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Page 4 of 17 Toyoda et al. Plast Aesthet Res 2022;9:17 https://dx.doi.org/10.20517/2347-9264.2021.118

Figure 1. Symptomatic neuroma of sciatic nerve after above-knee amputation (AKA). A 26-year-old man with a history of polyarteritis
nodosa who underwent left below-knee amputation as well as right AKA presented with right sciatic nerve symptomatic neuroma
approximately 1.5 years after his AKA. The symptomatic neuroma was diagnosed both clinically and radiographically with MRI. (A) In
situ sciatic nerve terminal neuroma in his right AKA surgical site. (B) The neuroma was excised, and sciatic nerve cut back to healthy-
appearing fascicles. The total resected neuroma and pathologic nerve measured roughly 6 cm long.

irritation from tethered scar or compression, myofibroblast proliferation, abnormal accumulation of
sodium and potassium channels which cause hyperexcitability, surrounding inflammation that chemically
[18]
stimulates nearby nociceptors, and release of inflammatory cytokines . The amount of axoplasmic flow,
the ratio of fascicles to epineural tissue, and the nutritional status of the peripheral nerve are thought to
affect neuroma formation .
[18]
Diagnosis of the symptomatic neuroma is based on pain with a scar, altered sensation in the nerve
distribution, and positive Tinel’s sign . In cases in which more than one nerve is involved, the picture may
[18]
be muddled, but the sensory issues should present in a dermatomal pattern . Nerve blocks can be
[17]
diagnostic and therapeutic in these patients.

Nonsurgical treatment of post-amputation pain
Treatment of post-amputation pain typically begins with non-specialized medical management, including a
multimodal pain regimen with nonsteroidal anti-inflammatory drugs, opiates, and non-opiate analgesics
like acetaminophen. When pain is not controlled, the patients often get referred to pain specialists where
they may receive neuropathic pain medication, including gabapentinoids, antidepressants, or NMDA
antagonists like ketamine, dextromethorphan, and memantine [1,22] . These are complemented by physical
therapy techniques such as massage or injection therapy, including lidocaine and/or corticosteroid .
[1]
Regional nerve blocks by pain specialists may serve both diagnostic and therapeutic purposes .
[17]
Given the significant psychological aspect of post-amputation pain, neurologic and psychologic treatment
[1]
such as biofeedback and cognitive behavioral therapy are trialed as well . Unique therapies, such as mirror
therapy may also be effective. A randomized controlled trial of fifteen amputees underwent mirror vs.
control covered mirror or mental visualization therapy . Over four weeks of regular sessions, patients who
[23]
underwent mirror therapy had a significant decrease in pain scores and daily length of time during which
they experienced pain compared to the control group . A systematic review of mirror therapy, motor
[23]
imagery, and virtual feedback techniques on phantom limb pain after amputation found that while these
techniques did seem to reduce pain, the quality of the studies was lacking, and given the limited scientific