American Society for Peripheral Nerve

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Treatment of Neuroma-induced Chronic Pain and Management of Subsequent Defect with Processed Nerve Allografts
Ivica Ducic, MD, PhD1; Erick DeVinney, BS2; Joshua Yoon, MD3
1Washington Nerve Institute, McLean, VA, 2AxoGen, Alachua, FL, 3The George Washington University, Washington, DC

Background: Neuromas irrespective of location can be a significant source of pain, which can negatively impact quality of life. Particularly amidst the current opioid crisis, treatments for chronic pain that limit the need for narcotics are much needed. Neuromas can cause chronic pain, and are often resistant to medical treatments. Treatment of symptomatic neuromas with radio-frequency ablation is associated with transient effectiveness and high rate of symptom relapse, while about half of all nerve stimulators maintain effectiveness beyond three years.
Traditional surgical option to treat neuroma pain is excision, followed by implantation or repair of acquired nerve gap. Nerve gap-bridging mediums such as autograft or processed nerve allograft will guide axonal growth leading to nerve regeneration. However, autograft could lead to donor site morbidity and pain. Processed nerve allografts eliminate operative donor site morbidity, and as such may be used after neuroma excision to restore continuity, limit recurrence of neuromas and associated donor site pain.

Methods: PubMed literature review was performed to find studies where the gap created by neuroma excision was repaired with allograft reconstruction and chronic pain assessed. Statistical analysis was performed on treatment effective and treatment ineffective groups, with further subgroup analysis on overall change of pre-operative and post-operative pain scores using a paired T-test.

Results: A total of 6 studies fulfilled inclusion criteria yielding a total of 41 patients who underwent neuroma resection with concomitant nerve allograft reconstruction. Over 90% of all patients with chronic pain resistant to medical treatments, who underwent neuroma excision with allograft reconstruction responded favorably and had decreased pain. The pre-operative and post-operative pain scores could be determined for only 39 of the patients. The mean pre-operative pain score was 7.87 and the mean post-operative score was 3.58. These results were found to be statistically significant using a paired T-test with a P-value of < .001.

Conclusions: Chronic pain that is caused by neuromas can be significantly improved with neuroma excision and restoration of neural continuity with the human processed nerve allograft. This approach prevents any donor-site morbidity associated with autograft harvesting, serves to restore sensation to the locoregional area, and offers a reliable surgical alternative to managing chronic pain that is caused or exacerbated by neuromas. Thus, in contrast to current pain management strategies, allograft nerve reconstruction following neuroma excision focuses on the root cause of the problem, which is an important treatment paradigm shift in the treatment of symptomatic neuromas.

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