Stump Neuroma Research Articles

Current Concepts of the Management of Painful Traumatic Peripheral Nerve Neuromas

Painful neuromas are a complex clinical condition that results in notable disability and functional impairment after injury to a peripheral nerve. When regenerating axons lack a distal target, they form a stump neuroma. Up to 60% of neuromas are painful because of mechanical sensitivity and crosstalk between nerve fibers. Clinical evaluation includes a thorough history and physical examination followed by directed diagnostic imaging and procedures to assess pain generators and their effect on quality of life. Nonsurgical management options may include pharmacological interventions, desensitization strategies, injections, and therapies to reduce pain perception and improve function. Surgical interventions, such as nerve reconstruction by direct repair or grafting, redirection to alternative targets, and containment of regenerating axons by relocation into innervated tissues or in grafts, are considered when conservative measures fail. A comprehensive and individualized treatment plan is crucial for optimizing patient outcomes with painful neuromas. The plan should consider the underlying pathology, pain generators, and psychosocial factors contributing to the patient's pain.

A case report of usage of luminex 500 in treatment of stump neuroma

A case report of usage of luminex 500 in treatment of stump neuroma

The role of preoperative ultrasound in the management of peripheral nerve injuries

BackgroundPeripheral nerve injury refers to any damage or trauma to the nerves located outside the central nervous system. Ultrasonography is a reliable, cheap, and minimally invasive method in clinical practice to give physicians useful information about nerve injury. Objectivesto assess the power of ultrasound in determining the presence, localization, and extent of neural damage in patients with clinical evidence of peripheral nerve lesions before surgery. MethodsThis cross-sectional study was conducted on 78 patients (56 females and 22 males, aged from 9 to 52 years) who had different pathologies including entrapment, tumoral, post-traumatic, and post-surgical nerve injuries at the Neurosurgery and Physical Medicine, Rheumatology, and Rehabilitation Departments, Tanta University Hospitals. All studied patients had preoperative evaluation; neurological examination, electrodiagnostic studies, and sonographic examinations with linear array transducers (frequencies ranging from 7.5 to 16 MHz). ResultsThe most common pathological condition was entrapment neuropathy (39 patients) (50%). Ultrasound complemented the electrodiagnostic studies by determining the site of entrapment manifested by increased mean maximum cross-sectional area of the nerve proximal to the site of entrapment and nerve hypoechogenicity. In post-traumatic and iatrogenic neuropathies (35 patients) (44.9%), the ultrasound finding revealed neuroma in continuity in nine cases (11.5%), complete neurotmesis with stump neuroma in eighteen patients (23.1%), and eight cases (10.3%) showed perineural adhesion. In all cases, the nerve was hypoechoic at the site of injury. The presence of hyperechoic fibrous tissue could indicate perineural adhesion and the necessity for neurolysis. This study also included three (3.8%) cases had schwannoma, and one case (1.3%) had neurofibroma. Ultrasound was used to confirm the diagnosis by determining the tumor's size and vascular supply. ConclusionsUltrasonography is a diagnostic and surgical planning tool that is becoming more and more useful for the management of peripheral nerve injuries. Its high resolution and real-time capability provide safe and cost-effective scans that aid in determining the extent of injuries. For patients with peripheral nerve injuries, ultrasound is advised to be added to the routine clinical and neurophysiological evaluation. It is also advised to use ultrasound as a first-line imaging modality for tumors thought to be of nerve origin.

Treatment of a patient with chronic causalgia after surgical removal of the neuroma in the second interdigital space

BACKGROUND: Mortons neuroma is a common pathology of the forefoot. Etiopathologically, this disease can be attributed to nerve fibrosis, not a tumor. We now have various therapeutic options for neuromas, the most frequent of which is traction neurectomy. Recurrent pain affects up to 35% of patients with traction neurectomy, and one-third have recurrent stump neuroma produced by the proliferation of fibrous scar tissue around the remaining nerve elements. Conservative treatment methods are more commonly used to treat recurrent neuromas and residual pain, but surgical therapy is required in some cases. Despite the relatively high prevalence, the treatment of such patients is a challenging task for orthopedic traumatologists.
 CLINICAL CASE DESCRIPTION: We show the effective treatment of a patient with stump neuroma and primary Mortons neuroma in two stages. The second interdigital space nerve was transposed, and the deep, transverse metatarsal ligament of the third interdigital space was dissected in the first stage. The second stage consists of removing the sensitive scar, resecting the plantar nerve of the third interdigital space, and performing a Weil osteotomy.
 CONCLUSION: Consistent use of conservative surgical procedures, appropriate revision of the subcutaneous nerve, and excision of a sensitive scar allows for a successful therapeutic outcome, pain alleviation, and the ability to wear normal shoes.

