胫神经腓肠肌运动分支乙醇溶解术治疗脑卒中后痉挛性垂足的初步研究

目的观察胫神经运动神经分支乙醇溶解术对脑卒中患者腓肠肌痉挛和步行功能的影响。方法符合条件的18例患者被收入本研究，应用BTL公司的5000e型电诊断仪在体表探测定位，然后应用无水乙醇进行运动分支神经溶解术。每一点的最大剂量不能超过1ml。结果注射后腓肠肌痉挛的各项指标均立即好转，疗效至少维持6个月；10m步行速度观察，在治疗后1个月有所改善，但没有达到统计学意义，治疗后3个月步行速度显著好于治疗前，疗效至少维持到治疗后6个月。不良反应的发生率很低，且多数为可恢复的。结论腓肠肌胫神经运动分支乙醇溶解术治疗脑卒中后腓肠肌痉挛安全有效，能显著缓解痉挛，改善患者步行功能。     

Alcohol neurolysis of the sciatic nerve in the treatment of hemiplegic knee flexor spasticity: clinical outcomes

OBJECTIVE: To study clinical outcomes after 50% to 100% alcohol neurolysis of the sciatic nerve in the treatment of chronic hemiplegic knee flexor spasticity. DESIGN: Case series using a convenience sample. SETTING: Rehabilitation teaching hospital. PATIENTS: Eight patients (mean age, 55.1 +/- 12.1 yr; mean duration to block, 4.4 +/- 3.7 mo) with chronic hemiplegia and severe spasticity (modified Ashworth scale [MAS] score < 2) secondary to cerebrovascular accidents (n = 5) and traumatic brain injuries (n = 3). Two patients were ambulant, 6 were wheelchair-bound. INTERVENTIONS: Fifty percent to 100% alcohol neurolysis of the sciatic nerve using repetitive electric stimulation to localize the sciatic nerve. MAIN OUTCOME MEASURES: MAS score, gain in knee range of motion (ROM), and visual inspection of gait at 0, 1, and 6 months postneurolysis. Nonparametric tests were used in statistical analysis. RESULTS: The mean preinjection MAS score was 2.8 +/- 0.7, which improved to 1.4 +/- 0.7 at 1 month (p = .005), and 1.8 +/- 0.9 (p = .01) and 1.9 +/- 1.1 (p = .02) at 3 and 6 months postinjection, respectively. The mean gain in knee ROM was 34.4 degrees +/- 15.7 degrees at 1 month postinjection and was maintained at 6 months postinjection. Improvements in gait were noted in both ambulant patients, and improved positioning in 3 of 6 wheelchair-bound patients. The incidence of dysesthetic pain was 0%. CONCLUSION: Fifty percent to 100% alcohol neurolysis of the sciatic nerve is a safe and effective method for treatment of hemiplegic knee flexor spasticity, with therapeutic effects lasting 6 months.     

Immediate and long-term phantom limb pain in amputees: incidence, clinical characteristics and relationship to pre-amputation limb pain

In a prospective study 58 patients undergoing limb amputation were interviewed the day before operation about their pre-amputation limb pain and 8 days, 6 months and 2 years after limb loss about their stump and phantom limb pain. All but one patient had experienced pain in the limb prior to amputation. Pre-amputation limb pain lasted less than 1 month in 25% of patients and more than 1 month in the remaining 75% of patients. At the first examination the day before amputation 29% had no limb pain. The incidence of phantom pain 8 days, 6 months and 2 years after amputation was 72, 65 and 59%, respectively. Within the first half year after limb loss phantom pain was significantly more frequent in patients with long-lasting pre-amputation limb pain and in patients with pain in the limb immediately prior to amputation. Phantom pain and pre-amputation pain were similar in both localization and character in 36% of patients immediately after amputation but in only 10% of patients later in the course. Both the localization and character of phantom pain changed within the first half year; no further change occurred later in the course. The incidence of stump pain 8 days, 6 months and 2 years after limb loss was 57, 22 and 21%, respectively. It is suggested that preoperative limb pain plays a role in phantom pain immediately after amputation, but probably not in late persistent phantom pain.     

