relevance: TMR represents one of the more promising treatments for neuroma pain. Prior research into "secondary" TMR performed in a delayed manner after amputation has shown great improvement in treating amputee pain issues because of peripheral nerve dysfunction. "Primary" TMR performed at the time of amputation suggests that it may prevent neuroma formation while avoiding the risks associated with a delayed procedure. In addition, TMR permits the target muscles to act as bioamplifiers to direct bioprosthetic control and function. Summary: TMR has the potential to treat pain from neuromas while enabling amputee patients to return to their activities of daily living and improve prosthetic use and tolerance. Recent research in the areas of secondary (i.e., delayed) and primary TMR aims to optimize efficacy and efficiency and demonstrates great potential for establishing a new standard of care for amputees.
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Affiliation(s)
- J. Byers Bowen
- Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Corinne E. Wee
- Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Jaclyn Kalik
- Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Ian L. Valerio
- Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
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Cheesborough JE, Smith LH, Kuiken TA, Dumanian GA. Targeted muscle reinnervation and advanced prosthetic arms. Semin Plast Surg 2015; 29:62-72. [PMID: 25685105 DOI: 10.1055/s-0035-1544166] [Citation(s) in RCA: 98] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Targeted muscle reinnervation (TMR) is a surgical procedure used to improve the control of upper limb prostheses. Residual nerves from the amputated limb are transferred to reinnervate new muscle targets that have otherwise lost their function. These reinnervated muscles then serve as biological amplifiers of the amputated nerve motor signals, allowing for more intuitive control of advanced prosthetic arms. Here the authors provide a review of surgical techniques for TMR in patients with either transhumeral or shoulder disarticulation amputations. They also discuss how TMR may act synergistically with recent advances in prosthetic arm technologies to improve prosthesis controllability. Discussion of TMR and prosthesis control is presented in the context of a 41-year-old man with a left-side shoulder disarticulation and a right-side transhumeral amputation. This patient underwent bilateral TMR surgery and was fit with advanced pattern-recognition myoelectric prostheses.
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Affiliation(s)
| | - Lauren H Smith
- Center for Bionic Medicine, Rehabilitation Institute of Chicago, Chicago, Illinois ; Department of Biomedical Engineering, Northwestern University, Chicago, Illinois
| | - Todd A Kuiken
- Center for Bionic Medicine, Rehabilitation Institute of Chicago, Chicago, Illinois ; Department of Biomedical Engineering, Northwestern University, Chicago, Illinois ; Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, Illinois
| | - Gregory A Dumanian
- Division of Plastic and Reconstructive Surgery, Northwestern University, Chicago, Illinois
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Souza JM, Cheesborough JE, Ko JH, Cho MS, Kuiken TA, Dumanian GA. Targeted muscle reinnervation: a novel approach to postamputation neuroma pain. Clin Orthop Relat Res 2014; 472:2984-90. [PMID: 24562875 PMCID: PMC4160494 DOI: 10.1007/s11999-014-3528-7] [Citation(s) in RCA: 233] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Postamputation neuroma pain can prevent comfortable prosthesis wear in patients with limb amputations, and currently available treatments are not consistently effective. Targeted muscle reinnervation (TMR) is a decade-old technique that employs a series of novel nerve transfers to permit intuitive control of upper-limb prostheses. Clinical experience suggests that it may also serve as an effective therapy for postamputation neuroma pain; however, this has not been explicitly studied. QUESTIONS/PURPOSES We evaluated the effect of TMR on residual limb neuroma pain in upper-extremity amputees. METHODS We conducted a retrospective medical record review of all 28 patients treated with TMR from 2002 to 2012 at Northwestern Memorial Hospital/Rehabilitation Institute of Chicago (Chicago, IL, USA) and San Antonio Military Medical Center (San Antonio, TX, USA). Twenty-six of 28 patients had sufficient (> 6 months) followup for study inclusion. The amputation levels were shoulder disarticulation (10 patients) and transhumeral (16 patients). All patients underwent TMR for the primary purpose of improved myoelectric control. Of the 26 patients included in the study, 15 patients had evidence of postamputation neuroma pain before undergoing TMR. RESULTS Of the 15 patients presenting with neuroma pain before TMR, 14 experienced complete resolution of pain in the transferred nerves, and the remaining patient's pain improved (though did not resolve). None of the patients who presented without evidence of postamputation neuroma pain developed neuroma pain after the TMR procedure. All 26 patients were fitted with a prosthesis, and 23 of the 26 patients were able to operate a TMR-controlled prosthesis. CONCLUSIONS None of the 26 patients who underwent TMR demonstrated evidence of new neuroma pain after the procedure, and all but one of the 15 patients who presented with preoperative neuroma pain experienced complete relief of pain in the distribution of the transferred nerves. TMR offers a novel and potentially more effective therapy for the management of neuroma pain after limb amputation.