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.

Rare Case of C4 Perineurinoma with Lambdatic Parieto-occipital Neuroma in Von Recklinghausen Disease in a 5 Years Old Child: A Case Report

Neuro fibromatosis groups together distinct diseases that most often share only certain cutaneous signs. Neurofibromatosis (NF) is a neurocutaneous syndrome characterized by the development of tumors of the central or peripheral nervous system including the brain, spinal cord, organs, skin, and bones. Prineurinoma is a relatively rare tumour that has been shown to be a proliferation of perineural cells with an incomplete basal lamina and no onion bulb appearance. Neuroma also known as traumatic neuroma or amputation neuroma or stump neuroma, is a focal non-neoplastic area of proliferative hyperplastic reaction secondary to peripheral nerve damage that commonly occurs after a focal trauma (acute or chronic) or surgery, such as amputation or partial transection; We report an extremely rare clinical case of a 5 year old child with neurfibromatosis congenita type 1 with asyntomatic medullary comrepssion and incidental discovery of a left intraductal C4 perineurinoma during the exploration of an occipital-parietal neuroma associated with a dehiscence of the lambda suture. He was operated on, with the postoperative course marked by paresis of the cervical muscles, which was in the process of recovery by physiotherapy.

Hopeless Neuroma—The Neurotized Free Flap Tissue Augmentation as Salvage Therapy—A Concept and Clinical Demonstration

Therapy-resistant neuroma pain is a devastating condition for patients and surgeons. Although various methods are described to surgically deal with neuromas, some discontinuity and stump neuroma therapies have anatomical limitations. It is widely known that a neurotizable target for axon ingrowth is beneficial for dealing with neuromas. The nerve needs "something to do". Furthermore, sufficient soft tissue coverage plays a major role in sufficient neuroma therapy. We aimed, therefore, to demonstrate our approach for therapy of resistant neuromas with insufficient tissue coverage using free flaps, which are sensory neurotized via anatomical constant branches. The central idea is to provide a new target, a new "to do" for the painful mislead axons, as well as an augmentation of deficient soft tissues. As indication is key, we furthermore demonstrate clinical cases and common neurotizable workhorse flaps.

Time-Dependent Proregenerative Effects of Exogenous Melatonin on the Transected Sciatic Nerve

Microsurgical procedures are the treatment of choice of peripheral nerve injuries, but often fail to reach full functional recovery. Melatonin has neuroprotective actions and might be used as a possible proregenerative pharmacological support. Therefore, the aim of this study was to analyze the time-dependence of the neuroprotective effect of melatonin on the overall fascicular structures of both ends of the transected nerve. Sciatic nerve transection was performed in 34 adult male Wistar rats divided in four groups: two vehicle groups (N=7) treated intraperitoneally for 7 (V7) or 21 (V21) consecutive days with vehicle (5 % ethanol in Ringer solution) and two melatonin groups (N=10) administered intraperitoneally 30 mg/kg of melatonin for 7 (M7) or 21 (M21) consecutive days. At the end of the experiment, proximal stump neuroma and distal stump fibroma were excised and processed for qualitative and quantitative histological analysis. Intrafascicular neural structures were better preserved and the collagen deposition was reduced in the melatonin treated groups than in the vehicle groups. Myelin sheath regeneration observed through its thickness measurement was statistically significantly (p<0,05) more pronounced in the M21 (1,23±0,18 µm) vs. V21 group (0,98±0,13 µm). The mean volume density of the endoneurium was lower in both melatonin treated groups in comparison to the matching vehicle treated groups. Although not statistically different, the endoneural tube diameter was larger in both melatonin groups vs. vehicle groups, and the effect of melatonin was more pronounced after 21 days (24,97 % increase) vs. 7 days of melatonin treatment (18,8 % increase). Melatonin exerts a time-dependent proregenerative effect on nerve fibers in the proximal stump and an anti-scarring effect in both stumps.

