Treatment of painful neuromas of sensory nerves in thehand: A comparison of traditional and newer methods

The results of treatment of 348 painful neuromas of sensory nerves of the hand in 172 patients wereevaluated. Three hundred and sixteen were treated by simple excisional neurectomy and these resultsmay be used for comparison with other methods. Sixty-five percent had an excellent or satisfactoryresult from a single such procedure. A repeated neurectomy improved the results to 78 percent. The useof silicone rubber caps as a secondary procedure over the nerve stump in 32 cases did not improve theresults. A technique of funicular resection with epineurial ligation in 45 patients with neuromasachieved about the same percentage of good results as did simple excisional neurectomy. The idealtreatment is not at hand yet, but at the present time it is recommended that treatment should consist ofexcisional neurectomy, repeated at least once if necessary.

Jack W. Tupper, M.D., Oakland, Calif., and Donald M. Booth, M.D., Portland, Maine

Painful neuromas of sensory nerves represent a dis-

abling condition to the patient and a frustrating problemfor the surgeon. They were first reported by Odier~ in1811, and Weir Mitchell z wrote extensively aboutthem in 1872. Not until 1920, when Huber and Lewisa

published their experimental work, was the histologicalmechanism of neuroma formation understood.

Following partial or complete interruption of theSchwann cells and endoneurium, the interrupted axonsbegin to proliferate and regenerate. Without intact en-doneurial tubes to guide their growth, the branching,disorganized mass of axons, fibroblasts, and Schwanncells soon form a neuromatous bulb on the proximalII~rve.

Many neuromas are not symptomatic. Why ten-derness develops in some and not in others is not under-stood, making it difficult to devise logical treatment.Infection, ischemia, excessive scarring, and thin skinflaps are said to encourage neuroma formation. Thereis, however, no evidence that any of these contributesto the formation of a neuroma. The proximity of aneuroma to an impact zone appears to be an aggravat-ing factor, but mere displacement of the divided nerveto a low impact zone does not always relieve the pain.

Tenderness is well localized to the site of theneuroma and varies from a mild and annoying sensa-tion to severe and incapacitating pain.

Received for publication Jan, 5, 1976

Reprint requests: Jack W. Tupper, M.D., 2938 Webster St., Oak-land, Calif. 94609.

Methods used to prevent the formation of painfulneuromas have included implanting the nerve endunder fascia, in muscle, bone, and veins,4-~ and eveninto its own intact proximal trunk (neurocampsis), well as transection and epineurial repair at a level prox-imal to the injury. The divided end has been ensheathedin materials such as Millipore, gold foil, ortantalum.~-~ Steroids, chemical fixatives, and scleros-ing agents, coagulation, and freezing all have beentried.~, ~o One report estimated that more than a total

of 150 physical and chemical methods have been.used.4 None of these methods has been uniformly suc-cessful.

When a painful neuroma is dissected from its sur-rounding tissue, often one or more funiculi can be_seenextending from the bulb and into the surrounding tis-sues (Fig. 1). Sunderland~a states that normal peri-neurium surrounding each funiculus presents an im-penetrable barrier to regenerating axons and that if thiscould be sealed, escape of regenerating axons could beprevented and forestall the subsequent disorderlygrowth of the neuroma. It has been observed clinicallythat a well sealed epineurial repair of a transected pe-ripheral nerve seldom develops a painful neuroma.These observations suggested that containment of theregenerating axons within the epineurial sheath mightprevent tenderness. Experience with excision of thefuniculi and ligation of the epineurial tissues will bereported as a portion of this study.

This report deals only with neuromas of pure sensorynerves of the palm and fingers, mostly in amputation

No. 2,er, 1976 Paitful neuromas of sensory nerves 145

I. Crush injury*

Results

No. ofneuromas

Follow-up(moo

Unsatisfactory

No.I %

74 31.9

13 35.2

4 80.00 0

Excellent Satisfactory

,ny No. % No. %

First 232 3 to 178 76 32.7 82 35.4Avg. 12

Second 37 3 to 17 12 32.4 I2 32.4Avg. 9

Third 5 Avg. 12 0 0 1 20.0Fourth 1 Avg. 9 0 0 I 100.0

*Patients: 104; neuromas presenting at onset of treatment: 232.

