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J Reconstr Microsurg
DOI: 10.1055/a-2576-0128
Original Article

The Efficacy of Upper Extremity Neuroma Surgery in Reducing Long-Term Opioid Use in Patients with Preoperative Opioid Use

Emmanuel O. Emovon III
1   Duke University School of Medicine, Durham, North Carolina
,
Hannah Langdell
2   Division of Plastic, Oral, and Maxillofacial Surgery, Duke University Medical Center; Durham, North Carolina
,
Elliott Rebello
3   Warren Alpert Medical School of Brown University, Providence, Rhode Island
,
J. Alex Albright
3   Warren Alpert Medical School of Brown University, Providence, Rhode Island
,
Ethan Ong
1   Duke University School of Medicine, Durham, North Carolina
,
Daniel Y. Joh
2   Division of Plastic, Oral, and Maxillofacial Surgery, Duke University Medical Center; Durham, North Carolina
,
Suhail K. Mithani
2   Division of Plastic, Oral, and Maxillofacial Surgery, Duke University Medical Center; Durham, North Carolina
4   Division of Hand, Upper Extremity, and Microvascular Surgery, Department of Orthopedic Surgery, Duke University Medical Center; Durham, North Carolina
,
Neill Y. Li
4   Division of Hand, Upper Extremity, and Microvascular Surgery, Department of Orthopedic Surgery, Duke University Medical Center; Durham, North Carolina
› Author Affiliations Funding None.
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Abstract

Background

Neuromas can cause severe neuropathic pain, leading to functional decline and psychosocial distress. For pain relief, patients refractory to medications for neuropathic pain may be prescribed opioids; however, such use has been shown to have unfortunate adverse effects. With increasing awareness and diagnostic capabilities for neuroma formation, this study evaluates whether upper extremity neuroma excision may reduce opioid use and if adjunctive nerve procedures further reduce opioid use.

Methods

The PearlDiver database was queried for patients undergoing upper extremity neuroma excision surgery from 2010 to 2020. Patients with opioid prescription fill records preoperatively were extracted and stratified by an operative technique involving either (1) excision alone, (2) nerve implantation into bone or muscle, or (3) nerve reconstruction. Records were then assessed at 1, 3, and 6 months postoperatively to assess for opioid use. Prescription fill rates at 1, 3, and 6 months postoperatively were then assessed across techniques.

Results

Of the 14,330 patients that underwent upper extremity neuroma excision, 4,156 filled opioids preoperatively. Excision led to significant reductions in opioid prescription fill rates postoperatively, decreasing to 67.4% at 1 month and to 57.5% by 6 months (p < 0.001). Excision alone resulted in lower opioid use compared with excision with implantation at all postoperative time points (p < 0.05). At 6 months, opioid use was also significantly less following excision with nerve reconstruction compared with implantation (56.4% vs. 65.6%, p = 0.0096). There were no differences between excision alone and excision with nerve reconstruction.

Conclusion

Neuroma excision significantly reduces opioid use in patients with preoperative opioid use while adjunctive operative techniques did not potentiate opioid reduction. This highlights the importance of understanding patient complaints, neuroma localization, and candidacy for excision as an effective measure for addressing opioid use in patients with preoperative opioid dependence.

Keywords

neuroma - opioids - neuroma surgery - nerve surgery

Presentation at

This work was presented at the 2024 American Society for Surgery of the Hand and The Australian Hand Surgery Society.




Publication History

Received: 05 October 2024

Accepted: 02 April 2025

Accepted Manuscript online:
07 April 2025

Article published online:
02 May 2025

© 2025. Thieme. All rights reserved.

