M I C R O S U R G I C A L POSSIBILITIES IN THE TREATMENT OF PERIPHERAL PAIN. A. C. J. Slooff* Submitted in honor of Prof. Dr. W. Noordenbos on the occasion of his retirement as Professor of Neurosurgery at the University of Amsterdam.
SUMMARY The author illustrates the benefits of microsurgery in the treatment of four patients with painful peripheral stump neuroma.
INTRODUCTION
A better understanding of the pathophysiology of pain has been followed, in a number of investigators, by greater prudence in the surgical treatment of patients with pain (NOORDENBOS, 1959 and 1974). Nevertheless, this same understanding of the pathophysiology, in combination with the benefit of microsurgery, has opened new pathways for surgery in patients with pain. Microsurgery signifies a better view, more selective intervention and better possibilities for sparing impor.tant anatomical structures. A less radical operation results from the application of the benefits of this technique. For example operations on the trigeminal nerve (JANETTA, 1976) and the posterior roots with this microtechnique (SINDOU et al., 1976), become more selective and save important structures. The microsurgical technique is also a great advance in the surgery of pain caused by periferal nerve injuries. CASE REPORTS
1. A patient born in 1950, was operated at an other hospital, for a 'hyperkeratotic' skin lesion on the dorsal side of the left hand, at the level of metacarpal II, in 1973. After the operation, she started to complain of unpleasant and numb feelings on the radial-dorsal side of the second finger. The left hand became blue and painful. Finally she had to stop work. On examination, two years after this first operation, a swollen, blue coloured radial side of the left hand, a painful scar area at the level of metacarpal II and some dysaesthesia on the back of the second finger were found. At operation, only scar * Neurosurgical department, 'De Weverziekenhuis °, Heerlen, The Netherlands. Clin. Neurol. Neurosurg., Vol. 80-2
108 tissue was encountered. The proximal and distal stumps o f the digital nerve were freed and using microtechniques, a perineural interfascicular autologous nerve graft (sural nerve) was made over a distance o f 3.5 cm. Post-operatively dystrophic signs disappeared very soon and within one year the sensory function was restored completely. She had no more complaints and resumed her original work. 2. A 44-year old woman was operated upon eleven years ago for a glasswound at the dorso-radial side of the right wrist. Afterwards, the infected wound was cleared twice of small glass particles. The resulting scar became painful at the proximal side and nine years after injury she underwent a correction of this scar. Since the last operation, she complained of spontaneous pain and painful paraesthesiae in the dorso-radial skin area of the right hand and in the first and second fingers. She could not tolerate the nice, lace cuff o f her blouse, as there was a painful neuroma in the most proximal scar. On examination the skin area distal to the scar at the hand and in the two fingers was found to be hypalgetic, hypaesthetic and, above all, dysaesthetic. As the skin area between the distal and proximal stump o f the superficial branch of the radial nerve was covered by extensive scar tissue, no attempt was made to graft the nerve, but a special operation on the proximal stump o f the nerve was choosen. With the help o f microtechniques, the neuroma was resected and the nerve was divided into two equal fascicles (Fig.). The free end of the two fascicles were then united end-to-end with each other and atraumatically joined with 10 x 0 sutures. By doing this, a closed circuit was made for the outgrowing axons. After the first anastomosis was completed, one of the fascicles was cut again and resutured.
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/
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Figure 1. stumpneuroma. 2. epineurium. 3. perineurium of the fascicle (group). 4. fascicle (group). 5. end-to-end interfascicular suture. 6. autologous interfascicular graft. 7. one fascicle (group) cut and resutered.
Two years after operation the painful sensations in the skin area as well as the spontaneous pain had disappeared. The proximal end of the nerve was only painful when it was touched.