A Retrospective Trial Comparing the Effects of Different Anesthetic Techniques on Phantom Pain After Lower Limb Amputation

Background

Pain and other sensations from an amputated or absent limb, called phantom pain and phantom sensations, are well-known phenomena.

Objective

The aim of this retrospective study was to evaluate the effects of anesthetic techniques on phantom pain, phantom sensations, and stump pain after lower limb amputation.

Methods

Ninety-two patients with American Society of Anesthesiologists physical status I to III were analyzed for 1 to 24 months after lower limb amputation in this retrospective study. Patients received general, spinal, or epidural anesthesia or peripheral nerve block for their amputations. Standardized questions were used to assess phantom limb pain, phantom sensation, and stump pain postoperatively. Pain intensity was assessed on a numeric rating scale (NRS) of 0 to 10. Patients' medical histories were determined from hospital records.

Results

Patients who received epidural anesthesia and peripheral nerve block perceived significantly less pain in the week after surgery compared with patients who received general anesthesia and spinal anesthesia (NRS [SD] values, 2.68 [1.0] and 2.70 [1.0], respectively). After approximately 14 to 17 months, there was no difference in phantom limb pain, phantom sensation, or stump pain among the anesthetic techniques for amputation.

Conclusions

In patients undergoing lower limb amputation, performing epidural anesthesia or peripheral nerve block, instead of general anesthesia or spinal anesthesia, might attenuate phantom and stump pain in the first week after operation. Anesthetic technique might not have an effect on phantom limb pain, phantom sensation, or stump pain at 14 to 17 months after lower limb amputation.     

Pulsed Radiofrequency Under Ultrasound Guidance for Persistent Stump‐Neuroma Pain

Limb amputation is a leading cause of pain and disability. Limb amputation can be associated with a myriad of symptoms, including phantom limb sensation, phantom limb pain, and stump pain. Treatment of phantom limb pain and stump pain, remains difficult, therefore optimal management must include a multidisciplinary approach. This case report describes the use of ultrasound for diagnosis and successful management, of persistent stump‐neuroma pain, using pulsed radiofrequency ablation.     

Phantom limb pain: a report of two cases

The efficacy of pre-emptive analgesia for phantom limb pain is still unclear. It is generally accepted that pre hyphen;amputation pain increases the incidence of phantom and stump pain, even if pre-emptive analgesia is performed before and during surgery and in the postoperative period. Two cases of traumatic upper limb amputations are described here with no pre-existing pain. Both received similar antinociceptive treatment by continuous block of the brachial plexus through infusion of ropivacaine 0.375% at 5 ml/h for 10 days. Treatment of case 1 was initiated immediately after surgery; however, this amputee developed intensive phantom limb pain which persisted at 6 months. Early use of the prosthesis after surgery was not possible for this patient. The intensity of phantom limb pain in case 2 decreased significantly after 6 months, even though brachial plexus blockade was not started until 5 weeks post-trauma. This patient used a functional prosthesis intensively beginning early after amputation. Serial magnetoencephalographic recordings were performed in both patients. Only case 2 showed significant changes of cortical reorganization. In case 1 markedly less cortical plasticity was found. A combination of relevant risk factors such as a painful neuroma, behavioural and cognitive coping strategies and the early functional use of prostheses are discussed as important mechanisms contributing to the development of phantom pain and cortical reorganization.     

Headache after resection of acoustic neuroma

Long-lasting severe headaches are reported to occur in up to 83% of patients who have undergone resection of acoustic neuroma, especially through a suboccipital approach. These headaches, however, are not well defined. The objective of this study was to assess the frequency and character of new-onset headaches after resection of acoustic neuroma by a suboccipital approach with cranioplasty. Review of the medical record was followed by a telephone interview with 48 patients (67% female; mean age, 52 years) who had undergone resection of an acoustic neuroma through a suboccipital craniotomy during the 2 years before the study. Of the 48 patients, 58% had post-operative head pain that lasted more than 7 days and could be categorized into two types. A moderate to severe, short-term head pain with gradual resolution occurred in 35% of the patients, and a mild, unremitting pain was reported by 23%. Both types of pain had a dull ache or pressure quality and were adjacent to or confined to the incisional area. Overall, 77% of the patients were pain-free within 4 months after operation. Age, sex, tumor size, or preoperative history of headache did not influence development of the postoperative pain.
We found that new-onset headache after resection of acoustic neuroma by a suboccipital approach with cranioplasty is much less common than previously reported and is best described as mild incisional pain rather than a severe headache. The literature regarding headaches after different surgica1 approaches for acoustic neuroma resection is reviewed, and possible explanations for development of the pain are discussed.     

