CLINICAL FEATURES AND MANAGMENT OF SYMPTOMATIC NEUROMA AFTER TRAUMATIC LIMB AMPUTATION CAUSED BY MINE BLAST TRAUMA Текст научной статьи по специальности «Клиническая медицина»

MEDICAL SCIENCES

CLINICAL FEATURES AND MANAGMENT OF SYMPTOMATIC NEUROMA AFTER TRAUMATIC LIMB AMPUTATION CAUSED BY MINE BLAST TRAUMA

Kikh A.

PhD, Head of Military Medical Clinical Treatment & Rehabilitation Center, Irpin, Ukraine

Bespalenko A.

MD, Traumatologist, Trauma Department, Military Medical Clinical Treatment & Rehabilitation Center,

Irpin, Ukraine Shchehliuk O.

MD, Neurologist, Department of Rehabilitation of the Patients with Limbs Amputation, Military Medical

Clinical Treatment & Rehabilitation Center, Irpin, Ukraine

Volyansky O.

PhD, PRM, Physical Medicine & Rehabilitation Doctor, Head of Clinic of Rehabilitation, Military Medical

Clinical Treatment & Rehabilitation Center, Irpin, Ukraine

Abstract

We performed the analysis of the structure, clinical features and treatments results of participants of the antiterrorist operation (ATO)/Joint Forces Operation (JFO) with symptomatic stump neuroma (SSN) after amputation caused by mine blast trauma (MBT). The rate of SSN was 10.1%. The rate of SSN among patients with upper and lower limbs amputation was 11% and 9.8%, accordingly. The main peculiarities of SSN were: early clinical manifestations (an average term was 4.6 months from the trauma); variety of clinical manifestations; low awareness of instrumental and imaging diagnostic techniques; limitation of mobility and ability to move around on prosthesis; sense of anxiety and depressive disorders in 37.5% of cases; low effectiveness of conservative treatment; using in management of SSN multiprofessional approach and surgery. There was a decrease of pain intensity from 7.3 to 2.4 points according to Visual Analog Scale (VAS) within three months after surgery.

Keywords: neuroma, amputation, stump, management

Background: According to the literature, 75% of MBT among participants of ATO/JFO leads to amputation [1]. SSN is the most common complication after limb amputation; it is caused by disruption of normal regeneration of the damaged nerve and often leads to severe dysfunction, restriction of prosthesis application and participation in daily activities. SSN occurred from 12% to 48% of the patients after amputation of the lower extremities [2, 3, 4], from 25% to 26% after amputation of the upper extremities [5, 6] and in 8% of the patients after amputation of the fingers [7]. Also, according to research of Walter Reed National Military Medical Center (USA) SSN was diagnosed in 48.7% of servicemen with limbs amputation [8], and there was a frequent association with post-traumatic stress disorder (PTSD) and depression. The main method of treatment is surgical [9]. However, after initial surgery, up to 42% of the patients may have persistent symptoms and redone surgery. The relevance of our research caused by the significant increase of amount of the patients with limbs amputation among the participants of the ATO/JFO, and lack of information about the prevalence and peculiarities of SSN.

The aim of research: to analyze the structure of SSN among participants of ATO/JFO with limbs amputations, to investigate the clinical manifestation and features of management, to assess the effectiveness of surgical and conservative methods of treatment.

Materials and methods. There were performed the analysis of the structure, clinical peculiarities and treatments results of 8 patients participants of ATO/JFO with diagnosis of SSN after amputation

caused by MBT. They were hospitalized in Department of Rehabilitation of the Patients with Limbs Amputation, Military Medical Clinical Treatment & Rehabilitation Center, in the term from 12/26/2016 to 05/12/2020. A total of 79 patients with amputation were hospitalized during this period. The average age of patients with SSN was 34.5 years (between the age of 18 and 46). There were 8 (100%) males. In all cases the amputation was caused by MBT. We use the VAS to assess the dynamics of pain syndrome and the effectiveness of treatment.

Results. Among 79 patients with amputation 63 (79.7%) had amputation of lower limbs, 8 (10.1%) had amputation of upper limbs, 7 (8.9%) patients had bilateral amputation, 1 (1.3%) have an amputation of both lower limbs and one upper limb. The rate of SSN among patients with upper and lower limbs amputation was 11% and 9.8%, respectively SSN of residual limbs was diagnosed among 8 (10.1%) of 79 amputees. 7 (87.5%) of 8 patients had SSN of the lower limbs and 1 (12.5%) of 8 patients have SSN of upper limb. According to the level of amputation: 1 (12.5%) patient had transfemoral residual limb, 6 (75%) - transtibial residual limbs, 1 (12.5%) - transforearm residual limbs. SSN of peroneal nerve branches was diagnosed in 5 (62.5%) of 8 patients, SSN of tibial nerve had 1 (12.5%) patient, SSN of sciatic nerve had 1 (12.5%), SSN of radial nerve was diagnosed in 1 (12.5%) of 8 patients.