Efficacy of radiofrequency ablation as a treatment option for post-amputation stump neuromas

Efficacy of radiofrequency ablation as a treatment option for post-amputation stump neuromas

Targeted Muscle Reinnervation of the Gastrocnemius for Preventing Neuropathic Pain

Debilitating pain from amputation stump neuromas is a difficult surgical prob- lem. Targeted Muscle Reinnervation (TMR) is a recent surgical technique involving residual peripheral nerve stumps being coapted to a proximal target muscle motor point to improve myoelectric bioprostheses control. Here, we evaluate the efficacy of TMR of gastrocnemius at amputation to manage a symptomatic tibial nerve injury.

Nerve-End Capping Treatment with a Polyglycolic Acid Conduit for Rat Sciatic Neuroma: A Preliminary Report.

The treatment of painful neuroma remains challenging. Recently, a nerve-end capping technique using a bioabsorbable nerve conduit was newly introduced to treat amputation neuroma. A collagen-coated polyglycolic acid (PGA) conduit has been commercially available for the reconstruction of peripheral nerve defects, yielding successful clinical outcomes. However, no experimental research has been conducted using this PGA nerve conduit as capping device for treating amputation neuroma. The purpose of this study was to investigate nerve-end capping treatment with the PGA conduit in the rat sciatic nerve amputation model, focusing on histological scar formation and neuroinflammation. Forty-seven rats were divided into two groups: no capping (transected nerve stump without capping; n = 25) and capping (nerve-end capping with collagen-coated PGA nerve conduit; n = 22). Twelve weeks after sciatic neurectomy, neuropathic pain was evaluated using the autotomy score. Stump neuromas were histologically evaluated or perineural scar and neuroinflammation. While autotomy scores gradually exacerbated in both groups, they were consistently lower in the capping group at 4, 8, and 12 weeks postprocedure. Twelve weeks after surgery, the transected nerve stumps in the no-capping group had formed macroscopic bulbous neuromas strongly adhering to surrounding tissues, whereas they remained wrapped with the PGA nerve conduits loosely adhering to surrounding tissues in the capping group. Histologically, distal axonal fibers were expanded radially and formed neuromas in the no-capping group, while they were terminated within the PGA conduit in the capping group. Perineural scars and neuroinflammation were widely found surrounding the randomly sprouting nerve end in the no-capping group. In capped counterparts, scars and inflammation were limited to closely around the terminated nerve end. Nerve-end capping with a collagen-coated PGA conduit after rat sciatic neurectomy might prevent neuroma formation by suppressing perineural scar formation and neuroinflammation around the nerve stump, potentially relieving neuropathic pain.

The efficacy of acupuncture on pain and functional status in patients with lower extremity amputation with stump neuroma: A prospective randomised controlled pilot study

Considering the low success rate of the treatment of neuroma, it is important to apply effective treatment methods alone or in combination with other approaches. This study was aimed to determine the effect of acupuncture treatment on pain severity and functional status in patients with lower extremity amputation with stump neuroma. Thirty below-knee amputees with symptomatic stump neuromas took part in this prospective randomised controlled study. Patients were randomised into two groups an acupuncture treatment group ( n = 15) or a control group ( n = 15). A rehabilitation program and transcutaneous electrical nerve stimulation was applied to the patients in both groups. All assessments (except for the 2 min walk test) were performed pre-treatment, post-treatment and 12 weeks after treatment. In both groups, there was significant decrease in VAS scores-at rest, -with movement, -at night and LANSS scores both at post-treatment and follow up at 12 weeks. A significant increase was detected in the distance walked in the 2 min walk test at post-treatment ( p = 0.001). Between two-group comparisons showed that VAS-at rest, VAS-with movement, LANSS and 2 min walk test scores changed between pre-treatment-post-treatment were significant in favor of acupuncture treatment group ( p = 0.002, p = 0.021, p = 0.001, p <0.001, respectively) (Table 3). It was observed that VAS-at rest, VAS-with movement, VAS-at night and LANSS scores changed between pre-treatment and at 12 weeks follow up were more statistically significant for the acupuncture treatment group ( p = 0.002, p = 0.015, p = 0.05, p <0.001, respectively) compared with the control group. Considering the low success rate of stump neuroma treatment methods and the high rate of neuroma recurrence, acupuncture therapy can be safely added to existing treatments. NCT05244369.

A Method for Entubulating Exposed Nerve Ends Following Neurectomy Using a Porcine Extracellular Matrix Nerve Cap.

