Patients with chronic intractable lower extremity neurogenic pain may be treated nonoperatively with medication, 29,30,43,48 physical therapy with desensitization modalities, 15,17 therapeutic nerve blocks, 5,11,41 and external electrical stimulation. 25,26 When nonoperative measures fail, surgery may be indicated.
Several surgical techniques have been developed to address the chronically and intractably damaged nerve: neurolysis, 40 transection, 1,3,4,6,9,10,12,13,18–21,28,34,35,37,44,45,49,51 containment procedures, 1,2,13,22,24,37,44 barrier procedures, 6,7,14,26,27,42 and peripheral nerve stimulation. 14,23,31,32,39,47,50 The choice of best procedure for a given etiology is individualized to the patient, depends on many factors, and often is difficult to determine.
Vein wrapping and peripheral nerve stimulation have been reported to be successful in controlling chronic upper extremity nerve pain that is resistant to standard treatments. 2,14,22,27,33,36,42,46 On this basis, the indication of these procedures has been expanded to include chronic intractable lower extremity pain 16 (Gould JS, Hart TS, O’Brien TS, Winkler MV: Outcome analysis of vein wrapping for intractable painful nerves in continuity. Presented at the 12th Annual Summer Meeting of the American Foot and Ankle Society, Hilton Head, SC, June 28, 1996). The purpose of the current investigation was to review the results of these two procedures in terms of relieving intractable lower extremity nerve pain.
MATERIALS AND METHODS
The current authors retrospectively reviewed the records of 120 surgeries on 104 patients at their institution between 1995 and 1999 in which vein wrapping or peripheral nerve stimulation had been used for intractable lower extremity pain secondary to various nerve injury mechanisms. All patients had undergone unsuccessful nonoperative treatment that included medical treatment with tricyclic antidepressants (amitriptyline or nortriptyline) or antiepileptic medications (carbamazepine, phenytoin, clonazepam, and Gabapentin), physical therapy, nerve blocks, transcutaneous electrical nerve stimulation, sympathetic blocks, desensitization techniques, and topical medications. All but one patient underwent one to 12 previous surgical nerve procedures.
Evaluation at the initial consultation included clinical assessment and electrodiagnostic studies. A careful history and physical examination were obtained for each patient. The history focused on evidence of systemic disease, mechanism of nerve insult, and specific nerve involvement. The results of previous surgical interventions were assessed to identify patients who had intractable lower extremity pain secondary to adhesive neuralgia (painful nerve trapped in scar tissue) who might benefit from vein wrapping rather than peripheral nerve stimulation. Physical examination identified specific nerve involvement and sites of potential nerve injury (surgical scar and trauma sites). Electrodiagnostic studies were done on each patient to help rule out a systemic peripheral neuropathy, to find more proximal areas of nerve compromise (double crush phenomenon), or to determine whether there was nerve compression or intraneural damage. Assessment included sequential nerve blocks with lidocaine and bupivacaine to help isolate the nerve or nerves involved.
Vein Wrap Group
Indications for vein wrapping included intractable neuropathic pain and failure of the nonoperative treatment protocol. Clinical findings consistent with adhesive neuralgia included tenderness to palpation or percussion along the scar (producing dysesthesias along the nerve’s territory or course) and dysesthesias with range of motion of the joint adjacent to the scar. Patients who experienced some temporary symptomatic relief after previous neurolysis, followed by subsequent deterioration, were considered to have adhesive neuralgia. Previous infection, wound complications, or both were not contraindications to vein wrapping.