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  • References

  • 1 Janes LE, Fracol ME, Dumanian GA, Ko JH. Targeted muscle reinnervation for the treatment of neuroma. Hand Clin 2021; 37 (03) 345-359
    CrossrefPubMedSearch in Google Scholar
  • 2 van der Avoort DJ, Hovius SE, Selles RW, van Neck JW, Coert JH. The incidence of symptomatic neuroma in amputation and neurorrhaphy patients. J Plast Reconstr Aesthet Surg 2013; 66 (10) 1330-1334
    CrossrefPubMedSearch in Google Scholar
  • 3 Vlot MA, Wilkens SC, Chen NC, Eberlin KR. Symptomatic neuroma following initial amputation for traumatic digital amputation. J Hand Surg Am 2018; 43 (01) 86.e1-86.e8
    CrossrefPubMedSearch in Google Scholar
  • 4 Wojtkiewicz DM, Saunders J, Domeshek L, Novak CB, Kaskutas V, Mackinnon SE. Social impact of peripheral nerve injuries. Hand (N Y) 2015; 10 (02) 161-167
    PubMedSearch in Google Scholar
  • 5 Domeshek LF, Krauss EM, Snyder-Warwick AK. et al. Surgical treatment of neuromas improves patient-reported pain, depression, and quality of life. Plast Reconstr Surg 2017; 139 (02) 407-418
    CrossrefPubMedSearch in Google Scholar
  • 6 Lipinski LJ, Spinner RJ. Neurolysis, neurectomy, and nerve repair/reconstruction for chronic pain. Neurosurg Clin N Am 2014; 25 (04) 777-787
    CrossrefPubMedSearch in Google Scholar
  • 7 Yao C, Zhou X, Zhao B, Sun C, Poonit K, Yan H. Treatments of traumatic neuropathic pain: a systematic review. Oncotarget 2017; 8 (34) 57670-57679
    CrossrefPubMedSearch in Google Scholar
  • 8 Bates D, Schultheis BC, Hanes MC. et al. A comprehensive algorithm for management of neuropathic pain. Pain Med 2019; 20 (Suppl. 01) S2-S12
    CrossrefPubMedSearch in Google Scholar
  • 9 Decrouy-Duruz V, Christen T, Raffoul W. Evaluation of surgical treatment for neuropathic pain from neuroma in patients with injured peripheral nerves. J Neurosurg 2018; 128 (04) 1235-1240
    CrossrefPubMedSearch in Google Scholar
  • 10 Alviar MJ, Hale T, Dungca M. Pharmacologic interventions for treating phantom limb pain. Cochrane Database Syst Rev 2016; 10 (10) CD006380
    PubMedSearch in Google Scholar
  • 11 Huse E, Larbig W, Flor H, Birbaumer N. The effect of opioids on phantom limb pain and cortical reorganization. Pain 2001; 90 (1–2): 47-55
    CrossrefPubMedSearch in Google Scholar
  • 12 Gilron I, Bailey JM, Tu D, Holden RR, Weaver DF, Houlden RL. Morphine, gabapentin, or their combination for neuropathic pain. N Engl J Med 2005; 352 (25) 2650-2651
    PubMedSearch in Google Scholar
  • 13 McNicol ED, Midbari A, Eisenberg E. Opioids for neuropathic pain. Cochrane Database Syst Rev 2013; 2013 (08) CD006146
    PubMedSearch in Google Scholar
  • 14 Sommer C, Klose P, Welsch P, Petzke F, Häuser W. Opioids for chronic non-cancer neuropathic pain. An updated systematic review and meta-analysis of efficacy, tolerability and safety in randomized placebo-controlled studies of at least 4 weeks duration. Eur J Pain 2020; 24 (01) 3-18
    PubMedSearch in Google Scholar
  • 15 Koch T, Höllt V. Role of receptor internalization in opioid tolerance and dependence. Pharmacol Ther 2008; 117 (02) 199-206
    PubMedSearch in Google Scholar
  • 16 Mayer P, Höllt V. Pharmacogenetics of opioid receptors and addiction. Pharmacogenet Genomics 2006; 16 (01) 1-7
    PubMedSearch in Google Scholar
  • 17 Pittenger C, Desan PH. Gabapentin abuse, and delirium tremens upon gabapentin withdrawal. J Clin Psychiatry 2007; 68 (03) 483-484