109 3. A third patient born in 1953, sustained a very severely complicated fracture o f the right tibia, with considerable skin lesions in 1969. The recovery was quite successful, but she began to complain o f spontaneous pain around the 6 cm large scar tissue, about 10 cm proximal to the medial malleolus. At the top o f the scar tissue there was a palpable neuroma which caused extremely severe pain radiating to the medial side o f the foot. The skin distal to the malleolus showed diminished sensation, but no dysaesthesia was felt. She was mostly irritated by her trouser leg rubbing against the scar tissue and its neuroma. After a diagnostic nerve block, it was decided to do a proximal neurotomy o f the saphenous nerve. Using the same technique as in the second patient, the saphenous nerve was freed from the stump n e u r o m a under the microscope, two equal fascicle groups were united end-to-end with each other, and atraumatically joined with 10 x 0 sutures. One fascicle was again cut and resutured. One year later the spontaneous pain had disappeared and the scar tissue was less dysaesthetic. She could now wear trousers again. The stump o f the saphenous was still painful to touch, with some radiating pain. The area o f diminished sensation was somewhat larger but there was no dysaesthesia. 4. The fourth patient was born in 1955. His second finger o f the fight hand was torn by the chain o f a motorcycle in 1975. The second and third phalanges had to be amputated. Afterwards the suture line on the palmar side of the finger stump was very painful to touch over a distance o f 1,5 cm, but the top itself was completely void of sensation. No neuroma was found on examination. After a diagnostic nerve block, it was decided to cut the two palmar digital nerves. Ten months' after the injury, both nerve stumps were sutured end-to-end to each other under the microscope, Thereafter one nerve was again cut and resutured. One year after the operation the painfulness of the suture line had disappeared. The nerve suture site was not painful any more and the anaesthetic area on the top o f the finger stump was not felt to be an annoyance.
DISCUSSION
The painful stump neuroma is a not infrequent phenomenon, and it can even lead to invalidity. The prevention o f neuroma formation during a surgical amputation is not always successful although the nerve is cut as proximally as possible, and also as many prefer - , it is injected with 96% alcohol between two sutures. It is still unexplained why one stump neuroma causes pain-syndromes, and the other does not. When it is necessary to treat this kind of patient it is advisable to use diagnostic nerve blocks before the operation. Both patient and doctor then realise which region becomes anaesthetic and what this m e a n s (WHITE and SWEET, 1969; MOORE, 1971). For the treatment of the painful neuroma, a proximal neurotomy - possibly in combination with alcohol injection o f the nerve stump - is successful in many cases. A better method, however, is to stow away the nerve stump in the marrow-cavity o f
110 a neighbouring bone, but this is not always possible. Surgery at higher levels of the nervous system (for example, posterior rhizotomy, chordotomy or even higher) seems to be seldom justified. It is more logical and more physiological to prevent the wild and uncoordinated outgrowth of axons at the nerve-end. This can be done by offering these axons the physiological sheath of the Schwann's cells, by which regulated instead of wild axon growth occurs. The goal of this operation is to restore continuity of the nerve fascicles. This restoration is the most desirable method to prevent the development of stump neuroma, and it deals at the same time with the restoration of motor and sensory functions. Direct suture of proximal with distal nerve stumps is hardly possible for there is usually a large defect between the nerve ends. In these cases a nerve graft is indicated. It has been the invaluable contributions of MILLESI(1967 and 1976) and SAMIffI975 and 1976), who have showed us the benefits of microsurgery for the peripheral nervous system. An interfascicular perineural autologous nerve graft can be used to restore the continuity of the nerve, which is sutured with the help of the microscope and the results in these cases are very good (see patient 1). However, this graft is not always possible as the distal stump may be unapproachable. Still, in order to have the regulating sheath of Schwann's cells available for the outgrowth of the axons, Millesi and Samii proposed to divide the proximal nerve stump into equal fascicles or fascicles-groups, and rearrange them in pairs. The free ends of two fascicles of each pair were sutured end-to-end to each other and the axons of the fascicles could then grow to each other, in a retrograde manner. To prevent the axons meeting each other at the suture line, a small nerve graft was fixed between the fascicles. The meeting of the axons could than take place in the graft. The situation of the graft could also be arranged by cutting one of the two fascicles and then re-suturing the fascicles at the same place. The results of this kind of operation are very promising. The patients show disappearance of spontaneous pains and unpleasant paraesthesiae as well as the dysaesthesia in the areas of sensory disturbance. In two of the three patients the nerve suture site continues to be painful to touch, with some pain radiating from it. Whether this technique will offer a solution to the so-called phantom limb pain remains an open question. The first results obtained elsewhere (Samii, 1976) are not completely favourable.
