Targeted muscle re-innervation for superficial radial neuroma
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Targeted muscle reinnervation (TMR) is a technique developed for the management of symptomatic neuromas. The ideal method of management for a neuroma is not clear. Different techniques may be required for different nerves in different locations. As a general rule though, reconstruction of the nerve gap created after resection of a neuroma is the optimum method of restoring some afferent signalling to the sensory cortex of the brain. Reconstructive procedures like this depend on the tissue bed, the quality of the distal nerve stump and the nerve gap.
Bridging a gap requires nerve graft and for some patients, the thought of creating a second nerve injury site for autologous nerve graft harvest, with the attendant risks of neuroma, sensory loss and neuropathic pain, is an unacceptable solution. TMR has demonstrated excellent results in the prevention of phantom pain, in the management of limb pain following amputation and in treating both mixed nerves and pure sensory nerves. The technique is “active” or reconstructive, directing regenerating axons into a distal motor branch of a nerve in the vicinity.
The superficial radial nerve is challenging to treat when sensitised, due to the prominent location and tendency fro irritation by contact from clothing. There is no wholly reliable method for management of the SRN. Applying the technique of TMR to the SRN is starting to demonstrate promise.
This technique demonstrates the use of TMR to treat a SRN proximal stump to the distal anterior interosseous nerve (AIN) to pronator quadratus (PQ) for the management of neuroma pain that followed injury to the SRN during injection to the thumb CMCJ. The initial attempts at neuroma management included in situ capping and relief was temporary, again becoming problematic at 2 years and being accompanied by CMCJ deterioration, in this case with pre-existing arthritis. Definitive treatment of the CMCJ arthritis with excision arthroplasty was planned and a decision to undertake TMR of the SRN at the same time was based on an attempt to find a more permanent resolution of the neuropathic pain.
Author:Dominic Power MA MB BChir FRCS FRCS Tr & Orth
Institution: Consultant Hand and Peripheral Nerve Surgeon
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Question 1 of 15
What is the autonomous sensory area supplied by the superficial radial nerve?CorrectIncorrect
Question 2 of 15
Which one of the following statements regarding SRN to AIN TMR is true?CorrectIncorrect
Question 3 of 15
The SRN emerges from under the muscle-tendon junction of which muscle in the mid forearm?CorrectIncorrect
Question 4 of 15
Which one of the following is the correct order of motor innervation in the AIN from proximal to distal?CorrectIncorrect
Question 5 of 15
Which one of the following is the correct term for neuropathic pain symptoms on light touch?CorrectIncorrect
Question 6 of 15
Which one of the following statements regarding Tisseel is correct?CorrectIncorrect
Question 7 of 15
Which one of the following is the last motor branch of the radial nerve?CorrectIncorrect
Question 8 of 15
Which on elf the following is the plane for exposure of the AIN in this procedure?CorrectIncorrect
Question 9 of 15
Which one of the following statements is false?CorrectIncorrect
Question 10 of 15
Which one of the following is the optimum method of management for a neuroma in continuity in a non-critical sensory nerve with a healthy tissue bed?CorrectIncorrect
Question 11 of 15
Which score has been used to grade sensory neuroma symptom severity?CorrectIncorrect
Question 12 of 15
Which authors described a systematic method of diagnosis neuromas in 2018?CorrectIncorrect
Question 13 of 15
Which one of the following statements regarding neuroma management is correct?CorrectIncorrect
Question 14 of 15
What size suture ir recommended for the nerve transfer neurorraphy?CorrectIncorrect
Question 15 of 15
Which on elf the following statements regarding TMR in lower limb amputation is false?CorrectIncorrect