- Case report
- Open Access
Traumatic neuroma of the superficial peroneal nerve in a patient: a case report and review of the literature
© The Author(s). 2016
Received: 23 September 2015
Accepted: 18 August 2016
Published: 10 September 2016
Traumatic neuromas are rare benign tumors, which are common in trauma or post-operation and accompanied with obvious symptoms of pain. This study will show the superficial peroneal nerve neuroma occurring after resection of hemangioma.
A 44-year-old male had an operation of the right leg cavernous hemangioma resection in 1995. Half a year after the operation, pain around the wound appeared and gradually aggravated. The patient had the lesion exploration resection in 2013, and the pathological result showed traumatic neuroma. Within half a year of the second operation, severe pain showed up again, so neuroma resection proceeded in May 2015. The postoperative pathological and immunohistochemical results showed traumatic neuroma. According to the postoperative follow-up, there were no symptoms of pain appearing again.
The pain is obvious, and B ultrasonography is the most efficient way to find neuromas. Both conservative and operative therapy have their advantages and disadvantages.
There remain many unanswered questions in relation to the treatment of traumatic neuromas, and further research is required, although we have already had adequate understanding of traumatic neuromas.
Traumatic neuromas are rarely seen in clinical practice but are common in trauma or post-operation. The main clinical manifestations are pain and paresthesia. Most scholars consider the occurrence of traumatic neuroma to be related to excess hyperplasia and irregular hyperplasia after nerve injury, so they are often regarded as benign tumors . Most reports show neuromas in the face, neck, and limbs, and the superficial peroneal nerve neuroma has not yet been reported in English literature at present. The purpose of this article is to show the details of a case of superficial peroneal neuroma after the operation of hemangioma, including clinical manifestation, clinical examination, diagnosis, and treatment, and review the relevant literature and which remain unanswered in the current literature.
Traumatic neuroma is very rare and seldom reported in English literature. Relatively, many traumatic neuromas occurring in the limbs, face, and neck can be found in the current literatures, and studies have also reported that traumatic neuroma could occur in the mammary gland, penis, and other body parts [1–4]. As discovered, most of the cases occurred secondary to direct trauma or operation. Currently, most scholars believe that this kind of lesion results from excessive repair and excess hyperplasia of oneself after nerve injury, so they do not consider it as tumor in situ [5–7]. Traumatic neuroma can be roughly classified into two categories. One is called terminal neuromas, which commonly occur in injured or divided proximal nerve terminal after injury or operation. After nerve division, distal axons begin apoptosis. To reconstruct nerve continuity, Schwann cells of the distal nerve will generate a channel for ingrowth of adjacent axons . However, in cases of too long distance between two segments of the injured nerve, proximal axons will grow toward multiple directions around so as to find a way for growth; thus, the appearance generally overgrows in bulbous-end-like shape , and besides, as nerve tissues grow more slowly than surrounding soft tissues, they will be mixed with other kinds of cells, such as fibroblast and mastocyte . The other one is spindle neuromas, which commonly occur in complete nerves and currently are considered as resulting from chronic stimulation and friction . There is also a report indicating that facial nerve hemangioma also can lead to traumatic neuroma under the condition of no trauma or operation history and no chronic stimulation and compression .
The generating mechanism of superficial peroneal neuroma reported in this study may be the reactive hyperplasia of the nerve. The injury is exactly at the branch of superficial peroneal nerve, reactive hyperplasia occurs in proximal end and further extends toward the trunk, thus generating eccentric neuroma occurring in superficial peroneal nerve trunk. In addition, we consider that the compression induced by scarring of surrounding soft tissues is also an important cause of traumatic neuroma.
The main manifestation of traumatic neuroma is pain, especially intense neuralgia [8, 11]. The pain may be generated for the following reasons or mechanisms: (1) stretched by surrounding scar tissues ; (2) compression on sensitive teleneuron by surrounding soft tissues ; (3) nerve tissue ischemia ; (4) ectopic foci of ion channels [15, 16]; (5) P substance, calcitonin gene related peptide and 5-hydroxytryptamine are released by mastocyte [9, 17]; and (6) peripheral regulation of kinds of ion channels or receptors (sodium channels, TRPA1, alpha1C receptors, and nerve growth factor) [15, 18–21]. The pain is often characterized by chixuxi low-intensity dull pain or intense paroxysmal burning pain and also can be induced by various outside simulations, such as temperature and touch. Tinel’s sign is usually positive . This kind of pain is difficult to control because it is often accompanied by central sensitization and social-psychological factors , and the change of voltage-gated calcium channels (VGCCs) may be the important element of central sensitization . There is also another pain that may be related to traumatic neuroma, called phantom pain, which results from sensing of the existence of amputated part . Ectopic discharge from a stump neuroma has been thought to be an important peripheral mechanism of phantom pain . Traumatic neuroma may also be characterized by paresthesia, such as hyperesthesia or feeling of numbness. One study reports on a case traumatic neuroma may have no manifestation during its development [8, 26].
