From the Department of Plastic Surgery, MedStar Georgetown University Hospital; and Georgetown University School of Medicine.
Plast Reconstr Surg. 2022 Apr 1;149(4):976-985. doi: 10.1097/PRS.0000000000008953.
Patients with major lower limb amputations suffer from symptomatic neuromas and phantom-limb pain due to their transected nerves. Peripheral nerve surgery techniques, such as targeted muscle reinnervation and regenerative peripheral nerve interface, aim to physiologically prevent this nerve-specific pain. No studies have specifically reported on which nerves most frequently cause chronic pain. The authors studied the nerve-specific incidence of symptomatic neuroma formation and phantom limb pain in patients undergoing a below-knee amputation, to better tailor use of targeted muscle reinnervation and regenerative peripheral nerve interface.
This was a retrospective review of all patients undergoing a below-knee amputation from January 1, 2013, to December 31, 2018, at MedStar Georgetown University Hospital. All below-knee amputations were performed with a posterior skin flap, myotenodesis, and traction neurectomies of all nerves. Postoperative notes were reviewed for the presence of a symptomatic neuroma, defined as localized pain and a Tinel sign over a known sensory nerve, and nerve-specific phantom limb pain, defined as pain of the missing limb corresponding to a known dermatome.
One hundred ninety-eight patients were included in this study. The rate of symptomatic neuroma formation was 14.6 percent (29 of 198), with the superficial peroneal and saphenous nerves most often involved. Diabetes and obesity were protective against symptomatic neuroma formation. The rate of nerve-specific phantom limb pain was 12.6 percent (25 of 198) and highly correlated with the presence of a symptomatic neuroma.
To optimize outcomes for amputees, it is critical that surgeons best understand what nerves are more likely to form symptomatic neuromas and lead to nerve-specific phantom limb pain, so that surgeons can best tailor primary or secondary management of the major sensory nerves.
CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.
由于下肢大截肢患者的神经被切断，他们会出现症状性神经瘤和幻肢痛。周围神经手术技术，如靶向肌肉再支配和再生周围神经界面，旨在从生理学上预防这种神经特异性疼痛。目前尚无研究专门报告哪种神经最常引起慢性疼痛。作者研究了接受膝下截肢的患者中，哪些神经最容易导致症状性神经瘤形成和幻肢痛，以便更好地调整靶向肌肉再支配和再生周围神经界面的应用。
这是对 2013 年 1 月 1 日至 2018 年 12 月 31 日期间在 MedStar Georgetown 大学医院接受膝下截肢的所有患者进行的回顾性研究。所有膝下截肢均采用后皮瓣、肌间神经吻合术和所有神经的牵引神经切除术。对术后记录进行了回顾，以确定是否存在症状性神经瘤，定义为局部疼痛和已知感觉神经上的 Tinel 征；以及神经特异性幻肢痛，定义为与已知皮节相对应的缺失肢体的疼痛。
本研究共纳入 198 例患者。症状性神经瘤形成率为 14.6%（198 例中有 29 例），最常涉及腓浅神经和隐神经。糖尿病和肥胖对症状性神经瘤的形成有保护作用。神经特异性幻肢痛的发生率为 12.6%（198 例中有 25 例），与症状性神经瘤的存在高度相关。
为了优化截肢患者的结局，外科医生必须充分了解哪些神经更有可能形成症状性神经瘤并导致神经特异性幻肢痛，以便外科医生能够更好地调整主要感觉神经的初次或二次管理。
临床问题/证据水平：风险，III 级。
