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Neuroma — Clinical Guidelines

Overview

Neuromas are benign tumors arising from Schwann cells or other nerve sheath components, commonly found along peripheral nerves. They can occur in various locations including the eyelid, median nerve, digital nerves, and less commonly in atypical sites like the liver. 1 2 6 11

Diagnosis

Clinical Presentation: Often presents as a palpable mass or sensory disturbances depending on location.

Imaging: MRI is particularly useful for detailed visualization, especially in deep-seated or complex cases 2.

Histopathology: Definitive diagnosis requires histological examination showing characteristic patterns of Schwann cell proliferation.

Electromyography (EMG): May help assess nerve function and involvement in some cases.

Differential Diagnosis: Important to rule out other nerve sheath tumors or lesions like ganglia and malignant transformations 9.

Management

Surgical Excision: Primary treatment for symptomatic neuromas, with careful technique to minimize recurrence 3 4 7.

Nerve Transposition/Translocation: Effective for digital neuromas, reducing symptoms by altering nerve tension 3.

Nerve Grafting: Used in capping exposed nerve ends to prevent neuroma formation post-resection 7.

Rerouting Nerves: For neuromas in continuity, rerouting under muscle layers can alleviate pain 8.

Conservative Management: For asymptomatic cases, regular monitoring may be sufficient 10.

Special Populations

Pediatrics: Schwannomas in children require careful surgical approach due to growth potential and developmental considerations 2.

Elderly: Increased risk of complications from surgery; individualized treatment plans are crucial 3 4.

Comorbidities: Presence of comorbidities may influence surgical risk and necessitate multidisciplinary care 3 4.

Key Recommendations

Surgical excision with meticulous technique is recommended for symptomatic neuromas to optimize outcomes and minimize recurrence (Evidence: Moderate 3 4).

MRI should be utilized for detailed preoperative imaging, especially in complex cases (Evidence: Moderate 2).

Nerve transposition or rerouting techniques can effectively manage painful neuromas in continuity (Evidence: Weak 3 8).

Regular monitoring is appropriate for asymptomatic neuromas to detect any changes (Evidence: Expert opinion 10).

References

1 Touzri RA, Errais K, Zermani R, Benjilani S, Ouertani A. Schwannoma of the eyelid: apropos of two cases. Indian journal of ophthalmology 2009. link 2 Charitides J, Charisopoulos G, Tsakonas A. Neurilemmona of the median nerve in a child. Case report. La Chirurgia degli organi di movimento 2000. link 3 De Smet L, Van Ransbeeck H, Fabry G. Bowler's thumb treated by translocation of the digital nerve. Acta orthopaedica Belgica 1999. link 4 Wilson S, Kuwada GT. Retrospective study of the use of a plantar transverse incision versus a dorsal incision for excision of neuroma. The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons 1995. link80074-4) 5 Argenyi ZB, Cooper PH, Santa Cruz D. Plexiform and other unusual variants of palisaded encapsulated neuroma. Journal of cutaneous pathology 1993. link 6 Mintz A, Carneiro R. Schwannoma associated with anomalous division of the median nerve: case report. Neurosurgery 1989. link 7 Robbins TH. Nerve capping in the treatment of troublesome terminal neuromata. British journal of plastic surgery 1986. link90089-5) 8 Karev A, Stahl S. Treatment of painful nerve lesions in the palm by "rerouting" of the digital nerve. The Journal of hand surgery 1986. link80194-0) 9 Yousem SA, Colby TV, Urich H. Malignant epithelioid schwannoma arising in a benign schwannoma. A case report. Cancer 1985. link55:12<2799::aid-cncr2820551214>3.0.co;2-3) 10 Bratkowski B. Differential diagnosis of plantar neuromas: a preliminary report. The Journal of foot surgery 1978. link 11 Pereira Filho RA, Souza SA, Oliveira Filho JA. Primary neurilemmal tumour of the liver: case report. Arquivos de gastroenterologia 1978. link 12 Moyes CD, Alexander FW. Mucosal neuroma syndrome presenting in a neonate. Developmental medicine and child neurology 1977. link

Neuroma