gms | German Medical Science

Objective: Phantom limb pain sensation, phantom limb perception and stump pain are the three main clinical pictures of sensory reorganisation that can be observed after amputations. The first two being triggered by projection and mirror-neurons cause the patient to have sensations and to feel pain in his amputated limb. On the other hand stump pain arises from neuroma of peripheral nerves. It comes to haphazard axonal sprouting outside the boundaries of the myelin sheath at the nerve stump influenced by a lack of organisation of ion-channels, the effect of glucosaminoglycans and other modulators. Such stump neuromatous pain hinders patients from wearing their prostheses, thus determinately reducing their quality-of-life. Surgical treatment modalities vary from simple resection and capping, insertion of the nerve stump into the bone marrow via a burr-hole or centro-central short-circuiting (CCSC) and coverage with vascularized soft tissue flaps. The last decade has seen a definitive shift in the literature favoring neuromodulation for treatment of pain irrespective of the genesis. In this study we will demonstrate that CCSC between tibial and peroneal parts of the sciatic nerve is still an effective technique for the treatment of stump neuroma pain.

Method: Between 2000 and 2012 we operated 8 patients suffering from severe stump pain making them unable to wear their own prostheses (3F& 5M, age range: 28 - 71 yrs). 6 patients were amputated above and 2 below knee level. In all patients the sciatic nerve was explored at mid-thigh area much proximal to the amputation site and a short-circuit between the tibial and peroneal parts was microsurgically established. The pain quality was surveyed before and after the treatment and quantified using the quadruple visual analogue scale (qVAS). Follow-up is 1 to 11 years.

Results: The mean value of pain as quantified with the qVAS dropped from 6.75/10 points before to a 0.63/10 after surgery, thus reducing the amount of medication intake. All patients were able to wear and use their limb prostheses after surgery. We were able to confirm the observation of 3 other groups that reported their results in the 1990's.

Conclusions: Although no other data were published after 1999, our results and those of other researchers clearly demonstrate that CCSC is a good and reproducible option in the treatment of painful stump neuromas. CCSC should be strongly considered before implanting neuromodulative devices.