Division of Plastic and Reconstructive Surgery, University of Washington, Harborview Medical Center, 325 9th Avenue, Box 359798, Seattle, WA, 98195, USA,
Clin Orthop Relat Res. 2014 Oct;472(10):2991-3001. doi: 10.1007/s11999-014-3602-1.
Symptomatic neuroma occurs in 13% to 32% of amputees, causing pain and limiting or preventing the use of prosthetic devices. Targeted nerve implantation (TNI) is a procedure that seeks to prevent or treat neuroma-related pain in amputees by implanting the proximal amputated nerve stump onto a surgically denervated portion of a nearby muscle at a secondary motor point so that regenerating axons might arborize into the intramuscular motor nerve branches rather than form a neuroma. However, the efficacy of this approach has not been demonstrated.
QUESTIONS/PURPOSES: We asked: Does TNI (1) prevent primary neuroma-related pain in the setting of acute traumatic amputation and (2) reduce established neuroma pain in upper- and lower-extremity amputees?
We retrospectively reviewed two groups of patients treated by one surgeon: (1) 12 patients who underwent primary TNI for neuroma prevention at the time of acute amputation and (2) 23 patients with established neuromas who underwent neuroma excision with secondary TNI. The primary outcome was the presence or absence of palpation-induced neuroma pain at last followup, based on a review of medical records. The patients presented here represent 71% of those who underwent primary TNI (12 of 17) and 79% of those who underwent neuroma excision with secondary TNI (23 of 29 patients) during the period in question; the others were lost to followup. Minimum followup was 8 months (mean, 22 months; range, 8-60 months) for the primary TNI group and 4 months (mean, 22 months; range, 4-72 months) for the secondary TNI group.
At last followup, 11 of 12 patients (92%) after primary TNI and 20 of 23 patients (87%) after secondary TNI were free of palpation-induced neuroma pain.
TNI performed either primarily at the time of acute amputation or secondarily for the treatment of established symptomatic neuroma is associated with a low frequency of neuroma-related pain. By providing a distal target for regenerating axons, TNI may offer an effective strategy for the prevention and treatment of neuroma pain in amputees.
在截肢患者中，有 13%到 32%会出现症状性神经瘤，导致疼痛，并限制或阻止他们使用假肢。靶向神经植入术（TNI）是一种通过将近端截肢神经残端植入附近肌肉的手术去神经部位的二级运动点，以防止或治疗截肢患者的神经瘤相关疼痛的手术，这样再生轴突可能会分支到肌内运动神经分支中，而不是形成神经瘤。然而，这种方法的疗效尚未得到证实。
问题/目的：我们询问：TNI（1）是否在急性创伤性截肢时预防原发性神经瘤相关疼痛，（2）是否减少上肢和下肢截肢患者的已建立的神经瘤疼痛？
我们回顾性地研究了一位外科医生治疗的两组患者：（1）12 例患者在急性截肢时接受 TNI 以预防神经瘤，（2）23 例患者有已建立的神经瘤，接受神经瘤切除术和二级 TNI。主要结果是根据病历回顾，在最后一次随访时是否存在触诊诱发的神经瘤疼痛。这里介绍的患者代表在研究期间接受原发性 TNI 的患者（17 例中的 12 例）的 71%，接受神经瘤切除术和继发性 TNI 的患者（29 例中的 23 例）的 79%；其余患者失访。原发性 TNI 组的最小随访时间为 8 个月（平均 22 个月；范围，8-60 个月），继发性 TNI 组为 4 个月（平均 22 个月；范围，4-72 个月）。
在最后一次随访时，原发性 TNI 后 12 例患者中的 11 例（92%）和继发性 TNI 后 23 例患者中的 20 例（87%）无触诊诱发的神经瘤疼痛。
无论是在急性截肢时进行原发性 TNI 还是继发性 TNI 治疗已建立的症状性神经瘤，都与神经瘤相关疼痛的低发生率相关。通过为再生轴突提供远端靶标，TNI 可能为截肢患者的神经瘤疼痛的预防和治疗提供一种有效的策略。
