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.
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.
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