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      Ultrasound-guided alcohol neurolysis and radiofrequency ablation of painful stump neuroma: effective treatments for post-amputation pain

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          Abstract

          Background

          Post-amputation pain (PAP) is highly prevalent after limb amputation, and stump neuromas play a key role in the generation of the pain. Presently, PAP refractory to medical management is frequently treated with minimally invasive procedures guided by ultrasound, such as alcohol neurolysis and radiofrequency ablation (RFA).

          Objective

          To record the immediate and long-term efficacy of alcohol neurolysis and RFA. We first used alcohol neurolysis and then, when necessary, we performed RFA on PAP patients.

          Study design

          Prospective case series.

          Setting

          Pain management center.

          Methods

          Thirteen subjects were treated with ultrasound-guided procedures.

          Results

          All patients were treated with neurolysis using alcohol solutions guided by ultrasound. Seven (54%) of 13 subjects achieved pain relief after 1–3 alcohol injection treatments. The remaining 6 subjects obtained pain relief after receiving 2 administrations of ultrasound-guided RFA. After a 6-month follow-up evaluation period, pain quantities were also assessed. Both stump pain (including intermittent sharp pain and continuous burning pain) and phantom pain were relieved. The frequency of intermittent sharp pain was decreased, and no complications were noted during the observation.

          Conclusion

          The use of ultrasound guidance for alcohol injection and RFA of painful stump neuromas is a simple, radiation-free, safe, and effective procedure that provides sustained pain relief in PAP patients. In this case series, RFA was found to be an effective alternative to alcohol injection.

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          Most cited references 14

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          Phantom limb pain: a case of maladaptive CNS plasticity?

          Phantom pain refers to pain in a body part that has been amputated or deafferented. It has often been viewed as a type of mental disorder or has been assumed to stem from pathological alterations in the region of the amputation stump. In the past decade, evidence has accumulated that phantom pain might be a phenomenon of the CNS that is related to plastic changes at several levels of the neuraxis and especially the cortex. Here, we discuss the evidence for putative pathophysiological mechanisms with an emphasis on central, and in particular cortical, changes. We cite both animal and human studies and derive suggestions for innovative interventions aimed at alleviating phantom pain.
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            A prospective randomized double-blinded pilot study to examine the effect of botulinum toxin type A injection versus Lidocaine/Depomedrol injection on residual and phantom limb pain: initial report.

            Botulinum toxin type A (Botox) injection has been used to manage pain. However, it remains to be proved whether Botox injection is effective to relieve residual limb pain (RLP) and phantom limb pain (PLP). Randomized, double-blinded pilot study. Medical College and an outpatient clinic in Department of Physical Medicine and Rehabilitation. Amputees (n=14) with intractable RLP and/or PLP who failed in the conventional treatments. Study amputees were randomized to receive 1 Botox injection versus the combination of Lidocaine and Depomedrol injection. Each patient was evaluated at baseline and every month after the injection for 6 months. The changes of RLP and PLP as recorded by VAS, and the changes of the pressure pain tolerance as determined by a pressure algometer. All patients completed the protocol treatment without acute side effects, and monthly assessments of RLP, PLP, and pain tolerance after the treatment. The time trend in the outcomes was modeled as an immediate change owing to the treatment followed by a linear tread afterward. Repeated measures were incorporated using mixed effects modeling. We found that both Botox and Lidocaine/Depomedrol injections resulted in immediate improvements of RLP (Botox: P=0.002; Lidocaine/Depomedrol: P=0.06) and pain tolerance (Botox: P=0.01; Lidocaine/Depomedrol: P=0.07). The treatment effect lasted for 6 months in both groups. The patients who received Botox injection had higher starting pain than those who received Lidocaine/Depomedrol injection (P=0.07). However, there were no statistical differences in RLP and pain tolerance between these 2 groups. In addition, no improvement of PLP was observed after Botox or Lidocaine/Depomedrol injection. Both Botox and Lidocaine/Depomedrol injections resulted in immediate improvement of RLP (not PLP) and pain tolerance, which lasted for 6 months in amputees who failed in conventional treatments.
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              Prevalence and characteristics of chronic phantom limb pain among American veterans. Results of a trial survey.

              Twelve hundred American amputees who are military veterans were surveyed by questionnaire about their amputations, pain sensitivity, demography, treatment history, stump problems, phantom sensations, and phantom pain. Over sixty percent responded and of these 85 percent reported significant amounts of phantom pain. This is in sharp contrast to both the literature and our clinical experience which indicate that although most amputees seen in a clinical setting report some occasional minor discomfort due to their phantoms, only between one half percent and five percent experience severe phantom pain. There was no relationship between reasons for amputation, use of prosthesis, pain sensitivity, age, years since amputation, or other demographic variables and presence of severity of phantom pain. Those respondents describing phantom pain usually had either momentary episodes of intense, debilitating pain, or virtually continuous discomfort varying in intensity but reaching debilitating levels occasionally. The fairly continuous pains were all similar in description to magnified versions of comfortable phantom sensations reported by other respondents. Few of the reported treatments were of any value.
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                Author and article information

                Journal
                J Pain Res
                J Pain Res
                Journal of Pain Research
                Journal of Pain Research
                Dove Medical Press
                1178-7090
                2017
                03 February 2017
                : 10
                : 295-302
                Affiliations
                Pain Management Center, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, People’s Republic of China
                Author notes
                Correspondence: Dongping Du, Pain Management Center, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, No. 600, Yishan Road, Shanghai, People’s Republic of China, Tel +86 21 2405 8896, Fax +86 21 2405 8330, Email dudp@ 123456sjtu.edu.cn
                Article
                jpr-10-295
                10.2147/JPR.S127157
                5305268
                © 2017 Zhang et al. This work is published and licensed by Dove Medical Press Limited

                The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.

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                Original Research

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