Interdisciplinary Surgical Decision Making for Painful Neuroma

Operative intervention for symptomatic neuromas is intended to provide pain relief by removing the neuroma and, ideally, preventing recurrence. However, not all patients require surgery to achieve pain relief and achieve their functional goals as neuromas are highly variable in presentation, location, and significance to the patient. Non-operative approaches including medication, therapy, and interventional pain approaches can be useful, concurrent components of a multimodal diagnostic and therapeutic strategy and may be complementary to operative intervention. The ideal operative reconstructive approach is to provide the regenerating proximal neuron the necessary elements to foster coordinated nerve regeneration, namely, a distal target, a neurotrophic signal, and a pathway or conduit across which to regenerate. Strategies including end-to-side neurorrhaphy, regenerative peripheral nerve interface (RPNI), and targeted muscle reinnervation (TMR) aimed to guide, rather than ablate, the regenerative potential of injured nerves can manage pain symptoms while preserving or restoring function. Optimal outcomes are more likely when patients are provided a comprehensive palette of interventions from which to make an informed decision based on tolerance of risk, surgical appetite, and desired durability of the outcome.