Stump Neuroma Research Articles

Centrocentral Short Circuiting for Management of Stump Neuroma Pain in Amputees

ostamputation pain (PAP) is a common cause of morbidity among amputees and poses challenging management for P the treating physician. Most amputees will suffer some degree of PAP, which often causes further disability owing to inability using the prosthesis. PAP can be categorized according to the basic mechanism and contributing level in the neuraxis with cortical and spinal cord reorganization or peripheral nervous system involvement. Understanding the pathophysiologic basis and appreciating the main etiology responsible for pain is vital to offer the appropriate treatment specifically tailored for each individual. Supratentorial mechanism involves reorganization of the somatosensory cortex of the deafferentated limb, resulting in phantom sensation and phantom limb pain. Reorganization also occurs in the spinal cord where decreased inhibitory impulses from brainstem reticular areas cause increased autonomous activity of the dorsal horn neurons. Peripheral nerve injury and regenerative sprouting result in increased sensory input, which is thought by many investigators to be the predominant mechanism involved in stump neuroma pain, also known as residual limb pain. The biomolecular bases comprise of altered expression of transduction molecules, voltage-sensitive sodium channels up-regulation, potassium channels down-regulation, and misdirected axons, which ultimately increase the afferent input into the central nervous system.

Peripheral nerve implants enriched with chemotactic factors for peripheral nervous tissue engineering

Peripheral nerve injuries are an important part of everyday medical practice since there are reported over 600,000 cases in Europe and in the United States annually [1]. Many of such nerve injures cause gaps between nerve stumps. Without intervention, they can lead to the formation of a stump neuroma, what can result in functional impairment of the nerve fiber. The current approaches to regeneration of damaged peripheral nerves include: autografting, allografting, and, last but not least, the implantation of polymeric tubes and conduits between nerve stumps. Nerve autografting is considered as the “gold standard” technique for the repair of peripheral nerve discontinuities, but it has a number of limitations, such as the requirement for the second surgical procedure to harvest the graft tissue, the donor site morbidity, additional injuries and scarring as well as the increased recovery time. Allografts (e.g., cadaver nerve grafts) and xenografts (e.g. animal nerve grafts) can be an alternative to autografts, but their main drawback lies in the high possibility of an undesirable immune response. The most promising materials for peripheral nerve conduits preparation are natural biopolymers. They are obtained from natural sources, exhibit similar properties to the tissues they are replacing and reveal good cell adhesion. Furthermore, they tend to accelerate regeneration processes due to specific chemical interactions within the human body, e.g. with extracellular matrix (ECM) molecules. The purpose of our study is to create a conduit with properties that will mimic the ones of the extracellular matrix of the peripheral nervous system. Our focus is put on natural polymers, especially chitosan. In addition, we use chemotactic factors which exhibit properties beneficial in regeneration of the peripheral nervous tissue.

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.

Neuropathic pain after bilateral sagittal split osteotomy: management and prevention

Neuropathic pain is characterized by spontaneous and provoked pain and other signs reflecting neural damage. Aberrant regeneration following peripheral nerve lesions leaves neurons unusually sensitive and prone to spontaneous pathological activity, abnormal excitability and heightened sensitivity to stimuli. This review covers the current understanding of neuropathic pain after bilateral sagittal split osteotomy (BSSO) of the lower jaw. The reported incidence of neuropathic pain after mandibular osteotomies is less than 1%, while the incidence in patients with iatrogenic inferior alveolar nerve (IAN) injuries during BSSO can be as high as 45%. The factors which modulate the healing process toward neuropathic pain during or after nerve damage have not yet been elucidated. Patients at highest risk for developing post-BSSO neuropathic pain are older than 45 years and have undergone procedures involving IAN compression, partial severance, or complete discontinuity of the lingual nerve with a proximal stump neuroma, patients with nerve injury repair delayed longer than 12 months and patients with chronic illnesses that compromise healing or increase risk for peripheral neuropathy. Although neuropathic pain tends to be long-lasting, some patients can recover completely. Preventive measures include risk assessment prior to surgery, prevention of nerve damage during surgery, and early repair of nerve injury.

