Benign Peripheral Nerve Tumors: Treatment Algorithm and New Reconstructive Options
Ivica Ducic, MD, PhD, Ali Al-Attar, MD, PhD.
Georgetown University Hospital, Washington, DC, USA.
BACKGROUND: Peripheral nerve tumors are mostly benign tumors, however their excision can lead to profound functional deficit. Surgical management requires refinements based on current available technologies. This prospective study evaluated a treatment strategy that is reliable, safe, and offers maximal possible functional recovery.
METHODS: Twenty patients with benign peripheral nerve tumors were treated using a uniform surgical paradigm between 2003 and 2007. Surgical tumor excision and reconstruction was performed in a single stage. No biopsies were performed. Nerve fascicles were dissected off of the tumor under magnification; the sacrificed nerve fascicle that gave origin to the tumor (was inseparable from tumor) was reconstructed using nerve conduits and or grafts. Patients were followed clinically from six to twenty-four months, and functional outcome was assessed.
RESULTS: All twenty consecutive patients had neuropathic pain in the distribution of the affected nerve before tumor excision; only one patient had pain that persisted postoperatively. Seventeen of the twenty patients had complete functional recovery following nerve reconstruction. No perioperative complications occurred.
CONCLUSIONS: Benign peripheral nerve tumors require specialized surgical care to ensure optimal functional results. Single-stage tumor excision under magnification, with immediate reconstruction, permits functional recovery and minimizes scarring. Biopsy is indicated only if quick tumor growth is observed, or if imaging suggests malignancy, otherwise it can further contribute to the damage of normal but displaced fascicles. Although some older protocols, where the tumor is resected but the nerve not repaired, are reported by surgeons and patients to be associated with an apparent absence of deficit or pain; these findings likely reflect more proximal resections involving damage to mixed fascicles. Given the availability of nerve conduits and allografts, nerve reconstruction should now be attempted to restore anatomic integrity to any sacrificed fascicles. Functional recovery and complete pain relief should be expected in the majority of cases, with minimal morbidity. The algorithm and the technique for this modified/new approach will be presented and should assist plastic surgeons dealing with these patients to minimize complications and thus provide better patient’s care.