| Objective:A stump neuroma occurs at the proximal end of a cut nerve as the disorganized axons grow out from the cut proximal end and become incorporated in a mass of proliferating granulation tissue. It is a common complication of an injured peripheral nerve or amputation. It often remains no pain, but in a minority of patients intractable pain develops. About 10% of patients with traumatic neuroma develop incapacitating pain directly related to the neuroma. Not all sectioned nerves form painful neuromas, and it is not uncommon to find that in the same amputated digital stump, one nerve, the ulnar digital nerve for example, may produce a painful neuroma while the radial digital nerve does not, even if both have received identical primary treatment. Many clinical and experimental investigations have aimed to discover ways of preventing and treating painful neuroma, but the results have not been completely satisfactory. Controversies still exist, though more and more methods have been described. Painful neuromas present a therapeutic dilemma for the surgeon. Our aim is to investigate the pathogenesis of painful neuroma and summarise the result of treatment andprevention, by means of implantation of neural stump into muscle in the experimental study in rats and clinical applications for treatment of 9 cases (21 neuromas) and prevention of 23 cases ( 41 nerve stumps). Methods:The experiment was carried out on 16 adult Sprague-Dawley rats of either sex, weighing 225-290 gm. The left posterior extremities were used as the experimental side, whereas the right as the experimental control side. The right sciatic nerve was exposed via posterior thigh approach, and cleanly severed with a razor, a segment was resected to create a gap between the ends to prevent spontaneous reinnervation; the left sciatic nerve was exposed, severed, and a gap was created, the proximal stump was implanted into a muscle sac that was made through a small incision on the nearby Adductor Magnus muscle. The epineurium of the sciatic nerve was fixed with the muscle membrane. According to loss of nails and toes, autotomy scores were calculated; gross observation, electrophysiological, microscopic and computer-aided analysis were used to assess the results postoperatively.The clinical applications include treatment and prevention. 9 patients with 21 painful terminal neuromas were treated with neuroma resection and muscle implantation in the treatment group, and the neuromas taken from the patients in the operation were examined pathologically. In the prevention group, 41 neural stumps in 23 patients were implanted into the muscle sacsin the amputations.Results:The autotomy score in the control side is greater than that inthe experimental side in every paired groups, and thedifference is significant. Neuroma forms in the control sidefrom 1 month after the operation, there are myofibroblasts inthe terminal neuroma, and nerve-muscle conduction velocity isslower, the latency is longer. Whereas in the experimental side,the nerve bundles disperse into the muscle fibers, no classicalneuroma forms, no myofibroblasts are found in the neural stump,nerve-muscle conduction velocity becomes slower, but it is alittle faster than the control neuroma side, and the latencyis shorter than the control side.In the treatment group, the 9 patients were followed up between6-11 years with an average of 8 years. Excellent or good resultswere obtained in 8 patients, and recalcitrant pain recured inthe other one patient with medial antebrachial nerve pulled outfrom the muscle sac.In the prevention group, no spontaneous pain or tendernessrelated with amputated nerve occured in the follow-up of 2months to 10 years.Conclusion:Implantation of neural stump into adjacent muscle sac is aneffective method in the treatment of painful terminal neuromawith resection of neuroma and in the prevention of neuromaformation of amputated nerve. It can be easily manipulated inthe same operative...
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