Surgical Interventions for the Treatment of Painful Neuroma: A Comparative Meta-Analysis
Louis H Poppler, MD, MSCI; Washington University in St. Louis, St. Louis, MO; Rajiv P Parikh, MD, MPHS; Plastic Surgery, Washington University School of Medicine, St. Louis, MO; Miles Bichanich, B.S.; Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, Saint Louis, MO; Kelsey A Rebehn, MD; St. Louis Univerisity, St. Louis, MO; Carrie Bettlach, FNP; Washington University, St. Louis, MO; Susan E. Mackinnon, MD; Department of Surgery, Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, Saint Louis, MO; Amy M. Moore, MD; Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, MO
Purpose: No consensus on the optimal treatment of painful neuromas exists. Our objective was to synthesize all available data on outcomes following surgical management of painful neuromas and to examine the role of surgical technique and confounding on outcomes.
Methods: In accordance with the PRISMA guidelines, we performed a literature search of Embase, Scopus, PubMed, Cochrane library, and ClinicalTrials.gov. Studies measuring the efficacy of the surgical treatment of painful neuromas in the extremities were included in this meta-analysis (excluding Mortonís neuroma and compression neuropathies). Surgical treatments were categorized as excision only, excision and transposition, excision and cap, excision and repair, or neurolysis and coverage. Data on the proportion of patients with a meaningful reduction in pain was collected and a random effects meta-analysis was performed. The effects of confounding, study quality, and publication bias were examined with stratified, meta-regression, and bias analysis.
Results: 54 articles met inclusion criteria, many with multiple treatment groups (Figure 1). Outcomes reporting varied significantly and few studies controlled for confounding. Overall, surgical treatment of neuroma pain was effective in 77% patients [95% confidence interval (CI): 73-81] No significant differences were seen between surgical techniques (Figure 2). In stratified analysis, "excision and transposition" and "neurolysis and coverage" were significantly more likely to result in a meaningful reduction in pain for patients with neuroma pain for greater than 24 months prior to their operation and in patients who had one or more prior operations (p<0.05) (Figure 3-4).
Conclusions: Surgical treatment of neuroma pain is helpful when patients are carefully diagnosed and managed. Standardization of surgical techniques, outcomes, and confounding reporting are needed in future studies to elucidate patient and surgical factors that predict successful outcomes and aid with patient selection.
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