Ultrasound-guided steroid injection in the treatment of stump neuroma: Pilot study

Stump neuroma is a major cause of postamputation pain. Ultrasound is a practical way of imaging stump neuromas and can be employed for guiding therapeutic injections. The aim of this pilot study was to investigate the effectiveness of ultrasound-guided steroid injection in the treatment of stump neuroma. The amputee patients with stump neuroma who underwent a single ultrasound guided steroid injection in amputee rehabilitation unit of our hospital were reviewed. The pain logs employing a 11-point pain scale for each evaluation time (before the procedure, one day, one week, 2 weeks, 4 weeks, 6 weeks after procedure) and a subsequent phone call approximately six months after procedure were used as the source of information in the study. Mean changes in pain levels (pain in rest and pain with prosthesis) over time were evaluated. The patients that had 50% decrease in pain scores were regarded as having treated successfully. Time after amputation and duration of pain symptom were compared between successfully (Group A) and unsuccessfully (Group B) treated patients. All patients (mean age, 29.7 ± 5.5 year) in the study were male (n=14). 12 patients were transtibial amputee (85.7%) and 2 patients were transfemoral amputee (14.3%). Both mean pain scores improved significantly in repeated measures (pain in rest F=25.35, p< 0.01; pain with prosthesis F=81,45, p <0,01). A total of 7 patients (50%) were regarded as having treated successfully. Time after amputation and duration of pain symptom were significantly longer in Group B. (p< 0.05, Group A: 16.8 ± 14.3 months after amputation, 3.5 ± 4.1 months pain duration; Group B: 80.2 ± 74.2 months after amputation, 52.8 ± 57.6 months pain duration). Steroid injection may have positive effect in the treatment of postamputation neuroma. The patients with shorter pain and amputation duration may respond well to the injection.

Morton’s neuroma neuro-osteodesis through a plantar approach

Morton’s neuroma is an entrapment neuropathy. Several surgical techniques were proposed for the management of this painful condition and to potentially limit the stump neuroma formation with variable results including attempts to seal the end of the nerve with cryogenic freezing, cauterization, electrocoagulation, carbon dioxide laser, chemical sclerosis, mechanical crush or ligation, fascial capping, and synthetic capping with methyl methacrylate, cellophane, collodion, silicone, glass, tin, tantalum, and silver and gold foils. In this study, 18 patients with Morton’s metatarsalgia were treated using a plantar approach, and neuro-osteodesis that entails burring the nerve into adjacent bone. All patients had satisfactory results except one case that necessitated a second surgery. Twelve patients were completely satisfied and five were satisfied with minor reservations. Based on the results provided by this prospective study, we believe that neuro-osteodesis through a plantar approach is expected to be a satisfactory measure for the management of this painful foot condition.

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.

Huge sciatic neuroma presented 40 years after traumatic above knee amputation

An amount of 70,000 minor/major amputees are annually performed for different reasons such as tumor, trauma, perivascular diseases or diabetic ulcera yearly in Germany. Over the course of time a lot of patients get problems with their stump, which leads to an incompatible prosthetic treatment and immobilisation. Handicapped patients are often characterized by a long history of pain. The fact that they often had comorbidities as diabetes, vascular diseases or other metabolic affection, leads to the situation that no other differential diagnoses are taken into account. We present a case of a 62 year old patient with a history of burning pain with punctum maximum at the dorso-medial part of the distal femur stump 40 years after a traumatic above-knee amputation. He had sought different medical consultations and had a lot of modifications on his prosthesis shaft with partial benefit. The clinical examination confirmed the suspected diagnosis of a stump neuroma from the sciatic nerve, which has been verified in the MRI. Concerning the symptoms and the increasing immobilisation caused by the burning pain, we indicated a surgical revision which includes a resection from the neuroma and a local flap graft correction. Postoperatively he described a complete pain relief. After 6 weeks under weight bearing mobilisation he was 100% free of pain in his new custom-made shaft prosthesis and could mobilised under full bearing. We conclude that neurinoma needs to be considered in handicapped patients with such symptomatology and has to be surgically revised, even if that decision especially for handicapped patients is often difficult for the surgeon.

