Painful Stump Research Articles

Management interventions for amputation stump neuromas: evidence based review and cost-benefit analysis

Amputation is a common military and civilian surgery with high morbidity. Patients without prostheses due to neuroma pain lose productivity and lifelong contributions, which is often underestimated. The surgical and non-surgical treatment of painful stump neuromas is controversial. An evidence-based assessment and cost-benefit analysis of painful stump neuroma management modalities emphasizes institutional awareness and disruptive technologies. An Oxford Centre for Evidence Based Methodology critical appraisal and structured literature review were used in the research. We found 154 records using a reproducible literature search strategy that included electronic databases and references. A full review of 27 manuscripts after exclusion criteria yielded data for analysis. Surgical, injectable, and electromagnetic spectrum methods were used. Surgical interventions had longer follow-up times than injection and radiofrequency treatments, which affected outcomes. CEBM level 4 evidence dominated primary literature, indicating low quality. No therapy was superior, but the risks varied. Injection therapies like sclerosing alcohol had limited success and side effects. Despite limited evidence, electromagnetic spectrum modalities showed potential. Including direct and indirect costs, amputation stump refitting costs millions annually. Compared to outpatient non-surgical interventions, laser therapy could save a lot of money. According to the study, surgical interventions are common but expensive and have limited functional success. Low-risk non-surgical methods like co-ablation, pulsed radiofrequency, and transcutaneous laser therapy have mixed results. The short follow-up of all non-surgical studies seems to limit them. Follow-up duration is crucial to outcome assessment. Long-term, low-risk laser-induced thermotherapy is promising for future research. This study emphasizes the need for more research and the economic benefits of disruptive technologies in treating painful stump neuromas.

Upper limb and lower limb radiofrequency treatments in orthopaedics.

Radiofrequency (RF) is a minimally invasive technique for disrupting or altering nociceptive pathways to treat musculoskeletal neuropathic and nociplastic pain. RF has been employed to treat painful shoulder, lateral epicondylitis, knee and hip osteoarthritis, chronic knee pain, Perthes disease, greater trochanteric pain syndrome, plantar fasciitis, and painful stump neuromas; it has also been employed before and after painful total knee arthroplasty and after anterior cruciate ligament reconstruction. The benefits of RF include the following:it is safer than surgery; there is no need for general anaesthesia, thereby reducing adverse effects; it alleviates pain for a minimum of 3-4 months; it can be repeatable if necessary; and it improves joint function and minimizes the need for oral pain medication. RF is contraindicated for pregnant women; unstable joints (hip, knee, and shoulder); uncontrolled diabetes mellitus; presence of an implanted defibrillator; and chronic joint infection (hip, knee, and shoulder). Although adverse events from RF are unusual, potential complications can include infection, bleeding, numbness or dysesthesia, increased pain at the procedural site, deafferentation effect, and Charcot joint neuropathy. Although there is a risk of damaging non-targeted neural tissue and other structures, this can be mitigated by performing the technique under imaging guidance (fluoroscopy, ultrasonography, and computed tomography). RF appears to be a valuable technique for alleviating chronic pain syndromes; however, firm proof of the technique's efficacy is still required. RF is a promising technique for managing chronic musculoskeletal of the limbs pain, particularly when other techniques are futile or not possible.

Peripheral nerve stimulator for terminal sciatic nerve neuromas in an amputee.

Neuromas are a difficult-to-treat peripheral nerve pathology that can cause crippling pain. Optimal treatment is widely debated as pharmacological intervention frequently is not sufficient and surgical interventions are plagued with recurrence. The majority of amputees report severe and chronic stump pain. Avoiding complex surgery at the stump site would prevent infection or wound dehiscence. Recent advances in neuromodulation with external pulse emitters allow for pain relief with localized nerve stimulation. The authors describe the novel placement of a sciatic nerve stimulator in a 77-year-old man for painful stump neuromas of the common peroneal and tibial nerves.The video can be found here: https://youtu.be/96kKs3qjtqc

Coaptation of Cutaneous Nerves for Intractable Stump Pain and Phantom Limb Pain after Upper Limb Amputation

