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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 35  |  Issue : 2  |  Page : 169-172

Painful traumatic neuroma formed in chronic osteomyelitis surgical scar treated by pulsed radiofrequency ablation


Epione Centre of Pain Relief and Beyond, Varma Union Hospital, Indore, Madhya Pradesh, India

Date of Submission08-Mar-2020
Date of Decision29-Mar-2020
Date of Acceptance21-Aug-2020
Date of Web Publication31-Aug-2021

Correspondence Address:
Dr. Rachna Varma
Epione Centre of Pain Relief and Beyond, Varma Union Hospital, 120 Dhar Road, Indore, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpn.ijpn_33_20

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  Abstract 


Traumatic neuromas are sometimes formed in the surgical scars. Peripheral nerve injuries lead to complex clinical presentation. They are benign tumors which are formed by critical nerve tissue interaction and are extremely painful. They are formed by intraneural or extraneural scar formation affecting the nerve-gliding plane. Their main clinical presentation is neuropathic pain. This condition is also termed as “painful scar neuropathy.” There have been different approaches to treatment depending on the type of lesion whether it is perineural, endoneurial, or combined and type of pain due to traction or trauma, rest pain, and severity. Varying degrees of therapeutic success has been described in literature using different techniques. There is no consensus on the best therapeutic approach to treat neuropathic pain due to scar tethering. Patient counseling about the condition and the need for multiple interventions, if needed, is essential. Here, we report a case of a 16-year-old female with traumatic neuroma of superficial peroneal nerve formed in the surgical scar of chronic osteomyelitis presenting with severe pain and paresthesia treated by pulsed radio frequency (PRF). PRF is a novel therapeutic method to treat many conditions in pain medicine as it offers treatment without motor deficits and deafferentation syndrome.

Keywords: Benign tumor, neuroma, osteomyelitis, paresthesia, scar


How to cite this article:
Varma R, Varma G, Dara S, Chandra M. Painful traumatic neuroma formed in chronic osteomyelitis surgical scar treated by pulsed radiofrequency ablation. Indian J Pain 2021;35:169-72

How to cite this URL:
Varma R, Varma G, Dara S, Chandra M. Painful traumatic neuroma formed in chronic osteomyelitis surgical scar treated by pulsed radiofrequency ablation. Indian J Pain [serial online] 2021 [cited 2021 Nov 30];35:169-72. Available from: https://www.indianjpain.org/text.asp?2021/35/2/169/325204




  Introduction Top


Neuromas formed in the surgical scars are often encountered and are also termed as “traumatic neuromas.” They are described in various literatures as benign tumors formed because of excessive and irregular hyperplasia of nerve tissue after nerve injury. Diagnostic tools which were used were ultrasound imaging in this case. The neuralgic symptoms can be due to the reactive neuroma or due to compression from surrounding soft tissue.


  Case Report Top


A 16-year-old female presented with severe pain and abnormal sensation in the surgical scar formed in the right leg for 1 year following surgery in the leg [Figure 1].
Figure 1: Scar of chronic osteomyelitis in the right leg

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She had been operated for continuous pus discharge following trauma to her leg. On investigations, it was diagnosed as chronic osteomyelitis of tibia, for which incision and debridement were done. The pain as reported by her was constant, severe, and burning with abnormal sensation in and around the scar. Her visual analog scale (VAS) score was 9/10. She reported the pain increased on touching.

On examination, an irregular scar of 4–5 cm was present [Figure 2]. There was severe tenderness and hyperalgesia and allodynia on the surrounding skin and scar. Tinel's sign was positive. She had been told that her condition was incurable, so she and her parents were in extreme anxiety and under depression. She had been investigated for persistent infection repeatedly.
Figure 2: Painful scar on the anterolateral part of the leg

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She had undergone innumerable investigations including magnetic resonance imaging (MRI) lumbar spine and knee joint, which were within normal limits. MRI of the right leg showed mild focal edema in the anterior cutaneous and subcutaneous soft tissue of the middle part of the right leg. Investigations were sent to rule out infection. Total white blood cell count was 6000 cu/mm, neutrophils were 60%, and C-reactive protein was 0.7 mg%, which was negative for infection. Ultrasound imaging revealed 6.5 cm by 0.5 cm spindle-shaped hypoechoic shadow in the subcutaneous tissue with clear boundaries [Figure 3].
Figure 3: Ultrasound image of scar neuroma

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The patient had been prescribed different analgesics, mainly nonsteroidal anti-inflammatory drugs and tramadol, to which she had responded poorly with varying degrees of momentary pain relief. She was put on tablet gabapentin 300 mg and tablet etoricoxib 60 mg for 7 days.

