Perineural injection of botulinum toxin-A in painful peripheral nerve injury – a case series: pain relief, safety, sensory profile and sample size recommendation

Background: Different procedures have been developed to improve the surgical outcome of peripheral nerve injuries. The purpose of this study was to evaluate the efficacy of wrapping the neurorrhaphy site utilizing dura substitute graft as an alternative conduit in the management of peripheral nerve injury. Methods: This retrospective clinical case series included 42 patients with a single peripheral nerve injury. The mean age was 26.8 ± 11 years, and the mean duration of symptoms was 3 ± 1.8 months. The visual analogue score (VAS) for pain and the Medical Research Council’s (MRC) grading for motor power were used to evaluate the functional outcome among our patients. All patients were operated on for primary microscopic end-to-end repair, followed by wrapping the neurorrhaphy site with dura substitute graft as a conduit. Patients were followed in the outpatient clinic with regular visits for average of 6 months. Results: Thirty-seven patients (83%), showed functional improvement in all aspects, the VAS for pain and the MRC for motor power, as well as the functional state. One patient (2.3%) developed a postoperative hematoma collection, which needed immediate evacuation. Superficial wound infection, reported in two patients (4.7%), was treated conservatively. No postoperative neuroma was observed among our patients during the follow-up period. Conclusion: Wrapping the neurorrhaphy site utilizing dura substitute as conduit appears to be safe and might prove effective in managing peripheral nerve injury.

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Perineural α2A-Adrenoceptor Activation Inhibits Spinal Cord Neuroplasticity and Tactile Allodynia after Nerve Injury

Anesthesiology ◽

10.1097/00000542-200210000-00033 ◽

2002 ◽

Vol 97 (4) ◽

pp. 972-980 ◽

Cited By ~ 44

Author(s):

Patricia M. Lavand'homme ◽

Weiya Ma ◽

Marc De Kock ◽

James C. Eisenach

Keyword(s):

Spinal Cord ◽

Sciatic Nerve ◽

Peripheral Nerve ◽

Nerve Injury ◽

Peripheral Nerve Injury ◽

Lumbar Spinal Cord ◽

Dependent Manner ◽

Withdrawal Threshold ◽

Perineural Injection ◽

Adrenergic Antagonist

Background Nerve injury in animals increases alpha(2)-adrenoceptor expression in dorsal root ganglion cells and results in novel excitatory responses to their activation, perhaps leading to the phenomenon of sympathetically maintained pain. In contrast to this notion, peripheral alpha(2)-adrenoceptor stimulation fails to induce pain in patients with chronic pain. We hypothesized that alpha(2) adrenoceptors at the site of nerve injury play an inhibitory, not excitatory role. Methods Partial sciatic nerve ligation was performed on rats, resulting in a reduction in withdrawal threshold to tactile stimulation. Animals received perineural injection at the injury site of clonidine, saline, or clonidine plus an alpha(2)-adrenergic antagonist, and withdrawal threshold was monitored. Immunohistochemistry was performed on the sciatic nerve ipsi- and contralateral to injury and on the spinal cord. Results Clonidine reduced this hypersensitivity in a dose-dependent manner, and this was blocked by an alpha(2A)-preferring antagonist. Perineural clonidine injection had a slow onset (days) and prolonged duration (weeks). Systemic or intrathecal clonidine, or transient neural blockade with ropivacaine, had short lasting or no effect on hypersensitivity. alpha(2A)-adrenoceptor immunostaining was increased near the site of peripheral nerve injury, both in neurons and in immune cells (macrophages and T lymphocytes). Phosphorylated cAMP response element binding protein (pCREB) in lumbar spinal cord was increased ipsilateral to nerve injury, and this was reduced 1 week after perineural clonidine injection. Conclusions These data suggest that peripheral alpha(2) adrenoceptors are concentrated at the site of peripheral nerve injury, and their activation receptors produce long-lasting reductions in abnormal spinal cord gene activation and mechanical hypersensitivity.

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Evaluation of surgical treatment for neuropathic pain from neuroma in patients with injured peripheral nerves

Journal of Neurosurgery ◽

10.3171/2017.1.jns161778 ◽

2018 ◽

Vol 128 (4) ◽

pp. 1235-1240 ◽

Cited By ~ 5

Author(s):

Valérie Decrouy-Duruz ◽

Thierry Christen ◽

Wassim Raffoul

Keyword(s):

Neuropathic Pain ◽

Pain Relief ◽

Peripheral Nerve ◽

Nerve Injury ◽

Revision Surgery ◽

Peripheral Nerve Injury ◽

Elective Surgery ◽

European Federation ◽

The Mean

OBJECTIVEChronic neuropathic pain after peripheral nerve injury is a major clinical problem. Its management is difficult, and therapeutic approaches vary and include oral medication, neurostimulation, and surgery. The aim of this study was to assess the adequacy of surgical nerve revision in a large series of patients with long-term follow-up.METHODSThe authors reviewed the charts of 231 patients (335 nerve injuries) who experienced neuropathic pain after peripheral nerve injury and underwent surgery for nerve revision at the authors’ institution between 1997 and 2012. The following parameters were recorded for each patient: history, location, duration, and severity of the pain and details of nerve revision surgery. In addition, patients were invited to participate in a follow-up consultation and were asked to score their pain at that time. Current medications and examination findings were also documented.RESULTSElective surgery was the source of nerve injury for 55.4% of the patients. The lower extremity was the most commonly involved anatomical region (54.3%), followed by the lower abdomen (16.4%) and the thoracic region (13%). The mean time between the onset of injury and revision surgery was 48 months. On average, 1.3 injured nerves per patient were explored, and surgery was performed 1.2 times per patient. Each nerve underwent revision 1.1 times on average. Neuromas-in-continuity and scar-tethered nerves were observed in 205 nerves (61%) and terminal neuromas were observed in 130 nerves (39%). The authors performed 186 (56%) neurolyses and 149 (44%) neuroma resections and translocations. The mean follow-up of the 127 (55%) patients who agreed to come back for a consultation was 68 months. These patients indicated an average pain decrease of 4 points in the visual analog scale (VAS) score. Pain relief greater than a 2-point decrease on the VAS, a criterion for a successful treatment according to the European Federation of Neurological Societies guidelines, was encountered in 80% of patients. Pain relief did not vary in a statistically significant way with regard to surgical technique, age and sex of the patient, affected nerve, or time between trauma and surgery. Before surgery, 76% of the patients were on a regimen of paracetamol and/or NSAIDs and 44% received opiates, while after nerve revision only 37% still required simple analgesia and 14% needed opiates.CONCLUSIONSBearing in mind that medication achieves satisfying pain relief in only 30%–40% of patients with neuropathic pain, surgery must be considered as an effective alternative therapy. No objective criteria were shown to be factors of poor prognosis. Systematic preoperative clinical mapping of the injured nerves and diagnostic nerve blocks could improve the primary success rate of the surgery.

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