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Affiliation(s)
- Jason M. Souza
- Division of Plastic Surgery, Northwestern Feinberg School of Medicine and Neural Engineering Center for Artificial Limbs, 675 N St Clair, Suite 19-250, Chicago, IL 60610 USA
| | - Jennifer E. Cheesborough
- Division of Plastic Surgery, Northwestern Feinberg School of Medicine and Neural Engineering Center for Artificial Limbs, 675 N St Clair, Suite 19-250, Chicago, IL 60610 USA
| | - Jason H. Ko
- Division of Plastic Surgery, Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, WA USA
| | - Mickey S. Cho
- Department of Orthopaedics and Rehabilitation, San Antonio Military Medical Center, San Antonio, TX USA
| | - Todd A. Kuiken
- Center for Bionic Medicine, Rehabilitation Institute of Chicago, Chicago, IL USA
| | - Gregory A. Dumanian
- Division of Plastic Surgery, Northwestern Feinberg School of Medicine and Neural Engineering Center for Artificial Limbs, 675 N St Clair, Suite 19-250, Chicago, IL 60610 USA
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Northrup NC, Barron GHW, Aldridge CF, Powers LV, Greenacre CB, Hutcheson JD, Morrisey JK. Outcome for client-owned domestic rabbits undergoing limb amputation: 34 cases (2000–2009). J Am Vet Med Assoc 2014; 244:950-5. [DOI: 10.2460/javma.244.8.950] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Advances in Transfemoral Amputee Rehabilitation: Early Experience with Targeted Muscle Reinnervation. CURRENT SURGERY REPORTS 2014. [DOI: 10.1007/s40137-014-0051-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Kim SA, Lee BH, Bae JH, Kim KJ, Steffensen SC, Ryu YH, Leem JW, Yang CH, Kim HY. Peripheral afferent mechanisms underlying acupuncture inhibition of cocaine behavioral effects in rats. PLoS One 2013; 8:e81018. [PMID: 24260531 PMCID: PMC3832370 DOI: 10.1371/journal.pone.0081018] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2013] [Accepted: 10/16/2013] [Indexed: 12/29/2022] Open
Abstract
Administration of cocaine increases locomotor activity by enhancing dopamine transmission. To explore the peripheral mechanisms underlying acupuncture treatment for drug addiction, we developed a novel mechanical acupuncture instrument (MAI) for objective mechanical stimulation. The aim of this study was to evaluate whether acupuncture inhibition of cocaine-induced locomotor activity is mediated through specific peripheral nerves, the afferents from superficial or deep tissues, or specific groups of nerve fibers. Mechanical stimulation of acupuncture point HT7 with MAI suppressed cocaine-induced locomotor activity in a stimulus time-dependent manner, which was blocked by severing the ulnar nerve or by local anesthesia. Suppression of cocaine-induced locomotor activity was elicited after HT7 stimulation at frequencies of either 50 (for Meissner corpuscles) or 200 (for Pacinian corpuscles) Hz and was not affected by block of C/Aδ-fibers in the ulnar nerve with resiniferatoxin, nor generated by direct stimulation of C/Aδ-fiber afferents with capsaicin. These findings suggest that HT7 inhibition of cocaine-induced locomotor activity is mediated by A-fiber activation of ulnar nerve that originates in superficial and deep tissue.