REFERENCES JANNETTA, p. J. (1976) Microsurgical approach to the trigeminal nerve lbr tic douloureux. Progr. Neurol. Surg. Vol. 7 Karger. Basel. MILLESI, H. J., GANGLBERGER, J. and nERGER, A. (1967) Erfahrungen mit der Mikrochirurgie peripherer Nerven. Chir. Plast. Reconstr. 3.47. MXLLESI, H., MEISSL, G. and BERGER, A. (1976) Further experience with interfascicular grafting o f the median, ulnar and radial nerves. J. Bone and Joint Surg. 58, 209. MOORE, D. ¢. (1971) Regional block 4 th Ed. Ch. C. T h o m a s Springfield I11. (1976). NOOaDE~aOS, W. (1959) Pain, Elsevier Amsterdam.
III NOORDENBOS, W. (1974) Pathological aspects o f central pain states. Advances in neurology. Vol. 4 Raven Press. New York. SAMII, M. (1975) Modern aspects o f peripheral and cranial nerve surgery. Advances and technical standards in neurosurgery, Springer Verlag. Wien, New York. SAMn, M. (1976) Pers. comm. SINDOU, M., FISCHER, G. and MANSUY, L. (1976) Posterior spinal rhizotomy and selective posterior rhizidiotomy. Progr. neurol, surg. Vol. 7 Karger. Basel. wHrrE, J. C. and SWEET, W. H. (1969) Pain and the neurosurgeaon. A forty years experience. Chr. C. Thomas. Springfield Ill.
SUMMARY The author illustrates the benefits of microsurgery in the treatment of four patients with painful peripheral stump neuroma.
INTRODUCTION
A better understanding of the pathophysiology of pain has been followed, in a number of investigators, by greater prudence in the surgical treatment of patients with pain (NOORDENBOS, 1959 and 1974). Nevertheless, this same understanding of the pathophysiology, in combination with the benefit of microsurgery, has opened new pathways for surgery in patients with pain. Microsurgery signifies a better view, more selective intervention and better possibilities for sparing impor.tant anatomical structures. A less radical operation results from the application of the benefits of this technique. For example operations on the trigeminal nerve (JANETTA, 1976) and the posterior roots with this microtechnique (SINDOU et al., 1976), become more selective and save important structures. The microsurgical technique is also a great advance in the surgery of pain caused by periferal nerve injuries. CASE REPORTS
1. A patient born in 1950, was operated at an other hospital, for a 'hyperkeratotic' skin lesion on the dorsal side of the left hand, at the level of metacarpal II, in 1973. After the operation, she started to complain of unpleasant and numb feelings on the radial-dorsal side of the second finger. The left hand became blue and painful. Finally she had to stop work. On examination, two years after this first operation, a swollen, blue coloured radial side of the left hand, a painful scar area at the level of metacarpal II and some dysaesthesia on the back of the second finger were found. At operation, only scar * Neurosurgical department, 'De Weverziekenhuis °, Heerlen, The Netherlands. Clin. Neurol. Neurosurg., Vol. 80-2
108 tissue was encountered. The proximal and distal stumps o f the digital nerve were freed and using microtechniques, a perineural interfascicular autologous nerve graft (sural nerve) was made over a distance o f 3.5 cm. Post-operatively dystrophic signs disappeared very soon and within one year the sensory function was restored completely. She had no more complaints and resumed her original work. 2. A 44-year old woman was operated upon eleven years ago for a glasswound at the dorso-radial side of the right wrist. Afterwards, the infected wound was cleared twice of small glass particles. The resulting scar became painful at the proximal side and nine years after injury she underwent a correction of this