    PubMedSearch in Google Scholar
  • 18 Mersfelder TL, Nichols WH. Gabapentin: abuse, dependence, and withdrawal. Ann Pharmacother 2016; 50 (03) 229-233
    CrossrefPubMedSearch in Google Scholar
  • 19 Grant GH. Methods of treatment of neuromata of the hand. J Bone Joint Surg Am 1951; 33-A (04) 841-848
    PubMedSearch in Google Scholar
  • 20 Mauch JT, Bae A, Shubinets V, Lin IC. A systematic review of sensory outcomes of digital nerve gap reconstruction with autograft, allograft, and conduit. Ann Plast Surg 2019; 82 (4S, suppl 3): S247-S255
    PubMedSearch in Google Scholar
  • 21 Tang P, Whiteman DR, Voigt C, Miller MC, Kim H. No difference in outcomes detected between decellular nerve allograft and cable autograft in rat sciatic nerve defects. J Bone Joint Surg Am 2019; 101 (10) e42
    PubMedSearch in Google Scholar
  • 22 Moore AM, Kasukurthi R, Magill CK, Farhadi HF, Borschel GH, Mackinnon SE. Limitations of conduits in peripheral nerve repairs. Hand (N Y) 2009; 4 (02) 180-186
    CrossrefPubMedSearch in Google Scholar
  • 23 Ducic I, Mesbahi AN, Attinger CE, Graw K. The role of peripheral nerve surgery in the treatment of chronic pain associated with amputation stumps. Plast Reconstr Surg 2008; 121 (03) 908-914
    CrossrefPubMedSearch in Google Scholar
  • 24 Eberlin KR, Ducic I. Surgical algorithm for neuroma management: a changing treatment paradigm. Plast Reconstr Surg Glob Open 2018; 6 (10) e1952
    CrossrefPubMedSearch in Google Scholar
  • 25 Poppler LH, Parikh RP, Bichanich MJ. et al. Surgical interventions for the treatment of painful neuroma: a comparative meta-analysis. Pain 2018; 159 (02) 214-223
    CrossrefPubMedSearch in Google Scholar
  • 26 McQuillan TJ, Zelenski NA, Ghareeb PA. The role of nerve tension on nerve repair success. J Hand Surg Glob Online 2024; 6 (05) 691-693
    PubMedSearch in Google Scholar
  • 27 Driscoll PJ, Glasby MA, Lawson GM. An in vivo study of peripheral nerves in continuity: biomechanical and physiological responses to elongation. J Orthop Res 2002; 20 (02) 370-375
    CrossrefPubMedSearch in Google Scholar
  • 28 He B, Zhu Z, Zhu Q. et al. Factors predicting sensory and motor recovery after the repair of upper limb peripheral nerve injuries. Neural Regen Res 2014; 9 (06) 661-672
    PubMedSearch in Google Scholar
  • 29 Leversedge FJ, Zoldos J, Nydick J. et al. A multicenter matched cohort study of processed nerve allograft and conduit in digital nerve reconstruction. J Hand Surg Am 2020; 45 (12) 1148-1156
    CrossrefPubMedSearch in Google Scholar
  • 30 Chou J, Liston JM, DeGeorge BR. Traditional neuroma management strategies: a systematic review. Ann Plast Surg 2023; 90 (6S, suppl 4): S350-S355
    PubMedSearch in Google Scholar
  • 31 Curtin C. Pain examination and diagnosis. Hand Clin 2016; 32 (01) 21-26
    PubMedSearch in Google Scholar
  • 32 Herr K. Neuropathic pain: a guide to comprehensive assessment. Pain Manag Nurs 2004; 5 (4, suppl 1): 9-18
    PubMedSearch in Google Scholar
  • 33 Katz J, Melzack R. Measurement of pain. Surg Clin North Am 1999; 79 (02) 231-252
    PubMedSearch in Google Scholar
  • 34 Lans J, Westenberg RF, Gottlieb RE, Valerio IL, Chen NC, Eberlin KR. Long-term opioid use following surgery for symptomatic neuroma. J Reconstr Microsurg 2022; 38 (02) 137-143
    PubMedSearch in Google Scholar