Ultrasound Neurography in the Evaluation of Sciatic Nerve Injuries

[Purpose] The aim of this clinical study was to investigate the benefits and the basic principles of ultrasonographic examination in the evaluation of sciatic nerve injuries. [Subjects and Methods] Patients with sciatic nerve injury were evaluated using a real-time utrasonographic examination. The capabilty of ultrasonography in terms of determination of the type and the localization of injury, the position of the proximal and distal nerve segments, the presence or absence of a neuroma, and perilesional scar tissue were evaluated in all cases. [Results] Ten cases with sciatic nerve injury were evaluated with real time sonography. Perilesional scar tissue formation was found in 4 (40%) cases. Two (20%) cases had stump neuroma diagnosed by sonographic examination. The capability of ultrasonographic examination was satisfactory for all evaluation parameters. [Conclusion] Ultrasonographic examination of sciatic nerve lesions may be used for the description of the degree of injury, determination of complete or incomplete nerve sectioning, the presence of hematoma and foreign body, the continuity of nerve, determination of nerve stumps, formation of perilesional scar tissue, and the presence of neuroma.

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.

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.

21. Phantom Pain

Phantom pain is pain caused by elimination or interruption of sensory nerve impulses by destroying or injuring the sensory nerve fibers after amputation or deafferentation. The reported incidence of phantom limb pain after trauma, injury or peripheral vascular diseases is 60% to 80%. Over half the patients with phantom pain have stump pain as well. Phantom pain can also occur in other parts of the body; it has been described after mastectomies and enucleation of the eye. Most patients with phantom pain have intermittent pain, with intervals that range from 1 day to several weeks. Even intervals of over a year have been reported. The pain often presents itself in the form of attacks that vary in duration from a few seconds to minutes or hours. In most cases, the pain is experienced distally in the missing limb, in places with the most extensive innervation density and cortical representation. Although there are still many questions as to the underlying mechanisms, peripheral as well as central neuronal mechanisms seem to be involved. Conservative therapy consists of drug treatment with amitriptyline, tramadol, carbamazepine, ketamine, or morphine. Based on the available evidence some effect may be expected from drug treatment. When conservative treatment fails, pulsed radiofrequency treatment of the stump neuroma or of the spinal ganglion (DRG) or spinal cord stimulation could be considered (evidence score 0). These treatments should only be applied in a study design.

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.

Pulsed Radiofrequency Ablation for Residual and Phantom Limb Pain: A Case Series

Residual limb pain (RLP) and phantom limb pain (PLP) can be debilitating and can prevent functional gains following amputation. High correlations have been reported between RLP and the stump neuromas following amputation. Many treatment methods including physical therapy, medications, and interventions, have been used with limited success. Pulsed radiofrequency ablation (PRFA) has shown promise in treating neuropathic pain because of the inhibition of evoked synaptic activity. We present 4 amputees who were treated with PRFA after failing conservative management for their RLP and PLP. All 4 patients underwent PRFA and demonstrated at least 80% relief of RLP for over 6 months. One patient reported a complete resolution of phantom sensation while another patient had significantly decreased frequency of spontaneous PLP and resolution of evoked PLP. In addition, all patients reported improved overall function including increased prosthetic tolerance and decreased oral pain medications. This case series suggests that PRFA is a viable treatment option which might be used for long-term relief of intractable RLP and/or PLP.

