Radiofrequency Ablation of Amputation Neuromas: A Small Case

Radiofrequency Ablation of Amputation Neuromas: A Small Case

Radiofrequency Ablation of Amputation Neuromas: A Small Case Series
Physical Medicine & Rehabilitation Service
Department of Rehabilitation
CPT Jennifer Windsor, MD; MAJ Yin-Ting Chen, MD; MAJ Matthew E Miller, MD; CDR Michael B. Jacobs, MD; MAJ David Reece, DO; MAJ William Kroski, DO

Introduction

Case Description

Painful amputation neuroma is a common condition after amputation, and a
significant issue facing our Servicemembers. In the modern era, there is a
consistent amputation rate of 7-8% during wartime over the past 50 years.
Amputation neuromas are a bundle of nerve endings that form via
regenerative sprouting after axonal nerve damage during an amputation, with
heightened sensitivity to pain to local pressure or palpation, often leading to
problems with prosthesis usage and function. Currently, no great definitive
option exists. Radiofrequency ablation (RFA) of neuroma is a novel technique
for treatment. The technique involves selective destruction of nervous tissue
to facilitate pain relief. RFA has wide applications, but is limited in the
treatment of neuromas. To the best of our knowledge, there are no reports in
the current literature for US-guided continuous RFA for the treatment of
neuroma pain in combat amputees.

Case 1: 31 yo AD male injured by an IED with severe ankle injuries leading to
elective transtibial amputation (TTA), presented 3 months post amputation
with 8-10/10 electric-like radiating pain into the phantom limb in peroneal
distribution, inhibiting prosthesis usage and ambulation. US evaluation
demonstrated a well-circumscribed hypoechoic spherical mass consistent with
peroneal neuroma. US-guided RFA of the left peroneal neuroma was
performed 4 weeks following a successful diagnostic injection. At 2- and 9month follow up, patient rated the pain at 2-3/10, with complete resolution of
the electric-like pain and significantly lowered pain medication usage. He was
able to ambulate with his prosthesis for more than 7 hours daily.

Figure 1. Example of a neuroma. Longitudinal axis view of a tibial neuroma in
the residual limb of a patient with transtibial amputation. The tibial nerve (^)
is seen diving deeper into the soleus muscle (S); a gradual thickening and loss
of the fibrillar internal architecture is notable before the nerve terminates in
the bulbous neuroma (*). Both the gastrocnemius (G) and the soleus muscles
are notable for mild atrophy.

US and Treatment Techniques
Neuromas are located through either sonopalpation or anatomical techniques.
Sonopalpation is performed by having the patient pinpoint the site of their
maximum tenderness that elicits the neuromal pain, and the US transducer is
placed directly over this location to identify the neuroma. An alternative
method is to trace the intact proximal nerve until reaching the neuroma.
Varying the pressure on the neuroma through the transducer can further
confirm if the underlying neuroma is the source of pain. Once the neuroma is
visualized, a low-volume diagnostic injection of the neuroma is performed
under ultrasound guidance; positive response to the diagnostic injection is the
prerequisite for RFA.
The NT1100 RF Generator (NeuroTherm, Massachusetts, USA) is used for the
RFA. The neuroma is again located using the above technique. 3mL of 2%
lidocaine is injected at 2-3 cm proximal to the neuroma to achieve anesthesia,
then under ultrasound guidance, the RF needle is guided until entering near
the center of neuroma, and the probe is set to 80 degrees Celsius for 90
seconds. The RF probe is then withdrawn and dressings applied.

Contact Information: CPT Jennifer Windsor, MD. [email protected]

Case 2: 25yo male status post IED blast with bilateral transfemoral
amputations (TFA) 12-months after injury, presented with sharp, radiating pain
of left lower residual limb, rated at 10/10, limiting usage of his prosthesis. US
evaluation was diagnostic of a symptomatic sciatic neuroma. US-guided RFA of
the left sciatic neuroma was performed 1 week following a successful
diagnostic injection. Patient reported complete pain cessation on subsequent
follow-ups at 2 week, 2 month, and 5 months. He reported decreased
medication usage and achieved all day use of his prosthesis.

Conclusion
Figure 2. Diagnostic injection
and pre-RFA anesthetic injection
are often performed with the
neuroma visualized in shortaxis. The needle is seen here
guided in an in-plane, lateral-tomedial approach in a peroneal
neuroma injection.

Figure 3. After the anesthetic injection,
the RFA probe is guided in an in-plane,
distal-to-proximal
approach
until
entering the center of the neuroma.

The use of continuous RFA was helpful in treating the amputation neuroma
pain in these two patients; both of them reported marked and long-lasting
decreases in pain, decreased medication usage and increased prosthesis
usage. Our findings are similar to current literature using pulsed rather than
continuous RFA, suggesting there may be no difference between continuous
vs. pulsed RFA, demonstrating its potential as a treatment option for neuroma
pain refractory to standard treatments. There is little research in RFA and the
treatment of neuromas; a larger clinical trial is required to further study the
effect of this treatment, the objective impact on function, incidence and types
of adverse outcome from the treatment, and to further refine the technique.

The views expressed in this poster are those of the authors and do not reflect the official policy of the Department of Army, Department of Defense, or United States Government.

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