Surgical interventions for the treatment of painful neuroma: a comparative meta-analysis

Abstract

A consensus on the optimal treatment of painful neuromas does not exist. Our objective was to identify available data and to examine the role of surgical technique on outcomes following surgical management of painful neuromas. In accordance with the PRISMA guidelines, we performed a comprehensive literature search to identify studies measuring the efficacy of the surgical treatment of painful neuromas in the extremities (excluding Morton's neuroma and compression neuropathies). Surgical treatments were categorized as excision-only, excision and transposition, excision and cap, excision and repair, or neurolysis and coverage. Data on the proportion of patients with a meaningful reduction in pain were pooled and a random-effects meta-analysis was performed. The effects of confounding, study quality, and publication bias were examined with stratified, meta-regression, and bias analysis. Fifty-four articles met the inclusion criteria, many with multiple treatment groups. Outcomes reporting varied significantly and few studies controlled for confounding. Overall, surgical treatment of neuroma pain was effective in 77% of patients [95% confidence interval: 73-81]. No significant differences were seen between surgical techniques. Among studies with a mean pain duration greater than 24 months, or median number of operations greater than 2 prior to definitive neuroma pain surgery, excision and transposition or neurolysis and coverage were significantly more likely than other operative techniques to result in a meaningful reduction in pain (P < 0.05). Standardization in the reporting of surgical techniques, outcomes, and confounding factors is needed in future studies to enable providers to make comparisons across disparate techniques in the surgical treatment of neuroma pain.

Figure 1

Study Selection Process

Figure 2

Fifty-four studies describing 74 groups were included in this meta-analysis of the proportion of patients successfully treated with surgery for neuroma pain. Overall, 77% (95% confidence interval: 73–83) of patients had a meaningful reduction in pain. The type of surgery performed did not make a significant difference to the proportion of patients successfully treated. Square grey boxes with a dot represent the reported proportion of patients with pain reduction. The line surrounding this box represents the 95% confidence interval for that proportion. The blue diamonds represent the estimate of proportion of patients with reduction in pain for each surgery type, and overall, derived from the study groups included using random effects meta-analysis of proportion.