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


METHODS
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.


RESULTS
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.


CONCLUSIONS
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.
Division of Reconstructive Neurosurgery, Department of Neurosurgery, Justus Liebig University, Giessen, Germany.
M Reza
MR
Boroumand
Division of Reconstructive Neurosurgery, Department of Neurosurgery, Justus Liebig University, Giessen, Germany.
Dirk
D
Schulz
Division of Reconstructive Neurosurgery, Department of Neurosurgery, Justus Liebig University, Giessen, Germany.
Eberhard
E
Uhl
Division of Reconstructive Neurosurgery, Department of Neurosurgery, Justus Liebig University, Giessen, Germany. Electronic address: k_g_krishnan@hotmail.com.
Kartik G
KG
Krishnan
D000328:Adult; D000368:Aged; D000672:Amputation Stumps / Q000601:surgery*; D000674:Amputees; D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000627:therapeutic use; D001186:Artificial Limbs; D001853:Bone Marrow / Q000601:surgery; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D009463:Neuroma / Q000188:drug therapy / Q000209:etiology / Q000601:surgery*; D010147:Pain Measurement; D010543:Peroneal Nerve / Q000601:surgery*; D012584:Sciatic Nerve / Q000601:surgery; D012585:Sciatica / Q000209:etiology / Q000601:surgery; D013524:Surgical Flaps; D013979:Tibial Nerve / Q000601:surgery*; D016896:Treatment Outcome
D000894:Anti-Inflammatory Agents, Non-Steroidal
Amputation; Centro-central short circuit; Neuromodulation; Postamputation pain; Residual limb pain; Stump neuroma pain