BackgroundVarious surgical treatments have been advocated for stump pain and phantom limb pain after limb amputation but the most effective is unknown. We report a case of intractable stump pain and phantom limb pain of the upper limb, which was successfully treated by end-to-end coaptation of the cutaneous nerves after multimodal treatment failures.Case descriptionA 39-year-old man was referred to our department with a history of severe stump neuroma-related pain and phantom limb pain of his right upper limb. He had undergone multiple treatments over 26 years including medication, nerve blocks, and repeated surgeries. None had been successful for relief of pain. The clinical assessment showed a point of marked tenderness around the medial stump of the upper arm. Ultrasound-guided peripheral infiltration of local anaesthetic around the medial stump produced significant relief of his pain. Exploration around the medial limb stump revealed two stump neuromas of the medial cutaneous nerves of the forearm. Both stump neuromas were resected, and their stumps were coapted to each other. After 4 years, he was completely relieved of his pain and without any sensory deficit.ConclusionSuccessful nerve coaptations for painful stump neuromas of the upper limb are reported rarely. This case suggests this method can be helpful. The patient burden was minimal because it involved the resection and coaptation of the two neuromas. This method should be encouraged for cases of intractable stump-related pain in the upper limb.How to cite this articleKadota H, Ishida K. Coaptation of Cutaneous Nerves for Intractable Stump Pain and Phantom Limb Pain after Upper Limb Amputation. Strategies Trauma Limb Reconstr 2020;15(1):50–53.

Ultrasound in pain management

Ultrasound is possibly underutilized in interventional pain management. It has distinct advantages over more common methods such as fluoroscopy and CT, as it allows the identification of nerves, soft tissues and vessels without exposing patients and personnel to radiation. Imaging can be performed continuously in real-time, allowing for monitoring of procedures and possibly reducing the risks of complications. Ultrasound guided nerve blocks and ablative procedures including radiofrequency ablations, targeting structures such as ilioinguinal/iliohypogastric nerves, peripheral nerve blocks of the extremities such as medial plantar nerve, lateral plantar nerve, Baxter's nerve or the medial calcaneal nerve, and painful stump neuromas. caudal epidural injections and injections of tender points. Ultrasound guided procedures, like diagnostic ultrasound, is operator dependent and requires appropriate training and experience.

Peripheral Interventions for Painful Stump Neuromas of the Lower Limb: A Systematic Review.

Painful stump neuromas in lower limb amputees are a significant burden on a person's quality of life due to interference with wearing prostheses and therefore the ability to walk. Treating painful stump neuromas is a challenge perhaps reflected by the lack of clinical guidelines. A systematic review was conducted to evaluate the efficacy of all treatments tried in the management of symptomatic neuromas in the lower limb amputation stump in order to establish whether one treatment is superior. Twenty-two studies were included in the final review which examined 14 different treatments both surgical and nonsurgical. Results showed that no single treatment showed superiority. The 4 treatments that showed most promise included targeted nerve implantation, traction neurectomy, nerve-to-nerve anastomosis, and perineurial gluing. The short follow-up times and small sample sizes of the studies highlighted the need for more robust clinical studies.

Ultrasound-guided alcohol neurolysis and radiofrequency ablation of painful stump neuroma: effective treatments for post-amputation pain.

BackgroundPost-amputation pain (PAP) is highly prevalent after limb amputation, and stump neuromas play a key role in the generation of the pain. Presently, PAP refractory to medical management is frequently treated with minimally invasive procedures guided by ultrasound, such as alcohol neurolysis and radiofrequency ablation (RFA).ObjectiveTo record the immediate and long-term efficacy of alcohol neurolysis and RFA. We first used alcohol neurolysis and then, when necessary, we performed RFA on PAP patients.Study designProspective case series.SettingPain management center.MethodsThirteen subjects were treated with ultrasound-guided procedures.ResultsAll patients were treated with neurolysis using alcohol solutions guided by ultrasound. Seven (54%) of 13 subjects achieved pain relief after 1–3 alcohol injection treatments. The remaining 6 subjects obtained pain relief after receiving 2 administrations of ultrasound-guided RFA. After a 6-month follow-up evaluation period, pain quantities were also assessed. Both stump pain (including intermittent sharp pain and continuous burning pain) and phantom pain were relieved. The frequency of intermittent sharp pain was decreased, and no complications were noted during the observation.ConclusionThe use of ultrasound guidance for alcohol injection and RFA of painful stump neuromas is a simple, radiation-free, safe, and effective procedure that provides sustained pain relief in PAP patients. In this case series, RFA was found to be an effective alternative to alcohol injection.

Repair of Stump Neuroma Using AxoGuard® Nerve Protector and Avance® Nerve Graft in the Lower Extremity

Surgical Neurectomy of peripheral nerves may be performed under rare cases in which chronic lower extremity pain has not responded to other treatments. Neuromas, being a disorganized proliferation of nerve fascicles, are a potential complication encountered in surgical neurectomies (Figure 1). After the development of a stump neuroma, these patients may benefit from a repair with nerve allograft in a nerve to no end technique. Nerve wraps are used to cover the native nerve and graft in order to minimize the recurrence of a painful stump neuroma.