Table II. Semisharp injury*

Neurectomy

ExcellentNo. of Follow-up

neuromas (too.) No.

First 65 3 to 29 26Avg. ! 2

Second 18 3 to 17 10Avg. 9

Third 5 5 to 10 1Avg. 8

Fourth 2 Avg. 22 0

Resuhs

Satisfactory

% No. %

Unsatisfactory

No. I %

40.0 10 15.3 29 44.6

55.5 7 38.9 l 5.6

20.0 ~ 2 40.0 2 40.0

0 2 1130.0 0 0

*Patients: 35; neuromas presenting at onset of treatment: 65.

stumps. No primary injuries, partial lacerations, orneuromas in continuity were included. All patientsavailable for examination or those in whom adequatefollow-up information was available from the chartwere;included. Follow-up in a few instances was bytelephone. All surgical procedures were done by the se-nior author..

Injuries were divided into crush, semisharp, andsharp by the following criteria:

Crush--blunt tearing type of injury with indefiniteinjury margins.

Semisharp--laceration by a saw or similar in-strument with more definite injury margins.

Sharp--cleanly incised by glass or blade with defi-nite injury margins.

The results of treatment were classified as excellent,satisfactory, and unsatisfactory. It was not unusual toachieve a good result on one nerve and a poor result onanother in the same patient. The unmeasurable ele-ments of secondary gain as well as the patient’s own in-nate pain threshold and adaptability render these clas-sifications somewhat subjective. When the patient’s

attention is directed elsewhere, flinching from localpressure is a semiobjective method of assessing sever-ity:

Excellent--no or minimal tenderness.Satisfactory--mild-to-moderate tenderness; able to

actively use the involved part.Unsatisfactory--severe tenderness; unable to ac-

tively use the part.One hundred and seventy-two patients with 348 clin-

ically symptomatic neuromas were seen over a 15 yearperiod. Including the repeat procedures, 484 neurec-tomies of different types were carried out: (1) simpleexcisional neurectomy; (2) silicone rubber capping the stump of the resected neuroma; (3) funiculectomyand ligation of the epineural sleeve distal to the funicu-lar stumps.

The first and largest group, 316 neuromas, was

treated by simple neurectomy. This consisted of lysisof the neuroma from surrounding scar, followed bytraction and resection of one to 2 cm. of nerve, allow-ing the proximal stump to retract into uninjured soft tis-sue. T~~’ d!,:~i:~i artery always was dissected free to

The Journal ofHAND SURGERY146 Tupper and Booth

Table III. Sharp injury*

NeurectomyNo. of

neuromasFollow-up

(moo

First 19 3 to 75Avg. 14

Second 4 Avg. 8

Results

Excellent Satisfactory Unsatisfactory

No. % No. % No. %

7 36.8 4 21.1 8 42.1

1 25.0 0 0 3 75.0

*Patients: 14; neuromas presenting at onset of lreatment: 19.

Table IV. Silicone rubber cap as secondary procedure*

InjuryNo. of

neuromasFollow-up

(mo.) No.

First neurectomy and capping:Crush 20 7 to 54 4

Avg. 18Semisharp 9 15 to 60 4

Avg. 44S harp 3 10 0

Second neurectomy and capping:Crush 8 2 to 37 2

Avg. 21Semisharp 2 Avg. 49 0Sharp 2 Avg. 6 0

Results

Excellent Si~tisfactory Unsatisfactory

% No.I% No.I%

20.0 3 15.0 13 65.0

44.5 2 22.2 3 33.3

0 0 0 3 100.0

25.0 2 25.0 4 50.0

0 0 0 2 100.00 0 0 2 100.0

*Patients: 17; neuromas at onset of treatment: 32.

prevent being included with the resected nerve.

Tables I, II, and III show the results of simpleneurectomy for each category of injury. Second, third,etc., neurectomies represent repeat procedures donebecause of unsatisfactory results. It should be notedthat a significant number of patients with unsatisfactoryresults did not desire additional surgery (or soughttreatment elsewhere).