MRI is only used in differential diagnosis with other soft tissue diseases , and its cost is high; patients have discomfort and real-time imaging cannot be used for display; thus, MRI has a limited value in diagnosis of traumatic neuroma.
The position and size of lesion and the relation between lesion and surrounding tissues and nerves can be detected directly via ultrasonography examination. Ultrasonography is one of most valuable methods in the diagnosis of traumatic neuroma. On one hand, ultrasonography examination is inexpensive, noninvasive, and non-harmful. And on the other hand, local nerve blocking can be conducted under the guidance of ultrasonography for the enhancement of the diagnosis, and pathological examination of living tissue can be implemented for the definite diagnoses [8, 28–30]. Ultrasound image of traumatic neuroma is generally oval, low-echo enclosed mass, clear and irregular probable boundary, diameter being greater than that of nerve trunk, and continuity with nerve . At histopathology, traumatic neuromas generally show in the following appearance: nonencapsulated tangled mass formed by Schwann cell, endoneurial cell, perineurial cell, and surrounding fibroblast .
The treatment of traumatic neuroma is still considered controversial. Conservative and operative therapy both have its advantage and disadvantage, which are listed in following content.
(1) Pharmacotherapy: Opioid analgesics, antidepressant drugs, antispasmodic drugs, α receptor blockers, and lidocaine are all used in the treatment of traumatic neuroma, but only have short-term therapeutic effect, and show significant side effects and declined therapeutic effect in long-term use [31–33]. Gabapentin and pregabalin are considered the effective medicine to inhibit central sensitization through affecting the calcium channels and reduce the excessive neurotransmitter release . (2) Repeated injection of lidocaine-hormone: It shows the symptom is improved in painful neuroma  but has significant side effects with long-term injection. (3) B ultrasound-guided percutaneous ethanol injection: can relieve painful neuroma significantly with continuous injection, and has high remission rate . (4) Transcutaneous magnetic stimulation (TMS): a rapid discharge of electric current is converted into dynamic magnetic flux for modulating neuronal functions . This analgesic effect seemed to be sustainable with repeated treatment delivered at a 6- to 8-week duration . (5) Injection of a tumor necrosis factor α blocker-enalapril to peripheral nerves can relieve the pain significantly . (6) Cryotherapy and radiofrequency ablation are both used in clinical treatment, but the therapeutic effect is unsatisfactory. Six months after radiofrequency ablation, there was significant decline in pain relief .
(1) Neuroma resection: Simple neuroma resection tends to have short-term therapeutic effect, together with relapse of neuroma . (2) Neuroma resection and ethanol injection: Appears to be only effective for patients who only suffer from short pain before operation, one-time nerve injury and one neuroma . (3) Neuroma resection and targeted nerve implantation (TNI): Such surgical method has been performed many times, and it is speculated to have a great role for prevention and treatment of neuroma . Its mechanism is as such: The proximal nerve ending at a secondary motor point is transplanted to an adjacent denervated muscle, and the regenerated axons may bifurcate and enter the myenteric motor nerve branches, so as to prevent formation of traumatic neuroma .
Adequate understanding of the traumatic neuroma appears essential. However, there remain many problems which require future research, such as (1) Should further remedial measures such as B ultrasound-guided percutaneous ethanol injection be taken after traumatic neuroma is confirmed by postoperative pathological report?; (2) Is it (traumatic neuroma) recurrent? Will it occur in sensory branch or motor branch?; (3) Does it develop to proximal trunk which is not adjacent with injured sites?; and (4) Is it useful to inject lidocaine when the nerve stump is closed? Further follow-up for condition of the patient and research is required.
We would like to thank the respondent of the study and all the people who provided help for this study.
The authors have no support or funding to report.
Availability of data and materials
All relevant data are within the paper.
JK participated in the design of this study and drafted the manuscript. PLY carried out the operation, together with QJZ, and collected important background information. XJH conceived of the study and participated in its design and helped to draft the manuscript. All authors read and approved the final manuscript.
The authors declare that they have no competing interests.
Consent for publication
We have obtained consent to publish from the participant to report his data.
