Systematic review for post-amputation pain in relation to surgical techniques for neuroma prevention

1. Vaikunthan Rajaratnam

3. Post amputation Pain
•8% for finger
•85% for major limb
residual limb pain (RLP) phan-tom limb pain (PLP)

4. Aim
Surgical techniques
for neuroma
prevention
Which method has
the best results on
post op pain

5. Methods
Literature
search
•26 Mar 2021.
Databases
• Embase,
Medline,
Cochrane,
Web of
Science, and
Google
Scholar
The
PICOS
framework
Search
strategy
• (((neuroma*
OR
((neuropathic*
OR phantom*
OR stump*
OR nerve)
NEAR/2
PRISMA
guidelines
Selection
Data
Extraction
Synthesis

6. • undergoing amputation
Population
• Surgical management for neuroma
prevention in amputation
Intervention
• Standard nerve managemnet
Control
• Neuropathic pain
Outcome
• Clinical studies > 3
Study
design

7. Selection criteria
Inclusion:
• reported incidence or intensity of neuropathic
pain after surgical neuroma prevention
methods during primary amputation surgery.
Exclusion
• reporting non-surgical prevention techniques
• case reports
• case series with less than four patients
• non-human studies
• non-full articles, such as conference abstracts
• Non-English manuscripts.

8. Data extraction & quality scoring
•Oxford centre for Evidence-Based Medicine (CEBM)
•Data extracted
pain prevention technique
amputation level
incidence, and VAS scores for the pain
• primary outcome measure - incidence of RLP and PLP
• Due to significant heterogeneity, a random-effects model
was used (P < 0.001)
• meta-analysis is not possible
• qualitative evidence synthesis

11. Results

13. A:
Neurovascular
island flap.
B: Centro-
central union.
C: Epineural
ligature -
D: Epineural
flap.
E: Epineural
graft.

15. Targeted muscle reinnervation.

16. Targeted nerve implantation

17. Concomitant nerve coaptation

18. Regenerative peripheral nerve implantation.

19. Targeted muscle reinnervation in finger amputation.

20. Forest plot of both (A) residual limb pain (RLP) or (B) phantom limb pain (PLP) across
different interventions at finger amputations and major limb amputations. Due to significant
heterogeneity, a random-effects model was used. The red diamonds represent the pooled
prevalence for each group. The lowest diamond represents the overall effect for all groups.
The blue squared represent the prevalence for each individual population. The white line
within the squared represents the estimated variance of the prevalence

21. Implications
• Centro-central union - finger amputations
• All techniques demonstrated efficacy in the
prevention of neuropathic pain – major limb
amputations
oTargeted muscle reinnervation.
oTargeted nerve implantation
oConcomitant nerve coaptation, and
oRegenerative peripheral nerve implantation
• Pain medication ranged between 16% and 50%

22. Limitations
Different descriptions of pain and
outcomes.
Significant heterogeneity for a meta-
analysis.
Standardize outcomes measure -
objective and subjective LANSS pain
scale or Douleur Neuropathique 4