Relationship between mechanical sensitivity and postamputation pain: a prospective study.

Limb amputation is followed by stump and phantom pain in a large proportion of amputees and postamputation pain may be associated with signs of hyperexcitability such as hyperalgesia to mechanical stimulation. The present study examined the possible relationship between mechanical pain threshold of the limb and early (after 1 week) and late (after 6 months) phantom pain. Thirty-five patients scheduled for amputation of the lower limb were examined before, 1 week and 6 months after amputation. On all three examination days pressure-pain thresholds were measured and compared with the simultaneous recording of ongoing pain intensity assessed on a visual analogue scale (VAS). There was a weak but significant inverse relationship between preamputation thresholds and early stump and phantom pain. There was no relationship between preamputation thresholds and late stump and phantom pain. One week after amputation there was a significant and inverse relationship between mechanical thresholds and phantom pain but no relationship was found after 6 months. The findings suggest that although tenderness of the limb before and after amputation is related to early stump and phantom pain, the relationship is weak. Neuronal sensitization peripherally or centrally may play a role in the development of phantom pain.     

Phantom limb, phantom pain and stump pain in amputees during the first 6 months following limb amputation

The incidence and clinical picture of non-painful and painful phantom limb sensations as well as stump pain was studied in 58 patients 8 days and 6 months after limb amputation. The incidence of non-painful phantom limb, phantom pain and stump pain 8 days after surgery was 84, 72 and 57%, respectively. Six months after amputation the corresponding figures were 90, 67 and 22%, respectively. Kinaesthetic sensations (feeling of length, volume or other spatial sensation of the affected limb) were present in 85% of the patients with phantom limb both immediately after surgery and 6 months later. However, 30% noticed a clear shortening of the phantom during the follow-up period; this was usually among patients with no phantom pain. Phantom pain was significantly more frequent in patients with pain in the limb the day before amputation than in those without preoperative limb pain. Of the 67% having some phantom pain at the latest interview 50% reported that pains were decreasing. Four patients (8%), however, reported that phantom pains were worse 6 months after amputation than originally. During the follow-up period the localization of phantom pains shifted from a proximal and distal distribution to a more distal localization. While knifelike, sticking phantom pains were most common immediately after surgery, squeezing or burning types of phantom pain were usually reported later in the course. Possible mechanisms for the present findings either in periphery, spinal cord or in the brain are discussed.     

A randomised double blind trial of the effect of pre-emptive epidural ketamine on persistent pain after lower limb amputation

Persistent pain has been reported in up to 80% of patients after limb amputation. The mechanisms are not fully understood, but nerve injury during amputation is important, with evidence for the crucial involvement of the spinal N-methyl d-aspartate (NMDA) receptor in central changes. The study objective was to assess the effect of pre-emptively modulating sensory input with epidural ketamine (an NMDA antagonist) on post-amputation pain and sensory processing. The study recruited 53 patients undergoing lower limb amputation who received a combined intrathecal/epidural anaesthetic for surgery followed by a randomised epidural infusion (Group K received racemic ketamine and bupivacaine; Group S received saline and bupivacaine). Neither general anaesthesia nor opioids were used during the peri-operative period. Pain characteristics were assessed for 12 months. The primary endpoint was incidence and severity of post-amputation pain. Persistent pain at one year was much less in both groups than in comparable studies, with no significant difference between groups (Group K=21% (3/14) and 50% (7/14); and Group S=33% (5/15) and 40% (6/15) for stump and phantom pain, respectively). Post-operative analgesia was significantly better in Group K, with reduced stump sensitivity. The intrathecal/epidural technique used, with peri-operative sensory attenuation, may have reduced ongoing sensitisation, reducing the overall incidence of persistent pain. The improved short-term analgesia and reduced mechanical sensitivity in Group K may reflect acute effects of ketamine on central sensitisation. Longer term effects on mood were detected in Group K that requires further study.     