The diagnosis of SSN was based on clinical signs and ultrasound visualization, but it was informative to confirm the diagnosis in only 2 (25%) of patients. The average period from trauma to clinical manifestation of

SSN was 4.6 months (range, 1-15 months). The average period from trauma to the operation was 6.1 months (range, 3-17 months), from the appearance of the first symptoms to the surgery was 1.5 months. Clinical manifestations of SSN were different. 100% of patients had shooting pain in the stump, which radiated above and below the lesion, in 3 (37.5%) of 8 patients it was combined with "phantom" pain, in 2 (25%) - with numbness in innervations area, in 1 (12.5%) - with the burning pain. Anxiety-depressive disorders were detected in 3 (37,5%) of 8 patients. It should be the important sign in manifestation of SSN and result of treatment.

Taking into account these features the management of SSN included a multiprofessional approach (neurologist, traumatologist, physical therapist, psychologist, prosthetist). Conservative treatment included medicine (pregabalin 150-600 mg per day), physiotherapy (electromyostimulation), cognitive-behavioral therapy and prosthesis correction. These methods had a slight positive effect at the beginning of treatment and reduced the pain from 7.3 points to 4.3 points according to VAS, but there was recurrence of pain in all cases when medicine was canceled. As a result, all patients had surgery with nerve revision and resection of SSN (Fig. 1).

Fig. 1 Surgery: resection of SSN of the peroneal nerve (left) and sciatic nerve (right).

The effectiveness of treatment was assessed according to pain decrease (VAS). The pain intensity was 7.3 points according to VAS before surgery. There was a significant improvement and reduction of pain to 1.4 points during the first month after surgery. Three

10 -

7,3

months after surgery the intensity of pain has been increased to 2.4 points in 3 (37.7%) patients (Fig. 2). 1 (12.5%) patient had redone surgery.

It can be concluded that surgery of SSN has shown a better result in pain relief than medical treatment.

0

1,4

2,4

before surgery ■ 1 month after surgery ■ 3 months after surgery

5

Fig. 2. Evaluation of pain according to VAS in patients with SSN before and after surgery (in points)

Summary. According to the results of the study, SSN in patients with amputation of the upper and lower limbs caused by MBT was 10.1%. SSN of peroneal nerve branches was diagnosed the most frequently (62.5%). The main peculiarities of SSN were: early clinical symptoms (an average term was 4.6 months from the trauma), a variety of clinical manifestations, low awareness of instrumental and imaging diagnostic techniques, limitation of mobility and ability to move around on prosthesis, sense of anxiety and depressive disorders in 37.5% of cases, low effectiveness of conservative treatment, using surgery in management of SSN. The experience showed that multiprofessional approach (including psychologist, traumatologist, physical therapist, neurologist, prosthetist) is an important aspect of treatment of patients with SSN.

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COMPARATIVE CHARACTERISTICS OF LIPID METABOLISM IN CHILDREN OF THE STAVROPOL TERRITORY SUFFERING FROM CYSTIC FIBROSIS, OBSTRUCTIVE BRONCHITIS, ATYPICAL PNEUMONIA AND BRONCHIAL ASTHMA

Grigoryants I.

Assistant at the Department of Hospital Pediatrics

FSBEI HE "StSMU" Vodovozova E.

Candidate of Medical Sciences, Associate Professor, Head of the Department of Hospital Pediatrics

FSBEI HE "StSMU" Ledeneva L.

Candidate of Medical Sciences, Associate Professor, Department of Hospital Pediatrics

FSBEI HE "StSMU" Enina E.

Candidate of Medical Sciences, Associate Professor of the Department of Hospital Pediatrics

FSBEI HE "StSMU"

СРАВНИТЕЛЬНАЯ ХАРАКТЕРИСТИКА ЛИПИДНОГО ОБМЕНА У ДЕТЕЙ СТАВРОПОЛЬСКОГО КРАЯ, СТРАДАЮЩИХ МУКОВИСЦИДОЗОМ, ОБСТРУКТИВНЫМ БРОНХИТОМ, АТИПИЧНОЙ ПНЕВМОНИЕЙ И БРОНХИАЛЬНОЙ АСТМОЙ

Григорьянц И.С.

ассистент кафедры госпитальной педиатрии ФГБОУ ВО «СтГМУ» Водовозова Э.В.

к.м.н., доцент, заведующая кафедрой госпитальной педиатрии

ФГБОУ ВО «СтГМУ» Леденева Л.Н.

к.м.н., доцент, кафедры госпитальной педиатрии

ФГБОУ ВО «СтГМУ» Енина Е.А.

к.м.н., доцент кафедры госпитальной педиатрии

ФГБОУ ВО «СтГМУ»

Abstract

Comparative characteristics of lipid metabolism in children of the Stavropol Territory suffering from cystic fibrosis, obstructive bronchitis, atypical pneumonia and bronchial asthma Аннотация

Сравнительная характеристика липидного обмена у детей Ставропольского края, страдающих муко-висцидозом, обструктивным бронхитом, атипичной пневмонией и бронхиальной астмой

Keywords: lipids, obstructive bronchitis, cystic fibrosis, atypical pneumonia

Ключевые слова: липиды, обструктивный бронхит, муковисцидоз, атипичная пневмония

Клинические и экспериментальные данные последних лет убедительно свидетельствуют, что хроническое воспаление дыхательных путей и оксида-тивный стресс играют ключевую роль в патогенезе развития и прогрессировали^ МВ и других заболеваний респираторного тракта. Оксидативный

стресс является общей магистралью, ведущей к повреждению эпителия бронхов [2,с.5-15, 3,с. 276280].

В отличие от других органов, легкие непосредственно подвергаются действию кислорода - ини-