Simple neurectomy as primary treatment of

established neuromas

Of 232 neuromas, 32.7 percent achieved an excellentresult after one neurectomy. Of the 74 unsatisfactoryresults, 37 had a second simple neurectomy, with 32.4

percent of these achieving an excellent result, giving acombined average of 38 percent excellent results if asecond simple neurectomy were carried out. Of 232neuromas, 68 percent achieved excellent or satisfactoryresults from one neurectomy, and of the 74 unsatis-

factory results, 37 b~ad a second simple neurectomy,

with 64.8 percent of these achieving a similar result,giving a combined average of 78.4 percent excellent orsatisfactory results if a second simple neurectom_z wereperformed. Presumably, if more of the primary failureshad had a second procedure, the success rate wouldhave been higher.

Of 65 neuromas, 40 percent achieved an excellentresult after one neurectomy. Of the 29 failures, 18 hada second similar procedure with a 55.5 percent of theseobtaining an excellent result. This gives a combinedaverage of 55 percent excellent results if a secondneurectomy were done.

Of 65 neuromas, 55 percent achieved excellent orsatisfactory results from a single neurectomy. Of the 29failures, 18 had a second similar procedure and of thisgroup 94.4 percent obtained an excellent or satisfactoryresult, raisir~g the combined average to 81 percent if a

second neurectomy were carried out.Of 19 neuromas, 36.8 percent received an excellent

resuk :.":,-:~r ~’~,.e .oe~rectomy. Of the eight failures, four

1 No. 2~rnber, 1976

Painful neuromas of sensory nerves 147

a second procedure, with 25 percent of thisachieving an excellent result, raising the com-

bined average to 42 percent if a second neurectomycarried out.

Of 19 neuromas, 58 percent achieved excellent or~tisfactory results from one simple neurectomy. Of..ight failures, four underwent a second procedure, with

a success rate of 25 percent raising the combinedaverage to 63 percent if a second procedure were per-formed.

If all three types of injury are included in a singlegroup, 36.5 percent received an excellent result afterone neurectomy; if a second neurectomy were carriedout, the over-all average improved to 45 percent.

In the same combined group, a simple neurectomyproduced 65 percent excellent or satisfactory resultse.f~er one procedure, and this improved to 78 percent ifa second procedure were done. In the combined group,ten failures after a second neurectomy elected to have athird operation, and 40 percent of this group achievedan excellent or satisfactory result.

The above data suggest that painful neuromas aremore common following crushing injury, yet appear toachieve better results after neurectomy than do thosedeveloping after more sharply incised wounds. Re-peated simple neurectomies are of value but offer adecreasing percentage of success after the second pro-cedure.

Silicone rubber caps

In 32 patients, following an unsuccessful simpleneurectomy, silicone rubber caps were placed over theresected proximal nerve stump in an effort to containthe developing neuroma and to decrease the amount offibrous: tissue reaction between the neuroma and thesurrounding tissue. Two types were used. (1) A sili-cone rubber .Ducker-Hayes tube was passed over theend of the nerve trunk, the proximal tube of which wassutured to the epineurium and the distal portion wasligated beyond the nerve end. (2) The silicone rubberFrackelton cap, shaped like the end of a tiny test tube,was anchored at the terminal portion with a No. 10-0suture. The Ducker-Hayes cuff was designed to have aloose fit, whereas the Frackelton type was designed fora rather snug fit.

Forty-four silicone rubber capping procedures werecarried out on 17 patients with 32 neuromas, as in-dicated in Table IV. Combining all injury classifica-tions into one group, 25 percent obtained excellentresults from one capping procedure; 31 percent ob-tained excellent results if the group is expanded toinclude a second similar procedure.

Fig. 1. Neuroma of proper digital nerve with three funicutiextending from the bulb into the surrounding tissue.

Fig. 2. Neuroma in a Frackelton cap. Tenderness stillpresent. Ery. thematous tip of nerve surrounded by yellow --fluid.

Fig. 3. The epineurium is drawn back to expose the funiculi.

148 Tupper and Booth

Fig. 4. The funiculi are drawn out just prior to being resected.Methylene blue has been used to aid the dissection.

The Journal ofHAND SURGERY

Fig. 6. Double tigation of epineurial tube after resecting thefuniculi.

