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Traumatic Neuroma After Hysterectomy and Bilateral Salpingo-Oophorectomy: A Rare Cause of Post Hysterectomy Pelvic Pain
Case Report
Traumatic Neuroma After Hysterectomy and Bilateral Salpingo-Oophorectomy: A Rare Cause of Post Hysterectomy Pelvic Pain Vivek Nama, MD, MRCOG*, Amit Patel, MRCOG, Joya Pawade, FRCPath, and John Murdoch, MD, FRCS, FRCOG From the Department of Gynecological Oncology (all authors), University of Bristol, Bristol, United Kindom.
ABSTRACT The cause of posthysterectomy pain is frequently undiagnosed, and a presumed diagnosis of adhesions is made. Surgical division of adhesions often fails to alleviate the pain. As a result, posthysterectomy pain is seldom investigated despite being associated with a significant deterioration in the quality of life. We report a case of posthysterectomy bilateral neuroma of the autonomic nerves to the ovary that leads to significant pelvic pain. Excision of these neuromas resulted in complete resolution of pelvic pain and significant improvement in the quality of life. This interesting observation does not support the widespread use of laparoscopy for posthysterectomy pain but should be considered in patients with pain that occurs at an interval after hysterectomy who have had no pelvic pain preceding the hysterectomy. Journal of Minimally Invasive Gynecology (2016) -, -–- Ó 2016 AAGL. All rights reserved. Keywords:
Hysterectomy; Pelvic pain; Traumatic neuroma
Posthysterectomy pain is often attributed to adhesions. The exact mechanisms of this pain are not known, but the persistent postsurgical pain is believed to be due to inflammation or nerve damage [1]. Once nerve injury occurs, there is spontaneous activity at the peripheral nerve endings with changes in ion channels and release of proinflammatory cytokines and neurotrophic factors. Unfortunately, there is minimal data on prediction or prevention of postsurgical pain. In most cases, little help is available to improve the quality of life. There is a reluctance among gynecologic surgeons to perform diagnostic surgery after hysterectomy. We report a case of posthysterectomy traumatic neuroma in the pelvis. Resection of this neuroma resulted in significant improvement in pain and quality of life. Traumatic neuroma is regeneration of the nerve to form a nodular structure. Neuromas are known to occur both in somatic and autonomic nerves and often occur after resection, The authors declare that they have no conflict of interest. Corresponding author: Dr. Vivek Nama, MD, MRCOG, Consultant Senior Lecturer, Department of Gyn Oncology, University of Bristol, St. Michael’s Hospital, Southwell Street, Bristol, UK, BS2 8EG. E-mail: [email protected] Submitted May 14, 2016. Accepted for publication July 5, 2016. Available at www.sciencedirect.com and www.jmig.org 1553-4650/$ - see front matter Ó 2016 AAGL. All rights reserved. http://dx.doi.org/10.1016/j.jmig.2016.07.006
compression, or stretching injuries to these nerves [2]. This is often associated with pain and discomfort. Some neuromas are known to regress spontaneously. There is some evidence that once they reach 5 cm in diameter they are unlikely to regress spontaneously [3]. They are common after head and neck surgery and have been reported after surgery for breast cancer and cholecystitis [4]. This is the first case reported in the literature of traumatic neuroma after hysterectomy. Health Research Authority is a web-based system, and a series of questions determines the decision for ethics approval. Ethical approval was not deemed necessary for our case report. However, patient consent was obtained to publish the case report. Case Report A 45-year-old white woman presented to the gynecology oncology clinic for risk reduction surgery. She was diagnosed to have breast cancer and had undergone a lumpectomy with adjuvant chemotherapy and radiotherapy. Since completion of treatment she had been on tamoxifen and later on letrozole. She also complained of menorrhagia and dysmenorrhea. There was no abdominal pain besides her period pains. She was otherwise fit and well with no significant medical or surgical complications.
