Lower Extremity Amputation Stump Neuromas: Patterns of Occurrence, Treatment, and Outcomes
Manas Nigam, MD, MedStar Georgetown University Hospital, Washington, DC, Patrick Harbour, MD, Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC and Grant M Kleiber, MD, Georgetown University, Washington, DC
Objectives: Stump neuromas are a debilitating consequence of amputation. Targeted muscle reinnervation (TMR) may offer lasting improvement1, and many now advocate for TMR at the index amputation to reduce symptomatic neuroma pain. Given these recent advances, our group performed a retrospective review of patients with lower extremity amputation stump neuromas to review affected nerves, treatment patterns, and outcomes from 2010 to 2019.
Materials & Methods: A retrospective chart review was performed for 66 lower extremity above-knee (AKA) and below-knee (BKA) amputees who underwent surgery for symptomatic neuromas from 2010 to 2019 by three surgeons. Patients were stratified by amputation level and surgical technique. The change in Visual-Analog-Scale (VAS) pain scores and rates of phantom limb pain (PLP) were also gathered. Outcomes of interest included which nerves were involved and changes in pain.
Results: 68 previously amputated limbs underwent secondary surgery for symptomatic neuromas. 143 painful neuromas were identified with 58% of cases presenting with multiple neuromas. In AKA patients (n=16), 100% had a neuroma of the sciatic nerve, 25% in the posterior femoral cutaneous nerve, and 13% in the saphenous nerve. Among BKAs (49 limbs in 47 patients), the superficial peroneal nerve was affected in 80%, sural nerve or its branches in 49%, saphenous in 49%, and deep peroneal in 39%. Symptomatic neuroma formation of the tibial nerve affected only two BKA limbs. Overall, 64% of all neuromas were managed by neuroma excision with implantation into muscle and 17% by excision with TMR. Traction neurectomy, centro-central coaptation, nerve capping, and others comprised the remaining 19%. Average improvement in VAS pain at 30-day follow-up was 54% for the TMR cohort versus 38% for other techniques. Significant pre-operative phantom pain was seen in 47% of patients. Of the patients with preoperative phantom pain, 78% of patients undergoing TMR noted significant improvement in their phantom pain, vs 61% for non-TMR techniques.
Conclusions: In this retrospective study the majority of patients undergoing surgery for lower extremity neuroma pain had multiple neuromas. A large majority of BKA patients presented with a symptomatic neuroma of the superficial peroneal nerve. Tibial neuromas, in contrast, are quite rare. Patients undergoing neuroma excision with TMR nerve transfer saw larger improvements compared to those treated by other techniques. Overall these findings support the case for using TMR to treat symptomatic amputation stump neuromas and to prophylactically address nerves most commonly associated with painful neuromas at the time of primary amputation.
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