|89th Annual Meeting Abstracts
Long Term Outcomes of Peripheral Neuromas of the Hand and Forearm
Darlene M. Guse, B.S., B.A., Steven L. Moran, M.D..
Mayo Clinic, Rochester, MN, USA.
Peripheral neuromas within the upper extremity result in significant disability. Treatment options vary and established protocols have yet to be determined. We performed a long-term outcome comparison examining different treatment options for peripheral upper extremity neuromas to determine which method provided superior results.
A retrospective chart review was performed for all patients undergoing surgical intervention from 1980 to 2005 for a symptomatic neuroma of the hand or forearm. Patient charts were reviewed for significant medical history, cause of neuroma development, and treatment outcomes. Patients were surveyed via Disabilities of the Arm, Shoulder, and Hand (DASH) and pain evaluation questionnaires.
We found 127 eligible patients with their index procedure performed at our institution. Fifty-six responded. In all cases, verification of a neuroma was made on pathologic and surgical grounds. Follow-up averaged 240 months from the time of surgery. Mean age at the time of surgery was 40 years (19 to 72). Twenty-nine dominant limbs were involved. Eleven patients were treated with muscle or bone transposition, 17 with simple excision and 28 with nerve repair and neurolysis. Average DASH score at final follow-up was 19.75 (0 to 78.3); DASH work module score was 13.6 (0 to 69).
Patients who underwent neuroma excision with nerve repair and neurolysis had significantly lower post-operative DASH scores, averaging 11.42, compared to muscle or bone transposition, averaging 22.42, and simple excision, averaging 31.98 (p = 0.01). The number of neuroma procedures (p = 0.04), pre-operative pain severity (p = 0.03), and post-operative pain severity (p = 0.04) all had an effect on the DASH score. Predictors of worse outcome as assessed by the DASH work module included a larger-sized neuroma (p = 0.04), a higher incidence of previous neuroma procedures (p=0.03), and use of alternative treatments prior to surgical intervention (p = 0.04). Location of the neuroma did not significantly influence the functional or pain-associated outcomes. Fifteen patients (27%) required more than 1 surgery with simple excision resulting in the highest incidence of re-operations (47%).
Treatment of upper extremity neuromas remains a complicated problem. Within this study, nerve repair and neurolysis yielded improved DASH scores compared to nerve transposition or simple resection. Resection alone was associated with an unacceptable recurrence rate and should be discouraged as treatment for upper extremity neuromas. Prior surgical procedures, neuroma size and the severity of pre-operative pain may all adversely impact the success of surgical intervention.
Success and Failure by Procedure Type
|N||Severe Pain |
p = 0.42
|>1 Procedure (%)|
p = 0.02
p = 0.07
|Transposition into muscle or bone||11||1 (9%)||4 (36%)||3 (27%)||5 (45%)||6 (55%)|
|Simple excision||17||4 (24%)||8 (47%)||4 of 16 (25%)||10 (59%)||7 (41%)|
|Nerve repair / neurolysis (neurorrhaphy or nerve graft)||28||3 (11%)||3 (11%)||1 of 27 (4%)||5 (18%)||23 (82%)|
|*DASH >40.25 defined by one standard deviation beyond patient population mean. DASH n=54 patients; percentages based upon available DASH n.|
**Failure defined as any one of the three other criteria listed.