Sonographically Guided Phenol Injection in Painful Stump Neuroma

Percutaneous treatments for residual and/or phantom limb pain in adults with lower-extremity amputations: A narrative review

Residual limb pain (RLP) and phantom limb pain (PLP) profoundly affect the lives of many individuals who have undergone lower- or upper-extremity amputation. Despite the considerable impact of RLP/PLP on quality of life in persons with amputation, there have been few attempts to evaluate the efficacy of percutaneous interventions in the treatment of RLP and/or PLP. This narrative review evaluates the effectiveness of percutaneous treatments for RLP and/or PLP in patients after lower-extremity amputation. Peripheral nerve stimulation, alcohol neurolysis, conventional thermal radiofrequency ablation, perineural corticosteroid injection, botulinum toxin injection, and etanercept injection were associated with varying success rates. Wide confidence intervals and small treatment cohorts impede assessments of overall success. High-quality studies of nonsurgical, percutaneous treatments for RLP and/or PLP are lacking. Well-designed randomized controlled trials and large cohort studies with comparison groups using validated outcomes are needed to determine the effectiveness of nonsurgical interventions for the treatment of RLP and PLP.

Residual limb pain: An evidence-based review

Acquired limb loss, whether from accident or amputation, occurs with an incidence of greater than 175,000 per year in the United States. Current prevalence is estimated at greater than 1.5 million and is expected to double within 30 years. While many patients with amputations may have no significant pain or sensory issues after healing from the initial loss, one-quarter to one-half of patients may have ongoing difficulties with residual limb pain, phantom limb pain, or phantom limb sensation. This review explores the potential etiologies of those symptoms, as well as a variety of treatment options that a practitioner may consider when approaching this condition.

Ultrasonography of the Peripheral Nerves of the Forearm, Wrist and Hand: Definition of Landmarks, Anatomical Correlation and Clinical Implications

BACKGROUND

 Peripheral nerve pathologies of the upper extremity are increasingly assessed by high-resolution ultrasonography (HRUS), yet rapid identification of nerve segments can be difficult due to small nerve diameters and complex regional anatomy. We propose a landmark-based approach to speed up and facilitate evaluation and intervention in this region.

METHOD

 Relevant landmarks and section planes for eleven nerve segments of the forearm, wrist and hand were defined by ultrasonography in cadaver arms before cryosection and topographical neurovascular preparation. Information on all nerve segments and a pictorial guide including anatomical cross-sections, topographical preparations and HRUS images are provided. The identification rates of these nerve segments were then assessed in 20 healthy volunteers.

RESULTS AND CONCLUSION

 Sonographic landmarks and guidelines for the rapid identification and assessment of nerves of the forearm, wrist and hand are presented in pictorial and tabular form, including discussion of normal variants. Utilizing this overview should facilitate training, diagnostic examinations and intervention for nerves of the upper extremity.

KEY POINTS

  · High-resolution ultrasound enables assessment of peripheral nerves of the forearm, wrist and hand.. · A landmark-based approach can facilitate and speed up nerve evaluation in these regions.. · High detection rates could be reproduced using the proposed landmark-based approach..

CITATION FORMAT

· Gruber L, Loizides A, Peer S et al. Ultrasonography of the Peripheral Nerves of the Forearm, Wrist and Hand: Definition of Landmarks, Anatomical Correlation and Clinical Implications. Fortschr Röntgenstr 2020; 192: 1060 - 1072.

Painful Traumatic Neuromas in Subcutaneous Fat: Visibility and Morphologic Features With Ultrasound

OBJECTIVES

Subcutaneous neuromas usually result from trauma and may lead to dissatisfaction in patients with a trigger point, loss of sensitivity in the relevant territory of innervation, and spontaneous neuropathic pain. Confirming clinically suspected cases of neuroma may prove difficult. The objective of this study was to evaluate the visibility and morphologic features of traumatic subcutaneous neuromas of the limbs with ultrasound (US).