In these 58 consecutive patients (58 limbs), all had adhesive neuralgia that was a result of a combination of the original nerve insult (primary compression or entrapment, traction or stretch injury, crush injury, transection, idiopathic etiology, deep infection, compartment syndrome, and injection injury) and subsequent surgery (such as scarring after surgery). Nerves involved included the posterior tibial nerve (50 limbs in 50 patients), tibial and sural nerves (one limb in one patient), sural nerve (one limb in one patient), superficial peroneal nerve (four limbs in four patients), and superficial with deep peroneal nerve (one limb in one patient). The duration of symptoms before vein wrapping averaged 62 months (range, 11–353 months). The number of previous surgeries for the same nerve problem averaged 2.5 (range, one-seven procedures). All patients had undergone at least one neurolysis procedure, which had provided a period of complete or partial pain relief. At the time of initial evaluation at the authors’ institution, 16 patients (16 limbs) had previous intentional or unintentional transection. Other complications of previous surgery that may have contributed to the chronic neuropathic pain included two deep-space infections and six wound dehiscences.
The age of the 34 women and 21 men averaged 42 years (range, 21–66 years) at presentation to the authors’ institution.
Peripheral Nerve Stimulation Group
The indications for peripheral nerve stimulation included patients with chronic peripheral neuralgia for intraneural compromise who underwent unsuccessful nonoperative treatment protocols, unsuccessful previous nerve release(s) combined with a containment procedure (vein, fat, or muscle graft), unsuccessful previous transection and transposition of nerve with burial into muscle or bone, unsuccessful previous nerve grafting and reanastomoses, or unsuccessful spinal cord stimulation. Patients who had did not respond to conventional surgical techniques and were being considered for either transection of the tibial, common peroneal, sciatic, or femoral nerve or a limb amputation were candidates for peripheral nerve stimulation. Previous infection or wound complications were not contraindications to peripheral nerve stimulation.
In these 62 consecutive patients (62 limbs), the intraneural disorder was a result of the initial nerve insult (crush injury, transection, traction or stretch injury, idiopathic etiology, and repetitive trauma), subsequent surgery, or both. The duration of symptoms before peripheral nerve stimulation averaged 46 months (range, 13–96 months). Of the 62 patients, 58 (94%) had undergone at least one previous peripheral neurosurgical procedure for treatment of the neuropathic pain. The number of previous peripheral neurosurgical surgeries averaged 2.8 (range, 0–12) and included neurolysis (57 patients), revision neurolysis (24 patients), vein wrapping after unsuccessful neurolysis (16 patients), transection (47 patients), and centrocentral anastomosis (three patients). Thirty-eight patients had stimulation of one nerve trunk. The remaining patients had stimulation of two to four nerves. The nerves stimulated included the tibial (28 patients), the tibial and sural (four patients), the tibial and the saphenous (three patients), the tibial and the superficial peroneal nerves (four patients), the superficial peroneal and the sural nerves (two patients), the superficial peroneal and the deep peroneal nerves (three patients), the sural (three patients), superficial peroneal (eight patients), the saphenous nerve (one patient), the deep peroneal nerve (one patient), the femoral nerve (one patient), and the tibial with at least two other nerves (four patients).
The age of these 31 females and 27 males averaged 38 years (range, 17–73 years) at presentation to the authors’ institution.
For the vein wrap procedure, 14,27,38 (Gould JS, Hart TS, O’Brien TS, Winkler MV: Outcome analysis of vein wrapping for intractable painful nerves in continuity. Presented at the 12th Annual Summer Meeting of the American Foot and Ankle Society, Hilton Head, SC 1996) the nerve is released circumferentially over the entire course of the suspected disorder (determined by scarring or tenderness to palpation). The saphenous vein is harvested (Fig 1) or, alternatively, an umbilical vein allograft is used (Fig 2). Typically the nerve is wrapped in a barber-pole fashion (Fig 3A–B) with the autograft, or in a clamshell fashion (Fig 3C) with the allograft, to encase the nerve and affected branches.
