A small painful neuroma of the transverse cervical nerve treated with pulsed radiofrequency: A case report

Abstract

BACKGROUND:

Neck pain is a common complaint seen amongst patients from all ages. When common causes of neck pain have been ruled out, it is important to investigate further. A careful physical exam can help identify the painful structures. An ultrasound of the area can also be helpful to identify possible structures involved. Neuromas can be treated with oral medications as well as more invasive techniques, such as pulsed radiofrequency (PRF).

CASE DESCRIPTION:

In this case report, we discuss a 67-year-old female who presented with left anterior neck pain after developing a cervical mass who was later diagnosed as non-Hodgkin lymphoma. A small neuroma of the left transverse cervical nerve was found on ultrasound and ultimately was treated with PRF with a complete resolution of her symptoms at two months follow-up.

CONCLUSION:

PRF seems to be a useful tool for controlling neuropathic pain caused by a neuroma.

Keywords

Neuralgia neuroma pulsed radiofrequency treatment ultrasonography

1. Background

Neck pain is a common complaint with some studies suggesting a prevalence of up to 86.8% in the general population and is one of the common causes of disability around the world [1]. Anterior neck pain etiologies are not well understood and have a socioeconomic impact. Patients might visit multiple physicians with unnecessary imaging, treatment, or referrals [2, 3]. Anterior neck pain is usually defined as pain anterior to the sternocleidomastoid (SCM) while posterior neck pain arises posterior to this muscle. The differential diagnosis of anterior neck pain is broad, including inflammatory, musculoskeletal, infectious, respiratory/esophageal related, thyroid/parathyroid origin, congenital, and neoplastic etiologies.

The transverse cervical nerve (TCN), also known as superficial cervical or transverse cutaneous nerve of the neck, arises from the C2 and C3 cervical roots and provides sensation to the anterolateral mid-neck [4, 5]. It originates in the cervical plexus and crosses the mid-portion of the sternocleidomastoid from posterior to anterior. It is located inferior to the great auricular nerve and usually passes deep to the external jugular vein. It then bifurcates into ascending and descending branches deep to the platysma and gives sensory innervation to the anterolateral cervical region [4, 5].

The deep cervical fascia is located superficial to the cervical region and a series of muscles as well as the prevertebral fascia compose the deeper portion. More superficially, the platysma, which is embedded in the subcutaneous tissue, covers the deep cervical fascia [6]. Many relevant nerves are running across the posterior and anterior triangle of the neck, such as the suprascapular, phrenic, supraclavicular, spinal accessory, lesser occipital, great auricular, and TCN. These nerves can be affected by different pathologies such as iatrogenic injuries, neuropathies, compressions, and they might be targeted for pain interventions including selective nerve blocks, nerve release, or nerve modulation management [6].

In this case report, we discuss a 67-year-old female who presented with left anterior neck pain after developing a cervical mass who was later diagnosed as non-Hodgkin lymphoma. The pain persisted despite radiotherapy and complete remission over a year later. A small neuroma was found on ultrasound and ultimately was treated with pulsed radiofrequency with a complete resolution of her symptoms at two months follow-up.

2. Case description

A 67-year-old female with a past medical history of non-specific arthritis and adrenal insufficiency presented with an atraumatic acutely enlarging left anterior cervical mass with associated cervical pain. A consult to urgent care led to a biopsy with an eventual diagnosis of stage 1 non-Hodgkin lymphoma. She received 15 treatments of radiotherapy with complete eradication of the lymphoma, but the neck pain persisted more than a year later.

The pain was described as a constant electric shock sensation over the skin of left lower portion of the anterior triangle of the neck, exacerbated by right neck rotation and lateral flexion bilaterally and by touching a very precise spot on the posterior aspect of the biopsy scar located over the mid portion of the SCM muscle. She graded the pain as being 7–8/10 on the numeric rating pain scale. Coughing did not exacerbate the pain and she was not complaining of dysphagia or dysphonia. She did not complain of brachialgia or symptoms of myelopathy. She had not been relieved or experienced side-effects with a variety of oral agents for neuropathic pain (gabapentinoids, selective serotonin reuptake inhibitors, and tramadol) and had a skin reaction to topical lidocaine.