scar. Since the last operation, she complained of spontaneous pain and painful paraesthesiae in the dorso-radial skin area of the right hand and in the first and second fingers. She could not tolerate the nice, lace cuff o f her blouse, as there was a painful neuroma in the most proximal scar. On examination the skin area distal to the scar at the hand and in the two fingers was found to be hypalgetic, hypaesthetic and, above all, dysaesthetic. As the skin area between the distal and proximal stump o f the superficial branch of the radial nerve was covered by extensive scar tissue, no attempt was made to graft the nerve, but a special operation on the proximal stump o f the nerve was choosen. With the help o f microtechniques, the neuroma was resected and the nerve was divided into two equal fascicles (Fig.). The free end of the two fascicles were then united end-to-end with each other and atraumatically joined with 10 x 0 sutures. By doing this, a closed circuit was made for the outgrowing axons. After the first anastomosis was completed, one of the fascicles was cut again and resutured.
:t/ \
/
6
5"
Figure 1. stumpneuroma. 2. epineurium. 3. perineurium of the fascicle (group). 4. fascicle (group). 5. end-to-end interfascicular suture. 6. autologous interfascicular graft. 7. one fascicle (group) cut and resutered.
Two years after operation the painful sensations in the skin area as well as the spontaneous pain had disappeared. The proximal end of the nerve was only painful when it was touched.
109 3. A third patient born in 1953, sustained a very severely complicated fracture o f the right tibia, with considerable skin lesions in 1969. The recovery was quite successful, but she began to complain o f spontaneous pain around the 6 cm large scar tissue, about 10 cm proximal to the medial malleolus. At the top o f the scar tissue there was a palpable neuroma which caused extremely severe pain radiating to the medial side o f the foot. The skin distal to the malleolus showed diminished sensation, but no dysaesthesia was felt. She was mostly irritated by her trouser leg rubbing against the scar tissue and its neuroma. After a diagnostic nerve block, it was decided to do a proximal neurotomy o f the saphenous nerve. Using the same technique as in the second patient, the saphenous nerve was freed from the stump n e u r o m a under the microscope, two equal fascicle groups were united end-to-end with each other, and atraumatically joined with 10 x 0 sutures. One fascicle was again cut and resutured. One year later the spontaneous pain had disappeared and the scar tissue was less dysaesthetic. She could now wear trousers again. The stump o f the saphenous was still painful to touch, with some radiating pain. The area o f diminished sensation was somewhat larger but there was no dysaesthesia. 4. The fourth patient was born in 1955. His second finger o f the fight hand was torn by the chain o f a motorcycle in 1975. The second and third phalanges had to be amputated. Afterwards the suture line on the palmar side of the finger stump was very painful to touch over a distance o f 1,5 cm, but the top itself was completely void of sensation. No neuroma was found on examination. After a diagnostic nerve block, it was decided to cut the two palmar digital nerves. Ten months' after the injury, both nerve stumps were sutured end-to-end to each other under the microscope, Thereafter one nerve was again cut and resutured. One year after the operation the painfulness of the suture line had disappeared. The nerve suture site was not painful any more and the anaesthetic area on the top o f the finger stump was not felt to be an annoyance.
