From the Guidelines
A painful neuroma is a benign growth of nerve tissue that develops after nerve injury, typically following trauma or surgery, and is characterized by severe, shooting or burning pain when touched or pressed. This condition occurs when a damaged or cut nerve attempts to regenerate but forms a tangled mass of nerve fibers and scar tissue instead. These neuromas commonly develop in the feet, hands, or areas where nerves have been severed, such as amputation sites or surgical scars. The hallmark symptom is severe, shooting or burning pain when the neuroma is touched or pressed, often described as an electric shock sensation. Some key points to consider in the management of painful neuromas include:
- Treatment options include conservative measures like padding, custom orthotics, and anti-inflammatory medications (such as ibuprofen 400-800mg three times daily or gabapentin 300-600mg three times daily for neuropathic pain) 1.
- For persistent cases, corticosteroid injections, alcohol sclerosing injections, or surgical removal may be necessary.
- The pain occurs because the damaged nerve endings become hypersensitive and send inappropriate pain signals to the brain, even with minimal stimulation.
- Early treatment is important as chronic neuromas can lead to persistent neuropathic pain that becomes increasingly difficult to manage over time. It's also worth noting that the management of neuropathic pain, including painful neuromas, often involves a step-wise approach, starting with first-line medications such as secondary-amine tricyclic antidepressants (TCAs) or selective serotonin norepinephrine reuptake inhibitors (SSNRIs), and calcium channel alpha-delta ligands like gabapentin or pregabalin 1. In cases where first-line treatments are ineffective, second- and third-line medications or referral to a pain specialist or multidisciplinary pain center may be considered 1. Overall, the management of painful neuromas requires a comprehensive approach that takes into account the underlying cause of the condition, as well as the patient's overall health and quality of life.
From the Research
Definition and Characteristics of Painful Neuroma
- A painful neuroma is a common complication of a peripheral nerve injury or amputation, causing tremendous pain that is resistant to most analgesics 2.
- It is characterized by the formation of a neuroma, a substantial cause of morbidity and reduction in quality of life, resulting from a disruption in motor and sensory function and debilitating effects of neuropathic pain 3.
- Painful neuromas are often accompanied by functional disorders, drastically reducing the patient's quality of life 2.
Pathophysiological Mechanisms
- Several pathophysiological mechanisms have been proposed to explain this type of neuropathic pain, including peripheral and central sensitisation and the involvement of nerve growth factor, α-smooth muscle actin, the cannabinoid CB2 receptor, and structural changes in neuroma fibres 2.
- The increased numbers of unmyelinated axis cylinders in traumatic neuromas could be related to the painful symptoms in some patients 4.
- The unrestricted growth of perineurial cells is an attempt to contain the regeneration of axis cylinders, and the maintenance of perineurial integrity by fascicle ligation is important in the relief of painful human neuromas 4.
Treatment Options
- Treatment of painful neuromas is limited to resection of the neuroma and implantation of the nerve in a muscle at a location where it is safe from irritation and trauma 5.
- End-to-side neurorraphy into adjacent sensory and/or motor nerves can provide a target for axons deprived of their endorgan, preventing neuroma formation and reducing pain 5.
- Surgical management remains challenging, with low success rates, and factors such as employment status, duration of pain, and CRPS symptoms can be prognostic of outcome 6.
- Diagnostic nerve blocks can be predictive of post-operative pain scores, and smoking can be related to worse outcome 6.