Tibioperoneal Short Circuiting for Stump Neuroma Pain in Amputees: Revival of an Old Technique

Stump neuroma pain in amputees can be quite challenging. Surgical treatment may be largely subdivided into neuromodulative and non-neuromodulative methods. The latter includes neurocapsis, insertion of nerve stump into the bone marrow, centro-central short circuit (CCSC), and coverage with vascularized soft tissue flaps. CCSC was shown to be extremely effective in alleviation of pain. Reports on CCSC for the treatment of stump neuroma pain have disappeared from the literature, with a shift toward neuromodulation for the treatment of pain irrespective of etiology. We observed 8 lower limb amputees undergoing CCSC of the sciatic nerve during a follow-up of 12 years. All had the same stump neuroma pain rendering them unable to wear their prostheses. The sciatic nerve was explored at the midthigh area, much proximal to the amputation site, and a short circuit was established between the tibial and peroneal parts of the nerve. Assessment was by means of pain quantification as per the quadruple visual analogue scale, medication intake, and ability to use prostheses. The median worst quadruple visual analogue scale before surgery was 8.0. After surgery it decreased to 2.5 (P = 0.00094). Medication intake was reduced from regular intake of a combination of opioids, nonsteroidal anti-inflammatory drugs, tricyclic antidepressants, and pregabalin in all patients to irregular intake of nonsteroidal anti-inflammatory drug alone in 3 of 8 patients. All patients were able to wear their limb prosthesis since surgery. CCSC is a simple, effective, and long-lasting method to treat painful stump neuromas in amputees. It should be strongly considered in deserving cases before resorting to neuromodulative methods.

(495) Pulsed radiofrequency neuromodulation of a painful saphenous vein stump

(495) Pulsed radiofrequency neuromodulation of a painful saphenous vein stump

Case study

This case report describes the revision of a trans-tibial amputation complicated by a proximal malunited fracture. It demonstrates the complexity of decisions involved in revisions of this nature. The patient presented has a painful stump due to breakdown of soft tissues. She had been suffering for over a year with pressure sores and inability to use a prosthesis resulting from this, decreasing her quality of life. Malunion of a tibial fracture proximal to the amputation complicated her condition. Initially it was feared that the amputation level would be converted to a through-knee amputation, but wedge osteotomy of the tibia allowed coverage of the stump, increasing functionality for the patient, while still maintaining a below-knee stump. This report highlights the importance of addressing the cause of soft tissue problems in an amputation revision, which must be addressed on a case-by-case basis. This case offers an insight into the decision-making process in limb reconstruction and suggests a solution for similar cases. It is important that all surgical options are considered before amputation length is sacrificed.

Outcomes of ultrasound-guided extracorporeal shock wave therapy for painful stump neuroma.

ObjectiveTo investigate the effect of extracorporeal shock wave therapy (ESWT) on painful stump neuroma.MethodsThirty patients with stump neuroma at the distal end of an amputation site were assigned randomly to the ESWT group (n=15) and the transcutaneous electrical nerve stimulation (TENS)+desensitization+pharmacological treatment group (n=15). For 3 weeks, the ESWT group received a weekly session involving 1,500 pulses at 0.10 mJ/mm2, while the control group was treated 10 times each, 40 minutes per day with TENS and desensitization treatment, and daily medication for 3 weeks. ESWT stimulation was given by focusing on the area at the neuroma site clearly identified by ultrasound.ResultsThe changes in the McGill pain questionnaire were 38.8±9.0 prior to treatment and 11.8±3.1 following the treatment. The corresponding values for the control group were 37.2±7.7 and 28.5±10.3. The changes between groups were significantly different (p=0.035). The change in visual analog scale prior to and after treatment was 7.0±1.5 and 2.8±0.8 in the ESWT group, respectively, and 7.2±1.4 and 5.8±2.0 in the control group. These changes between the groups were also significantly different (p=0.010). The outcome in the pain rating scale also showed significant differences between groups (p<0.001). Changes in neuroma size and pain pressure threshold (lb/cm2) were not significantly different between groups (p>0.05).ConclusionThe study findings imply that ESWT for stump neuroma is superior to conventional therapy.

