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Sonographically Guided Phenol Instillation of Stump Neuroma

Leeds Teaching Hospitals NHS Trust Leeds, United Kingdom

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The description by Gruber and col leagues [1] of their experience of using sonographically guided phenol injection to manage neuroma-related phantom limb pain in patients after amputation is of considerable interest. This work represents a valuable sequel to their initial article [2] in 2004 describing the technique. However, could the authors provide further comment on the following points?

Regarding inclusion criteria, the level of pain did not appear to be set as one of the inclusion criteria. The range of the visual analog scale (VAS) before any injection for all patients was from 2 to 10. Because a score of 2 suggests minimal pain, it is unclear why patients with a score of 2 wanted to participate in the study.

It would be useful to know the time that has elapsed since amputation. Phantom and stump pain have been reported to have a natural tendency to decrease in severity with time [3]. Patients also prefer to try oral medications first before considering anesthetic, surgical, or other widely used interventions. Do Gruber et al. [1] have information on how long the patients in this study had been on oral pharmacologic agents?

We also wonder whether the protocol allowed the patients the option of not undergoing further injections if the first or second injection worked well. It is understandable that 34 patients who experienced a significant drop in pain (VAS from 9 to 2) after a single injection chose not to undergo further injections. However, it appears that 22 patients had two injections despite a fall in their VAS from 9 to 2.5 after the first injection.

Do the authors think that, for best effect, three phenol injections are required? To enhance our understanding of the need of further phenol injections after a single injection, it would be useful to know the sonographic findings of the neuroma during the second and third injections. What amount of sclerosant effect was observed? Was any difficulty encountered in subsequent injections because of the sclerosant effect of the first injection?

Finally, the Gruber et al. [1] recommendation that a phenol injection should be offered to every patient with phantom or limb pain as an initial treatment option is difficult to justify on the basis of an uncontrolled study. Further work including a randomized comparison of phenol injections with other approaches would be needed.

References

1. Gruber H, Glodny B, Kopf H, et al. Practical experience with sonographically guided phenol instillation of stump neuroma: predictors of effects, success, and outcome. AJR 2008;190 :1263 –1269[Abstract/Free Full Text]
2. Gruber H, Kovacs P, Peer S, Frischhut B, Bodner G. Sonographically guided phenol injection in painful stump neuroma. AJR2004; 182:952 –954[Free Full Text]
3. Jensen TS, Krebs B, Nielsen J, Rasmussen P. Immediate and long-term phantom limb pain in amputees: incidence, clinical characteristics and relationship to pre-amputation limb pain. Pain1985; 21:267 –278[CrossRef][Medline]

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				H. Gruber, B. Glodny, and S. Peer Reply Am. J. Roentgenol., November 1, 2008; 191(5): W209 - W209. [Full Text] [PDF]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Sivan, M. Articles by Stoppard, E. Search for Related Content PubMed PubMed Citation Articles by Sivan, M. Articles by Stoppard, E. Social Bookmarking                      What's this? Hotlight (NEW!) What's Hotlight?