Fig. 5. Epineurial tube now empty after resection of funiculi.

After a single procedure, 41 percent achieved an ex-cellent or satisfactory result, 53 percent.if expanded toinclude those on whom a second similar procedure wascarried out.

The average patient on whom the initial cappingprocedure was carried out had had 1.5 previous unsatis-factory simple excisional neurectomies. Therefore, thedata in Table IV cannot be compared directly withthose in Tables I, II, and III. If we consider the patientgroup as somewhat comparable to those submitting to athird simple neurectomy, the results demonstrate no

Fig. 7. Successful funiculectomy (lowermost structure on thebackground material). Ligatures visible and nerve proximallyis enlarged. No growth of funiculi across the suture area.

improvement (40 percent excellent or satisfactory forthe third simple neurectomy compared with 41 percentafter a single capping procedure).

Twelve capping failures were re-explored. In six thecap (both types) had become dislodged and the end the nerve was adherent to the surrounding tissue. Intwo others (Ducker-Hayes), the cap had remained place but nerve fibers had grown out through the looseproximal opening. Only one of the more snugly fitting

~urnalRGERY

:Vol. I No. 2~teraber, 1976 Pait~d neuromas of sensory nerves 149

Table V. Funiculectomy as a secondary procedure*

No. ofInjury neuromas

Follow-up(moo

First funiculectomy:Crush 11 2 to 23

Avg. 17Semisharp 0 --Sharp 2 9 to 18

Avg. 14

Excellent

No. %

2 18.2

50.0

Second funiculectomy:Crush 3 6 to 16 l 33.3

Avg. 12Semisharp 0 -- -- --Sharp 1 9 0 0

Results

Satisfactory Unsatisfactory

No. % No. I%

2 18.2 7 63.6

0 0 1 50.0

2 66.7 0 0 .

0 0 1 I00.0

~g the *Patients: 9; neuromas at onset of treatment: 13.

Frackelton caps demonstrated swelling of the nerveproximal to the cap. None demonstrated actual funicu-lar escape. Two of the Frackelton caps had minimalswelling of the nerve inside the cuff, but the tip of thenerve was erythematous and there was a yellow serousfluid within the cuff surrounding the nerve (Fig. 2).Tissue sections of these demonstrated no foreign mate-rial. (Silicone rubber implants, by virtue of a staticcharge, may attract lint, etc., in the operating room.) similar reaction was seen on another nerve which hadminimal tenderness.

Funiculectomy and epineural ligation

In an attempt to confine the growth of regenerating

axons, CornerTM excised a wedge of a large mixednerve and attempted to obtain epineural closure. Chap-plY,la in 1918, attempted to draw and suture the epi-

neurium Over the end of large mixed nerves to obtain aseal. Chavanaz,TM in 1940, reported ligation of largemixed nerves. Due to the inherent turgor of the com-bined neuronal and fibrous elements of a peripheralnerve, a true direct ligation is difficult to accomplish.

In an effort to improve surgical results, a modificationhas been developed which will be described as a "funi-culectomy."

Technique. With use of the operating microscope,the nerve is transected sufficiently proximal to theneuromatous bulb so that there is no apparent in-traneural scar binding the funiculi. The end of the tran-sected nerve may be stained with methylene blue to aidin the funicular dissection. There usually are five funi-cull in an uninjured digital nerve. In the nerve immedi-

ately proximal to a neuroma, this number is increased,

but each funiculus is of smaller than normal size. Theepineurium is drawn back carefully, exposing the funi-culi (Fig. 3), which then are pulled out of the in-traneural epineurium individually (Fig. 4) and resectedabout one centimeter proximally. This leaves a tube ofcircumferential epineurium filled with intraneural epi-neurium devoid of neural elements (Fig. 5). The epi-neural tube distal to the cut ends of the funiculi then isdoubly ligated with No. 6-0 nylon (Fig. 6) in an at-tempt to completely seal the end of the nerve. Theligated nerve then is placed beneath the adjacent unin-jured soft tissue.

Fifty-two funiculectomies have been done on 28 pa-tients with 45 neuromas. These have been divided intotwo groups: those on whom the procedure was carrie.dout for failures of previous neuroma surgery and an-other group in whom it was the primary procedurecarried out for an established neuroma.

