Painful scar neuropathy: principles of diagnosis and treatment

Abstract

Nerve-tissue interactions are critical. Peripheral nerve injuries may involve intraneural and extraneural scar formation and affect nerve gliding planes, sometimes leading to complex clinical presentations. All of these pathological entities involve pain as the main clinical symptom and can be subsumed under the term "painful scar neuropathy". The authors review the literature on treatment approaches to peripheral nerve scar neuropathy and the outcomes of neurolysis-associated procedures and propose a simple classification and a therapeutic approach to scar neuropathy. The search retrieved twenty-one papers, twenty of which reported pain reduction or resolution with various techniques. There is no consensus on the best therapeutic approach to neuropathic pain due to scar tethering. Most authors report good or excellent results with different techniques, from nerve wrapping with anti-adhesion devices to nerve coverage or wrapping with vascularized tissue. The authors’ classification of and therapeutic approach to peripheral nerve scar lesions aims at promoting a logical approach based on the analysis of lesion type (perineural, or endoneural and perineural), pain type (due to traction or external trauma, pain at rest), and number of previous operations. Patients need to be informed that multiple procedures may be required, that outcomes may be partial, and that surgery can potentially worsen preoperative conditions. The review found no evidence for the best therapeutic approach to scar neuropathy, but there is consensus on a multidisciplinary approach.

Keywords

Complex regional pain syndrome type II / painful neuropathy / painful scar neuropathy / scar neuritis / traction neuropathy

References

[1] Lang J.On connective tissue and blood vessels of the nerves..Z Anat Entwicklungsgesch1962;123:61-79

[2] Millesi H,Reihsner R.Mechanical properties of peripheral nerves..Clin Orthop Relat Res1995;314:76-83

[3] Sunderland S.Stress-strain phenomena in denervated peripheral nerve trunks..Brain1961;84:125-7

[4] Clark WL,Swiontkowski MF.Nerve tension and blood flow in a rat model of immediate and delayed repairs..J Hand Surg Am1992;17:677-87

[5] Boyd BS,Gan J.Strain and excursion in the rat sciatic nerve during a modified straight leg raise are altered after traumatic nerve injury..J Orthop Res2005;23:764-70

[6] Wilgis EF.The significance of longitudinal excursion in peripheral nerves..Hand Clin1986;2:761-6

[7] McLellan DL.Longitudinal sliding of the median nerve during movements of the upper limb..J Neurol Neurosurg Psychiatry1976;39:566-70

[8] Hunter JM.Recurrent carpal tunnel syndrome, epineural fibrous fixation, and traction neuropathy..Hand Clin1991;7:491-504

[9] Elliot D.Surgical management of painful peripheral nerves..Clin Plast Surg2014;41:589-613

[10] Sunderland S.Nerve Injuries and Their Repair: A Critical Appraisal..3rd ed.1991;LondonChurchill Livingstone PMCID:PMC463083

[11] Sunderland S.Nerves and Nerve Injury..2nd ed.1978;LondonChurchill Livingstone PMCID:PMC1818488

[12] Ide C.Peripheral nerve regeneration..Neurosci Res1996;25:101-21

[13] Jones NF,Eo S.Revision surgery for persistent and recurrent carpal tunnel syndrome and for failed carpal tunnel release..Plast Reconstr Surg2012;129:683-92

[14] Amadio PC.Interventions for recurrent/persistent carpal tunnel syndrome after carpal tunnel release..J Hand Surg Am2009;34:1320-2

[15] Lowe JB3rd.Management of secondary cubital tunnel syndrome..Plast Reconstr Surg2004;113:E1-16

[16] Antoniadis G.Pain after surgery for ulnar neuropathy at the elbow: a continuing challenge..Neurosurgery1997;41:585-9

[17] Fransen P.Reduction of postoperative pain after lumbar microdiscectomy with DuraSeal Xact Adhesion Barrier and Sealant System..Spine J2010;10:751-61

[18] Mavrogenis AF,Stamatoukou A,Theoharis S,Zhang Z.Current treatment concepts for neuroma-in-continuity..Injury2008;39 Suppl 3:S43-8

[19] Millesi H,Reihsner R.Microsurgical neurolysis: its anatomical and physiological basis and its classification..Microsurgery1993;14:430-9

[20] Yamamoto T,Yoshimatsu H,Mihara M.Free anterolateral thigh flap with vascularized lateral femoral cutaneous nerve for the treatment of neuroma-in-continuity and recurrent carpal tunnel syndrome after carpal tunnel release..Microsurgery2014;34:145-8

[21] Mackinnon SE.Evaluation and treatment of the painful neuroma..Tech Hand Up Extrem Surg1997;1:195-212

[22] Carroll I.Management of chronic pain following nerve injuries/ crps type II..Hand Clin2013;29:401-8

[23] Davis EN.The Tinel sign: a historical perspective..Plast Reconstr Surg2004;114:494-9

