Surgical Management of Painful Neuromas

Chronic pain can be severely disabling and represents a greatly underestimated public health problem. “Pain can kill. It can kill the spirit, vitality and the will to live,” said Joel Saper, MD and president of the American Headache Society, in response to law the US Congress passed into provision in late 2000, declaring the following decade (January 1st 2001 – 2011) as the Decade of Pain Control and Research. A critical goal of the Decade of Pain initiative was to maximize the public and professional understanding of pain and pain management. Approximately 20% of adult Europeans suffer from chronic pain of moderate to severe intensity, seriously affecting the quality of their social and working lives. Neuropathic pain is thought to be a particularly distressing chronic pain condition that is often under-diagnosed and under-treated. Neuropathic pain has been defined as pain arising as a direct consequence of a lesion or disease affecting the somatosensory system, and is often therapy resistant for reasons largely unknown. Pain intensity and duration are reported to be higher in comparison to chronic pain without neuropathic characteristics. Recently published studies involving epidemiological surveys in Europe suggested neuropathic pain to have a prevalence of 7–8% in the general population. Approximately 3-5% of all patients involved in peripheral nerve injury develop a symptomatic neuroma. In the Netherlands, there are approximately 3.5/100,000 or 580 new cases of neuropathic pain caused by traumatic or iatrogenic nerve injury every year

Insufficient pain relief after surgical neuroma treatment: Prognostic factors and central sensitisation

Background: Treatment of patients with neuromatous pain is difficult. Numerous treatment methods have been described, but none has been completely effective in providing sufficient pain relief. Patient-specific prognostic factors, predicting pain after surgical neuroma treatment, can help clinicians in the process of patient treatment and care. Methods: A computerised bibliographical database (PubMed Medline) was searched for articles concerning prognostic factors predicting the outcome of surgical neuroma treatment, and all the reference lists were checked. Results: Evidence for predicting the outcome was found for neuromas of the radial sensory branch and digital nerves, discrete nerve syndrome, workers compensation, employment status, litigation involvement, duration of pain and number of previous operations. Psychosocial problems are often found in neuroma patients. In chronic neuropathic pain patients, changes in the central nervous system at the level of spinal cord and in the somatosensory cortex can be found. Conclusions: Neuromas of the radial sensory branch and digital nerves, discrete nerve syndrome, workers' compensation, employment status, litigation involvement, duration of pain and number of previous operations appear to predict the amount of pain after neuroma surgery. However, in a minority of patients, a bad outcome cannot be explained by these factors; in these patients, central sensitisation and psychosocial factors may play a role in maintaining pain. Research focussing on prognostic factors and the central changes induced by painful peripheral injury can lead to new and improved clinical treatment algorithms for the relief and prevention of chronic neuropathic pain. (C) 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved

Cold Intolerance in Surgically Treated Neuroma Patients: A Prospective Follow-Up Study

Purpose Cold intolerance may impose great changes on patients' lifestyle, work, and leisure activities, and it is often severely disabling. This study aims to investigate the prevalence and severity of cold intolerance in patients with injury-related neuromas of the upper extremity and improvement of symptoms after surgical treatment. Furthermore, we try to find predictors for cold intolerance and correlations with other symptoms. Methods Between January 2006 and February 2009, 34 consecutive patients with surgically treated neuroma-specific neuropathic pain of the upper extremities were sent a questionnaire composed of general questions concerning epidemiologic variables and several specific validated questionnaires, including the Visual Analog Scale for pain. To estimate the prevalence of cold intolerance objectively in neuroma patients, we used the validated CISS (Cold Intolerance Symptom Severity) questionnaire with a prespecified cutoff point. Results The CISS questionnaire was filled out by 33 patients before and 30 after surgery for neuroma-specific neuropathic pain, with a mean follow-up time of 24 months. We found a prevalence of cold intolerance of 91% before surgery, with a mean CISS score above the cutoff point for abnormal cold intolerance. After surgery, the prevalence of cold intolerance and the mean CISS score were not significantly different, whereas the mean Visual Analog Scale score decreased significantly (p < .01). CISS scores were lower in patients with neuromas associated with sharp injury of the peripheral nerve (p = .02). A higher VAS score correlated significantly with a higher CISS score (p = .01). Conclusions Cold intolerance is a difficult and persistent problem that has a high prevalence in patients with a painful injury-related neuroma. There seems to be a relationship between severity of cold intolerance as measured by CISS, pain as measured by the Visual Analog Scale, and type of injury. Cold intolerance may not disappear with time or surgical treatment. (J Hand Surg 2009;34A: 1689-1695. Copyright (c) 2009 by the American Society for Surgery of the Hand. All rights reserved.