Table V shows the results of secondary funiculec-tomyo In this group of 13 neuromas in nine patients, theprocedure was done for previous failures of simpleneurectomy or silicone rubber capping. In the firstfuniculectomy group, 23 percent obtained an excellentresult, 38 percent excellent or satisfactory. Combiningthe results if a second funiculectomy were carri6d out,61 percent derived an excellent or satisfactory result.The second funiculectomy group had an average of 2.8previous neurectomy procedures prior to the initialfuniculectomy an~t therefore the results are not directlycomparable to the results in any of the previous tables.The patient group undergoing an initial funiculectomy

150 Tupper and BoothThe Journal.

HAND SURGER,

Table VI. Funiculectomy as a primary procedure*

No. oflnjury neuromas

First funiculectomy..Crush 22

Semisharp 7

Sharp 3

FolloN-up(too,)

Excellent

Results

Satisfactory

No. %

Unsatisfactory

%__

4 to 64 14 63.6 4 18.2 4 18.2Avg. 214 to 21 5 71.4 1 14.3 1 14.3Avg. 147 to 8 1 33.3 1 33.3 l 33.3Avg. 8

0 1 100.0 0 0100.0 0 0 0 0

0 0 0 1 100.0

Second funiculectomy:Crush 1 5 0Semisharp 1 10 1Sharp 1 9 0

*Patients: 19; neuromas at onset of treatment: 32.

is similar somewhat to the group undergoing a secondsilicone rubber capping and demonstrates no improve-ment. In all three patients in whom a second funiculec-tomy was done; strands of nerve tissue, confirmed byhistological examination, were noted to have grownthrough the ligated epineural tube and the operationwas considered to be a technical failure. To date onlyone successful funiculectomy has been examined andthis revealed no funicular growth beyond the ligature(Fig. 7).

Table VI indicates the results of funiculectomy usedas a primary procedure in the treatment of established

neuromas. Combining the injury classifications, 53,1percent obtained an excellent result after a single funi-culectomy, whereas 81 percent obtained an excellent orsatisfactory result. If results are expanded to include

:those who had a second funiculectomy, 87 percentderived an excellent or satisfactory result.

Thirty-three funiculectomies were carried out in ninepatients with combined types of injuries. Although thenumbers are small, the percentage of excellent or satis-

factory results after the first procedure was 81 percent,compared with an average of 65 percent for the firstsimple neurectomy in a similar group of patients. If asecond procedure were done, this produced a total of87 percent good or satisfactory results in funiculec-tomy, compared with 78 percent of simple neurec-tomies. All three of the funiculectomies explored for a.second procedure showed nerve tissue growing throughthe ligature and were felt to represent a technically in-adequate ligature.

Summary

The results of treatment of 348 painful neuromas of

sensory nerves of the hand in 172 patients were evalu-ated: 316 were treated by simple excisional neurectomyalone and these results may be used as a standard forcomparison with other methods. If all types of injurywere included, 36.5 percent had an excellent resultfrom a single excisional neurectomy, 65 percent had anexcellent or satisfactory result from a single such pro-

cedure. Repeated simple neurectomies are of value andraise the final percentage of success. Combining all in-jury categories, 78 percent were excellent or satisfac-!9ry if a second simple neurectomy were carried out.

Silicone rubber capping did not improve the resultsof excisional neurectomy.

A consistently satisfactory method of containing re-generating axons within either the epineurial or theperineurial sheath has not been devised yet. At present,with the technique described, the results of funiculec-

tomy as a secondary procedure appear to be no betterthan those of an additional simple neurectomy.

There is some indication that funicutectomy as aprimary procedure may give superior results, but insuf-ficient numbers have been reported, At present, webelieve that simple excisional neurectomy, particularlyif repeated when failure occurs, gives results ~is good asthose obtained by the silicone rubber capping or funicu-lectomy.

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septembc

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5.C~

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~t

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TheND

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oo

10o.o

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saris fac-ed out.e results

ning re-

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yasai insuf-3t, We

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No.21976

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Painful neuromas of sensory nerves 151

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1811,