February 2017 #PRSJournalClub Wrap-Up: Surgical Treatment of Neuromas Improves Patient-Reported Pain, Depression, and Quality of Life

by Francesco M. Egro, MD, MSc, MRCS (@FrancescoEgro)

The February edition of the #PRSJournalClub offered an exciting discussion of a great PRS article entitled “Surgical Treatment of Neuromas Improves Patient-Reported Pain, Depression, and Quality of Life” by Leahthan F. Domeshek (@LDomeshek), Emily M. Krauss, Alison K. Snyder-Warwick (@DrAliSW), Osvaldo Laurido-Soto, Jessica Hasak, Gary Skolnick, Christine B. Novak, Amy M. Moore (@AmyMMoore20), Susan E. Mackinnon. 

In the article, Domeshek LF et al. reviewed retrospectively the outcomes of 70 patients underwent neuroma excision and proximal transposition of neuromoas  (37 with upper extremity neuromas and 33 with lower extremity neuromas). Statistically significant improvements in visual analogue scale scores were demonstrated for all four patient-rated qualities (p < 0.01) independent of duration of initial clinical follow-up. The change in preoperative to postoperative visual analogue scale scores was related inversely to the severity of preoperative scores for pain and depression. Neuroma excision and proximal transposition were equally effective in treating lower and upper extremity neuromas. Lastly, Upper extremity neuroma patients had a statistically signicant improvement in Disabilities of the Arm, Shoulder, and Hand questionnaire scores after surgical treatment (p < 0.02). Thus, the authors concluded that surgical neurectomy, crush, and proximal nerve transposition signicantly improved self-reported pain, depression, and quality-of-life scores, and suggest that surgical intervention is a viable treatment of neuroma pain and should be considered in patients with symptomatic neuromas refractory to nonoperative management.

The article was first discussed by the current Resident Ambassadors to the PRS Editorial Board Jordan Frey (@JordanFreyMD), Shuja Shafqat (@shujashafqatmd), and Chad Purnell (@ChadPurnellMD) join special guest moderator Greg A. Dumanian. Listen to the discussion now:


A vivid online discussion took place on twitter over a two-day period (February 26-27), where established plastic surgeons and residents were able to ask questions, and get answers from the authors of the article themselves! Don’t worry if you missed it! A summary of the exciting discussion is provided.

Enjoy it and see you all at the next PRS Journal Club!

Francesco

Discussion

@shujashafqatmd Feb 26: Podcast talked re: lidocaine block prior to OR.  Is this something you do as well?

@AmyMMoore20 Feb 26: @shujashafqatmd @LDomeshek @DrAliSW @cbn6789 Yes, we try preop block, but we are careful to not use it as the only indicator for surgery

@AmyMMoore20 Feb 26: @shujashafqatmd @LDomeshek @DrAliSW @cbn6789 And we counsel bc do now want to give an unrealistic expectation.

@danielzliu Feb 26: Excellent description of crush-cap-transpose! Do this prophylactically during amp? @LDomeshek @DrAliSW @cbn6789 @AmyMMoore20 #PRSJournalClub

@LDomeshek Feb 26: @danielzliu @DrAliSW @cbn6789 @AmyMMoore20 Yes! Any time there is a transacted nerve that cannot be repaired.

@JordanFreyMD Feb 26: Great paper! What adjuncts to surgical treatment do you recommend for patients? #PRSJournalClub

@LDomeshek Feb 27: @JordanFreyMD @DrAliSW @AmyMMoore20 @prsjournal @DrNikkiPhillips Neuropathic pain medications, desensitization, graded motor imagery.

@drAAmaldonado Feb 26: Any advice about neuromas in fingers after amputation?do u still use fibrin sealant? Thx! #PRSJournalClub @AmyMMoore20

@AmyMMoore20 Feb 26: @drAAmaldonado @LDomeshek @DrAliSW – isolate neuroma, crush proximal, excise and cauterize distally.  Then transpose onto self

@AraSalibianMD Feb 26: Great article! Any particular challenges/advice in re-op/prior transposition pts? #prsjournalclub

@LDomeshek Feb 26: @AraSalibianMD @DrAliSW @cbn6789 @AmyMMoore20 @prsjournal @JordanFreyMD Consider seprafilm/tisseel or allograft cap with transposition.

@LDomeshek Feb 26: @AraSalibianMD @DrAliSW @AmyMMoore20 @prsjournal Confirm dx, use multidisciplinary approach. transect nerve proximal to zone of injury.