Ultrasound in Acute and Chronic Pain Medicine

Ultrasound is becoming popular in anaesthetic practice because of numerous advantages. Its introduction in pain medicine is recent and its use is growing. It allows the identification of soft tissues, vessels and nerves, without the risk of radiation. The additional advantages in pain medicine are avoidance of repeated radiations and ease of use in outpatient clinics, thus saving time and decreasing work load on interventional theatres. Ultrasound has multiple applications in pain medicine. It finds use in providing acute pain relief in the form of peripheral nerve blocks. In chronic pain, possible applications include blocks of cervical and lumbar facet joints, stellate ganglion block, intercostal nerve blocks, blocks of painful stump neuromas, caudal epidural injections and injections of trigger or tender points. The nerves can be visualised directly, thus helping in destructive processes like cryoanalgesia, radiofrequency lesioning and chemical neurolysis. The disadvantages are loss of resolution for deep-seated structures and lack of controlled trials. The article presents a review of ultrasound usage in acute and chronic pain interventional procedures.

Sonographically Guided Alcohol Injection in Painful Stump Neuroma

Stump neuroma is a common cause of pain from disorganized proliferation of nerve fascicles occurring after limb amputation. Ultrasound guided alcohol injection in painful stump neuroma has been tried as a new treatment approach. Herein, we report 2 male patients, who had traumatic amputation and claimed severe and diffuse burning pain in the stump area. Neuroma at the distal end of an amputated nerve was clearly identified on sonography. The patients gradually developed increasing severe pain that could not be managed with conservative care. They were treated with neurolysis using alcohol solution. Using ultrasonographical guidance, 1.2 ml of 100% dehydrated alcohol was injected into the nerves proximal to neuroma. No complications occurred. The patients were initially pain free. After a few months, however, their stump pain recurred slightly. Repeat neurolysis was performed using 0.3 ml of 100% dehydrated alcohol. During the three months follow-up period, mild stump pain occurred but the patients did not require any analgesics.

(P1-101) Salvage of Traumatized Extremities Restores Morale in Working Class of Society

IntroductionTo improve quality of life among subjects with crush injuries of extremities as an outcome of traumata of various aetiology by salvage procedures. To prevent or minimize psycho-social derangement or implications by minimizing partial or total loss of traumatized body parts and restore useful function.Material20 year study/observation in trauma of limbs, hands, feet, fingers, toes with partial to near total vascular compromise sustained in road traffic, industrial, domestic, suicidal, homicidal, war wounds, fire work blasts, etc. accidents.MethodPre-operative/follow-up counselling of every patient, attendants and employer are of utmost importance. Primary debridement, stabilization, skin cover and serial paraffin-gauge dressings are followed with straps/splints, passive/active range of movement exercises and delayed suture removal. Antibiotic cover with sequential cultures are mandatory.Facts / FiguresSepsis is a challenge. Males, youth, hands, Grade II wounds and RTAs dominate incidence. Contamination, delayed presentation, poor compliance and follow-up, poor nutritional status, anaemia, etc., dread salvage. Initial poor tissue perfusion is no indication for early decision to amputate/terminalize.ResultsCompromised vascular crushes in which primary closure was achieved, salvage of limb and appendages was surprisingly possible. Cosmesis in working class is never the priority, but restoration of function and more so the chance of livelihood are. Dexterity and confidence come with practice. Richer the patient, difficult to convince. Psycho-social depression is more with early amputations than in revisions and much less in salvaged groups, commoner in men and unmarried illiterate women. Women adapt better to salvaged parts.ConclusionEven a nail lost with its bed is lost for ever, leaving a painful defunct stump. No riches can truly compensate. If soft tissue cover on bony elements and neuro-vascular bundles is achievable, an entire limb may survive and regain near normal function. When crush wounds remain aseptic a decision to amputate can wait.

Peripheral Nerves: Ultrasound-Guided Interventional Procedures

Specific ultrasound (US)-guided interventional procedures on peripheral nerves are reviewed in this article including regional anesthesia, biopsy of neural lesions, and some injection therapies. For these procedures, US is the best modality to provide a safe imaging guidance because of its excellent spatial resolution and real-time capabilities. With US guidance, the radiologist can visualize the needle tip continuously and ensure that the needle is placed precisely in the desired location, avoiding the risk of inadvertent nerve damage. Practical tips and tricks for US-guided needle placement, biopsy of neural lesions, and US-guided therapy are reviewed in this article. The use of US-guided injections in specific clinical settings, such as the percutaneous treatment of carpal tunnel syndrome, Morton's and saphenous neuromas, painful stump neuromas, piriformis syndrome, and meralgia paresthetica are also illustrated here. US allows the clinician to inject drugs with little or no patient discomfort.

