Evaluation of surgical treatment for neuropathic pain from neuroma in patients with injured peripheral nerves

Abstract

OBJECTIVE Chronic neuropathic pain after peripheral nerve injury is a major clinical problem. Its management is difficult, and therapeutic approaches vary and include oral medication, neurostimulation, and surgery. The aim of this study was to assess the adequacy of surgical nerve revision in a large series of patients with long-term follow-up. METHODS The authors reviewed the charts of 231 patients (335 nerve injuries) who experienced neuropathic pain after peripheral nerve injury and underwent surgery for nerve revision at the authors' institution between 1997 and 2012. The following parameters were recorded for each patient: history, location, duration, and severity of the pain and details of nerve revision surgery. In addition, patients were invited to participate in a follow-up consultation and were asked to score their pain at that time. Current medications and examination findings were also documented. RESULTS Elective surgery was the source of nerve injury for 55.4% of the patients. The lower extremity was the most commonly involved anatomical region (54.3%), followed by the lower abdomen (16.4%) and the thoracic region (13%). The mean time between the onset of injury and revision surgery was 48 months. On average, 1.3 injured nerves per patient were explored, and surgery was performed 1.2 times per patient. Each nerve underwent revision 1.1 times on average. Neuromas-in-continuity and scar-tethered nerves were observed in 205 nerves (61%) and terminal neuromas were observed in 130 nerves (39%). The authors performed 186 (56%) neurolyses and 149 (44%) neuroma resections and translocations. The mean follow-up of the 127 (55%) patients who agreed to come back for a consultation was 68 months. These patients indicated an average pain decrease of 4 points in the visual analog scale (VAS) score. Pain relief greater than a 2-point decrease on the VAS, a criterion for a successful treatment according to the European Federation of Neurological Societies guidelines, was encountered in 80% of patients. Pain relief did not vary in a statistically significant way with regard to surgical technique, age and sex of the patient, affected nerve, or time between trauma and surgery. Before surgery, 76% of the patients were on a regimen of paracetamol and/or NSAIDs and 44% received opiates, while after nerve revision only 37% still required simple analgesia and 14% needed opiates. CONCLUSIONS Bearing in mind that medication achieves satisfying pain relief in only 30%-40% of patients with neuropathic pain, surgery must be considered as an effective alternative therapy. No objective criteria were shown to be factors of poor prognosis. Systematic preoperative clinical mapping of the injured nerves and diagnostic nerve blocks could improve the primary success rate of the surgery.

Avive Soft Tissue Membrane Improves Outcomes of Revision Upper-extremity Nerve Decompression Surgery

“… 11 Clinically important changes in pain have been defined as a reduction of more than two points on the VAS or 30% reduction from preoperative pain. 47 Our cohort demonstrated a higher rate of clinically significant pain reduction (>2 point reduction) in the Avive PUCM group (64.9%) compared with controls (40.8%) ( Supplemental Digital Content 2, http://links.lww.com/PRSGO/C426 ). Patients in the Avive PUCM cohort were also significantly more likely to be satisfied with outcomes of the revision procedure.…”

Reversal of neuropathic pain is associated with corticostriatal functional reorganization after nerve repair in the spared nerve injury model

“…For instance, primary microsurgical reconstruction is indicated as the treatment of choice for PNI for the functional outcome and pain 12,16,29 while secondary nerve revision surgery remains a major therapeutic approach for chronic pain after PNI. 8,9,22 Second, after the acute onset, the neuropathic pain is usually diminished in a heterogeneous fashion, leaving only a proportion of patient with permanent intractable chronic pain, be it peripheral nerve, 11,19 spinal cord, 31 or brain injury. 10 Interestingly, in agreement with these clinical observations, a delayed repair of the NI in our study resulted in a wide variation in the transition to chronic pain.…”

Contemporary Review: Targeted Muscle Reinnervation for Foot and Ankle Applications

“…Those with PLP report unpleasant symptoms that are perceived in the missing limb, whereas residual pain involves those complaints within the residual limb and can include symptoms related to the presence of a neuroma. 14,16,41 In addition to the Tinel sign, light touch, vibration, pinprick, and cold/warm sensation can be assessed and mapped out to determine if they follow known peripheral sensory distributions. 32 When abnormal sensory signs such as hyperalgesia or allodynia are identified, the surgeon must rule out medical or inflammatory 10 causes such as mononeuritis multiplex 1,32 and complex regional pain syndrome (CRPS).…”