  • 35 Shipp MM, Sanghavi KK, Kolm P, Zhang G, Miller KE, Giladi AM. Preoperative patient-reported data indicate the risk of prolonged opioid use after hand and upper extremity surgeries. J Hand Surg Am 2022; 47 (11) 1068-1075
    PubMedSearch in Google Scholar
  • 36 Jildeh TR, Taylor KA, Tramer JS. et al. Risk factors for postoperative opioid use in arthroscopic shoulder labral surgery. Arthroscopy 2020; 36 (07) 1813-1820
    PubMedSearch in Google Scholar
  • 37 Giladi AM. et al. Patient-reported data augment health record data for prediction models of persistent opioid use after elective upper extremity surgery. Plast Reconstr Surg 2023; 152 (02) 358e-366e
    PubMedSearch in Google Scholar
  • 38 Felder JM, Ducic I. Impact of nerve surgery on opioid and medication use in patients with chronic nerve injuries. Plast Reconstr Surg Glob Open 2021; 9 (09) e3789
    PubMedSearch in Google Scholar
  • 39 Dumanian GA, Potter BK, Mioton LM. et al. Targeted muscle reinnervation treats neuroma and phantom pain in major limb amputees: a randomized clinical trial. Ann Surg 2019; 270 (02) 238-246
    CrossrefPubMedSearch in Google Scholar
  • 40 Souza JM, Cheesborough JE, Ko JH, Cho MS, Kuiken TA, Dumanian GA. Targeted muscle reinnervation: a novel approach to postamputation neuroma pain. Clin Orthop Relat Res 2014; 472 (10) 2984-2990
    CrossrefPubMedSearch in Google Scholar
  • 41 Jain SA, Nydick J, Leversedge F. et al. Clinical outcomes of symptomatic neuroma resection and reconstruction with processed nerve allograft. Plast Reconstr Surg Glob Open 2021; 9 (10) e3832
    PubMedSearch in Google Scholar
  • 42 Bibbo C, Rodrigues-Colazzo E, Finzen AG. Superficial peroneal nerve to deep peroneal nerve transfer with allograft conduit for neuroma in continuity. J Foot Ankle Surg 2018; 57 (03) 514-517
    CrossrefPubMedSearch in Google Scholar
  • 43 Bibbo C, Rodriguez-Colazzo E. Nerve transfer with entubulated nerve allograft transfers to treat recalcitrant lower extremity neuromas. J Foot Ankle Surg 2017; 56 (01) 82-86
    CrossrefPubMedSearch in Google Scholar
  • 44 Walsh AR, Lu J, Rodriguez E, Diamond S, Sultan SM. The current state of targeted muscle reinnervation: a systematic review. J Reconstr Microsurg 2023; 39 (03) 238-244
    Thieme ConnectPubMedSearch in Google Scholar
  • 45 Zamore Z, Yesantharao PS, Aravind P, Dellon AL. Economic cost-benefit analysis of nerve implanted into muscle versus targeted muscle reinnervation versus regenerative peripheral nerve interface, for treatment of the painful neuroma. J Reconstr Microsurg 2024; 40 (08) 642-647
    Thieme ConnectPubMedSearch in Google Scholar
  • 46 Anantavorasakul N, Lans J, Macken AA, Sood RF, Chen NC, Eberlin KR. Surgery for lower extremity symptomatic neuroma: long-term outcomes. J Plast Reconstr Aesthet Surg 2020; 73 (08) 1456-1464
    PubMedSearch in Google Scholar
  • 47 Lans J, Baker DJ, Castelein RM, Sood RF, Chen NC, Eberlin KR. Patient-reported outcomes following surgical treatment of symptomatic digital neuromas. Plast Reconstr Surg 2020; 145 (03) 563e-573e
    PubMedSearch in Google Scholar
  • 48 Zammit A, Coquet J, Hah J. et al. Postoperative opioid prescribing patients with diabetes: opportunities for personalized pain management. PLoS One 2023; 18 (08) e0287697
    PubMedSearch in Google Scholar
  • 49 Lans J, Groot OQ, Hazewinkel MHJ. et al. Factors related to neuropathic pain following lower extremity amputation. Plast Reconstr Surg 2022; 150 (02) 446-455
    CrossrefPubMedSearch in Google Scholar