Ethics approval and consent to participate
The study was permitted by the Ethical Review Committee of The Second Affiliated Hospital of Xi’an Jiaotong University Medical School (Xi’an, Shaanxi, China). The patient consented to participate in this study.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
- Li Q, Gao EL, Yang YL, et al. Traumatic neuroma in a patient with breast cancer after mastectomy: a case report and review of the literature. World J Surg Oncol. 2012;10:35.View ArticlePubMedPubMed CentralGoogle Scholar
- Cardoso TA, dos Santos KR, Franzotti AM, et al. Traumatic neuroma of the penis after circumcision—case report. An Bras Dermatol. 2015;90(3):397–9.View ArticlePubMedPubMed CentralGoogle Scholar
- Hoverson KR, Sasaki GT, Wohltmann WE. Traumatic neuroma of the penis. Dermatol Online J. 2014;20(1):21252.PubMedGoogle Scholar
- Allen KP, Hatanpaa KJ, Lemeshev Y, et al. Intratemporal traumatic neuromas of the facial nerve: evidence for multiple etiologies. Otol Neurotol. 2014;35(2):e69–72.View ArticlePubMedGoogle Scholar
- Lee EJ, Calcaterra TC, Zuckerbraun L. Traumatic neuromas of the head and neck. Ear Nose Throat J. 1998;77(8):670–4. 676.PubMedGoogle Scholar
- Rainsbury JW, Whiteside OJ, Bottrill ID. Traumatic facial nerve neuroma following mastoid surgery: a case report and literature review. J Laryngol Otol. 2007;121(6):601–5.View ArticlePubMedGoogle Scholar
- Yabuuchi H, Kuroiwa T, Fukuya T, et al. Traumatic neuroma and recurrent lymphadenopathy after neck dissection: comparison of radiologic features. Radiology. 2004;233(2):523–9.View ArticlePubMedGoogle Scholar
- Provost N, Bonaldi VM, Sarazin L, et al. Amputation stump neuroma: ultrasound features. J Clin Ultrasound. 1997;25(2):85–9.View ArticlePubMedGoogle Scholar
- Zochodne DW, Theriault M, Sharkey KA, et al. Peptides and neuromas: calcitonin gene-related peptide, substance P, and mast cells in a mechanosensitive human sural neuroma. Muscle Nerve. 1997;20(7):875–80.View ArticlePubMedGoogle Scholar
- Ashkar L, Omeroglu A, Halwani F, et al. Post-traumatic neuroma following breast surgery. Breast J. 2013;19(6):671–2.View ArticlePubMedGoogle Scholar
- Koch H, Haas F, Hubmer M, et al. Treatment of painful neuroma by resection and nerve stump transplantation into a vein. Ann Plast Surg. 2003;51(1):45–50.View ArticlePubMedGoogle Scholar
- Thomas AJ, Bull MJ, Howard AC, et al. Peri operative ultrasound guided needle localisation of amputation stump neuroma. Injury. 1999;30(10):689–91.View ArticlePubMedGoogle Scholar
- Fisher GT, Boswick Jr JA. Neuroma formation following digital amputations. J Trauma. 1983;23(2):136–42.View ArticlePubMedGoogle Scholar
- Mathews GJ, Osterholm JL. Painful traumatic neuromas. Surg Clin North Am. 1972;52(5):1313–24.View ArticlePubMedGoogle Scholar
- Lai J, Porreca F, Hunter JC, et al. Voltage-gated sodium channels and hyperalgesia. Annu Rev Pharmacol Toxicol. 2004;44:371–97.View ArticlePubMedGoogle Scholar
- Gold MS, Weinreich D, Kim CS, et al. Redistribution of Na(V)1.8 in uninjured axons enables neuropathic pain. J Neurosci. 2003;23(1):158–66.PubMedGoogle Scholar
- Nennesmo I, Reinholt F. Mast cells in nerve end neuromas of mice. Neurosci Lett. 1986;69(3):296–301.View ArticlePubMedGoogle Scholar
- Dawson LF, Phillips JK, Finch PM, et al. Expression of alpha1-adrenoceptors on peripheral nociceptive neurons. Neuroscience. 2011;175:300–14.View ArticlePubMedGoogle Scholar
- Balkowiec-Iskra E, Vermehren-Schmaedick A, Balkowiec A. Tumor necrosis factor-alpha increases brain-derived neurotrophic factor expression in trigeminal ganglion neurons in an activity-dependent manner. Neuroscience. 2011;180:322–33.View ArticlePubMedPubMed CentralGoogle Scholar
- Zoga V, Kawano T, Liang MY, et al. KATP channel subunits in rat dorsal root ganglia: alterations by painful axotomy. Mol Pain. 2010;6:6.View ArticlePubMedPubMed CentralGoogle Scholar
