Burchiel K J, Johans T J, Ochoa J
Division of Neurosurgery, Oregon Health Sciences University, Portland.
J Neurosurg. 1993 May;78(5):714-9. doi: 10.3171/jns.1993.78.5.0714.
Pain following suspected nerve injury was comprehensively evaluated with detailed examination including history, neurological evaluation, electrodiagnostic studies, quantitative sensory testing, thermography, anesthetic agents, and sympathetic nerve blocks. Forty-two surgically treated patients fell into four discrete groups: Group 1 patients had distal sensory neuromas treated by excision of the neuroma and reimplantation of the proximal nerve into muscle or bone marrow; Group 2 patients had suspected distal sensory neuromas in which the involved nerve was sectioned proximal to the injury site and reimplanted; Group 3 patients had proximal in-continuity neuromas of major sensorimotor nerves treated by external neurolysis; and Group 4 patients had proximal major sensorimotor nerve injuries at points of anatomical entrapment treated by external neurolysis and transposition, if possible. Patient follow-up monitoring from 2 to 32 months (average 11 months) was possible in 40 (95%) of 42 patients. Surgical success was defined as 50% or greater improvement in pain using the Visual Analog Scale or pain relief subjectively rated as either good or excellent, without postoperative narcotic usage. Overall, 16 (40%) of 40 patients met those criteria. Success rates varied as follows: 44% in 18 Group 1 patients, 40% in 10 Group 2 patients, 0% in five Group 3 patients, and 57% in seven Group 4 patients. Twelve (30%) of 40 patients were employed both pre- and postoperatively. It is concluded that: 1) neuroma excision, neurectomy, and nerve release for injury-related pain of peripheral nerve origin yield substantial subjective improvement in a minority of patients; 2) external neurolysis of proximal mixed nerves is ineffective in relieving pain; 3) surgically proving the existence of a neuroma with confirmed excision may be preferable; 4) traumatic neuroma pain is only partly due to a peripheral source; 5) demographic and neurological variables do not predict success; 6) the presence of a discrete nerve syndrome and mechanical hyperalgesia modestly predict pain relief; 7) ongoing litigation is the strongest predictor of failure; and 8) change in work status is not a likely outcome.
对于疑似神经损伤后的疼痛，通过详细检查进行了全面评估，包括病史、神经学评估、电诊断研究、定量感觉测试、热成像、麻醉剂以及交感神经阻滞。42例接受手术治疗的患者分为四个不同组：第1组患者有远端感觉神经瘤，通过切除神经瘤并将近端神经重新植入肌肉或骨髓进行治疗；第2组患者有疑似远端感觉神经瘤，在损伤部位近端切断受累神经并重新植入；第3组患者有主要感觉运动神经的近端连续性神经瘤，通过外部神经松解术治疗；第4组患者有解剖学卡压部位的近端主要感觉运动神经损伤，如有可能，通过外部神经松解术和神经移位治疗。42例患者中有40例（95%）进行了2至32个月（平均11个月）的患者随访监测。手术成功定义为使用视觉模拟量表疼痛改善50%或更多，或主观疼痛缓解评为良好或优秀，且术后无需使用麻醉剂。总体而言，40例患者中有16例（40%）符合这些标准。成功率如下：18例第1组患者中为44%，10例第2组患者中为40%，5例第3组患者中为0%，7例第4组患者中为57%。40例患者中有12例（30%）术前和术后均有工作。结论如下：1）对于周围神经源性损伤相关疼痛，神经瘤切除、神经切除术和神经松解术在少数患者中可产生显著的主观改善；2）近端混合神经的外部神经松解术在缓解疼痛方面无效；3）通过确认切除手术证明神经瘤的存在可能更可取；4）创伤性神经瘤疼痛仅部分归因于外周来源；5）人口统计学和神经学变量不能预测成功；6）离散神经综合征和机械性痛觉过敏的存在适度预测疼痛缓解；7）正在进行的诉讼是失败的最强预测因素；8）工作状态的改变不太可能是结果。