On physical examination, there was a slight limitation in right neck rotation as well as bilateral lateral flexion because it would exacerbate her left neck pain. There were no limitations nor pain in flexion and extension of the neck. The pain was also exacerbated by doing a right rotation and a left lateral flexion against resistance. There was no visible nor palpable mass on the left side of the neck. The scar was well healed and there were no obvious adherences of the underlying tissue. There was a very tender spot just beside the left SCM muscle which was adjacent to the posterior border of the biopsy scar, with a positive Tinel sign. The palpation of the rest of the neck structures, including the facet joints and spinous processes was not painful. The neurological examination of all four limbs was normal and Spurling’s test was negative bilaterally.

The patient already had: 1) a CT scan of the soft tissues of the neck that revealed no abnormalities; 2) an MRI of the cervical spine that showed a small, central herniated disc at the C5–C6 level as well as a minimal disc bulge at the C6–C7 level; and 3) a control positron emission tomography (PET) scan that revealed no signs of recurrence of the lymphoma.

An ultrasound examination, performed with a linear 7.0–14.0 MHz probe (Toshiba Aplio 500), showed a normal SCM muscle with absence of adenopathy. There was a small, non-compressible avascular circular structure of about 1 mm ${}^{2}$ with focal dilation just deep to the external jugular vein (Figs 1 and 2, Video 1). This structure seemed to be in the territory of the transverse cervical nerve, in between the superficial fibers of the SCM and the deep fibers of the platysma. There was no such structure found on the right side of the neck.

Figure 1.

A grayscale ultrasound image of a transverse view of the left sternocleidomastoid (SCM) muscle at the junction between its middle and distal third, where the transverse cervical nerve is seen coursing anteriorly with a focal dilatation (dotted turquoise lines) of 1 mm ${}^{2}$ , just under the external jugular vein (arrow) when no compression is applied with the probe (A). When slight pressure is applied with the ultrasound probe, the vein collapses, but the transverse cervical nerve (asterisk) is non compressible (B).

Figure 2.

Grayscale ultrasound images with color doppler activated (green rectangle $=$ region of interest) showing oblique cuts of the sternocleidomastoid muscle (SCM), with slight compression (A) revealing an absence of flow in and around the transverse cervical nerve (asterisk), and without compression (B) revealing the external jugular vein (arrows) in its longitudinal axis, with the nerve coursing immediately under it.

A first lidocaine diagnostic test was performed under ultrasound guidance around that circular structure, in between the SCM and the platysma muscles, with 1.5 mL of Xylocaine 1% mixed with Dextrose 5%. Immediately after the injection, the patient noted an increased range of motion of her neck as well as complete resolution of the pain on palpation of the left anterior neck. The pain relief lasted for about 4 hours and the pain came back to its usual intensity within 24 hours. A second nerve block was done about a month later with 1.5 mL of bupivacaine 0.5% mixed with Dextrose 5% at the same site as the previous block, also under ultrasound guidance. The patient reported once again complete resolution of her neck pain, for a period of about 48 hours. The pain slowly came back to its normal intensity after 72 hours. With the repeated diagnostic blocks, the patient’s pain was firmly believed to be induced by the small TCN neuroma and the patient was considered a good candidate for pulsed radiofrequency (PRF) of that same nerve with a radiofrequency lesion generator (Diros OWL URF-3AP[A7]; Diros Technology Inc., Markham, ON, Canada).

About a month after the second nerve block, a pulsed radiofrequency stimulation of the left transverse cervical nerve was done with a 54 mm/22-gauge needle for 360 seconds not exceeding 42 ${}^{\circ}$ Celsius (pulse rate 2 Hz, pulse duration 20 ms), after a positive reproduction of symptoms with was reported at 50 Hz and 0.3 to 0.5 mA (Fig. 3, Video 1). At follow-up, the patient described a significant reduction in her neck pain about 15 days after the procedure with a complete resolution of the pain up to two months later. It is to be noted that the patient was hospitalized for colitis with diverticulitis, from which she also contracted COVID-19 in between the PRF treatment and the follow-up visit. Between two and three months after the first PRF treatment, the pain eventually came back, but less severe (5–6/10). A second PRF treatment of that same nerve was done about 5 months after the first PRF treatment. The patient reported significant pain relief for up to 2 months and a half, with a relapse of her usual pain almost 3 months after the second PRF treatment. A subsequent PET scan was negative for neoplastic recurrence, and treatment was performed a third time with similar success.

