Pain resulting from nerve injury can originate from the site of injury (local neuroma pain) and from the collateral sprouting of adjacent sensory territories into the deinnervated territory (hyperalgesic pain). Surgical management of neuropathic pain is controversial and typical management of neuroma pain includes excision and transposition. In our institution, management includes a proximal crush injury to facilitate an axonal injury and a period of prolonged regeneration, neuroma resection with distal end cautery cap, and proximal intermuscular transposition. In the case, the patient presented with severe neuropathic pain in the anterior/lateral region of the ankle and foot, following surgery to correct flat foot deformity. Two attempts to surgically resolve the neuropathic pain from a sural neuroma failed before being referred to our institution. Examination and provocative tests revealed involvement of the sural nerve and superficial peroneal nerve. Surgical management included exploration and transposition of the sural nerve and superficial peroneal nerve with releases of the peroneal nerve at the fibular head, lateral sural nerve, and deep peroneal nerve. The nerves releases were included due to having positive provocative tests during examination.
Standard:
Extended:
POSITION
Lateral.
INCISION
The surgical management for neuropathic pain in this case involve multiple exposures that constitute nerve decompressions and neuroma excisions with proximal transpositions. Incisions were made to (1) identify the superficial peroneal neuroma, (2) identify the sural neuroma, (3) decompress the common peroneal nerve, and (4) decompress the deep peroneal nerve.
REFERENCES
- Watson CP, Mackinnon SE, Dostrovsky JO, Bennett GJ, Farran RP, Carlson T. Nerve resection, crush and re-location relieve complex regional pain syndrome type II: a case report. Pain. 2014 Jun;155(6):1168-73. PMID: 24502845.
- Vernadakis AJ, Koch H, Mackinnon SE. Management of neuromas. Clin Plast Surg. 2003 Apr;30(2):247-68, vii. Review. PMID: 12737355.
- Novak CB, van Vliet D, Mackinnon SE. Subjective outcome following surgical management of lower-extremity neuromas. J Reconstr Microsurg. 1995 May;11(3):175-7. PMID: 7650641.
- Dellon AL, Mackinnon SE. Treatment of the painful neuroma by neuroma resection and muscle implantation. Plast Reconstr Surg. 1986 Mar;77(3):427-38. PMID: 2937074.
Disclosure: No authors have a financial interest in any of the products, devices, or drugs mentioned in this production or publication.
It would be helpful if the camera would occasionally pull back to show the general orientation of the leg, and for the occasional wide view. Thanks for your efforts and exquisite videos. Your name was mentioned as a reference at the recent AAOS meeting in the lecture/symposium on compression neuropathies.