Surgical management of neuroma pain: A prospective follow-up study

Painful neuromas can cause severe loss of function and have great impact on the daily life of patients. Surgical management remains challenging; despite improving techniques, success rates are low. To accurately study the success of surgical neuroma treatment and factors predictive of outcome, a prospective follow-up study was performed. Between 2006 and 2009, pre- and post-operative questionnaires regarding pain (VAS, McGill), function (DASH), quality of life (SF-36), symptoms of psychopathology (SCL-90), epidemiologic determinants and other outcome factors were sent to patients surgically treated for upper extremity neuroma pain. Pain scores after diagnostic nerve blocks were documented at the outpatient clinic before surgery. Thirty-four patients were included, with an average follow up time of 22 months. The mean VAS score decreased from 6.8 to 4.9 after surgery (p < 0.01), 19 (56%) of patients were satisfied with surgical results. Upper extremity function improved significantly (p = 0.001). Neuroma patients had significantly lower quality of life compared to a normal population. Employment status, duration of pain and CRPS symptoms were found to be prognostic factors. VAS scores after diagnostic nerve block were predictive of post-operative VAS scores (p = 0.001). Furthermore, smoking was significantly related to worse outcome (relative risk: 2.10). The results could lead to improved patient selection and treatment strategies. If a diagnostic nerve block is ineffective in relieving pain, patients will most likely not benefit from surgical treatment. Patients should be encouraged to focus on activity and employment instead of their symptoms. Smoking should be discouraged in patients who will undergo surgical neuroma treatment. (C) 2010 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved

HIGH-RESOLUTION ULTRASONOGRAPHY OF THE CUTANEOUS NERVE BRANCHES IN THE HAND AND WRIST

Ultrasonography can be used in the diagnosis of various neuropathies, including nerve injury. Nerves often involved in traumatic and iatrogenic injury are small cutaneous branches in the hand and wrist, which cannot be seen in detail using current ultrasound probes. This study explored the potential of high-resolution ultrasonography in seeing these nerve branches in the human. The VisualSonics Vevo 770 system with a 15-82.5 MHz probe was compared to a commonly used 5-12 MHz probe and ultrasound machine. The accuracy was validated by ultrasound guided dye injection into cadaver nerves, with subsequent anatomical dissection and verification. Results were confirmed in two healthy volunteers. The Vevo 770 system was able to accurately identify the small cutaneous nerves. It could also depict the median nerve and its fascicles in greater detail. This may be useful for clinical diagnosis, localisation and follow-up of neuropathies and nerve injuries

Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer: a prognostic model to guide treatment selection

BACKGROUND: Brachytherapy was found to be preferable to metal stent placement for the palliation of dysphagia because of inoperable esophageal cancer in the randomized SIREC trial. The benefit of brachytherapy, however, only occurred after a relatively long survival. The objective is to develop a model that distinguishes patients with a poor prognosis from those with a relatively good prognosis. METHODS: Survival was analyzed with Cox regression analysis. Dysphagia-adjusted survival (alive with no or mild dysphagia) was studied with Kaplan-Meier analysis. Patient data is from the multicenter, randomized, controlled trial (SIREC, n = 209) and a consecutive series (n = 396). Patients received a stent or single-dose brachytherapy. RESULTS: Significant prognostic factors for survival included tumor length, World Health Organization performance score, and the presence of metastases (multivariable p < 0.001). A simple score, which also included age and gender, could satisfactorily separate patients with a poor, intermediate, and relatively good prognosis within the SIREC trial. For the poor prognosis group, the difference in dysphagia-adjusted survival was 23 days in favor of stent placement compared with brachytherapy (77 vs. 54 days, p = 0.16). For the other prognostic groups, brachytherapy resulted in a better dysphagia-adjusted survival. CONCLUSIONS: A simple prognostic score may help to identify patients with a poor prognosis in whom stent placement is at least equivalent to brachytherapy. If further validated, this score can provide an evidence-based tool for the selection of palliative treatment in esophageal cancer patient