|Rehab Clinician (OT/PT)|
OBJECTIVES: Painful stump neuromas in lower limb amputees are a significant burden on a person's quality of life due to interference with wearing prostheses and therefore the ability to walk. Treating painful stump neuromas is a challenge perhaps reflected by the lack of clinical guidelines.
MATERIALS AND METHODS: A systematic review was conducted to evaluate the efficacy of all treatments tried in the management of symptomatic neuromas in the lower limb amputation stump in order to establish whether one treatment is superior.
RESULTS: Twenty-two studies were included in the final review which examined 14 different treatments both surgical and nonsurgical. Results showed that no single treatment showed superiority.
DISCUSSION: The 4 treatments that showed most promise included targeted nerve implantation, traction neurectomy, nerve-to-nerve anastomosis, and perineurial gluing. The short follow-up times and small sample sizes of the studies highlighted the need for more robust clinical studies.
This review has a clear conclusion with useful recommendations for practice.
Most Plastic surgeons are aware of both this difficult problem and the lack of evidence for superiority of any one technique of treating it. This article highlights the lack of strong evidence and also provides direction for future studies.
This manuscript is a systematic review of the literature to evaluate treatments for post amputation pain and painful stump neuromas. They considered both surgical and nonsurgical treatments and looked at outcomes after each intervention. They found 22 studies, 11 surgical/11 nonsurgical to evaluate. They noted traction neurectomy, where the nerve end is retracted into soft tissue to produce a 58% pain free F/U which averaged 37 months. Vein implantation, where the vein is transected and the nerve end is inserted and sutured end to end, to have 50% of these patients pain free after 26 months. Muscle implantation implants the nerve end into muscle. VAS pain scores using this technique were reduced from 8 to 1 with 52% pain free at 26 months. Neuroablative therapies were also assessed but found targeted nerve implantation along with traction neurectomy to have the best outcomes. This would be of interest to pain physicians but of minimal interest to practicing anesthesiologists.
Four techniques were described. They targeted nerve implantation, traction neurectomy, nerve-to-nerve anastomosis, and perineurial gluing. There is no evidence to support a superior technique.
This review gives a good overview about the treatment options and is therefore useful for the daily work. From a scientific basis, it would be desirable to have a more comparative approach in this study.
There is a very select audience for this paper. It is specific for lower limb amputations and the interventions that were successful were all surgical. It is of possible interest to PTs who treat lower limb amputees but there is very little information that can applied to most of our day to day clinical practice.
The article is interesting since different evidence for treatments is valued. Recommendations for practice and necessary demands on future research are also given.
This article is strongly medically focused and heavy on intervention and surgical management. It fails to address and appreciate the current pain sciences around the entirety of pain physiology and does not relate to other therapeutic options available for physiotherapy such as graded motor imagery, or psychosocial therapies.