Peripheral Nerve Stimulation Procedure
For the peripheral nerve stimulation procedure, 38 the nerve trunk(s) proximal to the level of the disorder is/are exposed circumferentially. The fascial graft(s) harvested from adjacent fascial tissue is/are sewn to the lead(s) because it is thought to prevent the electrodes from damaging the nerve 38 (Fig 4). The wound is anesthetized, carefully avoiding nerve injection. The patient then is reversed from general anesthesia and a trial stimulation is done (Peripheral Nerve Stimulator, Medtronic, Inc, Minneapolis, MN). The trial stimulation frequency range is from 20 to 100 Hz, often starting at 40 Hz. The pulse width varies between 50 and 450 μs, often starting at 200 μs, and the range of the amplitude or strength of stimulation is .05 to 10.5 V, with the median at 2.5 V Electrode selection can be unipolar, bipolar, or multipolar and usually starts at −/+ −/+ on electrodes 0, 1, 2, and 3. Paresthesia in the zone of pain typically indicates good placement of the lead on the nerve. If this zone can be palpated or percussed during the stimulation with reduced or absent pain, the lead is secured in place over the nerve (Fig 5), the patient is reanesthetized (general), and the peripheral nerve stimulation generator is implanted. If there are still other zones of uncontrolled pain, the lead is moved around the nerve to improve the paresthesias and pain relief. If zones of uncontrolled pain still exist, intraoperative nerve blocks are done. Based on the subsequent relief of pain, a decision is made regarding additional nerve trunk stimulation versus additional nerve procedures (transection, transposition, centrocentral anastomoses, or additional nerve stimulation) in conjunction with the primary stimulation. If paresthesia in the zone of pain is obtained with minimal relief to palpation or percussion, a trial using a temporary external generator connected to the internal lead then is instituted. After 4 to 5 days, if the pain is controlled with adjustment of the external stimulator, an internal generator is implanted. If the pain has not decreased, a series of nerve blocks is done to identify the nerve producing or carrying the pain signal. Once this is determined, a second-stage procedure is done to adjust the leads, to add another lead to the other nerve(s), or to do additional nerve procedures (transection, translocation, or containment procedures).
After surgery, each limb was placed in a splint for 2 weeks. After this time, progressive range of motion and weightbearing was allowed as tolerated. For the patients with peripheral nerve stimulation, additional electrical signal modification was done on several occasions to maximize pain control.
The same assessment was completed for every patient with nerve compromise at each office visit. Therefore, preoperative and followup values were available for review. Ten-point scales were used to evaluate pain and dysfunction. 38 On the pain scale, 0 represented no pain and 10 represented pain severe enough to prompt a request for amputation of the affected extremity. On the dysfunction scale, 0 represented unlimited function and 10 represented the necessity of a wheelchair. A team member (other than the senior surgeon) ascertained a subjective rating by asking the patient whether he or she was satisfied, satisfied with some reservation, or dissatisfied.
Retrospective followup was available for all patients. The followup averaged 48.6 months (range, 12–92.6 months) after vein wrapping and 29.3 months (range, 13–61.4 months) after peripheral nerve stimulation.
Vein Wrap Group
Pain scores improved from a preoperative average of 8.8 points (range, 6–10 points) to a postoperative average of 5.1 points (range, 0–10 points). Dysfunction scores improved from a preoperative average of 7.4 points (range, 3–10 points) to a postoperative average of 4.4 points (range, 0–9 points). Time to maximum improvement in this group averaged 12 months (range, 3–30 months). Thirty-two (55%) patients were satisfied with the procedure, eight (14%) were satisfied with reservations (gaining mild or minimal relief of symptoms), and 18 (31%) had unsatisfactory results. No patients reported worsening of the symptoms after a suitable recovery from the surgical procedure.
Of the 58 patients, 38 had saphenous vein harvested. In seven of the 38 patients, there were complications from the saphenous vein harvest: three had mild saphenous nerve symptoms, three had mild wound healing problems, two had swelling from the vein harvest incisions, and two had prolonged donor site pain. All but two of the 38 patients had resolution of the symptoms. Umbilical veins were used to wrap nerves in 20 of the 58 patients. There were no infections, rejections, or wound complications. Despite fewer complications, only seven of 20 patients who received umbilical veins were satisfied and 11 were dissatisfied. Of the patients who had saphenous vein harvesting, 25 of 38 patients were satisfied and seven were dissatisfied.