DISCUSSION
The painful stump neuroma is a not infrequent phenomenon, and it can even lead to invalidity. The prevention o f neuroma formation during a surgical amputation is not always successful although the nerve is cut as proximally as possible, and also as many prefer - , it is injected with 96% alcohol between two sutures. It is still unexplained why one stump neuroma causes pain-syndromes, and the other does not. When it is necessary to treat this kind of patient it is advisable to use diagnostic nerve blocks before the operation. Both patient and doctor then realise which region becomes anaesthetic and what this m e a n s (WHITE and SWEET, 1969; MOORE, 1971). For the treatment of the painful neuroma, a proximal neurotomy - possibly in combination with alcohol injection o f the nerve stump - is successful in many cases. A better method, however, is to stow away the nerve stump in the marrow-cavity o f
110 a neighbouring bone, but this is not always possible. Surgery at higher levels of the nervous system (for example, posterior rhizotomy, chordotomy or even higher) seems to be seldom justified. It is more logical and more physiological to prevent the wild and uncoordinated outgrowth of axons at the nerve-end. This can be done by offering these axons the physiological sheath of the Schwann's cells, by which regulated instead of wild axon growth occurs. The goal of this operation is to restore continuity of the nerve fascicles. This restoration is the most desirable method to prevent the development of stump neuroma, and it deals at the same time with the restoration of motor and sensory functions. Direct suture of proximal with distal nerve stumps is hardly possible for there is usually a large defect between the nerve ends. In these cases a nerve graft is indicated. It has been the invaluable contributions of MILLESI(1967 and 1976) and SAMIffI975 and 1976), who have showed us the benefits of microsurgery for the peripheral nervous system. An interfascicular perineural autologous nerve graft can be used to restore the continuity of the nerve, which is sutured with the help of the microscope and the results in these cases are very good (see patient 1). However, this graft is not always possible as the distal stump may be unapproachable. Still, in order to have the regulating sheath of Schwann's cells available for the outgrowth of the axons, Millesi and Samii proposed to divide the proximal nerve stump into equal fascicles or fascicles-groups, and rearrange them in pairs. The free ends of two fascicles of each pair were sutured end-to-end to each other and the axons of the fascicles could then grow to each other, in a retrograde manner. To prevent the axons meeting each other at the suture line, a small nerve graft was fixed between the fascicles. The meeting of the axons could than take place in the graft. The situation of the graft could also be arranged by cutting one of the two fascicles and then re-suturing the fascicles at the same place. The results of this kind of operation are very promising. The patients show disappearance of spontaneous pains and unpleasant paraesthesiae as well as the dysaesthesia in the areas of sensory disturbance. In two of the three patients the nerve suture site continues to be painful to touch, with some pain radiating from it. Whether this technique will offer a solution to the so-called phantom limb pain remains an open question. The first results obtained elsewhere (Samii, 1976) are not completely favourable.
REFERENCES JANNETTA, p. J. (1976) Microsurgical approach to the trigeminal nerve lbr tic douloureux. Progr. Neurol. Surg. Vol. 7 Karger. Basel. MILLESI, H. J., GANGLBERGER, J. and nERGER, A. (1967) Erfahrungen mit der Mikrochirurgie peripherer Nerven. Chir. Plast. Reconstr. 3.47. MXLLESI, H., MEISSL, G. and BERGER, A. (1976) Further experience with interfascicular grafting o f the median, ulnar and radial nerves. J. Bone and Joint Surg. 58, 209. MOORE, D. ¢. (1971) Regional block 4 th Ed. Ch. C. T h o m a s Springfield I11. (1976). NOOaDE~aOS, W. (1959) Pain, Elsevier Amsterdam.
III NOORDENBOS, W. (1974) Pathological aspects o f central pain states. Advances in neurology. Vol. 4 Raven Press. New York. SAMII, M. (1975) Modern aspects o f peripheral and cranial nerve surgery. Advances and technical standards in neurosurgery, Springer Verlag. Wien, New York. SAMn, M. (1976) Pers. comm. SINDOU, M., FISCHER, G. and MANSUY, L. (1976) Posterior spinal rhizotomy and selective posterior rhizidiotomy. Progr. neurol, surg. Vol. 7 Karger. Basel. wHrrE, J. C. and SWEET, W. H. (1969) Pain and the neurosurgeaon. A forty years experience. Chr. C. Thomas. Springfield Ill.
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