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Affiliation(s)
- Seol Ah Kim
- College of Korean Medicine, Daegu Haany University, Daegu, South Korea
| | - Bong Hyo Lee
- College of Korean Medicine, Daegu Haany University, Daegu, South Korea
| | - Jong Han Bae
- Department of Physics, Yeungnam University, Gyeongsan, Gyeongbuk, South Korea
| | - Kwang Joong Kim
- College of Korean Medicine, Daegu Haany University, Daegu, South Korea
| | - Scott C. Steffensen
- Department of Psychology and Neuroscience, Brigham Young University, Provo, Utah, United States of America
| | - Yeon-Hee Ryu
- Acupuncture, Moxibustion & Meridian Research Center, Division of Standard Research, Korea Institute of Oriental Medicine, Daejeon, South Korea
| | - Joong Woo Leem
- Department of Physiology, Yonsei University College of Medicine, Seoul, South Korea
| | - Chae Ha Yang
- College of Korean Medicine, Daegu Haany University, Daegu, South Korea
- * E-mail: (CHY); (HYK)
| | - Hee Young Kim
- College of Korean Medicine, Daegu Haany University, Daegu, South Korea
- * E-mail: (CHY); (HYK)
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Kim PS, Ko JH, O'Shaughnessy KK, Kuiken TA, Pohlmeyer EA, Dumanian GA. The effects of targeted muscle reinnervation on neuromas in a rabbit rectus abdominis flap model. J Hand Surg Am 2012; 37:1609-16. [PMID: 22770416 DOI: 10.1016/j.jhsa.2012.04.044] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2011] [Revised: 04/25/2012] [Accepted: 04/25/2012] [Indexed: 02/02/2023]
Abstract
PURPOSE A targeted muscle reinnervation (TMR) model was created using a pedicled rabbit rectus abdominis (RA) flap to receive the input from previously amputated forelimb neuromas. We hypothesize that a segmental muscle flap can undergo TMR and that it is possible to differentiate the signal from 3 independent nerves. In addition, by virtue of the nerve coaptation, the morphology of the previous amputation neuroma would become more like that of an in-continuity neuroma. METHODS Five New Zealand white rabbits had a forelimb amputation. In a second-stage surgery, an RA flap was transposed onto the chest wall. After neuroma excision, 3 neurorrhaphies were made between the median nerve, radial nerve, and ulnar nerves, and 3 motor nerves of the RA. After 10 weeks, the electrophysiologic properties of the reinnervated flap were tested. Nerve specimens from the median, radial, and ulnar nerves were harvested before and after TMR to quantify the histomorphometric changes effected by TMR on the mixed nerve neuromas. RESULTS Of the 12 nerve coaptations performed in the 4 viable flaps, all 12 were grossly successful. Muscle surface EMG data demonstrated that the RA retained its segmental innervation pattern after TMR. Similarly, prolonged stimulation of 1 nerve reinnervating the RA resulted in the depletion of glycogen specific to the territory of the muscle stimulated by that nerve. TMR was found to favorably alter the histomorphometric characteristics of the neuroma by decreasing myelinated fiber counts and increasing fascicle diameter in the transferred nerves. CONCLUSIONS This study demonstrates that 1 segmented muscle having TMR by multiple nerve ingrowth and in turn generate discrete EMG signals. During this process, the previous amputation neuroma undergoes favorable morphologic alteration. CLINICAL RELEVANCE Based on these preclinical results, this technique might be useful in upper extremity amputees to recruit target muscles to have reinnervation to drive myoelectric prostheses and to treat symptomatic neuromas.
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Affiliation(s)
- Peter S Kim
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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A quantitative evaluation of gross versus histologic neuroma formation in a rabbit forelimb amputation model: potential implications for the operative treatment and study of neuromas. J Brachial Plex Peripher Nerve Inj 2011; 6:8. [PMID: 21992517 PMCID: PMC3207865 DOI: 10.1186/1749-7221-6-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2010] [Accepted: 10/13/2011] [Indexed: 11/28/2022] Open
Abstract
Background Surgical treatment of neuromas involves excision of neuromas proximally to the level of grossly "normal" fascicles; however, proximal changes at the axonal level may have both functional and therapeutic implications with regard to amputated nerves. In order to better understand the retrograde "zone of injury" that occurs after nerve transection, we investigated the gross and histologic changes in transected nerves using a rabbit forelimb amputation model. Methods Four New Zealand White rabbits underwent a forelimb amputation with transection and preservation of the median, radial, and ulnar nerves. After 8 weeks, serial sections of the amputated nerves were then obtained in a distal-to-proximal direction toward the brachial plexus. Quantitative histomorphometric analysis was performed on all nerve specimens. Results All nerves demonstrated statistically significant increases in nerve cross-sectional area between treatment and control limbs at the distal nerve end, but these differences were not observed 10 mm more proximal to the neuroma bulb. At the axonal level, an increased number of myelinated fibers were seen at the distal end of all amputated nerves. The number of myelinated fibers progressively decreased in proximal sections, normalizing at 15 mm proximally, or the level of the brachial plexus. The cross-sectional area of myelinated fibers was significantly decreased in all sections of the treatment nerves, indicating that atrophic axonal changes proceed proximally at least to the level of the brachial plexus. Conclusions Morphologic changes at the axonal level extend beyond the region of gross neuroma formation in a distal-to-proximal fashion after nerve transection. This discrepancy between gross and histologic neuromas signifies the need for improved standardization among neuroma models, while also providing a fresh perspective on how we should view neuromas during peripheral nerve surgery.
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