2
Given associated menstrual symptoms, a laparoscopic hysterectomy with bilateral salpingo-oopherectomy was performed in October 2011. A harmonic scalpel (Ethicon; Johnson and Johnson, Somerville, NJ) with advanced hemostasis was used to perform the hysterectomy. The immediate postoperative period was uneventful. She presented 3 months later with a dragging sensation in the lower pelvis that worsened on lifting weights and with sexual intercourse. She was unable to stand erect and described a dragging sensation on both sides of her pelvis. Bowel and bladder function remained normal. Her pain score was 8/10 and was limiting her daily activities. Pelvic ultrasound was normal. A diagnostic laparoscopy was arranged after discussion regarding the uncertain benefit of diagnostic laparoscopy in postsurgical pain. At laparoscopy, no bowel adhesions were visualized. On either side of the pelvis, superior and cephalic to the infundibulopelvic ligaments, nodular scar tissue was visualized. After dissecting the ureters, there appeared to be two nodular scar tissue–like structures, each less than 2 cm. These scar tissues were excised. Bipolar forceps and scissors were used for this procedure. The scar tissues were sent for histopathologic examination because of their nodularity. Microscopy showed aggregates of foreign body giant cells containing retractile material in the background of prominent nerve trunk fibers consistent with a traumatic neuroma (Fig. 1). The patient was reviewed in the clinic 2 weeks after the surgery and was completely pain-free. She was followed up for 6 and 12 months postexcision of the neuromas and continued to be pain-free. Discussion To the best of our knowledge, this is the first case reported in the literature of a neuroma of the autonomic nerves to the ovary. Posthysterectomy neuromas of the autonomic nervous system are presumed to be rare. Thousands of hysterectomies are performed every year across the world. It is unusual that this condition has not been published in literature. Missing the diagnosis of a neuroma is entirely plausible because posthysterectomy patients are often not investigated. In this case, surgery cured the pain with a substantial improvement in the quality of life. This case does not support extensive imaging or laparoscopy for patients with posthysterectomy pain. Patients who had no pain before the hysterectomy but developed pain within a few months of having a hysterectomy should have
Journal of Minimally Invasive Gynecology, Vol -, No -, -/- 2016
Fig. 1 Microscopic features of a traumatic neuroma are shown, in which variably sized nerve fibers with associated fibrosis and lack of active inflammation can be seen. Magnification, !200.
a diagnosis of neuroma considered and the patient carefully counseled about the risks and benefits of a diagnostic laparoscopy. The index of suspicion should be high if the patient complains of pain on either side of the pelvis and is unable to stand erect. We did not perform any imaging, but if a diagnosis of neuroma is considered on imaging, it seems perfectly reasonable to offer conservative management. However, there is no evidence to support or refute this. If a laparoscopy is performed and nodular scar tissue is seen, simple excision and histologic examination may make the diagnosis and improve symptoms and quality of life.
References 1. Antoniadis G, Kretschmer T, Pedro MT, Konig RW, Heinen CP, Richter HP. Iatrogenic nerve injuries: prevalence, diagnosis and treatment. Deutsch Arztebl Int. 2014;111:273–279. 2. Mathews GJ, Osterholm JL. Painful traumatic neuromas. Surg Clin North Am. 1972;52:1313–1324. 3. Coraci D, Pazzaglia C, Doneddu PE, et al. Post-traumatic neuroma due to closed nerve injury. Is recovery after peripheral nerve trauma related to ultrasonographic neuroma size? Clin Neurol Neurosurg. 2015;139: 314–318. 4. Li Q, Gao EL, Yang YL, Hu HY, Hu XQ. Traumatic neuroma in a patient with breast cancer after mastectomy: a case report and review of the literature. World J Surg Oncol. 2012;10:35.
Traumatic Neuroma After Hysterectomy and Bilateral Salpingo-Oophorectomy: A Rare Cause of Post Hysterectomy Pelvic Pain Vivek Nama, MD, MRCOG*, Amit Patel, MRCOG, Joya Pawade, FRCPath, and John Murdoch, MD, FRCS, FRCOG From the Department of Gynecological Oncology (all authors), University of Bristol, Bristol, United Kindom.
ABSTRACT The cause of posthysterectomy pain is frequently undiagnosed, and a presumed diagnosis of adhesions is made. Surgical division of adhesions often fails to alleviate the pain. As a result, posthysterectomy pain is seldom investigated despite being associated with a significant deterioration in the quality of life. We report a case of posthysterectomy bilateral neuroma of the autonomic nerves to the ovary that leads to significant pelvic pain. Excision of these neuromas resulted in complete resolution of pelvic pain and significant improvement in the quality of life. This interesting observation does not support the widespread use of laparoscopy for posthysterectomy pain but should be considered in patients with pain that occurs at an interval after hysterectomy who have had no pelvic pain preceding the hysterectomy. Journal of Minimally Invasive Gynecology (2016) -, -–- Ó 2016 AAGL. All rights reserved. Keywords:
Hysterectomy; Pelvic pain; Traumatic neuroma
Posthysterectomy pain is often attributed to adhesions. The exact mechanisms of this pain are not known, but the persistent postsurgical pain is believed to be due to inflammation or nerve damage [1]. Once nerve injury occurs, there is spontaneous activity at the peripheral nerve endings with changes in ion channels and release of proinflammatory cytokines and neurotrophic factors. Unfortunately, there is minimal data on prediction or prevention of postsurgical pain. In most cases, little help is available to improve the quality of life. There is a reluctance among gynecologic surgeons to perform diagnostic surgery after hysterectomy. We report a case of posthysterectomy traumatic neuroma in the pelvis. Resection of this neuroma resulted in significant improvement in pain and quality of life. Traumatic neuroma is regeneration of the nerve to form a nodular structure. Neuromas are known to occur both in somatic and autonomic nerves and often occur after resection, The authors declare that they have no conflict of interest. Corresponding author: Dr. Vivek Nama, MD, MRCOG, Consultant Senior Lecturer, Department of Gyn Oncology, University of Bristol, St. Michael’s Hospital, Southwell Street, Bristol, UK, BS2 8EG. E-mail: [email protected] Submitted May 14, 2016. Accepted for publication July 5, 2016. Available at www.sciencedirect.com and www.jmig.org 1553-4650/$ - see front matter Ó 2016 AAGL. All rights reserved. http://dx.doi.org/10.1016/j.jmig.2016.07.006
compression, or stretching injuries to these nerves [2]. This is often associated with pain and discomfort. Some neuromas are known to regress spontaneously. There is some evidence that once they reach 5 cm in diameter they are unlikely to regress spontaneously [3]. They are common after head and neck surgery and have been reported after surgery for breast cancer and cholecystitis [4]. This is the first case reported in the literature of traumatic neuroma after hysterectomy. Health Research Authority is a web-based system, and a series of questions determines the decision for ethics approval. Ethical approval was not deemed necessary for our case report. However, patient consent was obtained to publish the case report. Case Report A 45-year-old white woman presented to the gynecology oncology clinic for risk reduction surgery. She was diagnosed to have breast cancer and had undergone a lumpectomy with adjuvant chemotherapy and radiotherapy. Since completion of treatment she had been on tamoxifen and later on letrozole. She also complained of menorrhagia and dysmenorrhea. There was no abdominal pain besides her period pains. She was otherwise fit and well with no significant medical or surgical complications.
