Erasing Nerve Pain Post-Surgery

Easing nerve pain post-surgery12/15/2008 2:54 PMBy: Ivanhoe Broadcast News

Dr. Ivica Ducic, Ph.D., is a plastic surgeon at Georgetown University Hospital.

Q: Why do some amputees have chronic pain?

Dr. Ducic: The pain is there because the nerves, the very bottom part of the nerves, get into the scar tissue with the healing. Not every amputee has a chronic pain, but a good number of them have a phantom pain or actual true nerve pain due to the neuroma at the very distal portion of the stump



Q: Could these people live with this pain forever? Will it ever dull?

Dr. Ducic: They certainly suffer with this, and the quality of their life is certainly negatively affected because of it. The problem is that the pain usually doesn’t come up right after the amputation, but several months or a year or two after. At that point, people are already used to wearing their prosthesis, and then psychologically it’s quite a big burden for those patients to go back into the crutches or wheelchair, since they can’t use the prosthesis due to the pain.


Q: How are you able to help them?

Dr. Ducic: We first have to identify that there are no other common reasons for the amputation stump pain, which would be things like, too much rubbing of the prosthesis onto the leg if the fitting was not properly done, infection, or abnormal bony growth. Those are some of the more common things to happen, and those are fairly easy to find and address. Once those are ruled out, then there is a more sophisticated exam to look for the source of the pain. This is where the big crossroad is between the options that these patients have, and unfortunately, it also depends on whom they get to be referred to. Some specialists are going to prefer to give them pain medications, other specialists are going to want to give them special injections, and different specialists can opt to give them nerve stimulators or implantable probes that would go ahead and distract their pain. All of these treatments have one thing in common; they are treating symptoms. The difference with peripheral nerve surgery: what I do, is it brings a new view into the treatment of these patients. All of these patients are going to have the same symptoms, but, in my opinion, addressing the source is the only way to get rid of the symptoms, in a quality way.



Q: All of the other options seem very short term?

Dr. Ducic: I don’t want to be disrespectful towards my other colleagues. Everybody is doing the best they can, but again, if you’re chasing a symptom, and not addressing the cause, you really are not looking for a long-term solution



Q: What is the cause?
Dr. Ducic: The cause is the painful terminal end of the nerve called neuroma, which gives an amputee amputation stump pain.



Q: So what do you do?

Dr. Ducic: I identify exactly what nerve is involved in generating pain, and that’s fairly simple in a physical exam. MRIs, X-rays, CAT scans, bone scans--none of those things, unfortunately, will show you exactly where the neuroma is. They can anatomically point where the normal nerve is, but quantitatively, they will not tell you how much that nerve is in trouble, so you end up being dependent on the peripheral nerve surgery targeted exam looking for proper identification of the nerve generating the pain, and then surgically addressing it.



Q: How many nerves are usually involved?

Dr. Ducic: Depending on whether they are an above the knee or below the knee amputee, usually certain nerves, not all of the nerves, are acting up in terms of neuroma and pain. It is very important to know exactly what nerve is responsible for the pain in order to address the pain properly.



Q: How do you do that?

Dr. Ducic: Very simple. Asking the patient where it hurts, and performing a physical exam confirming where the pain is. So, it’s technically actually not that difficult.



Q: What do you do with the nerve?

Dr. Ducic: Once you identify the exact source of the pain, and location of the nerve responsible for that, then you take the patient to the operating room, and you identify that nerve interoperatively. Then you can remove the nerve higher to that site, so you disconnect the connection to the central nervous system and the painful neuroma, and you take a segment of the nerve out that is bad, and you implant that into the muscle so it won’t grow back as a painful neuroma.



Q: How long will it take for the patient to feel pain-free after the surgery?

Dr. Ducic: Well, theoretically, the patient should wake up pain-free, but everybody is somewhat different in the way they respond to the surgery. How they respond to the treatment can depend on how long the problem that they had was affecting the quality of the life, certainly, how much psychologically they are burdened with this problem. Somebody who suffered amputation because of a bomb blast, or a severe motor vehicle accident where they lost their family member, may have a significant other component of the pain that has to be addressed separately. So, those things can define how long after surgery somebody might respond rather it be sooner or later.



Q: Is there any downside to this?

Dr. Ducic: Besides general surgical risks, there is really are not many. There is always the risk of infection, bleeding, minor things, but this is a very clean, very short, outpatient procedure without much of the undertaking. So, they are fairly easy for patients to go through. Worst case scenario, 15 percent of the patients might not be able to respond in the most positive way we want.



Q: Why isn’t this done during the initial amputation?

Dr. Ducic: You can’t be just going after all of the nerves and dissecting the nerves because the risk of the tissue maceration, infection, and wound healing problems would be astronomically high. On the other hand, when amputations are being done, they need to be done in a proper way that, at least, the large nerves can be addressed in such a way that they are not immediately available to the scar tissue or the distal stump amputation.



Q: How long would a patient have to wait after having their leg amputated before this could be done?

Dr. Ducic: On average, just having amputation done entitles you to have some pain for at least several months or so. As a rule of thumb, don’t operate for at least six months from the time of the amputation, until the patient has been given at least a reasonable chance to recover and show the signs of normal recovery process.



Q: What kinds of amputations can this procedure help?

Dr. Ducic: Peripheral nerve surgery can be applied to any other nerve in the body. If you have a knee replacement and you’re having chronic knee pain after that, you can have these problems taking care of. Pain after a hernia surgery, hysterectomy or any other surgery in the body can cause chronic pain that, again, ideally is not being addressed just by treating the symptoms. Rather you need to address the source of the pain and that is probably a compromised nerve, once the other reasons for the chronic pain are ruled out



Q: Could this be something life-altering for the hundreds of thousands of people out there who are living with chronic pain right now?

Dr. Ducic: I love treating amputees. They are very appreciative patients. They are very thankful about what is being done for them. They can go back and resume their life and certainly with those that get a great response and they can move on with their life.



Q: Have you seen a good change with your patient Harry Friedman?

Dr. Ducic: Harry Friedman had a very nice change, although, his recovery took him several months to really start seeing. I think it was five months before he would really say that it really helped him the way it is. That really differs with what kind of preexisting factors were associated and variables causing the amputation. It has to do with how a person responds to pain. Every one of us has a different pain threshold, and we show that pain so to speak, in very different ways. I would say he is within very reasonable standard deviation of what we expect after the surgery.



Q: Why is this surgery important?

Dr. Ducic: The key information I want to bring to these patients is that this is a manageable problem, it is very simple outpatient surgery, and that chronic pain medications are not the absolute prescription for life. For these patients, if this surgery is being applied in a proper way, in terms of indication for surgery, any patient who has had amputation either below or above the knee, who has been suffering with the pain for more than six months, and other basic reasons for the amputation stump pain ruled out, then the peripheral nerve surgery evaluation should take place, and they can be very effectively treated.



Q: How long does the surgery last?

Dr. Ducic: About an hour, on average.



Q: What else should patients know going in?

Dr. Ducic: Another thing that is important, some people have a phantom pain, but not true stump pain, and that is very different. What I found out is that this phantom pain is more related to the manipulation and pressure on the distal end of the nerves that are not really painful as a true painful neuroma is. They cause the other component of the phantom pain, and that one can be also treated in some of these patients by re-sizing the terminal end of the nerve and organizing it in such a way that the nerves wouldn’t cause phantom pain any more.