The patient reported persistent pain with no relief after 1 week of medicine. A diagnostic injection of 2 ml lignocaine 2% under ultrasound guidance was done. The patient reported a decrease in pain and abnormal sensation immediately after injection. She was called the next day, and she and her parents were explained the method of treatment using pulsed radio frequency (PRF).

Written Informed consent was obtained. Prophylactic antibiotic intravenous ceftriaxone 1 g was given. The patient was taken in the operation theater. An 18G intravenous cannula was inserted, and pulse oximetry, noninvasive blood pressure monitor, and electrocardiogram leads were connected. Under ultrasound guidance, a 10 cm 22G 5-mm uninsulated tip radiofrequency needle was inserted using an in-plane technique [Figure 4] and [Figure 5]. Sensory stimulation at 50 Hz produced pain at 0.7 V, and motor stimulation at 2 Hz produced muscle twitch of peroneus muscles at 1.5 V. PRF lesion was done at 42° for 80 s with an applied voltage of 45 V. A second lesion was again done with a slight change in needle position.
Figure 4: Radio frequency needle inserted in scar

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Figure 5: Ultrasound image of the needle in scar neuroma

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The patient was discharged after observation with tablet etoricoxib 60 mg once a day and tablet gabapentin 300 mg 1 h for 10 days and was reviewed after 10 days. She reported a decrease in pain. Her VAS score was 2/10. She was advised tablet gabapentin 300 mg HS for another 15 days and reviewed. She had no complaints on her subsequent visit after 15 days. Analgesics and antineuropathic were stopped, and the patient was reviewed after 1 month and then for 6 months at a monthly interval. Her scar has healed [Figure 6]. VAS score was 0/10 on her last follow-up after 6 months.
Figure 6: Healed scar after 6 months

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After that, she did not come for follow-up but was followed up on the telephone where she reported being totally pain free.


  Case Discussion Top


Neuromas are seen commonly in scars due to trauma or surgery. A plenty of literature reports the formation of neuromas in limb, face, and neck. Various studies have also reported the formation of neuroma in mammary glands, penis, and other body parts.[1] Most of the neuromas occur secondary to nerve injury due to trauma or surgery. Most studies explain the formation of neuroma due to excessive repair and hyperplasia of the nerve tissue after injury. Scar neuroma or traumatic neuroma is of two types: (1) terminal neuroma – which occurs in injured or divided proximal nerve terminal after injury or operation. The proximal axons grow in multiple directions and become bulbous in shape. (2) Spindle neuroma – they occur in complete nerves and are thought to be due to chronic stimulation and friction.[2]

The cause of superficial peroneal nerve neuroma could be because of continuous friction, compression by surrounding scar or fibrous tissue, or by excessive reaction of the nerve tissue. The lesion can be perineural, endoneurial, or combined. The signs and symptoms of traumatic neuroma are neuralgic pain, hyperalgesia, allodynia, and positive Tinel's sign.[3],[4]

The cause of pain is supposed to be multiple. Compression by surrounding scar tissues, ischemia of nerve tissue, ectopic foci, substance P, calcitonin gene-related peptide, and 5-hydroxytryptamine released by mastocytes.[5] This pain is most likely due to central sensitization and has social–psychological effects. Diagnostic means include MRI and ultrasound. MRI is used only for differential diagnosis and is not very specific, and also the cost is prohibitive. Hence, its value as a diagnostic tool is limited. Ultrasound can delineate the lesion as well as its relationship with the surrounding tissue. Furthermore, it can aid in the diagnosis by injection of local anesthetic into the lesion.[6] The treatment options available are opioids, antidepressants, antineuropathic, α-blockers, repeated injections of lignocaine and corticosteroid, ultrasound-guided alcohol injection, transcutaneous magnetic stimulation, and cryotherapy. Most of the above therapies had to be done repeatedly, and pharmacological therapies have their own side effects and are undesirable for long-term use. PRF ablation was found to be effective even after 6–8 months, where the patient was free of pain.[7],[8]