Microsurgical Repair of the Peripheral Trigeminal Nerve After Mandibular Sagittal Split Ramus Osteotomy

Injuries to the inferior alveolar nerve (IAN) and lingual nerves (LNs) have long been known complications of the mandibular sagittal split ramus osteotomy (SSRO). Most postoperative paresthesias resolve without treatment. However, microsurgical exploration of the nerve may be indicated in cases of significant persistent sensory dysfunction associated with observed or suspected localized IAN or LN injury. We report the demographics and outcome of microsurgical exploration and repair of peripheral branches of the trigeminal nerve injured because of the SSRO. A retrospective chart review was completed on all patients who had microsurgical repair of peripheral trigeminal nerve injuries caused by mandibular SSRO and were operated on by the senior author (R.A.M.) between March 1986 and December 2005. A physical examination, including standardized neurosensory testing (NST) as described by Zuniga et al, was completed on each patient preoperatively. All patients were followed periodically after surgery for at least 1 year with NST repeated at each visit. NST results obtained at the last patient visit were used to determine the final level of recovery of sensory function. Sensory recovery was evaluated using guidelines established by the Medical Research Council scale. The following data were collected and analyzed: age of patient, gender, nerve injured, chief sensory complaint (numbness, pain, or both), duration (months) from injury to surgical intervention, intraoperative findings, surgical procedure, and neurosensory status at final evaluation. Given the retrospective nature of this study, the research was exempt from our institutional review board ethics committee. There were 54 (n = 54) patients (8 males and 46 females) with an average age of 36.9 years (range, 16 to 55 years) and a follow-up of at least 12 months. The most commonly injured/repaired nerve was the IAN (n = 39), followed by the LN (n = 14), and the long buccal nerve (n = 1). In 31 patients (57.4%), the chief sensory complaint was numbness, while 20 patients (37%) complained of pain and numbness, and 3 patients (5.5%) complained of pain without mention of numbness. The average time from nerve injury to repair was 9.4 months (range, 3 to 50 months). The most common intraoperative finding was a discontinuity defect (n = 18, 33.3%), followed by partial nerve severance (n = 15, 27.8%), neuroma-in-continuity (n = 11, 20.3%), and compression injury (n = 10, 18.5%). The most frequent surgical procedure was autogenous nerve graft reconstruction of the IAN using the sural or great auricular nerve (n = 22, 40.7%), followed by excision of a neuroma with or without neurorrhaphy (n = 13, 24.1%). All the LN injuries (n = 14) were partial or complete severances, of which 2 were reconstructed with autogenous nerve grafts and the other 12 underwent neurorrhaphy. The long buccal nerve injury required excision of a proximal stump neuroma without neurorrhaphy. After a minimum of 1-year follow-up, NST showed that 8 nerves (14.8%) showed no sign of recovery; 19 nerves (35.2%) had regained "useful sensory function," and 27 nerves (50%) showed full recovery as described by the Medical Research Council scale. Microsurgical repair of the IAN or LN injured during the SSRO can be considered in patients with persistent, unacceptable sensory dysfunction in the distribution of the involved nerve. Modifications of surgical technique may be helpful in reducing the incidence of such injuries. Based on our experience, an algorithm for evaluation and treatment is presented.

