Postsurgical neuropathic pain of foot

[SeniorWrangler]

I have been getting a lot of referrals from my esteemed orthopedic colleagues for patients with chronic foot pain after ankle surgery. The surgery is most often ankle ORIF or ankle fusion and they have always seen the ortho clinic multiple times and had multiple benign Xrays to rule out hardware failure.

The pain is neuropathic in quality, on the dorsum of the foot or sometimes anterior in the toes. It tends to be poorly responsive to all my usual tricks; pain creams, neuropathic meds, desensitization, orthotics, etc. Sometimes they get some benefit from PT if I can also identify something like extensor tendonitis.

Does anybody do any kind of IPM procedures for this pain? I was considering a peroneal nerve block since the surgeon requested it but I'm not sure how much diagnostic and therapeutic value it would provide.

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[willabeast]

here is the important question - why did the patient have the ankle surgery? if it was for pain, then the surgeon may have had the wrong treatment for the wrong diagnosis. if this is the case, then you need to get a detailed history from before the operation. for example, what made the pain better or worse before the operation.
OTOH if you want to take some shortcuts, obtain a lumbar MRI looking for a L5 (usually) impingement sometimes L4 or S1. could do EMG to isolate where the problem arises although this is mostly to CYA because once you stick a needle near the Peroneal N. you are now part of the history of what is becoming a failed surgical attempt.
seems to me before one starts sticking needles near nerves in a chronic pain patient you need to know exactly what the problem is. YMMV and of course none of this applies if the patient was not having pain before the ankle surgery.

 

[deleted472101]

I use History physical and waldman atlas to decide what I pick and try to block. If I get positive response then you isolated that nerve. If it doesn't fit try I think CRPS or higher up

 

[Timeoutofmind]

I have been getting a lot of referrals from my esteemed orthopedic colleagues for patients with chronic foot pain after ankle surgery. The surgery is most often ankle ORIF or ankle fusion and they have always seen the ortho clinic multiple times and had multiple benign Xrays to rule out hardware failure.

The pain is neuropathic in quality, on the dorsum of the foot or sometimes anterior in the toes. It tends to be poorly responsive to all my usual tricks; pain creams, neuropathic meds, desensitization, orthotics, etc. Sometimes they get some benefit from PT if I can also identify something like extensor tendonitis.

Does anybody do any kind of IPM procedures for this pain? I was considering a peroneal nerve block since the surgeon requested it but I'm not sure how much diagnostic and therapeutic value it would provide.

Anyone doing this? Basically a lead u tunnel along a peripheral nerve and they use an external battery/Ipg/programming unit

Seems super intuitive and minimally invasive. Don't have to implant a bulky ipg peripherally

I'm thinking about it as I have a lot of similar patients...

 

[Orin]

SCS/DRG stim or peripheral stim seems reasonable to try. I'm hoping to do a few of the latter in a few weeks if I can find appropriate patients.

 

[Taus]

SCS/DRG stim or peripheral stim seems reasonable to try. I'm hoping to do a few of the latter in a few weeks if I can find appropriate patients.

Perhaps if all else failed..... but before workup for clear etiology and more conservative treatment?!


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[Orin]

Perhaps if all else failed..... but before workup for clear etiology and more conservative treatment?!

Sure, I've got no problem with a workup or more conservative treatment modality but in the ivory tower they've already gone through all that before they get to me.

We could discuss whether aggressive implants which mask the symptoms early are better than letting them languish while we pursue cheaper less effective conservative or more expensive and traumatic surgical therapies to fix the problem.

 

[lobelsteve]

Sure, I've got no problem with a workup or more conservative treatment modality but in the ivory tower they've already gone through all that before they get to me.

We could discuss whether aggressive implants which mask the symptoms early are better than letting them languish while we pursue cheaper less effective conservative or more expensive and traumatic surgical therapies to fix the problem.

They are all appropriate patients.