Putting the freeze on post-amputation pain
HHS treatment program first of its kind provincially
When Tillsonburg resident Richard Wiens lost his left leg to cancer 40 years ago, he was determined to return his life to normal. But despite his resilience, life was never quite the same because of a neuroma that formed at the amputation site, causing decades of chronic, debilitating pain.
“I couldn’t sleep well for years because the pain was so bad,” says Wiens, age 80, adding that neuroma pain also made it challenging to use his prosthesis (artificial leg).
A neuroma is a thickened bundle of nerve tissue that can form after an amputation, causing severe pain. Like many post-amputation patients with neuromas, Wiens visited a pain clinic and tried powerful medications and surgeries in search of relief, with no luck.
But thanks to a novel procedure at Hamilton Health Sciences’ (HHS) Hamilton General Hospital (HGH) for treating post-amputation neuroma pain, Wiens has been able to live pain-free for the first time in four decades.
“It worked for me, 100 per cent. It’s unbelievable.” — Richard Wiens, patient
After 40 years of living with severe neuroma pain, Tillsonburg resident Richard Wiens found relief through cryoablation treatment at HHS’ Hamilton General Hospital.
How cryoablation works
Cryoablation is a minimally invasive procedure that takes just 20 minutes to perform. It involves tiny cuts instead of a large surgical incision, and most patients return home afterwards. It’s performed by an interventional radiologist, who uses ultrasound guidance to precisely target the neuroma using small probes rather than surgery.
When a nerve is cut, it can form a thickened bundle of nerve tissue called a neuroma. If the neuroma becomes overly sensitive, it can cause pain that has traditionally been very difficult to treat.
An extremely cold probe is used to freeze the nerve that’s sending pain signals from the amputation site. The nerve is then allowed to thaw, and this freezing and thawing is repeated. This process disrupts the nerve’s ability to carry pain messages to the brain by damaging the part of the nerve that transmits signals, while leaving its outer structure mostly intact. As a result, pain signals are reduced or blocked, often providing relief for months or more while the nerve slowly heals.
Since nerves eventually grow back, cryoablation isn’t a permanent fix. But it can bring relief for several months or longer. In Wiens’ case, it brought relief for over a year. The pain has started creeping back, says Wiens, who plans to return to HGH for another treatment.
Dr. Zain Badar is an interventional radiologist at HHS’ Hamilton General Hospital. Badar suggested using cryoablation for patients with amputations who experience neuroma pain.
High success rate
So far, about 35 HGH patients with post-amputation neuroma pain, including Wiens, have received cryoablation treatment, with close to an 85 per cent success rate in eliminating or significantly reducing pain and improving daily function, says Dr. Zain Badar, the interventional radiologist who suggested trying cryoablation for patients with amputations who experience neuroma pain.
Neuroma pain in the form of intense sharpness, burning, or electric shock-like sensations is a fairly common complication after an amputation and can last a lifetime.
The interventional radiology team at HGH partnered with HHS’ Regional Rehabilitation Centre – where patients with amputations receive support, including learning to use a prosthesis – to explore cryoablation for pain relief.
Dr. Sharon Grad, Regional Rehabilitation Centre
“These patients are ready to continue their rehabilitation journey but can’t tolerate the pressure of a prosthesis on their amputated limb,” says Dr. Sharon Grad, who specializes in amputee rehabilitation at the Regional Rehabilitation Centre. “It’s a huge frustration for them.”
Building on the success of cryoablation, HGH has become the first hospital in the province to offer an official cryoablation program to treat debilitating pain in patients who have undergone an amputation.
“It worked for me, 100 per cent,” says Wiens. “It’s unbelievable. For the first time in years, I’ve been able to sleep through the night.”
Understanding neuromas
When a nerve is cut, it can form a thickened bundle of nerve tissue called a neuroma. If the neuroma becomes overly sensitive, it can cause pain that has traditionally been very difficult to treat.
Grad has seen many patients over the years, including Wiens, whose lives were deeply impacted by severe neuroma pain. Their pain persisted despite powerful painkillers and treatments like corticosteroid injections, which can help calm irritated tissue and reduce inflammation, and phenol injections, which work by disrupting a nerve’s ability to send pain signals.
When medications and injections didn’t work for Wiens, he underwent several surgeries at a London hospital to trim back the affected nerve, only to see it grow back. In search of relief, he then tried having a spinal cord stimulator surgically implanted. This device uses electrical impulses to disrupt pain signals before they reach the brain, but in Wiens’ case, it didn’t bring relief so he underwent another surgery to remove it.
“Nothing worked until I had cryoablation at Hamilton General Hospital,” Wiens says.
Quality of life
Neuroma pain in the form of intense sharpness, burning, or electric shock-like sensations is a fairly common complication after an amputation and can last a lifetime, interfering with everything from work to relationships, and contributing to exhaustion, stress, anxiety, and depression.
For people who have had an amputation, getting an artificial limb is a powerful step toward reclaiming independence and rebuilding everyday life, says Grad. But neuroma pain can make it impossible to wear a prosthesis, get a good night’s sleep, return to work, or enjoy simple pleasures like walking.
Treating multiple neuromas
Michelle Bisaillon, 35, has undergone three cryoablation procedures at HGH this year, in February, April and July. “I have multiple neuromas in my stump, which is why I required three procedures,” says Bisaillon, whose treatments were scheduled several months apart to give her time to recover between procedures.
Michelle Bisaillon, HHS social worker and cryoablation patient
Bisaillon, an HHS social worker, was diagnosed with acute myeloid leukemia at age 14, and developed septic shock that led to a partial amputation of both feet. Complications persisted with her right foot, leading her to choose a below-knee amputation at age 18. In her early 20s, when muscle separated from bone at the amputation site, she required a second surgery. The neuromas developed following that procedure.
“With my original amputation I didn’t have neuromas,” says Bisaillon. “It was the re-cutting with the second surgery that caused neuromas to form.”
Constant pain made wearing her prosthesis challenging. “But I’m very stubborn,” says Bisaillon, who tried different pain-relief options with little luck. “Regardless of the pain I was in, I would still wear my prosthetic leg.”
Bisaillon noticed less pain after her first two cryoablation procedures and hopes her most recent treatment will bring even more relief lasting several months or even longer.
Understanding the impact
While results from patients treated so far look promising, studies are needed to gauge this treatment’s success over time.
“We don’t know how long the pain relief will last because this treatment option is so new,” says Grad. “We expect that at some point in the future, the pain will return and we’ll need to repeat the treatment. But we’re hopeful this could be a durable treatment option that offers patients long stretches of meaningful pain relief.”
An innovative use for an established treatment
While cryoablation is new for post-amputation neuroma pain, it has been used at HHS for the past few years to treat patients with vascular malformations, which are an abnormal tangle of veins that can cause pain, swelling and discomfort. It has also been used in cancer treatment for the past few years to destroy tumours without surgery.
“The uniqueness of this treatment for patients with amputations isn’t the technology, because we’ve had it for several years,” says Badar. “It’s how we’re using this technology to help a new patient population so they can hopefully move on with their lives.”