Peripheral Nerve Stimulation Group
Pain scores improved from a preoperative average of 9 points (range, 7–10 points) to a postoperative average of 5.1 points (range, 0–8 points), and dysfunction scores improved from a preoperative average of 8 points (range, 7–10 points) to a postoperative average of 6.4 points (range, 3–10 points). The average overall percentage improvement reported by the patients was 42%. Time to maximum improvement after peripheral nerve stimulation averaged 5.2 months (range, 1–10 months). Satisfaction was reported in 38 of 62 (61%) patients, satisfaction with reservations was reported in 13 of 62 (21%) patients, and dissatisfaction was reported in 11 of 62 (18%) patients. In 48 of 58 (83%) patients who were satisfied, only one patient had complete relief of symptoms and, at 2.5 years followup, no longer uses the peripheral nerve stimulation. In these 48 patients, there were improvements in hours of sleep per night, hours of uninterrupted sleep, and average walking distance. These patients generally thought their quality of life and psychologic well-being had improved.
Of 62 patients, 29 required revisions during the 5-year study period. Major revisions with lead replacements were done in 21 of 29 patients. Of these 21, 10 required another nerve to be stimulated at a later surgery, and eight had revisions of the pulse generator for battery depletion during a lead revision. There were new pulse generators inserted in two of 29 patients. The average battery life was 2.7 years, but one patient requires a new device every 3 to 4 months. This patient has good improvement but only fair pain relief from the stimulator. She also had persistent equinovarus of the foot and ankle and clawing of the toes that have been resistant to multiple releases. She has ultimately required fusions of her hindfoot and forefoot to address these progressive contractures. Despite her need for revision surgeries, she continues to work. In four of the 29 patients, there have been minor hardware revisions.
There were revisions for postoperative infections in four of 29 patients (three already are counted in the 21 of 29 major revisions) within 6 months of implantation (one patient had a previous history of osteomyelitis) and in two of 29 for late infections, one at 1.5 years and one at 3 years (in a patient who had undergone additional lead insertion within 3 months postoperatively) that required removal of some or all of the implanted components. Four of the six patients had resolution of the infection with intravenous antibiotics and subsequently had reimplantation of the peripheral nerve stimulation with satisfactory results. The patient with a history of osteomyelitis did not have adequate relief with the initial implantation and requested an amputation. The other patient, who initially was satisfied with his pain relief for 1.3 years, did not think there was adequate functional improvement. Two months before he presented with his sudden onset of a late infection (1.5 years) he decided to undergo transtibial amputation. After his amputation, he had improvement of pain and function.
Chronic intractable neuralgia (pain) in the distribution of a nerve(s) that does not respond to nonoperative and operative treatment presents a difficult problem in that it encompasses a wide spectrum of causes. 38 The current study sought to analyze relatively new treatment options for patients with chronic intractable neuralgia.
In general, vein wrapping with revision neurolysis, a barrier procedure designed to protect a nerve from external compromise, 7,27 can relieve symptoms and improve function in patients with adhesive neuralgia. Sotereanos et al 42 reported good and excellent results with this procedure in the upper extremity. Gould 14 and Gould et al (Gould JS, Hart TS, O’Brien TS, Winkler MV: Outcome analysis of vein wrapping for intractable painful nerves in continuity. Presented at the 12th Annual Summer Meeting of the American Foot and Ankle Society, Hilton Head, SC 1996) reported that 63% of patients had an excellent or good outcome with this technique for treatment of chronic lower extremity neurogenic pain but that 25% of patients reported an increase in symptoms.