- Hagenacker T, Ledwig D, Busselberg D. Feedback mechanisms in the regulation of intracellular calcium ([Ca2+]i) in the peripheral nociceptive system: role of TRPV-1 and pain related receptors. Cell Calcium. 2008;43(3):215–27.View ArticlePubMedGoogle Scholar
- Rajput K, Reddy S, Shankar H. Painful neuromas. Clin J Pain. 2012;28(7):639–45.View ArticlePubMedGoogle Scholar
- Stokvis A, Coert JH, van Neck JW. Insufficient pain relief after surgical neuroma treatment: prognostic factors and central sensitisation. J Plast Reconstr Aesthet Surg. 2010;63(9):1538–43.View ArticlePubMedGoogle Scholar
- Li CY, Song YH, Higuera ES, et al. Spinal dorsal horn calcium channel alpha2delta-1 subunit upregulation contributes to peripheral nerve injury-induced tactile allodynia. J Neurosci. 2004;24(39):8494–9.View ArticlePubMedPubMed CentralGoogle Scholar
- Flor H. Phantom-limb pain: characteristics, causes, and treatment. Lancet Neurol. 2002;1(3):182–9.View ArticlePubMedGoogle Scholar
- Sturm V, Kroger M, Penzholz H. Problems of peripheral nerve surgery in amputation stump pain and phantom limbs. Chirurg. 1975;46(9):389–91.PubMedGoogle Scholar
- Adams 2nd WR. Morton’s neuroma. Clin Podiatr Med Surg. 2010;27(4):535–45.View ArticlePubMedGoogle Scholar
- Fornage BD. Peripheral nerves of the extremities: imaging with US. Radiology. 1988;167(1):179–82.View ArticlePubMedGoogle Scholar
- Hughes DG, Wilson DJ. Ultrasound appearances of peripheral nerve tumours. Br J Radiol. 1986;59(706):1041–3.View ArticlePubMedGoogle Scholar
- Reuter KL, Raptopoulos V, DeGirolami U, et al. Ultrasonography of a plexiform neurofibroma of the popliteal fossa. J Ultrasound Med. 1982;1(5):209–11.PubMedGoogle Scholar
- Gruber H, Glodny B, Kopf H, et al. Practical experience with sonographically guided phenol instillation of stump neuroma: predictors of effects, success, and outcome. AJR Am J Roentgenol. 2008;190(5):1263–9.View ArticlePubMedGoogle Scholar
- Chabal C, Jacobson L, Russell LC, et al. Pain response to perineuromal injection of normal saline, epinephrine, and lidocaine in humans. Pain. 1992;49(1):9–12.View ArticlePubMedGoogle Scholar
- Dworkin RH, O’Connor AB, Audette J, et al. Recommendations for the pharmacological management of neuropathic pain: an overview and literature update. Mayo Clin Proc. 2010;85(3 Suppl):S3–14.View ArticlePubMedPubMed CentralGoogle Scholar
- Dooley DJ, Taylor CP, Donevan S, et al. Ca2+ channel alpha2delta ligands: novel modulators of neurotransmission. Trends Pharmacol Sci. 2007;28(2):75–82.View ArticlePubMedGoogle Scholar
- Greenfield J, Rea Jr J, Ilfeld FW. Morton’s interdigital neuroma. Indications for treatment by local injections versus surgery. Clin Orthop Relat Res. 1984;185:142–4.PubMedGoogle Scholar
- Hughes RJ, Ali K, Jones H, et al. Treatment of Morton’s neuroma with alcohol injection under sonographic guidance: follow-up of 101 cases. AJR Am J Roentgenol. 2007;188(6):1535–9.View ArticlePubMedGoogle Scholar
- 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(7):1196–9.View ArticlePubMedGoogle Scholar
- Dahl E, Cohen SP. Perineural injection of etanercept as a treatment for postamputation pain. Clin J Pain. 2008;24(2):172–5.View ArticlePubMedGoogle Scholar
- Restrepo-Garces CE, Marinov A, McHardy P, et al. Pulsed radiofrequency under ultrasound guidance for persistent stump-neuroma pain. Pain Pract. 2011;11(1):98–102.View ArticlePubMedGoogle Scholar
- Guse DM, Moran SL. Outcomes of the surgical treatment of peripheral neuromas of the hand and forearm: a 25-year comparative outcome study. Ann Plast Surg. 2013;71(6):654–8.View ArticlePubMedGoogle Scholar
- Pet MA, Ko JH, Friedly JL, et al. Does targeted nerve implantation reduce neuroma pain in amputees? Clin Orthop Relat Res. 2014;472(10):2991–3001.View ArticlePubMedPubMed CentralGoogle Scholar