METHODS

Between January 2012 and August 2016, 38 consecutive patients clinically suspected of having subcutaneous neuromas were investigated with US. The diagnosis was confirmed on the basis of a focal morphologic abnormality of the nerve associated with trigger pain. Each neuroma was classified into 1 of 3 subtypes based on its injury pattern. The subtypes were terminal neuroma, spindle neuroma, and scar encasement, either isolated or associated with these subtypes.

RESULTS

Forty-four lesions were found in the 38 patients, including 29 spindle neuromas (65.9%), 14 terminal neuromas (31.8%) and 1 scar encasement with no nerve caliber abnormality (2.3%). Fifteen neuromas (35% of all neuromas) were associated with scar encasement. In 13 cases that required surgery, the diagnosis of neuroma or scar encasement could be surgically proven and confirmed the validity of the US findings.

CONCLUSIONS

Ultrasound can be used to show and classify subcutaneous nerves of the upper and lower limbs with high accuracy. The US trigger sign provides an indication of neuroma involvement in pain. This modality can play a substantial role both in the preoperative planning of neuroma surgery and in therapeutic US-guided procedures.

[Ultrasound-guided interventions on the peripheral nervous system]

CLINICAL/METHODICAL ISSUE

Up to the advent of high-resolution ultrasound, interventions on the peripheral nervous system, including local anesthesia and pain treatment were performed without visual guidance, which in some cases led to treatment failure or local tissue and nerve damage.

METHODICAL INNOVATIONS

Progress in the field of ultrasound has enabled the functional visualization, anesthesia and anti-inflammatory or neurolytic treatment of many peripheral nerves, such as the brachial plexus, nerves of the upper and lower extremities and various nerves of the trunk. Contrast medium-guided biopsies have also become feasible.

ACHIEVEMENTS

This article discusses the general prerequisites for such interventions and details the visualization and the interventional algorithms for interventions on the brachial plexus, on large nerves often affected by compression neuropathies, such as the median, ulnar, sciatic and femoral nerves and small nerves, such as the lateral cutaneous nerves of the thigh. Furthermore, contrast medium-aided biopsies of intraneural and perineural masses are discussed. Finally, the treatment of stump neuromas via phenol instillation is described.

PRACTICAL RECOMMENDATIONS

Innovations in high-resolution ultrasound allow the reliable and safe diagnosis and treatment of various pathologies of the peripheral nervous system with few side effects. Compared to older methods, which did not use visual guidance ultrasound provides higher success rates and lower adverse event rates in many instances.

Ultrasound-guided alcohol neurolysis and radiofrequency ablation of painful stump neuroma: effective treatments for post-amputation pain

BACKGROUND

Post-amputation pain (PAP) is highly prevalent after limb amputation, and stump neuromas play a key role in the generation of the pain. Presently, PAP refractory to medical management is frequently treated with minimally invasive procedures guided by ultrasound, such as alcohol neurolysis and radiofrequency ablation (RFA).

OBJECTIVE

To record the immediate and long-term efficacy of alcohol neurolysis and RFA. We first used alcohol neurolysis and then, when necessary, we performed RFA on PAP patients.

STUDY DESIGN

Prospective case series.

SETTING

Pain management center.

METHODS

Thirteen subjects were treated with ultrasound-guided procedures.

RESULTS

All patients were treated with neurolysis using alcohol solutions guided by ultrasound. Seven (54%) of 13 subjects achieved pain relief after 1-3 alcohol injection treatments. The remaining 6 subjects obtained pain relief after receiving 2 administrations of ultrasound-guided RFA. After a 6-month follow-up evaluation period, pain quantities were also assessed. Both stump pain (including intermittent sharp pain and continuous burning pain) and phantom pain were relieved. The frequency of intermittent sharp pain was decreased, and no complications were noted during the observation.

CONCLUSION

The use of ultrasound guidance for alcohol injection and RFA of painful stump neuromas is a simple, radiation-free, safe, and effective procedure that provides sustained pain relief in PAP patients. In this case series, RFA was found to be an effective alternative to alcohol injection.

Pulsed radiofrequency ablation under ultrasound guidance for huge neuroma

Amputation neuroma can cause very serious, intractable pain. Many treatment modalities are suggested for painful neuroma. Pharmacologic treatment shows a limited effect on eliminating the pain, and surgical treatment has a high recurrence rate. We applied pulsed radiofrequency treatment at the neuroma stalk under ultrasonography guidance. The long-term outcome was very successful, prompting us to report this case.

