Peripheral nerve regeneration following traumatic injury is susceptible to the formation of a neuroma due to disorganized growth of nerve fibers. Such neuromas are fibrotic, minimally vascular, and often associated with pain and paresthesia in the affected area. Neuroma formation can occur following surgical procedures, trauma, and mild repetitive trauma, or the cause may be unknown. Neuropathic pain occurs due to compression, ischemia of nerve fibers within scar tissue, and random firing of nociceptors. The initial management of a neuroma is pain medications and avoiding possible aggravating factors, such as pressure or trauma. If pain persists, opioids, antidepressants, or anticonvulsants (e.g., pregabalin or gabapentin) are tried. If this fails, steroid injections with local anesthetic, intercostal nerve blocks, radiofrequency ablation, chemical neurectomy, or surgical intervention can be tried . Though there are several reports related to the surgical treatment of neuromas in the extremities, report on intercostal neuromas in the abdominal wall is scarce and often misdiagnosed.
The surgical approach to treat this condition has been to maintain a microenvironment conducive for nerve regrowth via translocating the nerve stump to the site of minimal stimulation [1, 2]. The techniques include proximal ligation to the nerve stump with or without resection of the neuroma. This method has high re-operation rates. The second technique is burying the nerve stump into the muscle. This method has good results with a reduction of pain and histological findings of improved organization of nerve fibers. There is also a report of transplantation of a nerve stump into the bone. Another approach involves covering the nerve stump with muscle to create a stable environment . One of the techniques caps the nerve by suturing the epineural cuff to prevent neuroma formation. Studies have used arteries and synthetic tubing to function as a sleeve to join the nerve ends. Complications include nerve fibers extending through the cap, fluid build-up, and possible displacement of the cap. The effectiveness of this technique is unclear as success rates vary. The next technique uses nerve-to-nerve anastomosis. Variations for this method include the use of vein or nerve grafts. Yet, another method is to implant the transected ends of a nerve to an extended autologous venous nerve conduit or processed allograft. This protects the nerve from surrounding scar tissue and attenuates the regeneration of neuronal fibers .
There are scarce reports of thoracic intercostal nerve neuromas [3,4,5] and post-operative thoracic-abdominal intercostal nerve neuroma formation which had successful outcomes following surgery. Furthermore, surgical treatment is rarely considered because this condition is often misdiagnosed, or the treating physician believes that surgical intervention is ineffective. This has resulted in long-term pain medication intake by patients and drug addiction. The authors, therefore, are reporting a case of post-surgical abdominal intercostal neuroma that was surgically treated with excellent results.