Retrospective Review of Microsurgical Repair of 222 Lingual Nerve Injuries

Injury to the lingual nerve (LN) is a known complication associated with several oral and maxillofacial surgical procedures. We have reviewed the demographics, timing, and outcome of microsurgical repair of the LN. A retrospective chart review was completed of all patients who had undergone microsurgical repair of the LN by one of us (R.A.M.) from March 1986 through December 2005. A physical examination, including standardized neurosensory testing, was completed of each patient preoperatively. All patients were followed up periodically after surgery for at least 1 year, with neurosensory testing repeated at each visit. Sensory recovery was determined from the patient's final neurosensory testing results and evaluated using the guidelines established by the Medical Research Council Scale. The following data were collected and analyzed: patient age, gender, nerve injury etiology, chief sensory complaint (numbness or pain, or both), interval from injury to surgical intervention, intraoperative findings, surgical procedure, and neurosensory status at the final evaluation. The patients were classified according to whether they achieved "useful sensory recovery" or better, according to the Medical Research Council Scale, or had unsatisfactory or no improvement in sensation. Logistic regression methods and associated odds ratios (OR) were used to quantify the association between the risk factors and improvement. Receiver operating characteristic curve analysis was used to find the age threshold and duration that maximally separated the patient outcomes. A total of 222 patients (51 males and 171 females; average age 31.1 years, range 15 to 61) underwent LN repair and returned for at least 1 year of follow-up. The most common cause of LN injury was mandibular third molar removal (n = 191, 86%), followed by sagittal split mandibular ramus osteotomy (n = 14, 6.3%). Most patients complained preoperatively of numbness (n = 122, 55%) or numbness with pain (n = 94, 42.3%). The average interval from injury to surgery was 8.5 months (range 1.5 to 96). The most commonly performed operation was excision of a proximal stump neuroma with neurorrhaphy (n = 154, 69%), followed by external decompression with internal neurolysis (n = 29, 13%). Nineteen patients (8.6%) underwent an autogenous nerve graft procedure (greater auricular or sural nerve) for reconstruction of a nerve gap. A collagen cuff was placed around the repair site in 8 patients (3.6%; external decompression with internal neurolysis in 2 and neurorrhaphy in 6). Recovery from neurosensory dysfunction (defined by the Medical Research Council Scale as ranging from "useful sensory function" to a "complete return of sensation") was observed in 201 patients (90.5%; 146 patients with complete recovery and 55 patients with recovery to "useful sensory function"), and 21 patients (9.5%) had no or inadequate improvement. Using the logistic regression model, a shorter interval between nerve injury and repair resulted in greater odds of improvement (OR 0.942, P = .0064); with each month that passed, the odds of improvement decreased by 5.8%. The receiver operating characteristic analysis revealed that patients who waited more than 9 months for repair were at a significantly greater risk of nonimprovement. Statistical significance was observed between patient age and outcome (OR 0.945, P = .0067) representing a 5.5% decrease in the chance of recovery for every year of age in patients 45 years old and older. The odds of a return of acceptable neurosensory function were better when the patient's presenting symptom was pain and not numbness (OR 0.04, P < .001). Microsurgical repair of LN injury has the best chance of successful restoration of acceptable neurosensory function if done within 9 months of the injury. The likelihood of recovery after nerve repair decreased progressively when the repair occurred more than 9 months after injury and with increasing patient age.

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 Demonstration of Vascularity Changes With Changes in Pain Perception in a Stump Neuroma

Pain in the residual limb after an amputation has posed many challenges in treatment. Ultrasound (US) imaging has helped in the visualization of neuroma and its selective targeting for interventions. A 58-year-old man presented to the pain clinic with chronic stump pain after a below knee amputation during the Vietnam war. After multiple similar steroid injections around the area of pain in the following months, we decided to use the US to better target the stump neuroma. Color flow Doppler showed extensive vascularity around the posterior aspect of the neuroma where there was scar tissue. During a follow-up visit for intra-articular steroid injection to the L5-S1 left lumbar facet for coincidental lumbar facet arthropathy, an US scan of the stump neuroma with color flow Doppler was performed out of curiosity. Multiple US views of the neuroma with color flow Doppler was performed and all showed a significant decrease in vascularity. Similar absence of vascularity was noted after a spinal cord stimulator placement. This is a case report of US demonstration of increased vascularity in a stump neuroma coinciding with the patient's pain. This serendipitous demonstration makes the need for US visualization useful in the evaluation of neuroma. It is also useful to use US guidance to avoid the vascular structures when testing the beneficial response to various medications. Larger randomized controlled studies are needed to further correlate the US demonstration of vascularity and neuroma pain.

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.