A stage-based approach to pain syndrome management in patients with warfare injuries to the peripheral nerves of the extremities

Abstract

Objective: To develop a stage-based treatment algorithm for pain syndrome in patients with warfare injuries to the peripheral nerves of the extremities and to determine the optimal timing for surgical intervention on peripheral nerves through analysis of the literature and our own clinical data.

Materials and methods: Pain management outcomes were analyzed in 1,053 patients with peripheral nerve injuries sustained during warfare. All patients underwent clinical and ultrasonographic examination, and pain intensity was assessed using the Visual Analogue Scale (VAS). Patients were divided into two treatment groups: primary conservative treatment and primary surgical treatment. The primary conservative treatment group included 265 patients who were managed using conservative methods (pharmacotherapy, nerve hydrodissection, administration of steroid anti-inflammatory agents, platelet-rich plasma injections, or botulinum toxin). The primary surgical treatment group comprised 788 patients with warfare injuries to the peripheral nerves of the extremities who required surgical nerve repair, including patients with painful neuromas after limb amputations. Pain intensity (VAS) was reassessed at 1, 3, 6, and 12 months after treatment.

Results: Conservative treatment demonstrated satisfactory outcomes in cases of mild pain syndrome with maintained positive dynamics during the first month from treatment initiation. Surgical treatment of warfare injuries to peripheral nerves resulted in a stable and predictable effect in the majority of cases. However, in the long-term follow-up period, some patients experienced worsening of regenerative pain during skeletal muscle reinnervation. Patients with painful neuromas represented the most challenging subgroup, as pain in these cases was typically chronic and difficult to manage.

Conclusions: Patients with warfare injuries to the peripheral nerves of the extremities should undergo ultrasound examination. In the absence of nerve compression or irritation and with preserved anatomical continuity, treatment should begin with pharmacotherapy; if necessary, nerve hydrodissection or injection therapy with steroids or botulinum toxin may be performed. In cases of significant compression, nerve disruption, or lack of effect after conservative treatment within 6 weeks, surgical intervention is recommended.