@pallabc Feb 26: @LDomeshek @DrAliSW Article mentions 1saphenous nerve release in the thigh. Where exactly? #PRSJournalClub

@LDomeshek Feb 26: Medial thigh deep to vastoadductor septum, sartorius. Check out http://passioeducation.com/saphenous-nerve-release/ …

@JuhaKii Feb 26: 70/270 pat incl to the study. What were most common excl reasons? @danielzliu @LDomeshek @DrAliSW @cbn6789 @AmyMMoore20 #PRSJournalClub

@LDomeshek Feb 26: @JuhaKii @danielzliu @DrAliSW @cbn6789 @AmyMMoore20 Missing VAS scores; nerve manipulations other than just crush, dunk, transpose.

@RajaMohanMD Feb 26: Any advice on treating neuromas found in the abdomen or the breast? @prsjournal #PRSJournalClub

@AmyMMoore20 Feb 26: often these are intercostal nerves and intercostal block can help locate/identify . Then if block success then I would consider isolating IC nerve and crush and transpose + allograft

@RajaMohanMD Feb 26: What is your opinion on alternative rx methods for neuromas? http://journals.sagepub.com/doi/abs/10.1177/1071100716655348 … #PRSJournalClub

@LDomeshek Feb 26: @RajaMohanMD @DrAliSW @AmyMMoore20 They’re great. Should use multimodal approach – should get pain specialists and PT involved early.

@Kavi_Rang Feb 26: Interesting article! Is + Tinel’s required, or is response to local/anatomic distribution enough?

@AmyMMoore20 Feb 26: @Kavi_Rang @DrAliSW @LDomeshek – I use the tinel to locate the neuroma. I would say it is required in my algorithm.

@DrAliSW Feb 26: @Kavi_Rang @AmyMMoore20 I think the Tinel’s sign is more specific as well. A good exam is essential!

@JordanFreyMD Feb 26: What are important patient predictors of success after neuroma surgery? #PRSJournalClub @prsjournal

@AmyMMoore20 Feb 26: @JordanFreyMD @LDomeshek @DrAliSW @prsjournal – these pts are hard. Expectations need to be tempered. “Success” has different meaning here

@ChadPurnellMD Feb 26: Do you get any imaging for workup of #neuroma patients? #PRSJournalClub @prsjournal

@AmyMMoore20 Feb 26: @ChadPurnellMD @LDomeshek @DrAliSW @prsjournal – I use ultrasound but nothing else has been that helpful. :/

@DrAliSW Feb 26: @ChadPurnellMD @LDomeshek @AmyMMoore20 @prsjournal I also frequently employ ultrasound. Definitely communicate with imaging colleagues.

@NickBerlin_MD Feb 26: Do you work w/ other groups @WUSTLmed to find and treat these pts early? #PRSJournalClub

@LDomeshek Feb 27: @NickBerlin_MD @DrAliSW @AmyMMoore20 @WUSTLmed Many of our patients are referrals from other groups – pain medicine, other surgical services

@NickBerlin_MD Feb 26: Congrats on this great study! Did you consider including a control group? #PRSJournalClub

@AmyMMoore20 Feb 26: @NickBerlin_MD @LDomeshek @DrAliSW – what would the control be? Not operating? In the end- we want to highlight surgery as an option but not indicated for all- and sadly not perfect for all. More research is needed! Thank you for interest

@NickBerlin_MD Feb 26: @AmyMMoore20 Great points. I agree! I was thinking maybe pts who had neuroma tx at PM&R/Neuro w/o surgery over similar period?

@AmyMMoore20 Feb 26: @NickBerlin_MD – thanks Nick. That’s a great idea, just hard to do as you could imagine. They come to us for the surgery.  Inherent bias. 🙂

@RajaMohanMD Feb 26: Do you routinely send neuroma specimens for pathological evaluation? #PRSJournalClub

@DrAliSW Feb 26: @RajaMohanMD @LDomeshek @AmyMMoore20 when restoring nerve continuity and function to ensure healthy nerve/out of scar.

@DrAliSW Feb 26: @RajaMohanMD @LDomeshek @AmyMMoore20 we do send for other indications not covered in this study: 2nd stage CFNG, birth-related BP, etc

@LDomeshek Feb 26: @RajaMohanMD @DrAliSW @AmyMMoore20 No. We generally operate/transect nerve proximal to zone of injury, so there is no actual specimen.

@AliQureshiMD Feb 26: @LDomeshek @RajaMohanMD @DrAliSW @AmyMMoore20 anything special to do with the distal end of the nerve?

@DrAliSW Feb 26: @AliQureshiMD @LDomeshek @RajaMohanMD @AmyMMoore20 nope… not necessary. Great question!