Reflex sympathetic dystrophy of the stump in below-knee amputees.

OBJECTIVE: To document the occurrence of reflex sympathetic dystrophy of the stump in two patients with below-knee amputation. DESIGN: A retrospective survey emphasising two clinical case reports. SETTING: Department of orthopaedic rehabilitation at a teaching rehabilitation hospital. PATIENTS: Lower limb amputees (n = 164) were accepted for prosthetic rehabilitation. Twenty-one amputees were regarded as rehabilitation failures; in two below-knee amputees intractable pain was the major problem. RESULTS: Clinical manifestations, radiological, and scintigraphic findings in the two amputees with intractable pain met the criteria for diagnosis of reflex sympathetic dystrophy. CONCLUSIONS: Reflex sympathetic dystrophy of the stump should be suspected in below-knee amputees whenever severe pain persists over a period of 3 to 4 months following amputation.     

21. Phantom Pain

Abstract: Phantom pain is pain caused by elimination or interruption of sensory nerve impulses by destroying or injuring the sensory nerve fibers after amputation or deafferentation. The reported incidence of phantom limb pain after trauma, injury or peripheral vascular diseases is 60% to 80%. Over half the patients with phantom pain have stump pain as well. Phantom pain can also occur in other parts of the body; it has been described after mastectomies and enucleation of the eye. Most patients with phantom pain have intermittent pain, with intervals that range from 1 day to several weeks. Even intervals of over a year have been reported. The pain often presents itself in the form of attacks that vary in duration from a few seconds to minutes or hours. In most cases, the pain is experienced distally in the missing limb, in places with the most extensive innervation density and cortical representation. Although there are still many questions as to the underlying mechanisms, peripheral as well as central neuronal mechanisms seem to be involved. Conservative therapy consists of drug treatment with amitriptyline, tramadol, carbamazepine, ketamine, or morphine. Based on the available evidence some effect may be expected from drug treatment. When conservative treatment fails, pulsed radiofrequency treatment of the stump neuroma or of the spinal ganglion (DRG) or spinal cord stimulation could be considered (evidence score 0). These treatments should only be applied in a study design.     

乙醇和酚甘油皮下注射对实验兔皮肤的影响研究

目的：研究不同浓度乙醇和酚甘油皮下注射对实验兔皮肤的影响，探讨皮下注射神经毁损药物是否会导致皮肤结构的严重损害这一涉及临床安全的问题。方法：实验兔皮下分别注射50％、75％、99．5％乙醇或7．5％、15％酚甘油各2ml。观察实验兔笼养期间皮肤外观和行为改变以及注药后1周、1月、3月皮肤病理改变。结果：50％、75％乙醇注射区仅出现轻度的皮肤和皮下改变，而99．5％乙醇、7．5％酚甘油和15％的酚甘油引起大部分实验兔注射区皮肤的溃烂或坏死，这些改变在一个月内很难修复愈合。实验兔在进食、精神状态等方面无显著异常。结论：外周皮下小神经损毁使用50％或75％的乙醇是安全的，而无水乙醇、7．5％、15％的酚甘油则不能使用。     

MRI and leg stump neuroma]