The utility of musculoskeletal ultrasound in rehabilitation settings

Aside from its prompt use in musculoskeletal injuries (sports lesions, degenerative/inflammatory joint disorders, and peripheral nerve pathologies), ultrasonographic imaging can be used quite conveniently in various types of rehabilitation conditions as well. If used in a rehabilitation setting, ultrasound can significantly contribute to the diagnostic/therapeutic algorithm of rehabilitation patients. Accordingly, in this article, the authors focus on the diagnostic/interventional utility of ultrasound particularly for shoulder problems, overuse injuries of wheelchair users, heterotopic ossification, amputee follow-up, peripheral nerve and botulinum toxin injections, and diaphragm imaging/electromyography.

Ultrasound-guided injection of steroid in multiple postamputation neuromas

After limb amputation, neuromas may be asymptomatic when not compressed, but can cause unexplained discomfort when a prosthesis is worn. The sonographic presentation of multiple postamputation neuromas has rarely been reported. A 40-year-old female with a left, below-elbow amputation suffered from late-onset stump pain and prosthesis intolerance. Physical examination revealed a painful nodule, whereas sonographic findings disclosed three hypoechoic masses derived from the median, ulnar, and radial nerves. Marked pain reduction was reported 2 weeks after sonography-guided steroid injection. Investigation of all damaged nerves in the residual limbs is important.

Sonographically guided alcohol injection in painful stump neuroma

Stump neuroma is a common cause of pain from disorganized proliferation of nerve fascicles occurring after limb amputation. Ultrasound guided alcohol injection in painful stump neuroma has been tried as a new treatment approach. Herein, we report 2 male patients, who had traumatic amputation and claimed severe and diffuse burning pain in the stump area. Neuroma at the distal end of an amputated nerve was clearly identified on sonography. The patients gradually developed increasing severe pain that could not be managed with conservative care. They were treated with neurolysis using alcohol solution. Using ultrasonographical guidance, 1.2 ml of 100% dehydrated alcohol was injected into the nerves proximal to neuroma. No complications occurred. The patients were initially pain free. After a few months, however, their stump pain recurred slightly. Repeat neurolysis was performed using 0.3 ml of 100% dehydrated alcohol. During the three months follow-up period, mild stump pain occurred but the patients did not require any analgesics.

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.

Neuroma in bilateral upper limb amputation

To evaluate the prevalence of neuroma in bilateral upper limb amputees and investigate the effect of level of amputation on their pain, 86 patients with bilateral upper limb amputation were thoroughly examined by an orthopedic surgeon. Of 172 bilateral amputated upper limbs (86 victims of war) 17.1+/-6.1 years after injury, physical examination revealed that 26.2% had moderate to severe stump pain and clinical signs suggestive of neuroma. Statistical analysis showed no relation between level of amputation, prosthesis usage, and occurrence of neuroma. Although high occurrence of neuroma among traumatic bilateral upper limb amputation had no significant effects on wearing prosthesis, its treatment can deeply influence alleviation of their pain and subsequently their quality of life.

Practical experience with sonographically guided phenol instillation of stump neuroma: predictors of effects, success, and outcome

OBJECTIVE

Phantom limb pain and stump pain frequently occur after limb amputation, and stump neuromas play an important role in generation of the pain. The purpose of this study was to evaluate the effects of a previously described optimized procedure for sclerosis of painful stump neuromas under real-time high-resolution sonographic guidance.

SUBJECTS AND METHODS

In this prospective study, neurosclerosis was performed on 82 patients by means of high-resolution sonographically guided injection of up to 0.8 mL of 80% phenol solution according to a standardized protocol.

RESULTS

During treatment all patients had marked improvement in terms of reduction of pain measured with a visual analog scale. Twelve (15%) of the subjects were pain free after one to three treatments, nine of the 12 achieving relief with the initial instillation. At 6-month follow-up evaluation, 52 patients assessed their present pain quantity with a simplified three-step score. Twenty (38%) of the 52 patients reported almost unnoticeable pain, and 33 (64%) reported pain equal to the minimum reached during therapy. In 18 (35%) of the 52 patients, the incidence of painful periods had markedly decreased. The neurosclerosis procedure had a low complication rate (5% rate of minor complications, 1.3% rate of major complications).