@IraSavetskyMD Feb 26: Have the results of your study change in how you counsel pts preop? @AmyMMoore20 @LDomeshek @DrAliSW @prsjournal #PRSJournalClub

@AmyMMoore20 Feb 26: @IraSavetskyMD @LDomeshek @DrAliSW @prsjournal – It definitely has made me spend more time educating and tempering expectations. But it also gives me hope- these patients who are suffering…have an option.

@ChadPurnellMD Feb 27: How have nerve allografts changed your #neuroma #pain treatment? #PRSJournalClub @prsjournal

@AmyMMoore20 Feb 27: @ChadPurnellMD @LDomeshek @DrAliSW @prsjournalallografts are a useful adjunct…and we use them often given our work in the laboratory

@JordanFreyMD Feb 27: What are the biggest questions remaining in #neuroma surgery? #PRSJournalClub @prsjournal @DrRodRohrich

@LDomeshek Feb 27: @JordanFreyMD @AmyMMoore20 @DrAliSW @prsjournal @DrRodRohrich Lot of unknowns! One big one – why some people form neuromas and others don’t.

@shujashafqatmd Feb 27: @LDomeshek @DrAliSW @AmyMMoore20 what is your feeling on Dr Cedernas work using free muscle grafts for neuroma control? #PRSJournalClub

@AmyMMoore20 Feb 27: @shujashafqatmd @LDomeshek @DrAliSW – Dr. Cederna’s work is impressive. It is great to have multiple options to treat this difficult problem

@AraSalibianMD Feb 27: @LDomeshek @DrAliSW @AmyMMoore20 At what length gap do you decide crush/cap/transpose vs. restoration? Other factors? #PRSJournalClub

@LDomeshek Feb 27: @AraSalibianMD @DrAliSW @AmyMMoore20 We prefer to repair whenever possible. Unfortunately, two graftable ends are not often available.

@AChandMD Feb 27: @LDomeshek @DrAliSW @AmyMMoore20 How effective is cautery to “cap”? Other materials that could be compared head-to-head? #PRSJournalClub

@LDomeshek Feb 27: @AChandMD @DrAliSW @AmyMMoore20 It’s effective, though we  are moving to allograft or seprafilm/tisseel in many patients.

@AChandMD Feb 27: @LDomeshek @DrAliSW @AmyMMoore20 Would a crush-cap-transpose device be useful for faster tx or possibly less invasive tx?  #PRSJournalClub

@LDomeshek Feb 27: @AChandMD @DrAliSW @AmyMMoore20 Great idea. May be difficult 2/2 complex dissection needed to locate/free-up nerve & prep transposition bed.

@AChandMD Feb 27: @LDomeshek @DrAliSW @AmyMMoore20 Thx! Interesting to see how RF, HiFU, and cryo therapies will compare to surg tx going fwd #PRSJournalClub

@IraSavetskyMD Feb 27: Do you foresee a role of administering localized lethal doses of neurotoxin for neuromas?@AmyMMoore20 @LDomeshek @DrAliSW #PRSJournalClub

@DrAliSW Feb 27: @IraSavetskyMD @AmyMMoore20 @LDomeshek Localized drug delivery is a rapidly evolving area of investigation in nerve reconstruction, however!

@DrAliSW Feb 27: @IraSavetskyMD @AmyMMoore20 @LDomeshek A lot of neurotoxins work at the synapse (NMJ), so may not be useful.

@DrNikkiPhillips Feb 27: @LDomeshek @AmyMMoore20 @DrAliSW @cbn6789 Effects on reported depression interesting. Any tie-in to work/ disability status?#PRSJournalClub

@LDomeshek Feb 27: @DrNikkiPhillips @AmyMMoore20 @DrAliSW We didn’t look at relationship, though wouldn’t be surprised if one exists. Good thing to study.

@RajaMohanMD Feb 27: @LDomeshek@AmyMMoore20@DrAliSW Any plans to do any studies comparing diff techniques for neuroma rx in the future?  #PRSJournalClub

@AmyMMoore20 Feb 27: @RajaMohanMD@LDomeshek@DrAliSW – my DOD grant is looking at allograft treatment of neuroma in large and small animals- data looks great

@AmyMMoore20 Feb 27: @RajaMohanMD@LDomeshek@DrAliSW Next step is the clinical trial.  Comparing traction neurectomy in amputations.


Join us for the March 2017 #PRSJournalClub Live Twitter discussion with
the authors of “Intraoperative Comparison of Anatomical versus Round Implants in Breast Augmentation: A Randomized Controlled Trial” on Sunday and Monday, March 26th and 27th!

3. March2017_JC_Graphic.jpg
Listen to the podcast:


And read the article by Hidalgo et al “Intraoperative Comparison of Anatomical versus Round Implants in Breast Augmentation: A Randomized Controlled Trial”

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