OBJECTIVE: To describe RMI aspects of leg stump neuroma and to evaluate RMI scan interest for neuroma diagnosis and management.POPULATION AND METHOD: During a 2 years period, 224 amputated patients consulting for pain or prostetics problems were studied. In 10 cases, a characteristic pain leads to neurona diagnosis. This is described as a sensation of ascending or descending electric shock induced by the stimulation of an identified point with a reproducible topography. In all these cases, RMI scans were performed. In thirty two other cases, a RMI scan was performed to confirm a pathology (bursitis, bone abnormality) or in order to establish an etiologic diagnosis. Twelve neuromas were diagnosed.RESULTS: RMI scan showed a neuroma in the ten cases with a clinical suspicion and two asymptomatic neuromas were diagnosed out of the 32 patients without clinical suspicion. Medium delay between amputation and neuroma diagnosis is 11,6 year. In six cases, staking was modified and in six other cases, surgery was necessary. In aIl cases, clinical manifestations disappeared. Vanous RMI aspects ofneuromas are described and illustrated. Neuroma is observed on the extremity of a nerve that have a wavy aspect on its top. The neuroma is an oblong structure, with clear limits. There is an hyposignal with Ti sequence and variable signal with T2 and after gadolinium injection.DISCUSSION: RMI scan is a good way to diagnose amputee neuroma. It makes it possible to demonstrate the pathological character of the neuroma. It has to be performed when a neuroma is suspected. It enables to confirm the diagnosis and establish the exact topography and anatomic connection. Mechanical strains role as a factor of discovering the neuroma is discussed because of the concomitant evolution of associated lesions (bursitis, bone edema).Surgical repair takes place after correcting abnormal mechanical strains.     

截肢时神经断端肌肉内埋入预防残端神经瘤

目的探讨截肢时将神经近断端埋入肌肉预防残端神经瘤的机制,报告该手术方法的临床疗效。方法用此方法预防神经瘤的形成23例41个神经断端。根据患者术后的自我满意程度,有无自发性疼痛,局部有无触痛和Tinel征,对术后效果做出评价。结果23例患者,术后随访时间为2个月～10年,无自发性疼痛,局部无触痛。患者满意。结论神经近断端肌肉内埋入是一有效的预防残端神经瘤形成的方法。此方法疗效高,操作简单。     

Occipital Nerve Release in Patients With Whiplash Trauma and Occipital Neuralgia

The results of 18 greater occipital nerve release operations in 13 patients were analyzed. All patients had deep aching pain in the occipital area due to a whiplash trauma, and in all cases the pain was relieved temporarily by local anesthesia of the occipital nerve. The time from accident to operation was 6 to 96 months. The results of 13 (72.2%) operations were reported as good or excellent, although complete pain relief was not attained in any patient. It is concluded that neurolysis of the greater occipital nerve after whiplash injury can give meaningful pain relief in selected patients.     

Transcutaneous Electrical Nerve Stimulation for Phantom Pain and Stump Pain in Adult Amputees

Abstract Following amputation, 50% to 90% of individuals experience phantom and/or stump pain. Transcutaneous electrical nerve stimulation (TENS) may prove to be a useful adjunct analgesic intervention, although a recent systematic review was unable to judge effectiveness owing to lack of quality evidence. The aim of this pilot study was to gather data on the effect of TENS on phantom pain and stump pain at rest and on movement. Ten individuals with a transtibial amputation and persistent moderate‐to‐severe phantom and/or stump pain were recruited. Inclusion criteria was a baseline pain score of ≥3 using 0 to 10 numerical rating scale (NRS). TENS was applied for 60 minutes to generate a strong but comfortable TENS sensation at the site of stump pain or projected into the site of phantom pain. Outcomes at rest and on movement before and during TENS at 30 minutes and 60 minutes were changes in the intensities of pain, nonpainful phantom sensation, and prosthesis embodiment. Mean (SD) pain intensity scores were reduced by 1.8 (1.6) at rest (P < 0.05) and 3.9 (1.9) on movement (P < 0.05) after 60 minutes of TENS. For five participants, it was possible to project TENS sensation into the phantom limb by placing the electrodes over transected afferent nerves. Nonpainful phantom sensations and prosthesis embodiment remained unchanged. This study has demonstrated that TENS has potential for reducing phantom pain and stump pain at rest and on movement. Projecting TENS sensation into the phantom limb might facilitate perceptual embodiment of prosthetic limbs. The findings support the delivery of a feasibility trial.     

IRM et névromes des moignons damputation des membres inférieursMRI and leg stump neuroma.

