Surgical treatment of pain syndrome in patients with amputation defects of the limbs resulting from combat trauma

BACKGROUND: Combat-related limb injury requiring amputation is a severe, disabling injury. Effective prosthetic fitting is key to the quality of life of such patients. One of the main obstacles to prosthetic fitting is chronic pain syndrome. AIM: To evaluate the efficacy of various surgical treatment methods for pain syndrome in patients with amputated limb defects resulting from combat trauma, and to identify factors influencing the treatment outcome. METHODS: Pain was assessed using a visual analog scale and a neuropathic pain diagnostic questionnaire. To identify independent predictors of failure in pain control, unsuccessful prosthetic fitting, and recurrence, a multivariable logistic regression analysis was performed. RESULTS: Neurosurgical operations using microsurgical techniques and the addition of alcohol neurolysis (chemical neurolysis with alcohol) were superior to similar operations without alcoholization. Thus, the median visual analog scale score after treatment was 0.5 points versus 1 point (p = 0.018), and the success rate of prosthetic fitting was 76% versus 53% (p = 0.022). In 66.7% of patients who underwent repeated surgeries, switching to neurosurgical interventions using microsurgical techniques and nerve alcoholization ensured successful prosthetic fitting. A correlation was identified between the time from injury to admission and the duration of treatment (r = 0.42; p = 0.004). Operations without nerve alcoholization were the strongest independent risk factor for failure in pain relief, unsuccessful prosthetic fitting, and recurrence (odds ratio = 5.05; p = 0.009; 5.81; p = 0.011; and 5.21; p = 0.015, respectively). Therapeutic blocks were associated with a lower risk of failure in pain relief and prosthetic fitting (odds ratio = 0.1; p = 0.040 and 0.06; p = 0.046, respectively). Amputation at the thigh level was a predictor of unsuccessful prosthetic fitting and recurrence (odds ratio = 4.18; p = 0.025 and 3.82; p = 0.036, respectively); each additional neuroma increased the risk of unsuccessful prosthetic fitting by 2.1-fold (p = 0.025) and the risk of recurrence by 2.41-fold (p = 0.012). CONCLUSION: Adding nerve alcoholization to microsurgical interventions significantly improves the outcomes of neuroma treatment and reduces the risk of recurrence; surgeries without nerve alcoholization are not recommended as a standalone method for this population. The identified predictors can be used for risk stratification, but they require confirmation in larger samples.