Current Concepts in Upper-Extremity Amputation.

Advances in motor vehicle safety, trauma care, combat body armor, and cancer treatment have enhanced the life expectancy and functional expectations of patients with upper-extremity amputations. Upper-extremity surgeons have multiple surgical options to optimize the potential of emerging prosthetic technologies for this diverse patient group. Targeted muscle reinnervation is an evolving technique that improves control of myoelectric prostheses and can prevent or treat symptomatic neuromas. This review addresses current strategies for the care of patients with amputations proximal to the wrist with an emphasis on recent advancements in surgical techniques and prostheses.

Peripheral Neuromodulation for the Treatment of Postamputation Neuroma Pain: A Case Report.

Neuroma pain can be severe, persistent, and treatment resistant. We present a case of a 37-year-old female amputee who suffered from severe neuroma pain, which had proved resistant to pharmacologic treatment, glycerol injections, spinal cord stimulation, radiofrequency thermocoagulation, and repeated surgical removals. After treatment with peripheral nerve stimulation, using a St. Jude Medical Octrode lead implanted percutaneously under ultrasound guidance close to her painful neuroma, her ongoing pain dramatically decreased from 8 to 3 on a numeric rating scale (0-10). Peripheral neuromodulation is a promising relatively new treatment that can be used for neuroma pain.

Sea urchin injuries to the hand: a case report and review of the literature.

Sea urchin injuries to the hand are uncommon. A variety of home remedies can be found on the internet and other sources for dealing with this problem in the acute setting. Many long term complications such as granulomas, arthritis, and tenosynovitis can result from a neglected sea urchin injury. We report an unusual case of a patient with a remote sea urchin injury who presented with ulnar digital nerve paresthesias. A traumatic neuroma was found on surgical exploration. We review the literature on injuries to the hand caused by sea urchins and their management. Management of sea urchin injuries to the hand with retained spines requires surgical debridement in order to prevent significant long term complications including stiffness, tenosynovitis, granulomas, and arthritis.

Vein grafts used as nerve conduits for obstetrical brachial plexus palsy reconstruction.

BACKGROUND: Limited availability of donor nerve grafts along with donor-site morbidity has stimulated research toward other alternatives for the repair of severe nerve injuries. The authors provide a comprehensive review of "tubulization" biology and share with the readers their experience with two cases of obstetrical brachial plexus paralysis where they used vein grafts with "minced" nerve tissue, to accomplish connectivity of proximal donors with distal targets. Usage of vascular tissue as conduits for nerve regeneration was first reported more than 100 years ago. It has been suggested that the vein's wall allows diffusion of the proper nutrients for nerve regeneration, acts as a barrier against ingrowth of scar, and prevents wastage of regenerating axons. METHODS: In this report, vein grafts of 2.4, 3.5, and 22 cm in length filled with minced peripheral nerve tissue were used as bridges in two cases of obstetrical brachial plexus paralysis. RESULTS: By filling the vein lumen with small pieces of nerve tissue suspended in a heparinized saline solution, a potential problem associated with vein collapse caused by compression was solved. CONCLUSION: The authors suggest that tubulization techniques should be kept in mind in clinical practice when autologous nerve grafts are insufficient for distal target connectivity or as an alternative to conventional nerve grafts for bridging certain nerve defects.

Surgical treatment of painful neuroma in medial antebrachial cutaneous nerve.

The branches of the medial antebrachial cutaneous nerve (MACN) are located at the medial site of the elbow. The MACN, especially the posterior branches, may be injured or transected during cubital tunnel surgery or other medial approaches to the elbow. Damage to the nerve can cause a neuroma, which leads to disabling pain and restriction of elbow movement. The initial treatment of the neuroma is nonsurgical, and includes local massage, desensitization, physiotherapy, and systemic medication. If after 6 months of these nonsurgical treatments there is no improvement, surgery is indicated. The authors report their experience with 12 patients treated surgically for painful neuroma by high resection of the proximal end or its implantation into the triceps muscle. After surgery there was a high success rate of pain relief and functional improvement in both elbow movement and handgrip strength.

Dolor en pie de origen simpático / Pain in the foot by sympathetic disorders

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Rapid relief of a painful, long-standing posttraumatic digital neuroma treated by transcutaneous vibratory stimulation (TVS).

A case of a patient with a painful posttraumatic digital neuroma that had been present for 13 years is presented. Treatment for the painful neuroma was twice a week for one month using transcutaneous vibratory stimulation (TVS). The patient was assessed using various tests before and after this period of treatment. There was a reduction in pain, and dexterity and strength improved. The method of treatment and the assessment techniques are described. In this case, the therapeutic benefit of the method could be clearly differentiated from the natural healing course, since no significant improvement had occurred spontaneously over many years.

Traumatic neuroma of the intestine.

A traumatic neuroma of the intestine arising at the site of a previous ileocolic anastomosis is reported. Barium enema examination showed an extramucosal mass in a patient who presented with abdominal pain, rectal bleeding, and anemia. Although rare, traumatic neuroma should be included in the differential diagnosis of an intestinal mass occurring after intestinal surgery.

The painful stump neuroma and its treatment.

Successful clinical management of symptomatic neuromas continues to present a challenge to the responsible surgeon. It is unexplained why some patients with neuromas are completely asymptomatic while others exhibit debilitating symptoms. Prevention of neuromas is paramount with precise attention to severed nerves following amputations and other surgical procedures. Once established, treatment of neuromas consists of careful patient counseling, local massage, and desensitization procedures. Sympathetic blockade with guanethidine may be beneficial in some patients. When necessary, surgical excision of the neuroma along with a combination of funiculectomy, epineurial sleeve suture ligation, and silicone capping offers the best chance for eradication. In intractable or recurrent cases and following careful patient selection, neuroma excision followed by nerve grafting combined with sympathetic blockade using guanethidine can be successful in a significant number of cases.

Painful trigger points in surgical scars.

A group of 69 patients with painful trigger points in operative scars were treated following abdominal, inguinal, lumbar, or extremity surgery. Patients undergoing thoracotomies, neurosurgical procedures, or limb amputations, and patients with neurotic features or seeking secondary gains were excluded. The diagnosis was made by finding one or more definite, consistent, tender trigger points in the scar in which total, transient relief of pain was provided by injection of bupivacaine. Repeated injections of alcohol into the trigger point proved to be a simple, safe, and effective treatment with permanent cure or marked improvement in 63 (91%) patients.