Unmasking Neuroma Pain in the Upper Extremity Amputee
John M. Rinaldi, MD1; Samuel Louis Posey, MD2; Susan M. Odum, PhD3; Bryan J. Loeffler, MD4; R. Glenn Gaston, MD1
1OrthoCarolina, Charlotte, NC; 2Atrium Health, Charlotte, NC; 3OrthoCarolina Research Institute, Charlotte, NC; 4Hand Center, OrthoCarolina, Charlotte, NC
INTRODUCTION Effective surgical management of a symptomatic neuroma can result in the development of pain in a previously asymptomatic amputated nerve, and there are very few reports of this occurrence. [1-3] We report our institution’s experience with the diagnosis and management of this “unmasking” phenomenon in upper extremity amputees. To the best of our knowledge, this is the largest case series to describe this phenomenon in the literature to date.
METHODS Our prospectively managed amputee Research Electronic Data Capture database was sequentially reviewed for patients who underwent surgery for symptomatic neuroma on greater than one nerve in an upper limb in a serial fashion over a 3-year period, 11/2017 - 11/2020. Descriptive statistics were used. All patients presented with a painful neuroma that was previously asymptomatic but became symptomatic after successful surgical management of a separate nerve in the same extremity.
RESULTS The incidence of unmasked neuroma pain in the upper extremity amputee database was 4 of 69 (5.7%) patients. The average time from the index procedure until the clinical diagnosis of an unmasked neuroma was 10 months. The unmasked nerve in this series varied from a digital nerve (n=2), the superficial radial nerve (n=1), or the median nerve (n=1). 3 of the 4 patients opted for surgical treatment of the unmasked neuroma; 2 patients underwent Targeted Muscle Reinnervation (TMR) and 1 patient was treated with the creation of a Regenerative Peripheral Nerve Interface (RPNI). The average follow-up from the unmasked treatment procedure was 8 months (minimum 3 months) with all patients reporting a significant improvement in pain following the procedure. No patients underwent revision surgery following treatment of the unmasked nerve.
SUMMARY
- The description and incidence of neuroma “unmasking” is an important phenomenon for surgeons managing symptomatic neuromas to be aware of for both diagnosing and counseling amputee patients about treatment options.
- In our experience, surgical management of the unmasked neuroma with TMR or RPNI has been very effective, and further unmasking of an additional previously asymptomatic neuroma (i.e. a third neuroma) has not been observed in this case series.
- Further study is required to determine risk factors for the unmasking of an asymptomatic neuroma. Treatment algorithms may need to be refined to include management of asymptomatic neuromas when addressing a symptomatic neuroma to prevent future neuroma unmasking and additional surgery.
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