Compression and irritation at the plantar aspect of the transverse intermetatarsal ligament may lead to a compressive neuropathy called Morton's neuroma. There are many treatment options for Morton's neuroma, with the most common surgical option being traction neurectomy. While there has been success in many surgical procedures, up to 35% of patients treated with traction neurectomy have recurrent pain and up to one-third of these patients have a recurrent stump neuroma. These neuromas are caused by abnormal axonal growth during regeneration, leading to an unorganized mass of fibrotic collagenous tissues, Schwann cells, and axons. More recent surgical treatments of neuromas have included nerve capping, which has been proposed to prevent painful neuroma formation by isolating the nerve end from external chemosignaling and reducing disorganized axonal outgrowth. An off-the-shelf, biocompatible porcine small intestine submucosa (pSIS) derived nerve cap with internal chambering has been investigated in a rodent study, which showed less pain sensitivity and less axonal swirling indicative of reduced likelihood of neuroma formation. Furthermore, a recent clinical study indicated that patients experienced a significant reduction in pain 3 months after Morton's neuroma excision followed by repair using a nerve cap. This article describes the surgical technique of the aforementioned clinical study to mitigate neuroma formation, where a Morton's neuroma is excised, and the remaining proximal nerve stump is inserted within a nerve cap and buried in the surrounding muscle.Level of Evidence: Level V: Expert opinion.

Minimally Invasive Peripheral Neuromodulation for Postamputation Stump Neuroma: A Case Report

BACKGROUND: Postamputation neuromas are a significant cause of pain and suffering in amputees. In patients who are nonresponsive to medical therapy, open surgery is often required but has limited efficacy. CASE REPORT: Here we present a case of the successful use of percutaneous peripheral nerve stimulation in a 77-year-old man with a postamputation neuroma that was refractory to medical therapy. He had significant pain reduction allowing a return to his daily activities. CONCLUSION: This case report demonstrates that peripheral nerve stimulation may reduce pain in patients with postamputation neuroma. Percutaneous peripheral nerve stimulation is a promising treatment to reduce pain and improve patient function without irreversible manipulation. KEY WORDS: Case report, neuromodulation, peripheral nerve stimulation, postamputation pain, stump neuroma

Long-term results of dorsal neuroma/nerve transposition in the surgical management of Morton\u2019s neuroma and correlation with intraoperative anatomical variations

BackgroundMorton's neuroma (MN) is a common cause of forefoot pain. After failure of conservative management, surgical procedures include neurectomy or neuroma preserving procedures; resection of deep transverse intermetatarsal ligament only (DTIML), dorsal neurolysis, dorsal nerve transposition (DNT).ObjectivesThis retrospective study evaluates the long-term results of open DNT, and it also reports anatomical variants in the plantar interdigital nerve.Material and methodsThe study included 39 patients (30 females and 9 males) who were treated for MN between 2002 and 2016.ResultsThe mean pre-operative Giannini score of 13 (0–30) improved to 61 (20–80) (p < .0001), with only 6 patients scoring less than 50 (poor). Using Coughlin’s criterion for overall satisfaction, 9 patients (23%) reported excellent, 18 patients (46%) good, 6 patients (15%) fair and 6 patients (15%) reported poor results. In the long term, 25 patients (64%) had no pain, 8 patients (20%) had mild pain, and 6 patients (16%) had severe pain. Ten patients (26%) reported normal sensitivity in their toes, 26 patients (66%) had numbness, and 3 patients (8%) reported dysesthesia in their toes. Twenty-two patients (56%) could wear fashionable shoes, 11 patients (28%) comfortable shoes, and 6 patients (16%) modified shoes. Regarding walking distance, 30 patients (77%) had no limitation, and 9 patients (23%) reported some limitation. Nineteen per cent regretted having surgery. Around 40% (17 out of 43 web spaces) showed anatomical variations in either the nerve or in the web space and we could not identify any specific risk factors in relation to the outcome.ConclusionDividing the DTIML or dorsal neurolysis should be considered as the primary surgical treatment and, if this fails, neurectomy would be an option. DNT can be considered if one is concerned about stump neuroma, but this may be technically demanding and in some patients it may not be possible.Level of Evidence: Level IV - Case Control Retrospective study.

Preoperative ultrasound accurately characterizes surgically confirmed extracranial spinal accessory nerve injuries.

