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Treatment
Of A Case Of
Post-Traumatic Neuralgia
Rowena Archibald, MD
OBJECTIVE
To describe the use of acupuncture in treating a case of posttraumatic
neuralgia.
PROBLEM
A 50-year-old woman with pain and cold sensitivity in the right hand.
History of Present Illness
A 50-year-old, right-handed woman presented in March 1999 complaining
of burning over the radial portion of the right middle finger, severe
right palm pain, and extreme sensitivity of the right hand to cold temperatures.
In November 1996, she underwent a decompression of a stenosing tenosynovitis
(trigger finger) and partial flexor digitorum superficialis (FDS) of
this same digit. Her pain persisted to the point that she sought relief
from a second surgeon. A second procedure, performed in November 1997,
revealed paired radial digital nerves in the right middle finger, one
of which had been seemingly damaged during the first surgery. A neuroma
was excised from the damaged area, and the injured nerve was buried
into the interosseous musculature. The patient's pain remained poorly
controlled despite 2 subsequent surgeries that involved tenolysis of
the FDS and flexor digitorum profundus, excision of the second radial
digital nerve as well as the dorsal branch of the radial nerve, and
sympathectomy of the radial digital artery. Despite these anatomic disruptions,
she somehow maintained normal 2-point discrimination over the radial
aspect of the right middle finger. After each procedure, the patient
stated that her pain worsened; neither did she improve sufficiently
with medication nor with transcutaneous electrical nerve stimulation.
She was subsequently referred for acupuncture evaluation.
Past History
Pertinent past medical history included diagnoses of fibromyalgia and
rheumatoid arthritis.
Physical Examination
Review of systems was notable for morning stiffness with occasional
pain and swelling of multiple joints, hair loss since being treated
with arthritic medications, color changes in both hands on exposure
to cold temperatures, and recent tinnitus. While obtaining her Chinese
medical history, she revealed that she disliked winter, was rarely fearful,
and preferred pastel and gray colors.
On physical examination, the patient was tender to light touch over
the right palm and middle finger scars, which were raised and red. Two-point
discrimination was 5 mm over each of the areas served by the individual
middle finger digital nerves. She was tender bilaterally |over points
KI 7 and KI 10. Her tongue had yellow "fur" posteriorly and
was pale.
TREATMENT
The patient was treated as follows: KI 7, KI 10, and BL 60 formed the
basic treatment circuit. The needles at KI 7 were attached to those
at KI 10, with an electrical stimulation unit at 4 Hz (Figure 1). In
addition, GB 39 was picqured bilaterally. Several needles were placed
locally to surround the scar; the patient was treated for 12 minutes.
Outcome
The patient experienced a decrease in pain shortly after the treatment
and a decrease in scar prominence after a few days. The same needle
program was repeated 4 additional times over the next 4 months, with
the patient reporting almost immediate pain improvement after most treatments.
The scar tissue continued to decrease in size and redness. One year
later, she reported continuing marked sensitivity to cold, but the remaining
discomfort involved only the DIP and digital
phalanx of the middle finger. She stated this pain to be about 50% of
its pre-acupuncture treatment levels. She reported no further significant
discomfort over the right palm nor in the right middle finger proximal
to the DIP. The patient declined further acupuncture treatments, considering
the level of improvement acceptable.
DISCUSSION
Post-traumatic neuralgia is difficult to treat. Consensus holds that
the sole successful treatment is the restoration of a normal input of
non-painful impulses, i.e., successful repair of the affected nerve.
In this patient's case, several months had lapsed after the initial
surgery before nerve injury was suspected. Many hand surgeons believe
that nerve grafting of non-border digital nerves is not justified; thus,
the patient's second surgery in November 1997 was an excision of a radial
digital neuroma with burying of the proximal stump of this nerve into
the interosseous musculature.
With interruption of nerve continuity, a variety of changes occur. At
the site of the injury, the nerve fiber ends retract and the traumatized
area develops an inflammatory reaction. Capillary hemorrhage and increased
capillary permeability allow an exudate to form around the ends of the
nerve fiber. Macrophages accumulate at the site of the injury. Eventually,
endoneurial fibroblasts and Schwann cells from the stumps of the injured
nerve multiply. These cells then migrate, forming a connective tissue
- Schwann cell structure that also includes collagen fibers, macrophages,
and capillaries. Changes in the proximal stump extend centrally for
a distance that varies according to the severity of the injury. In the
proximal stump, immediately central to the site of trauma, axons develop
swelling and the portion of the axon between the swelling and the border
of the stump collapses. Nerve fibers in this area are reduced in diameter;
this change is even more pronounced if re-establishment of functional
corrections to the peripheral stump is delayed or prevented. These axons
can regain most of their original caliber over time, but some degree
of deficit does appear to be permanent. Reduction in the fiber caliber
is associated with a slowing in conduction velocity.
When the entire nerve structure is severed, the above changes are more
severe, and the onset of regeneration is delayed. Because they are no
longer confined to endoneurial tubes, regenerating axons form growths
at the ends of severed nerves. Capillaries enter the site of injury
from the nerve ends via intraneural rather than extraneural vessels.
Regenerating axon tips from the proximal stump penetrate this area of
swelling and take circuitous routes, some even coursing backward along
the nerve and surrounding tissue. Eventually, the site develops into
dense scar tissue.
Rationale
for Treatment Plan
In current medical literature, there is little information concerning
acupuncture as a treatment modality for traumatic neuralgia. Regardless,
some logic can be used in conceiving a treatment plan in such cases.
According to tradition, the "marrow" falls under the Kidney
sphere of influence. The brain is referred to as the "Sea of Marrow."
By extension, the nervous system is ruled by the brain. In a patient
displaying other signs of strong Kidney influence, it appears reasonable
to specifically target the Kidney meridian for examination. Additional
inclusion of the GB 39 point is justified since it is the Hui point
for marrow. In this patient's case, her presenting complaint, coupled
with her medical history and physical examination findings, strongly
suggested an approach using a Kidney circuit in conjunction with GB
39. While it would be difficult to precisely define the mechanism of
her recovery, her improvement was significant and has remained intact
since August 1999 without need for further treatment.
AUTHOR INFORMATION
Dr Rowena Archibald is Board-certified in Occupational Medicine. Dr
Archibald practices Medical Acupuncture for a wide range of conditions,
especially chronic pain.
Rowena Archibald, MD, MPH
Medical Director, Las Clinicas del Norte
PO Box 237
El Rito, NM 87530
Phone: 505-581-4728 •Fax: 505-581-4789 • E-mail: Rowena@LCDN.org
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