[24] Klauser AS,Allen GM,Campbell R,Grainger A,McNally E,Ostlere S,Reijnierse M,Silvestri E,Martinoli C.Clinical indications for musculoskeletal ultrasound: a Delphi-based consensus paper of the European Society of Musculoskeletal Radiology..Eur Radiol2012;22:1140-8

[25] Wang Y,Passe SM,Thoreson AR,Amadio PC.Transverse ultrasound assessment of median nerve deformation and displacement in the human carpal tunnel during wrist movements..Ultrasound Med Biol2014;40:53-61 PMCID:PMC3849116

[26] Kerasnoudis A.Which ultrasound method has the upper hand in the follow-up of the patients with recurrent carpal tunnel syndrome?.Ann Rheum Dis2013;72:e11

[27] Padua L,Liotta G,Pazzaglia C,Briani C,De Franco P,Martinoli C.Ultrasound as a useful tool in the diagnosis and management of traumatic nerve lesions..Clin Neurophysiol2013;124:1237-43

[28] Andreisek G,Studer A.Upper extremity peripheral neuropathies: role and impact of MR imaging on patient management..Eur Radiol2008;18:1953-61

[29] Thawait SK,Subhawong TK,Hashemi SS,Thawait GK,Carrino JA.Peripheral nerve surgery: the role of high-resolution MR neurography..AJNR Am J Neuroradiol2012;33:203-10

[30] Lipinski LJ.Neurolysis, neurectomy, and nerve repair/reconstruction for chronic pain..Neurosurg Clin N Am2014;25:777-87

[31] Haider N,Chiravuri S.Pulsed radiofrequency of the median nerve under ultrasound guidance..Pain Physician2007;10:765-70

[32] Adani R,Tarallo L.Treatment of painful median nerve neuromas with radial and ulnar artery perforator adipofascial flaps..J Hand Surg Am2014;39:721-7

[33] Hieb LD.Spontaneous postoperative cerebrospinal fluid leaks following application of anti-adhesion barrier gel: case report and review of the literature..Spine2001;26:748-51

[34] Burns JW,Colt MJ,Rose R.A hyaluronate based gel for the prevention of postsurgical adhesions: evaluation in two animal species..Fertil Steril1996;66:814-21

[35] Atzei A,Breda B,Pajardi G.Clinical evaluation of a hyaluronan-based gel following microsurgical reconstruction of peripheral nerves of the hand..Microsurgery2007;27:2-7

[36] Gago LA,Chauhan S,Diamond MP.Seprafilm (modified hyaluronic acid and carboxy-methylcellulose) acts as a physical barrier..Fertil Steril2003;80:612-6

[37] Hiro D,Matsuta K.Hyaluronic acid is an endogenous inducer of interleukin-1 production by human monocytes and rabbit macrophages..Biochem Biophys Res Commun1986;140:715-22

[38] Mensitieri M,Nicolais L,O'Regan M.Viscoelastic properties modulation of a novel autocrosslinked hyaluronic acid polymer..J Mater Sci Mater Med1996;7:695-8

[39] Sheldon HK,Cassidy MR,Stucchi AF.A sprayable hyaluronate/carboxymethylcellulose adhesion barrier exhibits regional adhesion reduction efficacy and does not impair intestinal healing..J Gastrointest Surg2012;16:325-33

[40] Arakawa T.Mechanism of poly (ethylene glycol) interaction with proteins..Biochemistry1985;24:6756-62

[41] Liu LS.Adhesion barriers of carboxymethylcellulose and polyethylene oxide composite gels..J Biomed Mater Res2002;63:326-32

[42] Thomsen L.Incidence of painful neuroma after end-to-end nerve suture wrapped into a collagen conduit. A prospective study of 185 cases..Chir Main2013;32:335-40

[43] Soltani AM,Best MJ,Panthaki ZJ.Revision decompression and collagen nerve wrap for recurrent and persistent compression neuropathies of the upper extremity..Ann Plast Surg2014;72:572-8

[44] Abzug JM,Osterman AL.Surgical options for recalcitrant carpal tunnel syndrome with perineural fibrosis..Hand (N Y).2012;7:23-9 PMCID:PMC3280361

[45] Masaer JR,Mary ET.Venous wrapping of nerve to prevent scarring..J Hand Surg1990;15A:817-8

[46] Sotereanos DG,Mitsionis GI,Herndon JH.Vein-graft wrapping for the treatment of recurrent compression of the median nerve..Microsurgery1995;16:752-6

[47] Alligand-Perrin P,Jeudy J,Saint-Cast Y,Raimbeau G.Vein conduit associated with microsurgical suture for complete collateral digital nerve severance..Orthop Traumatol Surg Res2011;97:S16-20

[48] Cramer LM.Lankford LL.Local fat coverage for the median nerve..Correspondence Newsletter for Hand Surgery1985;Chicago, IIIASSH35