Peripheral nerve stimulation in the lower extremity can benefit patients with intrinsic nerve compromise who have undergone unsuccessful release, transection, transposition, grafting, and/or reanastomosis. 16,33,36,46 Peripheral nerve stimulation is a neuromodulation technique based primarily on the gate mechanism of pain that theorizes that selective stimulation of large myelinated delta nerve fibers modulate afferent nociceptive input centrally or at the dorsal horn of the spinal cord. 23 There have been several reports of peripheral nerve stimulation for the treatment of intractable neurogenic pain in the upper extremity, but little has been reported for the lower extremity. In the upper extremity, Nashold et al, 33 Waisbrod et al, 46 and Cooney 8 have reported success ranging from 53% to 84%.
In patients with intraneural disorders, the alternative to peripheral nerve stimulation is transection and burial. 1,3,4,6,9,10,12,13,18–21,28,34,35,37,44,45,49,51
This is a good procedure in selected patients because it is technically easy to do and the patient does not require complex treatment after surgery. There are several potential problems with nerve transection: (1) deafferentation pain or anesthesia dolorosa; (2) motor denervation (that may result in muscle imbalance and deformities); (3) vulnerability to ulcers and infections from insensate plantar aspect of the foot; and (4) ectopic or spontaneous neuralgia. In the current series, 47 of 62 patients (the peripheral nerve stimulation group) (76%) had previously undergone transection and burial before peripheral nerve stimulation. Of these 47 patients, eight did not respond adequately to peripheral nerve stimulation and had failed results. The remainder all had allodynia that responded to some degree to peripheral nerve stimulation of the transected nerves. The current authors’ approach is to consider transection and burial or peripheral nerve stimulation if a patient presents with chronic intractable neurogenic pain of the lower extremity secondary to intraneural disorders involving nerves other than the posterior tibial nerve and if the patient has undergone unsuccessful nonoperative modalities and neurolysis. However, if the posterior tibial nerve also is involved, the patient would be offered a trial of peripheral nerve stimulation before transection. Finally, if the patient has a neuroma from a transected nerve, the first revision is usually a more proximal transection and burial. Failure after this procedure warrants consideration for peripheral nerve stimulation.
Vein wrapping and peripheral nerve stimulation can be effective surgical techniques for the treatment of intractable chronic neurogenic pain secondary to adhesive neuralgia and intraneural pathology, respectively. Ongoing analysis of a larger series of patients and a prospective study of peripheral nerve stimulation at the senior authors institution may ultimately lead to better selection criteria and better technique. Cost analysis and long-term outcome studies of these complex patients with or without these procedures are under investigation.
The authors thank Elaine Bulson, Jennifer Shores, and Lyn Camire for assistance in preparing the manuscript.
1. Barbera J, Albert-Pamplo R: Centrocentral anastomosis of the proximal nerve stump in the treatment of painful amputation neuromas of major nerves. J Neurosurg 79: 331–334, 1993.
2. Barbera J, Gonzalez J, Gil JL, et al: The quality and extension of nerve fibre regeneration in the centrocentral anastomosis of the peripheral nerve. Acta Neurochir (Wien) 43 (Suppl): 205–209, 1988.
3. Battista A, Cravioto H: Neuroma formation and prevention by fascicle ligation in the rat. Neurosurgery 8: 191–204, 1981.
4. Battista AF, Lusskin R: The anatomy and physiology of the peripheral nerve. Foot Ankle 7: 65–70, 1986.
5. Bonica JJ: Regional Anesthesia with Local Anesthetics. In Bonica JJ (ed). The Management of Pain. Ed 2. Philadelphia, Lea & Febiger 1883–1996, 1990.
6. Brown H, Flynn JE: Abdominal pedicle flap for hand neuromas and entrapped nerves. J Bone Joint Surg 55A: 575–579, 1973.
7. Campbell JT, Schon LC, Burkhardt LD: Histopathologic findings in autogenous saphenous vein graft wrapping for recurrent tarsal tunnel syndrome: A case report. Foot Ankle Int 19: 766–769, 1998.
