1. By Hossam Ismail, MD MANSOURA UNIVERSITY
Centro-central Nerve Union in the Treatment of Amputation Stump Neuromas of the upper limb By
Hossam Ismail, MD MANSOURA UNIVERSITY

2. Introduction
Terminal neuroma naturally results from transection of a peripheral nerve if the nerve ends are not reunited.
Although 30% of neuromas are painful often leading to severe functional impairment of an extremity a fully reliable method of preventing or treating painful neuromas has not yet been found (Herndon ,1982).

3. Modes of Treatment of Neuroma(Low et al., 1999).
Nonsurgical treatment
Desensitization with mechanical stimulation as percussion, local , massage, and
ultrasound, transcutaneous electrical nerve stimulation (Herndon and Hess, 1991)
Surgical treatment
I-Inhibition of axonal growth
Chemical treatment, Ligation, cauterization, capping Physical concomitant:
- Physiological concomitant: Nerve‑to‑nerve repair and grafting techniques.
II-Translocation away from noxious stimuli
- Excision and retraction
- Implantation in muscles
- Implantation in bone
- En bloc translocation away from stimuli
Low et al., 1999 reported that the more clinically
successful treatment is physiologic containment
nerve-to-nerve repair and grafting.

4. What is mean by centro-central nerve union ?
The term centro-central nerve union was used to describe the end-to-end connection across interposed nerve grafts between two nerve cords of proximal origin (Low et al, 1999).

5. aim Of the Study
In this study, we present and evaluate our results with centro-central nerve union in the treatment of painful stump neuromas in the upper limb.

6. Material & methods
Nine patients with symptomatic amputation stump neuromas (7 males & 2 females) with main age 31.4 years underwent resection of the neuromas and centro-central nerve union was performed between both proximal nerve stumps with autologus nerve graft.
Etiologies were amputation, crush and gunshot injury.
The affected nerves were median & ulnar nerves (N =2)
the palmar digital nerves (N=7).
The duration of painful symptoms at the time of operation ranged from 3 to 9 months.
No patients have previously undergone surgery.

7. Diagnosis of painful neuromas
Point of neuromatous pain described as an electric shock, sometimes as spontaneous discharge and may elicited through any pressure or contact on the area corresponding to the sectioned nerve.
Tinel's sign positive in all cases.

8. Surgical technique
Marking of the site of the point of neuromatous pain.
Anesthesia general or regional nerve block.
Approached through the previous incision.
Exploration & identification of neuromas were done.
Neuromas and scar tissue were resected to healthy tissue.
Mobilization of the nerve stumps and transposing it to each other's

9. End-to-end union was performed between both proximal nerve stumps using 9-0 nylon sutures. 4-5 SIS were done with the aid of Microscopic magnification & microsurgical instruments.
One of the proximal nerve stumps was severed again at proximal level to providing about 6- 9mm autologus nerve graft.
Then a second end- to- end tension free repair was done.

10. Diagram illustrates the steps of centro-central nerve union with an autologous nerve graft in bilateral digital nerves neuromas

11. Evaluation of our results
Subjective Methods
Objective Methods
Meaning
Grade
Pain
I Non
II Mild, no interfere with daily activity
III Moderate, work with limitations
IV sever, inability to work or to use hand
Patient acceptance
I Improved , no disability
II Improved, some mild disability
III Improved. But unable to work
IV No change
V Worse
Meaning
Grade
Tinel's signs
I none
II mild, slight parasethia
III moderate, uncomfortable
IV sever, inability to use hand
Objective function
I Normal no interference
II some interference with work
III Inability to use hand
The grading system described by(labored, et al, 1982)

12. Follow Up
The Follow-up period averaged 13.8 months (range, month).

13. Clinical Cases

14. Case 1
21 years male patient presented by Painful neuroma in Lt. Thumb after previous amputation of the pulp and full thickness skin graft was done

15. Case 1

16. Case 2
35 years male patient presented by Painful neuroma in Rt. index finger after previous amputation of the distal phalanx

17. Case 2

18. Case 3
25 years male patient presented by painful neuromas in both median and ulnar nerves after previous amputation of the left hand at the wrist joint

19. Case 3

20. Histopathology
Tissue diagnosis of the resected masses (stained with H&E X10) It shows haphazard arrangement of the proliferating spindle cells nerves with collagenous stroma that are characteristic of neuroma

21. Table 2: Results According to Evaluation Criteria
Objective Criteria
Subjective Criteriaٍٍٍ
Objective function
I II III
Tinel's signs
I II III IV
Patient acceptance
I II III IV V
Pain
I II III IV
Preoperative
Postoperative
Subjectively, after surgery using the LGS,
Seven patients(77.6%) have experienced complete relief of pain eout IDA (excellent results).
One patient(11.2%) felt Mild sensitivity to direct pressure at the site of nerve union, eout IDA ( good results).
One patient(11.2%) ,painful symptoms recurred 2 months after surgery, ( bad result).

22. Subjective patient acceptance of surgery
Seven patients (77.6%)improved no IDA
one patient (11.2%) improved, slight interference but work is possible
one patient (11.2%) not improved

23. Objectively for Tinel's sign and function at follow-up revealed
No hyperesthesia, or pain with normal function in 7 patients (77.6%).
Mild pain and hyperesthesia &some interference with work in 1 patient (11.2%).
sever, inability to use hand  1 patient (11.2%)..

24. Discussion
Symptomatic neuromas has been managed by the numerous methods of treatment, till now there is no procedure that is completely and consistently successful in preventing neuroma formation (Koch et al., 2003).

25. Koch et al., 2003 comparing the results of the clinical studies of different surgical techniques in the treatment of painful neuromas in series involving at least 10 patients. They concluded that The centro-central nerve union via an interposed nerve graft has given the best results among the studies.

26. Why interposed autologus nerve graft?
Seckel, 1984 theorized that the newly formed axons under pressure in the area of the graft resulted in inhibiting central nerve cell protein production and thus inhibit neuroma formation .

27. these neurotrophic factors inhibit the axonal outgrowth
Gorkisch et al.,1984
postulated that structures distal to the cut nerve such as sensory receptors and/or muscles produce TDNF that stimulate and guide the regenerating proximal nerve stump to the correct end organ. There is strong evidence that absence of
these neurotrophic factors inhibit the axonal outgrowth
This technique works by
isolating the proximal segment from the (TDNF) and confining them in a non target environment, which suppresses axon advancement (neuroma )

28. Belcher and Pandya (2000) theorized that if a graft is not used, axon sprouts of fascicles cannot penetrate into each other because endoneurial tubes are full and axons will penetrate into neighboring connective and scar tissue forming a neuroma.

29. The results of my study more or less coincide with the results of Gorkisch et al.,1984, Kon and Bloem, 1987 , Wood and Mudge, and Barbera and Albert‑Pamplo, used the centro-central nerve union in patients with neuromas ,all of them showed agood clinical results(ranging from 97 %- to 100% pain‑free).

30. Conclusion
they concluded that the centro-central nerve union has several advantages
1-Easy , reliable & not time consuming.
2-Suitable for all nerves except monofasicular
nerves.
3-No donor site morbidity
Our results of this study are encouraging in the treatment of digital stump neuromas

31. Thank You