Ultrasound and chronic pain

Ultrasound (US) is an increasingly used imaging technique in interventional pain management. It allows the identification of soft tissues, vessels and nerves, without exposing patients and personnel to radiation. Imaging can be performed continuously and the fluid injected is visualized in a real time fashion. Possible applications are nerve blocks of the cervical and lumbar zygapophysial joints, stellate ganglion block, intercostal and paravertebral nerve blocks, inguinal nerve blocks, occipital nerve blocks, blocks of painful stump neuromas, caudal epidural injections and injections of trigger/tender points. Due to direct nerve visualization, US has a potential application for destructive procedures, such as cryoanalgesia, radiofrequency lesions or chemical neurolysis. Limitations are the poor resolution of narrow-gauge needles, the loss of resolution with increasing working depth and possible interference of echoes from overlying structures with the image of the target area. US opens new perspectives in interventional pain management. However, there is a need for more clinical trials investigating efficacy and safety of US-guided pain procedures. Until these studies are completed, US can not replace fluoroscopy or computed tomography in most interventional pain procedures and remains the domain of well-trained and experienced physicians. The limited evidence supporting the clinical utility of nerve blocks remains a problem, irrespective of the imaging technique employed.

Ultrasound and chronic pain: Innovative approaches

Ultrasound (US) is an increasingly used imaging technique in interventional pain management. It allows the identification of soft tissues, vessels and nerves, without exposing patients and personnel to radiation. Imaging can be performed continuously and the fluid injected is visualized in a real time fashion. Possible applications are nerve blocks of the cervical and lumbar zygapophysial joints, stellate ganglion block, intercostal and paravertebral nerve blocks, inguinal nerve blocks, occipital nerve blocks, blocks of painful stump neuromas, caudal epidural injections and injections of trigger/tender points. Due to direct nerve visualization, US has a potential application for destructive procedures, such as cryoanalgesia, radiofrequency lesions or chemical neurolysis. Limitations are the poor resolution of narrow-gauge needles, the loss of resolution with increasing working depth and possible interference of echoes from overlying structures with the image of the target area. US opens new perspectives in interventional pain management. However, there is a need for more clinical trials investigating efficacy and safety of US-guided pain procedures. Until these studies are completed, US cannot replace fluoroscopy or computed tomography in most interventional pain procedures and remains the domain of well-trained and experienced physicians. The limited evidence supporting the clinical utility of nerve blocks remains a problem, irrespective of the imaging technique employed.

Ultrasound in interventional pain management

Ultrasound (US) is an increasingly used imaging technique in interventional pain management. It allows the identification of soft tissues, vessels and nerves, without exposing patients and personnel to radiation. Imaging can be performed continuously and the fluid injected is visualized in a real time fashion. Possible applications are nerve blocks of the cervical and lumbar zygapophysial joints, stellate ganglion block, intercostal nerve blocks, blocks of painful stump neuromas, caudal epidural injections and injections of trigger/tender points. Due to direct nerve visualization, US has a potential application for destructive procedures, such as cryoanalgesia, radiofrequency lesions or chemical neurolysis. Limitations are the poor resolution of narrow-gauge needles, the lost of resolution with increasing working depth and possible interference of echoes from overlying structures with the image of the target area. US opens new perspectives in interventional pain management. However, there is a need for clinical trials investigating efficacy and safety of US-guided pain procedures. Until these studies are made, US can not replace fluoroscopy or computed tomography in routine clinical practice and remainS domain of well-trained and experienced physicians. The limited evidence supporting the clinical utility of nerve blocks remains a problem, irrespective of the imaging technique employed.

Practical Experience with Sonographically Guided Phenol Instillation of Stump Neuroma: Predictors of Effects, Success, and Outcome

Phantom limb pain and stump pain frequently occur after limb amputation, and stump neuromas play an important role in generation of the pain. The purpose of this study was to evaluate the effects of a previously described optimized procedure for sclerosis of painful stump neuromas under real-time high-resolution sonographic guidance. In this prospective study, neurosclerosis was performed on 82 patients by means of high-resolution sonographically guided injection of up to 0.8 mL of 80% phenol solution according to a standardized protocol. During treatment all patients had marked improvement in terms of reduction of pain measured with a visual analog scale. Twelve (15%) of the subjects were pain free after one to three treatments, nine of the 12 achieving relief with the initial instillation. At 6-month follow-up evaluation, 52 patients assessed their present pain quantity with a simplified three-step score. Twenty (38%) of the 52 patients reported almost unnoticeable pain, and 33 (64%) reported pain equal to the minimum reached during therapy. In 18 (35%) of the 52 patients, the incidence of painful periods had markedly decreased. The neurosclerosis procedure had a low complication rate (5% rate of minor complications, 1.3% rate of major complications). The high-resolution sonographically guided neurosclerosis procedure had a significantly better outcome than other documented treatments. Sonographically guided neurosclerosis should be included in the management of chronic phantom limb and stump pain.