The Peripheral Nerve Surgeon’s Role in the Management of Neuropathic Pain

Caragher, Seamus P.; Khouri, Kimberly S.; Raasveld, Floris V.; Winograd, Jonathan M.; Valerio, Ian L.; Gfrerer, Lisa; Eberlin, Kyle R.

doi:10.1097/gox.0000000000005005

Cited by 10 publications

(1 citation statement)

References 113 publications

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“…One such technique is targeted muscle reinnervation (TMR), where a nerve end is coaptated to a terminal motor nerve branch of a muscle that is in close proximity. [2][3][4] As a relatively novel modality, TMR has gained popularity for the treatment of these sequela and its utilization as a prophylactic modality is being more widely adopted across the United States. 5 However, it has been identified that access to this technique at time of amputation (primary TMR) is not always available for many geographical locations.…”

Section: Introductionmentioning

confidence: 99%

Social Deprivation is Associated with Increased Pain in Patients Presenting with Neuropathic Pain

Raasveld,

Lans,

Valerio

et al. 2024

Plastic and Reconstructive Surgery - Global Open

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Background: Neuropathic pain following nerve injury can be debilitating and negatively impact quality of life. Targeted muscle reinnervation (TMR) is an efficacious technique for the management of neuropathic pain. However, this technique may be unequally available for many geographical locations. Therefore, the aim of this study was to evaluate the association between Area Deprivation Index (ADI) and preoperative pain in patients undergoing TMR for treatment of neuropathic pain. Methods: Patients who underwent TMR for neuropathic pain in the lower and upper extremities were prospectively enrolled at our tertiary care clinic. A chart review was conducted to obtain socioeconomic, surgery, and comorbidity parameters. Preoperative pain scores (0–10 pain score index), and the ADI, reflecting deprivation status on a 0–100 scale, were collected. Results: A total of 162 patients from 13 different states were included, of which 119 were amputees (74%). The median ADI was 25 (IQR: 16–41) and the median preoperative pain score was 6 (IQR: 5–8). A higher ADI was independently associated with higher preoperative pain. The time interval from nerve injury to TMR was not associated with ADI. Conclusions: Patients undergoing surgical treatment of neuropathic pain from more socially deprived settings have increased pain experience upon initial evaluation, despite having similar time from nerve injury or amputation to TMR. These findings highlight the importance of identifying patients presenting from socially deprived settings, as this may impact their physical and mental health along with their coping mechanisms, resulting in increased pain.

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Section: Introductionmentioning

confidence: 99%

Social Deprivation is Associated with Increased Pain in Patients Presenting with Neuropathic Pain

Raasveld,

Lans,

Valerio

et al. 2024

Plastic and Reconstructive Surgery - Global Open

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Pain Remission Following Delayed Targeted Muscle Reinnervation in Amputees

Raasveld,

Mayrhofer‐Schmid,

Johnston

et al. 2024

Microsurgery

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IntroductionTargeted muscle reinnervation (TMR) has demonstrated efficacy for treatment of neuropathic pain. This study aims to identify patients for whom delayed TMR may be most effective and to identify associated factors for favorable pain outcomes in this patient population.MethodsAn analysis was conducted on prospectively enrolled amputee patients who underwent delayed TMR at a tertiary care center from 2017 to 2024. Data on demographics, comorbidities, surgical details, and pain outcomes were collected. Patient reported pain severity on a 0–10 scale was prospectively collected. The main pain outcome was pain remission (achieving the minimally clinically important difference (MCID)). Additionally, sustained mild pain (pain score ≤ 3/10 for ≥ 3 months), and pain disappearance (pain score 0/10 for ≥ 3 months) were assessed. Multivariable regression analyses identified factors influencing pain outcomes.ResultsOut of 101 patients included in this study, 64 patients (63.4%) achieved pain remission within a two‐year post‐operative period, and 37 patients (36.6%) did not. Sustained mild pain, which could be achieved in addition to pain remission, was achieved by 45.8% of patients, with 17.8% of these achieving complete pain disappearance. Patients achieving pain remission demonstrated lower pain over the entire post‐operative trajectory (p < 0.001). Lower pre‐operative pain scores, absence of depression, no pre‐operative opioid use, lower Elixhauser Comorbidity Index, and distal amputation levels were correlated with favorable outcomes following delayed TMR (p < 0.05).DiscussionPre‐operative pain severity, psychiatric comorbidities, and opioid use significantly influenced pain outcomes, emphasizing the need for comprehensive patient assessment. These findings will help with patient stratification and pre‐operative counseling to support patients who are best suitable for delayed TMR surgery.

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Neuroma morphology: A macroscopic classification system

Raasveld,

Weigel,

Liu

et al. 2024

Muscle and Nerve

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Introduction/AimsNeuromas come in different shapes and sizes; yet the correlation between neuroma morphology and symptomatology is unknown. Therefore, we aim to investigate macroscopic traits of excised human neuromas and assess the validity of a morphological classification system and its potential clinical implications.MethodsEnd‐neuroma specimens were collected from prospectively enrolled patients undergoing symptomatic neuroma surgery. Protocolized images of the specimens were obtained intraoperatively. Pain data (Numeric rating scale, 0–10) were prospectively collected during preoperative interview, patient demographic and comorbidity factors were collected from chart review. A morphological classification is proposed, and the inter‐rater reliability (IRR) was assessed. Distribution of neuroma morphology with patient factors, was described.ResultsForty‐five terminal neuroma specimens from 27 patients were included. Residual limb patients comprised 93% of the population, of which 2 were upper (8.0%) and 23 (92.0%) were lower extremity residual limb patients. The proposed morphological classification, consisting of three groups (bulbous, fusiform, atypical), demonstrated a strong IRR (Cohen's kappa = 0.8). Atypical neuromas demonstrated higher preoperative pain, compared with bulbous and fusiform. Atypical morphology was more prevalent in patients with diabetes and peripheral vascular disease.DiscussionA validated morphological classification of neuroma is introduced. These findings may assist surgeons and researchers with better understanding of symptomatic neuroma development and their clinical implications. The potential relationship of neuroma morphology with the vascular and metabolic microenvironment requires further investigation.

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The Peripheral Nerve Surgeon’s Role in the Management of Neuropathic Pain

Cited by 10 publications

References 113 publications

Social Deprivation is Associated with Increased Pain in Patients Presenting with Neuropathic Pain

Social Deprivation is Associated with Increased Pain in Patients Presenting with Neuropathic Pain

Pain Remission Following Delayed Targeted Muscle Reinnervation in Amputees

Neuroma morphology: A macroscopic classification system

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