Figure 3.

Ultrasound-guided diagnostic injection of the left transverse cervical nerve (asterisk), using a 30G, 1-inch needle (arrowheads), in-plane, lateral to medial approach was performed with 1.5 mL of a 5% dextrose solution with 1% lidocaine.

3. Discussion

In this case report, we reported clinical characteristics, diagnostic workup, and our treatment approach of an uncommon etiology of anterior neck pain: a neuroma of the transverse cervical nerve.

Neuropathic pain has been described as burning and shooting pain with or without numbness in the related territory of the nerve. The basic treatment includes pharmacotherapy with antidepressants, anticonvulsants, and opioids. The initial positive response to the US-guided selective nerve blocks is an essential step to confirm the diagnosis of nerve related pain and allows to orient further targeted treatments.

Local injections and radiofrequency are other treatment options, as well as surgical resection [7, 8]. Surgical resection seems to have considerable success rates but involves a more invasive procedure along with higher risks of complications [7, 8]. This option was discussed with our patient, but she did not want to get re-operated [9].

Drilcek et al. published the only article that describes cases of neuropathic pain being improved by blockade of the transverse cervical nerve [10]. Their work focused on visualization, diagnostic assessment, and blockade of the TCN in anatomic specimens, healthy volunteers and patients suffering from anterolateral neck pain. They reported on 6 patients, from 25 to 71 years of age, who presented anterolateral pain after either surgery for a glomus tumor, thyroidectomy, partial laryngectomy, breast cancer or fracture of the clavicle. A TCN neuroma was found in 3 of those patients, but 5 reported partial pain relief after TCN nerve block with lidocaine.

For identification of the TCN with ultrasonography, a linear high-frequency probe should be placed on the posterior border of the SCM, at the level of the lower third of the neck. Moving the transducer cranially, the TCN is the first nerve that emerges from the posterior border of the SCM and runs horizontally across the SCM. Another landmark for TCN identification is the external jugular vein, which the nerve runs underneath and perpendicular to the vein’s long axis (Fig. 1A) [6].

Continuous radiofrequency causes damage to peripheral nerves and regional tissue with the possibility of secondary neuroma formation. It was not considered in this case given the very superficial nature of the nerve of interest and its proximity with the external jugular vein. On the other hand, pulsed radiofrequency (PRF) consists of heating the tissues up to 42 ${}^{\circ}$ C and generates a strong electromagnetic field, which modulates the nerve conduction. Radiofrequency procedures are well known in the treatment of many pain disorders, especially in nerve injury or neuropathies. It has been used specifically in neuroma-related pain of the lower and upper extremity stumps in amputees [11, 12, 13] in a series of 20 patients with Morton neuroma [14], as well as in a post-nephrostomy neuroma scar formation [15]. It is considered a safe method without having adverse effects like depigmentation, fat atrophy, increase in blood pressure, or blood sugar [16]. Response to the regional block before performing nerve PRF is recommended and considered as a precondition in the literature. Significant pain reduction on the numerical rating scale qualifies the patient for the PRF procedure [16].

In this case, some aspects remain unclear. It is unclear if the neuroma was a consequence of the biopsy, or of the lymphoma. The radiotherapy she received might have also played a role in her neuropathic pain [17]. When looking at the other possible sources of their pain, the only other finding we had was an MRI showing lower cervical facet joints degenerative changes, which would not explain the anterior neuropathic symptomatology of the patient.

To our knowledge, this is the first case report on PRF treatment for neck pain caused by a neuroma of the transverse cervical nerve. The use of PRF treatments for painful neuromas in lower extremity amputation is more common, but more literature is needed on the procedure being done in other types of patients to evaluate the efficacy of this treatment in neuropathic pain.

4. Conclusion

This case report discusses a 67-year-old female who presented with left anterior neck pain after developing a cervical mass diagnosed as non-Hodgkin lymphoma. A small neuroma was found on ultrasound and ultimately was treated with pulsed radiofrequency with a complete resolution of her symptoms at two months follow-up. The pain did come back, but with less intensity, with a temporary relief after a second PRF treatment.

