Many patients come in to see Dr. Eric H. Williams to receive treatment for severe nerve pain. There are numerous causes of their nerve pain, including neuromas. In these particular cases, Dr. Williams might recommend the use of neuroma resection to potentially provide relief.
What Are Neuromas?
In its most basic definition, a neuroma is painful swelling that develops after a nerve is injured. This can happen when a peripheral nerve tries to repair itself after it has been crushed, severely stretched, cut in half, or even compressed on a chronic basis.
When a nerve has been cut, new growth cones will sprout from the nerve ending. The goal for these cones is to form new nerve tissue that reaches out and moves across the gap to connect with the other severed end. In other instances, the affected nerve has not been cut in half, but is severely crushed. This causes new tissue to grow down and repopulate the downstream portion of the injured, still-intact nerve.
Typically, neuromas form when affected nerves are unable to successfully regrow. If it helps, you can think of the nerve as becoming frustrated when the nerve endings can’t go anywhere. In their frustration, a ball of aimless nerve endings develop, which is the source of the problem.
Not all nerve injuries lead to these painful neuromas, though. We currently cannot explain why the same injury for one person will cause one, yet it might not for someone else. There are certainly many different factors at play, any of which could affect the ultimate outcome of the nerve injury. This also relates to the fact that some people tend to have worse symptoms than others who experienced the same kind of nerve damage.
Basically, a neuroma can potentially develop in any of the body’s existing peripheral nerves. All of these nerves, when damaged, will attempt to regrow to a certain point. Some nerves just happen to be better at this than others.
There are two basic types of neuromas – stump neuromas and in-continuity neuromas.
A stump neuroma is essentially when the proximal portion—the part still attached to the spinal cord (the “upstream” part of a severed nerve)—of the peripheral nerve tried to regrow but was unable to locate the distal end – the end that is “downstream” from the injury. When this happens, a ball of scar tissue forms on the “stump” end of the nerve.
The most familiar situation people may think about in this regard is an individual who has had a limb amputation. All of the nerves in the affected limb have been cut, but sometimes the “live” nerve ending—the “stump”—continues to cause problems.
It’s important to note that this situation is not only connected to amputations; it can happen after almost any surgery. Surgeons simply cannot cut skin to perform an operation without cutting at least some nerves. Now, some procedures are inherently more risky than others because they are performed closer to larger nerves, ones that may cause problems.
As an example, you cannot replace a knee joint without cutting through the skin on the knee. When surgeons do that, they will obviously cut through some of the nerves leading to the skin around the knee. While most patients do fine after these surgeries, there are other who will develop terrible pain from the “live” stump of the infrapatellar branch of the saphenous nerve that was divided. This same problem can occur after hernia repair, or any operation that breaks the skin for that matter.
In the case of an in-continuity neuroma, the nerve itself is not actually cut completely apart. Instead, it may have simply been stretched too far, which has caused the inside of the nerve to snap like a rubber band. The outside, however, will appear to be intact. Also, the nerve may have been crushed, in which case the inside of the nerve is once again disrupted while the outside appears intact.
In both of those situations, the nerve upstream (closer to the spinal cord) will try to regrow down the same pathway it used to occupy.
It might help to think of this in the context of having a large cable containing smaller, individual cables inside it. When the insulation provided by the larger cable has been damaged, the smaller cables respond by sprouting growth cones that want to grow back down their original path. Unfortunately, they have greater difficulty doing this than they would if the insulation was intact and able to keep the nerves on track. An undamaged insulation also prevents nerves from escaping their previous pathways. If a nerve is unable to successfully regenerate, it causes an in-continuity neuroma.
Resection refers to the surgical removal of part or all of a damaged biological structure. Before Dr. Williams recommends this course of treatment, though, he will first take the time to understand your condition, carefully examine the problem area, and review your medical history. Dr. Williams may also use a temporary nerve block as a further diagnostic tool for his initial assessment.
If he feels it will be beneficial to you, and if the nerve is expendable, Dr. Williams might discuss using a neuroma resection procedure to remove the damaged nerve tissue. For instance, you probably would not want to lose a nerve to your index finger, but you may not need a small nerve to the side of your knee.
In a neuroma resection, the affected nerve branch causing the problem is identified. Dr. Williams will cut the nerve branch above the injury site, but then something needs to be done with that nerve ending to try to prevent the same thing from happening that brought the patient into the office to begin with. There are several techniques that are used to try to prevent a painful neuroma, and while none of them are 100% successful, good to excellent results can be expected in most patients. While an explanation of every technique is not possible in this short description, some basic goals are to move the nerve ending to a more protected environment to protect the nerve ending from being constantly stimulated, place the sensory nerve ending into a location where it does not want to regrow and form a large ball on the end of it, or to try to cap the nerve with a cadaver nerve graft so the cut nerve will try to regrow for a short distance, but not form a bulbous neuroma. Each of these techniques are very important tools that are used to try to maximize your chances of improvement.
As with any surgical procedure, there are certain risks entailed with neuroma resection, including potential infection, fluid buildup (seroma), bleeding, and anesthesia concerns. There are some patients that simply do not respond to having any type of nerve cut out. These patients can fail to improve or in some situations see worsening of symptoms. It can be difficult to determine who these patients are prior to operating on them. Our published success rates are as high as 85% in the correctly selected patients.
Sometimes just resecting a neuroma is not the best option for a patient. Sometimes a nerve just needs to be reconstructed so that it will grow back down stream and reconnect with the nerve ending that it used to be connected to. There are many times when this might be a better option. For instance if a nerve is NOT considered expendable – you don’t just want to cut it out – you would want to reconstruct it. If the nerve to all your fingers has been cut in half or injured then the nerve needs to be explored, and reconstructed to give you the best chance of return of function and relief of pain.
Nerves can be reconstructed in a variety of ways. Depending on the injury and the damage that has been done, a nerve might be able to be repaired simply by coapting or sewing the two nerve endings together. However, if more injury was done and the two ends cannot be put back together again then patients may need nerve grafting – which means putting another nerve in the gap to allow the nerve to regrow across the bridge to get to the other side. This can be done with one’s own nerves, or in some cases his can be down with donated nerve tissue that has been processed to allow the recipient of that nerve graft to accept it as their own nerve. There are other possibilities for nerve reconstruction where one may be able to borrow a nerve from somewhere else and transfer it to a place that needs it more; this is called a nerve transfer.
The risks of these procedures are dependent on many factors, but Dr. Williams will discuss this with you prior to making any decision about moving forward with surgery so you can make an informed decision for your medical care.
At this time, there is nothing clinically available to completely stop nerve regeneration, so it is important to note that a neuroma can return, even after neuroma resection. Accordingly, most treatments are centered on lessening the amount of abnormal interaction an injured nerve has with its environment.
Neuromas are a source of nerve pain, but, as we noted earlier, there are other sources as well. Dr. Eric H. Williams can work with you to diagnose the condition causing your pain, determine if any of his techniques might work, and then discuss and perform possible options that may help you find the relief you need. If you have any questions about Dr. Williams’ Baltimore, MD office—or need to request an appointment for a consultation—give us a call at (410) 337-5400. Our staff is glad to answer any questions and work with you to set up an appointment that is convenient for you, so call today!