8. Cooney III, WP: Chronic Pain Treatment with Direct Electrical Nerve Stimulation. In Gelberman RH (ed). Operative Nerve Repair and Reconstruction. Philadelphia, JB Lippincott Co 1551–1561, 1991.
9. Dellon AL, Aszmann OC: Treatment of superficial and deep peroneal neuromas by resection and translocation of the nerves into the anterolateral compartment. Foot Ankle Int 19: 300–303, 1998.
10. Dellon AL, MacKinnon SE: Susceptibility of the superficial sensory branch of the radial nerve to form painful neuromas. J Hand Surg 9B: 42–45, 1984.
11. Devor M, Govrin-Lippmann R, Raber P: Corticosteroids suppress ectopic neural discharge originating in experimental neuromas. Pain 22: 127–137, 1985.
12. Goldstein SA, Sturim HS: Intraosseous nerve transposition for treatment of painful neuromas. J Hand Surg 10A: 270–274, 1985.
13. Gorkisch K, Boese-Landgraf J, Vaubel E: Treatment and prevention of amputation neuromas in hand surgery. Plast Reconstr Surg 73: 293–299, 1984.
14. Gould JS: Treatment of the Painful Injured Nerve In-Continuity. In Gelberman GH (ed). Operative Nerve Repair and Reconstruction. Philadelphia, JB Lippincott Co 1541–1550, 1991.
15. Grant GH: Methods of treatment of neuromata of the hand. J Bone Joint Surg 33A: 841–848, 1951.
16. Hassenbusch SJ, Stanton-Hicks M, Schoppa D, et al: Long-term results of peripheral nerve stimulation for reflex sympathetic dystrophy. J Neurosurg 84: 415–423, 1996.
17. Herndon JH: Neuromas. In Green DP (ed). Operative Hand Surgery. New York, Churchill Livingstone 939–955, 1982.
18. Herndon JH: Neuromas. In Green DP, Hotchkiss RN (eds). Operative Hand Surgery. Ed 3. New York, Churchill Livingstone 1387–1400, 1993.
19. Herndon JH, Eaton RG, Littler JW: Management of painful neuromas in the hand. J Bone Joint Surg 58A: 369–373, 1976.
20. Herndon JH, Hess AV: Neuromas. In Gelberman RH (ed). Operative Nerve Repair and Reconstruction. Philadelphia, JB Lippincott Co 1525–1540, 1991.
21. Karev A, Stahl S: Treatment of painful nerve lesions in the palm by “rerouting” of the digital nerve. J Hand Surg 11A: 539–542, 1986.
22. Kon M, Bloem JJ: The treatment of amputation neuromas in fingers with a centrocentral nerve union. Ann Plast Surg 18: 506–510, 1987.
23. Krames ES: Implantable Technologies: When to Use Spinally Administered Opioids or Spinal Cord Stimulation: An Algorithm for Decision-Making. In Campbell JN (ed). Pain 1996–An Updated Review. Refresher Course Syllabus. Seattle, International Association of the Study of Pain (IASP Press) 201–206, 1996.
24. Lidor C, Hall RL, Nunley JA: Centrocentral anastomosis with autologous nerve graft treatment of foot and ankle neuromas. Foot Ankle Int 17: 85–88, 1996.
25. Long DM: Electrical stimulation for the control of pain. Arch Surg 112: 884–888, 1977.
26. Masear VR, Bonatz E: Painful Neuromas of the Lower Extremity and Postneurectomy Pain. In Omer Jr GE, Spinner M, Van Beek AL (eds). Management of Peripheral Nerve Problems. Ed 2. Philadelphia, WB Saunders Co 151–156, 1998.
27. Masear VR, Tulloss JR, St. Mary E, et al: Venous wrapping of nerves to prevent scarring. J Hand Surg 15A:817–818, 1990. Abstract.
28. Mass DP, Ciano MC, Tortosa R, et al: Treatment of painful hand neuromas by their transfer into bone. Plast Reconstr Surg 74: 182–185, 1984.