CONCLUSION

The high-resolution sonographically guided neurosclerosis procedure had a significantly better outcome than other documented treatments. Sonographically guided neurosclerosis should be included in the management of chronic phantom limb and stump pain.

[Ultrasound guided interventional radiology]

Ultrasound is a valuable imaging technique for musculoskeletal pathology. It is increasingly used for image-guided procedures such as aspiration of superficial or deep collections, injection of drugs, or biopsies. Ultrasound guidance is an interesting alternative to procedures performed either blindly or under fluoroscopic or CT guidance. Advantages of US-guided procedures include the absence of ionizing radiation, real-time monitoring during needle placement, decreased risk of injury to neighboring structures (namely vessels and nerves), real time confirmation of procedure success (injection, drainage, biopsy). Minor inconveniences relate to the proper conditions for performance of ultrasound. Complications are rare and can be avoided by using proper sterile technique and evaluate for potential contra-indications to the procedure. As with any other image guided procedure, informed consent is required.

High-resolution ultrasound of peripheral neurogenic tumors

Peripheral nerve tumors are not frequent, but due to their association with a nerve they are somewhat special. They may be encountered incidentally during evaluation of a soft-tissue mass or when a nerve lesion is clinically suspected and the recognition of such a lesion and its differential diagnosis is key for successful therapy and patient prognosis. As sonography is often the first line modality in the work-up of a soft-tissue mass, the sonographer should be aware of the typical features of such lesions in order to arrive at the correct diagnosis, and this article tries to give an overview of the histological subtypes of peripheral nerve tumors and their sonographic characteristics.

Ultrasound-guided interdigital neuroma injections: short-term clinical outcomes after a single percutaneous injection--preliminary results

PURPOSE

To describe the procedure of ultrasound-guided Morton's neuroma and recurrent stump neuroma injections and early clinical outcomes after a single injection.

MATERIALS AND METHODS

Retrospective review of 44 percutaneous ultrasound-guided neuroma injections in 24 patients who had completed clinical outcomes questionnaires. A 10-point pain scale [scale of 1 (no pain) to 10 (severe pain)] in a 7-day pain log format was distributed to patients at the time percutaneous neuroma injection was performed.

RESULTS

Neuromas were clearly visualized with sonography as hypoechoic nodules and were distinguishable from other causes of forefoot pain, such as metatarsophalangeal joint synovitis and intermetatarsal bursae. The sizes of the neuromas injected ranged between 4 and 19 mm. Postinjection, all neuromas displayed increased echogenicity and/or the appearance of fluid surrounding it, confirming localization of the therapeutic mixture. We arbitrarily subdivided the pain ratings into symptomatic (greater than 4) and asymptomatic (less than or equal to 4) for statistical analysis. Average pain level pre injection was 5.2 and average pain level was 3.7 at 7 days post single injection, with 62% of the initially symptomatic patients asymptomatic on day 7 (p < 0.000001). Overall, 76% of the total number of neuromas injected once were asymptomatic on day 7.

CONCLUSION

Ultrasound can be used to accurately target Morton's neuromas and, therefore, appropriately direct therapeutic interventions, with good short-term clinical results.

[Interventional sonography]

Diagnostic and therapeutic interventional procedures are rapidly expanding and, when guided by imaging, are more efficient then when performed with a blinded technique. Compared to fluoroscopy and CT, ultrasound does not utilize ionizing radiation. It can facilitate needle placement for arthrography, tenography or bursography or it can guide a variety of procedures such as aspiration, arthrocentesis, local steroid injections and needling of tendon calcifications. Technological improvements have increased the precision of ultrasound guidance and have contributed to reduce the risk of complication. Real time scanning allows simultaneous visualization of the target and of needle progression and has diminished the rate of complications, that are infrequent if the operator uses a strict sterile technique and respects the contraindications.