[49] Rose EH,Kowalski TA,Flegler EJ.Palmaris brevis turnover flap as an adjunct to internal neurolysis of the chronically scarred median nerve in recurrent carpal tunnel syndrome..J Hand Surg Am1991;16:191-201

[50] Wulle C.The synovial flap as treatment of the recurrent carpal tunnel syndrome..Hand Clin1996;12:379-88

[51] Becker C.The cubital flap..Ann Chir Main1988;7:136-42

[52] Vögelin E,Constantinescu M.Revision surgery after carpal tunnel release using a posterior interosseous artery Island flap..Handchir Mikrochir Plast Chir2008;40:122-7

[53] Adani R,Battiston B.Management of neuromas in continuity of the median nerve with the pronator quadratus muscle flap..Ann Plast Surg2002;48:35-40

[54] Goitz RJ.Microvascular omental transfer for the treatment of severe recurrent median neuritis of the wrist: a long-term follow-up..Plast Reconstr Surg2005;115:163-71

[55] Huntoon MA.Ultrasound-guided permanent implantation of peripheral nerve stimulation (PNS) system for neuropathic pain of the extremities: original cases and outcomes..Pain Med2009;10:1369-77

[56] Deer TR,Rosenfeld EL.Prospective clinical study of a new implantable peripheral nerve stimulation device to treat chronic pain..Clin J Pain2010;26:359-72

[57] Simpson EL,Holmes MW,Chilcott J.Spinal cord stimulation for chronic pain of neuropathic or ischaemic origin: systematic review and economic evaluation..Health Technol Assess2009;13:1-154

[58] Reisman NR.The abductor digiti minimi muscle flap: a salvage technique for palmar wrist pain..Plast Reconstr Surg1983;72:859-65

[59] Strickland JW,Lourie GM.The hypothenar fat pad flap for management of recalcitrant carpal tunnel syndrome..J Hand Surg Am1996;21:840-8

[60] Rose EH.The use of the palmaris brevis flap in recurrent carpal tunnel syndrome..Hand Clin1996;12:389-95

[61] Jones NF.Treatment of chronic pain by ''wrapping'' intact nerves with pedicle and free flaps..Hand Clin1996;12:765-72

[62] Giunta R,Lanz U.The hypothenar fat-pad flap for reconstructive repair after scarring of the median nerve at the wrist joint..Chir Main1998;17:107-12

[63] Frank U,Krimmer H.Relocation of the median nerve after scarring along the carpal tunnel with hypothenar fatty tissue flap-plasty..Handchir Mikrochir Plast Chir1999;31:317-22

[64] Guillemot E,Colin D,Hu W.Perineural fibrosis of the median nerve at the wrist. Treatment by neurolysis and dermal-hypodermal graft..Chir Main1999;18:279-89

[65] Mathoulin C,Roukoz S.Pedicled hypothenar fat flap for median nerve coverage in recalcitrant carpal tunnel syndrome..Hand Surg2000;5:33-40

[66] De Smet L.Pedicled fat flap coverage of the median nerve after failed carpal tunnel decompression..J Hand Surg Br2002;27:350-3

[67] Dahlin LB,Kardum P.Coverage of the median nerve with free and pedicled flaps for the treatment of recurrent severe carpal tunnel syndrome..Scand J Plast Reconstr Surg Hand Surg2002;36:172-6

[68] Luchetti R,Papini Zorli I.Protective coverage of the median nerve using fascial, fasciocutaneous or island flaps..Handchir Mikrochir Plast Chir2006;38:317-30

[69] Craft RO,Smith AA.Management of recurrent carpal tunnel syndrome with microneurolysis and the hypothenar fat pad flap..Hand (N Y)2007;2:85-9 PMCID:PMC2527148

[70] Fusetti C,Mathoulin C,Lucchina S.A reliable and simple solution for recalcitrant carpal tunnel syndrome: the hypothenar fat pad flap..Am J Orthop2009;38:181-6

[71] Elliot D,Hazari A,Anand P.Relief of the pain of neuromas-in-continuity and scarred median and ulnar nerves in the distal forearm and wrist by neurolysis, wrapping in vascularized forearm fascial flaps and adjunctive procedures..J Hand Surg Eur Vol2010;35:575-82

[72] Espinoza DP,Egloff DV.Neurolysis using a carbohydrate polymer gel for the treatment of postoperative neuropathic pain..Scand J Plast Reconstr Surg Hand Surg2010;44:12-6

[73] Varitimidis SE,Vardakas DG.Recurrent compressive neuropathy of the median nerve at the wrist: treatment with autogenous saphenous veinwrapping..J Hand Surg Br2000;25:271-5

[74] Masear VR.Nerve wrapping..Foot Ankle Clin2011;16:327-37

[75] Kokkalis ZT,Sotereanos DG.Vein wrapping at cubital tunnel for ulnar nerve problems..J Shoulder Elbow Surg2010;19:91-7

[76] Vernadakis AJ,Mackinnon SE.Management of neuromas..Clin Plast Surg2003;30:247-68, vii