29. Max MB, Culnane M, Schafer SC, et al: Amitriptyline relieves diabetic neuropathy pain in patients with normal or depressed mood. Neurology 37: 589–596, 1987.
30. McQuay HJ, Carroll D, Glynn CJ: Dose-response for analgesic effect of amitriptyline in chronic pain. Anaesthesia 48: 281–285, 1993.
31. Melzack R, Wall PD: Pain mechanisms: A new theory. Science 150: 971–979, 1965.
32. Nashold Jr BS, Goldner JL, Bright DS: Direct electrical stimulation of the peripheral nerves for relief of intractable pain. J Bone Joint Surg 57A:729, 1975. Abstract.
33. Nashold Jr BS, Goldner JL, Mullen JB, et al: Long-term pain control by direct peripheral-nerve stimulation. J Bone Joint Surg 64A: 1–10, 1982.
34. Otfinowski J, Pawelec A, Kaluza J: Implantation of peripheral neural stump into muscle and its effect on the development of posttraumatic neuroma. Pol J Pathol 45: 195–202, 1994.
35. Petropoulos PC, Stefanko S: Experimental observations on the prevention of neuroma formation. J Surg Res 1: 241–248, 1961.
36. Picaza JA, Cannon BW, Hunter SE, et al: Pain suppression by peripheral nerve stimulation. Part II. Observations with implanted devices. Surg Neurol 4: 115–126, 1975.
37. Robbins TH: Nerve capping in the treatment of troublesome terminal neuromata. Br J Plast Surg 39: 239–240, 1986.
38. Schon LC, Easley ME: Chronic Pain. In Myerson MS (ed). Foot and Ankle Disorders. Philadelphia, WB Saunders Co 851–881, 2000.
39. Shealy CN, Mortimer JT, Reswick JB: Electrical inhibition of pain by stimulation of the dorsal columns: Preliminary clinical report. Anesth Analg 46: 489–491, 1967.
40. Skalley TC, Schon LC, Hinton RY, et al: Clinical results following revision tibial nerve release. Foot Ankle Int 15: 360–367, 1994.
41. Smith JR, Gomez NH: Local injection therapy of neuromata of the hand with triamcinolone acetonide: A preliminary study of twenty-two patients. J Bone Joint Surg 52A: 71–83, 1970.
42. Sotereanos DG, Giannakopoulos PN, Mitsionis GI, et al: Vein-graft wrapping for the treatment of recurrent compression of the median nerve. Microsurgery 16: 752–756, 1995.
43. Spiegel K, Kalb R, Pasternak GW: Analgesic activity of tricyclic antidepressants. Ann Neurol 13: 462–465, 1983.
44. Sunderland S: Nerves and Nerve Injuries. Ed 2. New York, Churchill Livingstone 1978.
45. Tupper JW, Booth DM: Treatment of painful neuromas of sensory nerves in the hand: a comparison of traditional and newer methods. J Hand Surg 1A: 144–151, 1976.
46. Waisbrod H, Panhans C, Hansen D, et al: Direct nerve stimulation for painful peripheral neuropathies. J Bone Joint Surg 67B: 470–472, 1985.
47. Wall PD, Sweet WH: Temporary abolition of pain in man. Science 155: 108–109, 1967.
48. Watson CP, Evans RJ, Reed K, et al: Amitriptyline versus placebo in postherpetic neuralgia. Neurology 32: 671–673, 1982.
49. Whipple RR, Unsell RS: Treatment of painful neuromas. Orthop Clin North Am 19: 175–185, 1988.
50. White JC, Sweet WH: Pain and the Neurosurgeon: A Forty-Year Experience. Springfield, IL, Charles C Thomas 1969.
51. Williams HB: The painful stump neuroma and its treatment. Clin Plast Surg 11: 79–84, 1984.
Osaretin B. Idusuyi, MD; and G. James Sammarco, MD, Guest Editors© 2001 Lippincott Williams & Wilkins, Inc.