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

Abstract

OBJECTIVEChronic 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.METHODSThe 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.RESULTSElective 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.CONCLUSIONSBearing 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.