Hospital For Special Surgery, New York, NY, USA.
University of Iowa Department of Orthopaedics and Rehabilitation, Iowa City, IA, USA.
Foot Ankle Int. 2023 Sep;44(9):845-853. doi: 10.1177/10711007231184472. Epub 2023 Jul 21.
Somatic nerve pain is one of the most common complications following surgery of the foot and ankle but may also arise following traumatic injury or chronic nerve compression. The sural nerve is a commonly affected nerve in the foot and ankle; it is at risk given the proximity to frequently used surgical approaches, exposure to crush injuries, and traction from severe ankle inversion injuries. The purpose of this study is to investigate the outcomes of sural nerve neurectomy with proximal implantation for sural neuromas (SN) and chronic sural neuritis (CSN).
Patients that underwent neurectomy with proximal implantation (20 muscle, 1 adipose tissue) by 2 foot and ankle specialists for isolated SN- and CSN-related pain at a single tertiary institution were included. Demographic data, baseline outcomes including 36-Item Short Form Health Survey (SF-36), Foot and Ankle Ability Measure (FAAM), and visual analog scale (VAS) were recorded. Final follow-up questionnaires using Patient Reported Outcomes Measurement Information System (PROMIS) lower extremity function, pain interference (PI), and neuropathic pain quality, FAAM, and VAS were administered using REDCap. Perioperative factors including neuropathic medications, diagnostic injections, the use of collagen wraps, and perioperative ketamine were collected from the medical record. Descriptive statistics were performed and potential changes in patient-reported outcome measure scores were evaluated using Wilcoxon signed-rank tests.
The 21 patients meeting inclusion criteria for this study had a median age of 47 years (interquartile range [IQR], 43-49) and had median follow-up duration of 33.7 months (IQR, 4.5-47.6). Median FAAM activities of daily living score improved from 40.6 (38.7-50.7) preoperatively to 66.1 (53.6-83.3) postoperatively, = .032. FAAM sports scores improved from 14.1 (7.8-21.9) to 41.1 (25.0-60.9) postoperatively, = .002. VAS scores improved from a median of 9.0 (8.0-9.0) to 3.0 (3.0-6.0), < .001. At final follow-up, patients reported PROMIS lower extremity function score median of 43.8 (35.6-54.9), PROMIS neuropathic pain quality score of 54.1 (43.6-61.6), and PROMIS PI of 57.7 (41.1-63.8). Patients with both anxiety and depression reported less improvement in pain and physical. Other perioperative factors lacked sufficient numbers for statistical analysis.
Sural nerve neurectomy and proximal implantation (20 muscle, 1 adipose) provided significant improvement in pain and function for patients with sural neuromas and chronic sural neuritis at median follow-up of 33.7 months. Anxiety and depression were associated with significantly poorer outcomes following surgery. Patients with CRPS as well as recent nicotine use tended to report less improvement in pain and worse function after surgery, although this sample size was too limited for statistical analysis of these variables. Further research is needed to identify the ideal surgical candidates and perioperative factors to optimize patient outcomes.
Level IV, retrospective case series.
躯体神经痛是足部和踝关节手术后最常见的并发症之一，但也可能由创伤性损伤或慢性神经压迫引起。腓肠神经是足部和踝关节常见的受累神经；由于其靠近常用的手术入路、易受挤压伤和严重踝关节内翻伤的牵引，因此存在风险。本研究的目的是调查腓肠神经神经瘤（SN）和慢性腓肠神经炎（CSN）的近端植入腓肠神经神经切除术的结果。
纳入了 21 名在一家三级医院接受了由 2 名足踝专家进行的近端植入（20 块肌肉，1 块脂肪组织）的神经切除术的患者，这些患者是由于孤立性 SN 和 CSN 相关疼痛而接受手术的。记录了人口统计学数据、基线结果，包括 36 项简短健康调查问卷（SF-36）、足踝能力测量（FAAM）和视觉模拟量表（VAS）。使用 REDCap 对最终随访问卷进行了患者报告的测量信息系统（PROMIS）下肢功能、疼痛干扰（PI）、神经病理性疼痛质量、FAAM 和 VAS 的评估。从病历中收集了围手术期因素，包括神经病理性药物、诊断性注射、胶原包裹的使用和围手术期氯胺酮。使用 Wilcoxon 符号秩检验评估患者报告的结果测量评分的潜在变化。
这项研究纳入的 21 名符合纳入标准的患者的中位年龄为 47 岁（四分位距 [IQR]，43-49），中位随访时间为 33.7 个月（IQR，4.5-47.6）。FAAM 日常生活活动评分从术前的 40.6（38.7-50.7）改善到术后的 66.1（53.6-83.3）， = .032。FAAM 运动评分从术前的 14.1（7.8-21.9）改善到术后的 41.1（25.0-60.9）， = .002。VAS 评分从术前的 9.0（8.0-9.0）改善到术后的 3.0（3.0-6.0）， < .001。在最终随访时，患者报告的 PROMIS 下肢功能评分中位数为 43.8（35.6-54.9），PROMIS 神经病理性疼痛质量评分为 54.1（43.6-61.6），PROMIS PI 评分为 57.7（41.1-63.8）。同时患有焦虑和抑郁的患者在疼痛和身体方面的改善明显较少。其他围手术期因素缺乏足够的统计分析数量。
腓肠神经神经瘤和慢性腓肠神经炎患者在中位随访 33.7 个月时接受近端植入（20 块肌肉，1 块脂肪）的腓肠神经神经切除术，疼痛和功能显著改善。焦虑和抑郁与术后结果明显较差相关。患有复杂性区域疼痛综合征和近期尼古丁使用者的患者术后疼痛和功能改善程度较低，尽管这种样本量对于这些变量的统计分析来说太小。需要进一步研究以确定理想的手术候选人和围手术期因素，以优化患者的预后。
IV 级，回顾性病例系列研究。