PRF was developed as an alternative to conventional radiofrequency ablation as it is not neurodestructive and does not cause motor deficits or deafferentation syndromes. Relief of pain is attributed to the pulsed electric field exerting a central modulatory effect due to certain as yet unknown series of physiological events. The current is delivered in pulses with the temperature maintained at or below 42°C. This avoids the destructive lesion and exerts the therapeutic effect. PRF uses radiofrequency current in short (20 ms), high-voltage bursts around 18,500 V/m at applied volts of 45 V with a silent phase of (480 ms) of PRF allows time for heat elimination, generally keeping the target tissue below 42°C.[9],[10]

Antinociceptive effects of PRF are attributed to it causing activation of c-fos (proto-oncogene) and activating transcription factor-3 (cyclic AMP-dependent transcription factor). Whether applied percutaneously, transcutaneous or intra-articular PRF has been applied for all manner of pain regardless of the pathophysiology.[11],[12]


  Conclusion Top


Traumatic neuroma formed in a scar is a painful condition associated with a lot of morbidity and social and psychological trauma to the patient. PRF is a good and effective therapeutic tool. The need for the day is more research and a better understanding of the condition and therapeutic options.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kang J, Yang P, Zang Q, He X. Traumatic neuroma of the superficial peroneal nerve in a patient: A case report and review of the literature. World J Surg Oncol 2016;14:242.  Back to cited text no. 1
    
2.
Mathews GJ, Osterholm JL. Painful traumatic neuromas. Surg Clin North Am 1972;52:1313-24.  Back to cited text no. 2
    
3.
Tos P, Crosio A, Pugliese P, Adani R, Toia F. Stefano artiaco painful scar neuropathy: Principles of diagnosis and treatment. Plast Aesthet Res 2015;2:156-64.  Back to cited text no. 3
    
4.
Rajput K, Reddy S, Shankar H. Painful neuromas. Clin J Pain 2012;28:639-45.  Back to cited text no. 4
    
5.
Zochodne DW, Theriault M, Sharkey KA, Cheng C, Sutherland G. Peptides and neuromas: calcitonin gene-related peptide, substance P, and mast cells in a mechanosensitive human sural neuroma. Muscle Nerve 1997;20:875-80.  Back to cited text no. 5
    
6.
Hughes DG, Wilson DJ. Ultrasound appearances of peripheral nerve tumours. Br J Radiol 1986;59:1041-3.  Back to cited text no. 6
    
7.
Dworkin RH, O'Connor AB, Audette J, Baron R, Gourlay GK, Haanpää ML, et al. Recommendations for the pharmacological management of neuropathic pain: An overview and literature update. Mayo Clin Proc 2010;85:S3-14.  Back to cited text no. 7
    
8.
Leung A, Fallah A, Shukla S. Transcutaneous magnetic stimulation (TMS) in alleviating post-traumatic peripheral neuropathic pain States: A case series. Pain Med 2014;15:1196-9.  Back to cited text no. 8
    
9.
Restrepo-Garces CE, Marinov A, McHardy P, Faclier G, Avila A. Pulsed radiofrequency under ultrasound guidance for persistent stump-neuroma pain. Pain Pract 2011;11:98-102.  Back to cited text no. 9
    
10.
Byrd D, Mackey S. Pulsed radiofrequency for chronic pain. Curr Pain Headache Rep 2008;12:37-41.  Back to cited text no. 10
    
11.
Munglani R. The longer term effect of pulsed radiofrequency for neuropathic pain. Pain 1999;80:437-9.  Back to cited text no. 11
    
12.
Sluijter M, Racz G. Technical aspects of radiofrequency. Pain Pract 2002;2:195-200.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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Case Discussion
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