Free muscle flap coverage as last resort for therapy-resistant neuropathic pain in the upper extremity: A long-term retrospective follow-up study.

BACKGROUND: Persistent neuropathic pain severely impacts physical functioning and quality of life (QoL). However, optimal surgical management of persistent neuropathic pain remains unclear. Extensive neurolysis with subsequent free muscle flap coverage, a new surgical procedure for neuropathic pain in the upper extremity, can be performed as a final option to establish pain reduction. METHODS: All consecutive patients who received extensive microsurgical neurolysis with subsequent free muscle flap for persistent neuropathic pain in the upper extremity between 2007 and 2014 were identified. Patient-reported upper extremity function and QoL were assessed using three questionnaires (36-item short-form health survey (SF-36), the disabilities of the arm, shoulder, and head questionnaire, and the Michigan hand outcomes questionnaire). RESULTS: Fifteen patients were identified; 80% had neuropathic pain in the upper extremity due to nerve injury and a median of 3.0 previous surgeries (range 1-6). Sixty-seven percent developed some kind of complication, flap loss occurred in 22%, and all received a new free flap (one failed again). At last follow-up, pre- and postoperative visual analog scale (VAS) scores significantly differed (p = 0.002), and the median VAS at last follow-up was 1.5. Ten patients (67%) responded to the questionnaires after a median follow-up of 5.7 year (range 2.6-7.3 years). Patients on average reported poorer SF-36 "Physical Component Score" (PCS) and "Bodily Pain" compared to Dutch norms. Forty percent of patients reported still having always (very) severe pain. However, 64% had a postoperative decrease of at least 3.0 on VAS. CONCLUSION: Extensive neurolysis with free muscle flap coverage for persistent neuropathic pain in the upper extremity showed a positive effect on pain reduction on short-term follow-up, and also at five-year follow-up. The impact of pain on functional outcomes remained. Nevertheless, 60% of the patients still experience sufficient pain reduction.

What is evidence based in the reconstruction of digital nerves? A systematic review.

BACKGROUND: An intact digital nerve is obligatory for hand function. When transected, the hand surgeon has several options. However, there is no hard evidence which technique to choose. OBJECTIVE: The aim of this study was to provide an evidence-based overview of the effectiveness of interventions used in reconstruction and post-surgical management of digital nerve injuries. METHODS: The Cochrane Library, PubMed, EMBASE, CINAHL and PEDro databases were searched. Two reviewers independently applied the inclusion criteria to select potential relevant randomised controlled trials (RCTs) and controlled clinical trials (CCTs), extracted data and performed a methodological quality assessment of the included studies. The Grades of Recommendation, Assessment, Development and Evaluation (GRADE) method was used to summarise the results. RESULTS: Eight RCTs were included, five on surgical and three on post-surgical interventions. Low-quality evidence was found for effectiveness in favour of a polyglycolic acid conduit compared to primary neurrorhaphy or autologous graft, in digital nerve gaps of ≤4 mm and ≥8 mm at long-term follow-up. Very low quality of evidence was found for effectiveness in favour of EMLA crème, compared to placebo, in enhancing sensory relearning for the short-term, but not for the long-term outcomes. Low quality of evidence was found for effectiveness in favour of sensory re-education compared with control at long-term follow-up. For other interventions, no evidence for effectiveness was found. CONCLUSIONS: Indications for effectiveness of some treatment strategies in digital nerve repair were found, but due to a minimal number of RCTs in this field no firm conclusions could be drawn for the different techniques. More high-quality RCTs are needed for a more confident estimate of effect. LEVEL OF EVIDENCE: Therapeutic II.

Surgical management of neuroma pain: a prospective follow-up study.

Painful neuromas can cause severe loss of function and have great impact on the daily life of patients. Surgical management remains challenging; despite improving techniques, success rates are low. To accurately study the success of surgical neuroma treatment and factors predictive of outcome, a prospective follow-up study was performed. Between 2006 and 2009, pre- and post-operative questionnaires regarding pain (VAS, McGill), function (DASH), quality of life (SF-36), symptoms of psychopathology (SCL-90), epidemiologic determinants and other outcome factors were sent to patients surgically treated for upper extremity neuroma pain. Pain scores after diagnostic nerve blocks were documented at the outpatient clinic before surgery. Thirty-four patients were included, with an average follow up time of 22 months. The mean VAS score decreased from 6.8 to 4.9 after surgery (p<0.01), 19 (56%) of patients were satisfied with surgical results. Upper extremity function improved significantly (p=0.001). Neuroma patients had significantly lower quality of life compared to a normal population. Employment status, duration of pain and CRPS symptoms were found to be prognostic factors. VAS scores after diagnostic nerve block were predictive of post-operative VAS scores (p=0.001). Furthermore, smoking was significantly related to worse outcome (relative risk: 2.10). The results could lead to improved patient selection and treatment strategies. If a diagnostic nerve block is ineffective in relieving pain, patients will most likely not benefit from surgical treatment. Patients should be encouraged to focus on activity and employment instead of their symptoms. Smoking should be discouraged in patients who will undergo surgical neuroma treatment.