2
Given associated menstrual symptoms, a laparoscopic hysterectomy with bilateral salpingo-oopherectomy was performed in October 2011. A harmonic scalpel (Ethicon; Johnson and Johnson, Somerville, NJ) with advanced hemostasis was used to perform the hysterectomy. The immediate postoperative period was uneventful. She presented 3 months later with a dragging sensation in the lower pelvis that worsened on lifting weights and with sexual intercourse. She was unable to stand erect and described a dragging sensation on both sides of her pelvis. Bowel and bladder function remained normal. Her pain score was 8/10 and was limiting her daily activities. Pelvic ultrasound was normal. A diagnostic laparoscopy was arranged after discussion regarding the uncertain benefit of diagnostic laparoscopy in postsurgical pain. At laparoscopy, no bowel adhesions were visualized. On either side of the pelvis, superior and cephalic to the infundibulopelvic ligaments, nodular scar tissue was visualized. After dissecting the ureters, there appeared to be two nodular scar tissue–like structures, each less than 2 cm. These scar tissues were excised. Bipolar forceps and scissors were used for this procedure. The scar tissues were sent for histopathologic examination because of their nodularity. Microscopy showed aggregates of foreign body giant cells containing retractile material in the background of prominent nerve trunk fibers consistent with a traumatic neuroma (Fig. 1). The patient was reviewed in the clinic 2 weeks after the surgery and was completely pain-free. She was followed up for 6 and 12 months postexcision of the neuromas and continued to be pain-free. Discussion To the best of our knowledge, this is the first case reported in the literature of a neuroma of the autonomic nerves to the ovary. Posthysterectomy neuromas of the autonomic nervous system are presumed to be rare. Thousands of hysterectomies are performed every year across the world. It is unusual that this condition has not been published in literature. Missing the diagnosis of a neuroma is entirely plausible because posthysterectomy patients are often not investigated. In this case, surgery cured the pain with a substantial improvement in the quality of life. This case does not support extensive imaging or laparoscopy for patients with posthysterectomy pain. Patients who had no pain before the hysterectomy but developed pain within a few months of having a hysterectomy should have
Journal of Minimally Invasive Gynecology, Vol -, No -, -/- 2016
Fig. 1 Microscopic features of a traumatic neuroma are shown, in which variably sized nerve fibers with associated fibrosis and lack of active inflammation can be seen. Magnification, !200.
a diagnosis of neuroma considered and the patient carefully counseled about the risks and benefits of a diagnostic laparoscopy. The index of suspicion should be high if the patient complains of pain on either side of the pelvis and is unable to stand erect. We did not perform any imaging, but if a diagnosis of neuroma is considered on imaging, it seems perfectly reasonable to offer conservative management. However, there is no evidence to support or refute this. If a laparoscopy is performed and nodular scar tissue is seen, simple excision and histologic examination may make the diagnosis and improve symptoms and quality of life.
References 1. Antoniadis G, Kretschmer T, Pedro MT, Konig RW, Heinen CP, Richter HP. Iatrogenic nerve injuries: prevalence, diagnosis and treatment. Deutsch Arztebl Int. 2014;111:273–279. 2. Mathews GJ, Osterholm JL. Painful traumatic neuromas. Surg Clin North Am. 1972;52:1313–1324. 3. Coraci D, Pazzaglia C, Doneddu PE, et al. Post-traumatic neuroma due to closed nerve injury. Is recovery after peripheral nerve trauma related to ultrasonographic neuroma size? Clin Neurol Neurosurg. 2015;139: 314–318. 4. Li Q, Gao EL, Yang YL, Hu HY, Hu XQ. Traumatic neuroma in a patient with breast cancer after mastectomy: a case report and review of the literature. World J Surg Oncol. 2012;10:35.