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Technical Innovation |
1 Department of Radiodiagnostics, University Hospital Innsbruck, Anichstrasse
35, Innsbruck 6020, Austria.
2 Department of Orthopaedics, University Hospital Innsbruck, Innsbruck 6020,
Austria.
Received August 15, 2003;
accepted after revision September 26, 2003.
Address correspondence to G. Bodner.
Introduction
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Painful neuromas may be treated surgically [1]. The best results are achieved by using sonographic guidance to mark the formations and minimize tissue damage during the operation [2] or by using chemical axonotmesis, which is the injection of therapeutic agents to cause focal degeneration of axons. Central nervous system processes have been proposed as causes of neuroma pain [3], but no clinical explanation for its origin is generally accepted yet.
Steroid agents can help in the treatment of neuromas by decreasing inflammatory reactions and loosening the connective tissue that surrounds and possibly compromises the nerve [4]. Intramuscular injections of phenol and type A Clostridium botulinum toxin are used to treat spasticity, and peri- and intraneural injections are used to treat pain. Westerlund et al. [5] showed that phenol produced focal swelling of the nerve after intrafascicular and extrafascicular intramural injection and caused severe demyelination, axonal degeneration, edema, and hemorrhage, which finally led to complete architectural nerve disruption. Glycerol works similarly on the nerves but is less effective [5] because its high viscosity makes it difficult to inject through a fine needle. Alcohol has a slower action, is more irritating to adjacent tissues (has more sclerosing effects), and is more likely to cause painful neuritis [6].
Sonography has become a preferred technique for the visualization of even small pathologic alterations in peripheral nerves and localized nerve conditions [7, 8]. We describe here a minimally invasive technique for treating painful stump neuromas after limb amputation.
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Phenol injection was performed according to the following algorithm, after informed written consent was obtained from each subject: Patients were placed in a convenient position for the intervention, which varied with the location of the neuroma. The region of interest was cleansed, sterile coverage was placed over the probe and the patient, and a local anesthetic was administered subcutaneously (Figs. 1A and 1B) using a sterile 0.9 x 40 mm 21-gauge needle (Microlance 3, Becton Dickinson). The needle was advanced toward the nerve of concern and slightly proximal to the stump neuroma. Identification of the pain-causing neuroma was considered successful if the patient responded with complete cessation of pain after the injection. Fifteen milliliters of local anesthetic was administered with sonographic guidance around the nerve proximal to the neuroma.
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Next, the same needle was advanced into the nerve proximal to the neuroma under direct visual control in the scanning plane and used to inject 0.3–1 mL of 80% phenolic solution consisting of 8.0 g of crystalline phenol in 2.0 mg of distilled water prepared by our pharmacist. When the injection of the nerve was successful, an artificial swelling could be observed sonographically (Figs. 1C and 1D). Phenol injections usually provoked a slight burning pain, although they were performed with the patient under local anesthesia.
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After injection and during retraction, the needle was flushed with saline (Natrium chloratum, Fresenius Kabi) to avoid inadvertent spreading of phenol in the adjacent tissue.
A follow-up sonogram of each patient was obtained within 1 week after the intervention or whenever success was considered insufficient on clinical follow-up. A second injection was performed in two patients who showed insufficient outcomes after 40 and 67 days, respectively.
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In three patients, the reduction in neuroma-induced pain was only transient and slight, beginning when the effects of the local anesthetic wore off. These patients refused to undergo a second injection. Sonographic follow-up a month later showed that the echogenicity and shape of their neuromas had not markedly changed.
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We prefer sonographically guided phenol injection over any surgical procedure with its possible complications and poor outcomes [1] because of the long-lasting success in seven of our patients (including the two who underwent a second injection) and the lack of inadvertent damage to the surrounding soft tissues.
In the future, we will collect and publish data on more patients, observing them over a longer time and monitoring them for success rate, possible complications, and long-term changes.
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