To determine the accuracy of preoperative ultrasound and MRI in surgically confirmed spinal accessory nerve injuries and present the benefits of a multimodality image review. A retrospective review of 38 consecutive patients referred to a peripheral nerve surgical practice at an academic teaching hospital with surgically confirmed spinal accessory nerve injuries. All cases were reviewed for patient demographics, date and cause of injury, preoperative EMG, and surgical diagnosis and management. Additionally, prospective interpretation of preoperative ultrasound and MRI reports were reviewed for concordance or discordance with the surgical diagnosis. Iatrogenic injury was present in 37 (97%) cases and most commonly a result of an excisional lymph node biopsy (68%). Surgically confirmed spinal accessory nerve injury diagnoses consisted of 25 (66%) stump neuromas and 13 (34%) incomplete nerve injuries. Nine months was the average time from injury to surgery. Twenty-nine patients underwent preoperative ultrasound and/or MRI evaluation: 12 ultrasound only, 10 MRI only, and seven with both ultrasound and MRI. Eighteen (95%) preoperative ultrasound reports compared to four (24%) preoperative MRI reports were concordant with the surgical diagnosis. In the seven cases with both preoperative ultrasound and MRI, six had discordant ultrasound and MRI imaging diagnoses for which the ultrasound was concordant with the surgical diagnoses in all cases. Preoperative ultrasound more accurately characterizes spinal accessory nerve injuries compared to MRI and should serve as the modality of choice when a spinal accessory nerve injury is suspected.

Nerve capping treatment using a bioabsorbable nerve conduit with open or closed end for rat sciatic neuroma

Background and aimsNerve capping treatment using bioabsorbable nerve conduits has recently been introduced for painful amputation neuroma. However, no clinical or experimental data are available for comparing nerve conduits with open distal ends and closed distal ends. Here, we investigated the nerve conduit with open or closed distal ends as the superior capping device, using a commercially available polyglycolic acid (PGA) nerve conduit in a rat sciatic nerve amputation model. MethodsNinety-one rats were assigned to three groups: no-capping (n = 30), capping the resected nerve stump with open ends (n = 31), and closed-end nerve conduits (n = 30). Twelve weeks after sciatic neurectomy, with or without capping, the evaluation of neuropathic pain using the autotomy score was performed. Stump neuromas with perineural scars and neuroinflammation were evaluated histologically. ResultsThe mean autotomy scores in the closed-end nerve conduit group were significantly lower than those in the no-capping group. However, the difference between the open-end nerve conduit and the closed-end nerve conduit groups was insignificant. Histologically, distal axonal fibers expanded radially and formed neuromas in the no-capping group while they were terminated within the PGA conduit in both capping groups. In particular, the closed-end version of the PGA nerve conduit blocked scarring from intruding through the open end and protected the nerve stump with less neuroinflammation. Nerve capping with the closed-end version of the PGA nerve conduit most effectively suppressed perineural neuroinflammation and scar formation around the resected nerve stump. InterpretationNerve capping with the PGA nerve conduit, particularly those with closed ends, after rat sciatic neurectomy prevented amputation neuroma and relieved neuropathic pain.

Ultrasound features of traumatic digital nerve injuries of the hand with surgical confirmation.

Characterize the appearance of digital nerve injuries in different ultrasound planes and correlate the presence and size of neuromas with time from injury. Surgically confirmed nerve injuries were retrospectively evaluated. Appearances of the nerve injury in the available imaging planes were reviewed by two readers. Associations between presence and size of neuroma with time from injury were analyzed. Injuries of 29 digital nerves (3 incomplete lacerations, 17 complete lacerations, 6 with 7 stump neuromas, 3 neuromas-in-continuity) noted on ultrasound were surgically confirmed. Among the 20 lacerations, long-axis images were obtained in 15, of which 10 depicted the injury and 4 did not. Among the 10 depicting the injury in long axis, 2 showed a discrete gap, and 7 showed the nerve obscured by laceration tissue without a gap. In short axis, the nerve injury was visible in all 20, and nerve laceration was seen as a discrete gap in 2, and obscuration by laceration tissue in 14. Neuromas were hypoechoic and well-defined. There was a positive association between time and presence of neuroma (OR = 1.3, p = 0.002). Correlations between time and cross-sectional area (rs = 0.45) and volume (rs = 0.57) of neuromas were moderately positive. Ultrasound long axis may be less useful, and those short axis may be more reliable for assessing digital nerve injuries than previously reported. Neuromas are hypoechoic and well-defined, and their size can vary based on time from injury.

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