Efficacy of Neuroma Excision for Treatment of Severe Neuropathic Burn Pain

Introduction: Neuropathic pain after burn injury can severely impair functional recovery, and can persist despite maximal pharmacotherapy, laser remodeling of hypertrophic scars, and fat grafting to the scar interface.  We present a novel algorithm involving neuroma exploration, excision, and nerve implantation, for refractory cases.

Methods: We performed a retrospective analysis of 41 burn patients with incapacitating neuropathic pain refractory to medical, pharmacologic, and conventional surgical management, and positive Tinel sign; who underwent excision of 63 hypertrophic scars and neuromas from Jan 2014 – Feb 2018 (mean age 43.5 years, range 11-67; median burn surface area 8.0%).  Hypertrophic scar was excised in continuity with neuroma and deep fascia, from distal to proximal, until a feeding nerve was identified, divided, and implanted into muscle (22), fascia (15), or fat (22), with 5 patients having no identifiable source.  Improvement was rated as definite (subjective decrease in pain AND decreased use of pain medications), somewhat (decrease in pain OR medications), none, or worse.

Results: Forty-one burn patients, with severe neuropathic pain refractory to pharmacologic therapy, proximal nerve decompression, laser resurfacing, and fat grafting, underwent hypertrophic scar excision in the lower extremities (31), upper extremities (23), trunk (8), and face (1), an average of 2.2 years post-burn.  Neuromas were identified on pathology for 33 excisions. Wound healing complications occurred in 10.0% of procedures (12 complications in 10 patients), including dehiscence (6.7% of cases) and recurrence of neuroma (11.5% of cases).  At a mean of 20.2 months postop, 53.3% of patients reported definite improvement, 36.6% had somewhat improved, 5.0% had no improvement, and 5.0% were worse.

Conclusions: In patients with severe neuropathic burn pain, refractory to aggressive medical, pharmacologic, and surgical interventions, the presence of a neuroma may be the cause of neuropathic pain, and scar tissue may impact cutaneous sensory nerves. Excision of the hypertrophic scar and neuroma can provide long-term relief and decrease the use of pain medication; as such, surgery is indicated in the majority of these carefully selected patients.