OBJECTIVE: To describe RMI aspects of leg stump neuroma and to evaluate RMI scan interest for neuroma diagnosis and management.POPULATION AND METHOD: During a 2 years period, 224 amputated patients consulting for pain or prostetics problems were studied. In 10 cases, a characteristic pain leads to neurona diagnosis. This is described as a sensation of ascending or descending electric shock induced by the stimulation of an identified point with a reproducible topography. In all these cases, RMI scans were performed. In thirty two other cases, a RMI scan was performed to confirm a pathology (bursitis, bone abnormality) or in order to establish an etiologic diagnosis. Twelve neuromas were diagnosed.RESULTS: RMI scan showed a neuroma in the ten cases with a clinical suspicion and two asymptomatic neuromas were diagnosed out of the 32 patients without clinical suspicion. Medium delay between amputation and neuroma diagnosis is 11,6 year. In six cases, staking was modified and in six other cases, surgery was necessary. In aIl cases, clinical manifestations disappeared. Vanous RMI aspects ofneuromas are described and illustrated. Neuroma is observed on the extremity of a nerve that have a wavy aspect on its top. The neuroma is an oblong structure, with clear limits. There is an hyposignal with Ti sequence and variable signal with T2 and after gadolinium injection.DISCUSSION: RMI scan is a good way to diagnose amputee neuroma. It makes it possible to demonstrate the pathological character of the neuroma. It has to be performed when a neuroma is suspected. It enables to confirm the diagnosis and establish the exact topography and anatomic connection. Mechanical strains role as a factor of discovering the neuroma is discussed because of the concomitant evolution of associated lesions (bursitis, bone edema).Surgical repair takes place after correcting abnormal mechanical strains.     

Treatment of phantom pain with botulinum-toxin A. A pilot study

BACKGROUND: Therapy of phantom pain following amputation is still difficult, since pathophysiological mechanisms are not clarified. Botulinum-toxin A never has been used for this issue. We report four successfully treated cases with chronic phantom pain longer than 3 years. METHODS: We injected 100 IU botulinum-toxin A (4x25 IU in 0,5 ml preservative-free saline 0.9%) in four muscle-triggerpoints of the amputation stump of each patient. All triggerpoints were painful to compression before injection, all patients reported referred sensations in the phantom-foot from at least one of them. Controls were performed by questioning and pain-diaries after 1,2 and 5 weeks. RESULTS: In all cases phantom pain was reduced about 60-80%.The three patients, who had pain attacks, reported a dramatically reduction of the number of attacks (about 90%). In two of them duration of attacks shortened from 120 to 5-10 min and a reduction of pain intensity from VAS 9 to VAS 1 and VAS 9 to VAS 2 was reported. Disorder of sleep disappeared in both affected patients within 2-3 weeks. Three patients,who could move the phantom foot (mental), had a subjective weakness a few days after botulinum-toxin A injection; in one case although injection was performed in the muscles of the femur! CONCLUSIONS: This is the first report of the use of botulinum-toxin A in the treatment of phantom pain. The contribution of the muscles in the cause of phantom pain is unclear and may be local, as a trigger of spinal reflexes or by modulation of "cortical reorganisation" after amputation. Botulinum-toxin A could work analgesic by the relaxation of the stump muscles or by modulation of neuronal transmitters, for example substance P, with an indirect influence of the CNS.     

Pain in traumatic upper limb amputees in Sierra Leone

Data on 40 upper limb amputees (11 bilateral) with regard to stump pain, phantom sensation and phantom pain is presented. All the patients lost their limbs as a result of violent injuries intended to terrorise the population and were assessed 10-48 months after the injury. All amputees reported stump pain in the month prior to interview and ten of the 11 bilateral amputees had bilateral pain. Phantom sensation was common (92.5%), but phantom pain was only present in 32.5% of amputees. Problems in translation and explanation may have influenced the low incidence of phantom pain and high incidence of stump pain. In the bilateral amputees phantom sensation, phantom pain and telescoping all showed bilateral concordance, whereas stump pain and neuromas did not show concordance. About half the subjects (56%) had lost their limb at the time of injury (primary) while the remainder had an injury, then a subsequent amputation in hospital (secondary). There was no association between the incidence of phantom pain and amputation irrespective of being primary or secondary.