Ethical approval

The study was approved by the Institutional Review Board of Yeungnam University Hospital (2022-06-031).

Funding

This work was supported by the National Research Foundation of Korea Grant funded by the Korean Government (Grant no NRF-2019M3E5D1A02069399).

Informed consent

Informed consent was waived due to the retrospective nature of this study.

Author contributions

MM, AB, MB, and MCC contributed to the study conception and design, and wrote the manuscript. MCC supervised the study. All authors read and approved the final manuscript.

Supplementary data

The supplementary files are available to download from https://dx-doi-org.web.bisu.edu.cn/10.3233/BMR-220114.

Footnotes

Acknowledgments

None to report.

Conflict of interest

The authors have no conflicts of interests to disclose.

References

Hoy

Protani

Buchbinder

. The epidemiology of neck pain. Best Pract Res Clin Rheumatol. 2010; 24(6): 783-92.

Ulloa

Gill

Childress

. Acute calcific tendonitis of the longus colli: An uncommon cause of neck pain in the emergency department. Cureus. 2020; 12(7): e9295.

Ella

Langbour

Caix

Midy

Deliac

Burbaud

. Transverse cervical and great auricular nerve distribution in the mandibular area: A study in human cadavers. Clin Anat. 2015; 28(1): 109-17.

Reuther

Blythe

Anand

Brennan

. Communication of the transverse cervical nerve with the marginal mandibular nerve: A previously unreported anatomical variant. Br J Oral Maxillofac Surg. 2014; 52(6): 577-8.

Brennan

Mak

Massetti

Parry

. Communication between the transverse cervical nerve (C2, 3) and marginal mandibular branch of the facial nerve: A cadaveric and clinical study. Br J Oral Maxillofac Surg. 2019; 57(3): 232-35.

Picasso

Zaottini

Pistoia

Perez

Klauser

Rossi

, et al. High-resolution ultrasound of small clinically relevant nerves running across the posterior triangle of the neck. Semin Musculoskelet Radiol. 2020; 24(2): 101-12.

Coughlin

Pinsonneault

. Operative treatment of interdigital neuroma. A long-term follow-up study. J Bone Joint Surg Am. 2001; 83(9): 1321-8.

Novak

van Vliet

Mackinnon

. Subjective outcome following surgical management of upper extremity neuromas. J Hand Surg Am. 1995; 20(2): 221-6.

Bogduk

. Diagnostic nerve blocks in chronic pain. Best Pract Res Clin Anaesthesiol. 2002; 16(4): 565-78.

10.

Drlicek

Riegler

Pivec

Mayer

Paraszti

Traxler

, et al. High-resolution ultrasonography of the transverse cervical nerve. Ultrasound Med Biol. 2020; 46(7): 1599-607.

11.

Kim

Jung

Lee

Kim

Yoo

. Pulsed radiofrequency ablation under ultrasound guidance for huge neuroma. Korean J Pain. 2014; 27(3): 290-3.

12.

Restrepo-Garces

Marinov

McHardy

Faclier

Avila

. Pulsed radiofrequency under ultrasound guidance for persistent stump-neuroma pain. Pain Pract. 2011; 11(1): 98-102.

13.

West

. Pulsed radiofrequency ablation for residual and phantom limb pain: A case series. Pain Pract. 2010; 10(5): 485-91.

14.

Deniz

Purtuloglu

Tekindur

Cansız

Yetim

Kılıckaya

, et al. Ultrasound-guided pulsed radio frequency treatment in Morton’s neuroma. J Am Podiatr Med Assoc. 2015; 105(4): 302-6.

15.

Williams

Bonet

. 82 Pulsed-radiofrequency (PRF) therapy in the management of chronic neurophatic pain due to a neuroma formation in a nephrostomy scar: A case report. Regional Anesthesia & Pain Medicine. 2021; 70: A42-3.

16.

Brzeziński

Rȩkas-Dudziak

Maruszewska

. Pulsed radiofrequency as alternative method for phantom pain treatment. Case report. Clin Case Rep. 2020; 8(10): 2060-2.

17.

Delanian

Lefaix

Pradat

. Radiation-induced neuropathy in cancer survivors. Radiother Oncol. 2012; 105(3): 273-82.