







































Guo S, Mansour R, Henderson Slater D. Ultrasound-guided continuous radiofrequency ablation of painful residual limb neuroma in individuals with limb 
amputation- a retrospective case series. Canadian Prosthetics & Orthotics Journal. 2019; volume2, Issue1, No.4. https://doi.org/10.33137/cpoj.v2i1.33061 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
 

 
 

 
 

 

 

 

 

 

ISSN: 2561-987X 

VOLUME 2, ISSUE 1 

 2019 

 

(ONLINE) 

CASE SERIES 

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https://doi.org/10.33137/cpoj.v2i1.33061
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mailto:cpoj@online-publication.com


 

 

Guo S, Mansour R,  Henderson Slater D. Ultrasound-guided continuous radiofrequency ablation of painful residual limb neuroma in individuals with limb 

amputation- a retrospective case series. Canadian Prosthetics & Orthotics Journal. 2019; volume2, Issue1, No.4. https://doi.org/10.33137/cpoj.v2i1.33061 
1 

 
OPEN  ACCESS 

CONTINUOUS RADIOFREQUENCY ABLATION OF PAINFUL RESIDUAL LIMB NEUROMA 

Volume 2, Issue 1, Article No.4, November 2019 

 

 
CASE SERIES  

 

ULTRASOUND-GUIDED CONTINUOUS RADIOFREQUENCY ABLATION OF PAINFUL 
RESIDUAL LIMB NEUROMA IN INDIVIDUALS WITH LIMB AMPUTATION-  
A RETROSPECTIVE CASE SERIES 

 
Guo S.1*, Mansour R.2, Henderson Slater D.1 
 

1 Oxford Centre for Enablement, Nuffield Orthopaedic Centre, Oxford, UK. 
2 Department of Radiology, Nuffield Orthopaedic Centre, Oxford, UK. 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INTRODUCTION   

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Post-amputation pain is very common after limb 

amputation, and residual limb neuroma is a significant 

cause of this, which can include both pain around the 

residual limb and phantom pain. However, it is also 

recognised that many individuals with limb amputation 

have neuromas that are not apparently causing pain.1  

Neuromas are commonly seen as incidental findings on 

scans carried out for other clinical reasons, and the precise 

degree of correlation between the presence of a neuroma 

and phantom pain due to the neuroma is not known.2 

Residual limb neuroma-associated pain can be difficult to 

treat and is often managed using an interdisciplinary 

approach with a combination of neuropathic analgesia, 

ABSTRACT 

BACKGROUND: Residual limb neuromas are a significant cause of post-amputation pain. 

There is little knowledge concerning ultrasound-guided (US) radiofrequency ablation (RFA) 

as treatment. 

OBJECTIVE: To investigate US-guided RFA for neuroma associated pain in individuals with 

limb amputation.  

METHODOLOGY: The notes of nine consecutive patients were retrospectively reviewed. 

Information obtained included neuroma size and nerve, RFA duration/temperature, pain 

scores, analgesic requirements and ease/comfort of prosthetic use. Eight patients had 

lower-limb amputations and one had a trans-radial amputation.  All except one, underwent 

diagnostic US-guided steroid injection to confirm the neuroma as the source of pain, prior 

to RFA. 

RESULTS: Six patients reported significant reduction in pain scores (defined as at least 

50% reduction) and an improvement in comfort/ease of wearing their prosthetic limb, with 

no adverse effects. Three of these six patients also reported a reduction in analgesic 

requirements. Of the three remaining patients – one had a large sciatic nerve neuroma that 

was eventually surgically excised, another had confounding pain from an adjacent bony 

spur, whilst the third patient did not receive a routine diagnostic steroid injection prior to 

RFA.    

CONCLUSIONS: Our findings suggest that US-guided RFA is safe and effective for small 

to medium-sized residual limb neuroma associated pain in individuals with limb amputation. 

It can reduce pain and analgesic requirements, improve comfort/ease of wearing the 

prosthesis and potentially avoid surgical excision. We recommend patients should undergo 

a diagnostic steroid injection prior to RFA to confirm that the neuroma is the source of pain. 

 

CITATION 

Guo S, Mansour R, Henderson 

Slater D. Ultrasound-guided 

continuous radiofrequency 

ablation of painful residual limb 

neuroma in individuals with limb 

amputation- A retrospective 

case series. Canadian 

Prosthetics & Orthotics Journal. 

2019; volume2, Issue1, No.4. 

https://doi.org/10.33137/cpoj.v2i

1.33061 

 KEYWORDS 

Prosthetics, rehabilitation, 

amputations, neuroma, pain, 

radiofrequency ablation 

 

*CORRESPONDING AUTHOR 

Shigong Guo, 

LLM MSc(Orth Eng) MRCS, Specialty Registrar in Rehabilitation Medicine 

Oxford Centre for Enablement, Nuffield Orthopaedic Centre, Oxford, UK. 

Email: shigong@doctors.org.uk 

DOI: https://doi.org/10.33137/cpoj.v2i1.33061 

ARTICLE INFO 

Received: September 10, 2019 

Accepted: October 21, 2019 

Published: November 3, 2019 

 

https://doi.org/10.33137/cpoj.v2i1.33061
https://doi.org/10.33137/cpoj.v2i1.33061
https://doi.org/10.33137/cpoj.v2i1.33061
mailto:shigong@doctors.org.uk
https://doi.org/10.33137/cpoj.v2i1.33061


 

 

Guo S, Mansour R,  Henderson Slater D. Ultrasound-guided continuous radiofrequency ablation of painful residual limb neuroma in individuals with limb 

amputation- a retrospective case series. Canadian Prosthetics & Orthotics Journal. 2019; volume2, Issue1, No.4. https://doi.org/10.33137/cpoj.v2i1.33061 
2 

CONTINUOUS RADIOFREQUENCY ABLATION OF PAINFUL RESIDUAL LIMB NEUROMA 

Volume 2, Issue 1, Article No.4, November 2019 

 

 

https://jps.library.utoronto.ca/index.php/cpoj/index 

 

physiotherapy, adjustments to the prosthesis, prosthetic 

counselling and eventual surgical excision.3 

Neuroma-associated pain could be due to residual limb 

pain or phantom pain or a combination of both. Residual 

limb pain (also known as stump pain) has been described 

as a sharp, burning, ‘electric shock’-like pain which the 

patient often attributes to an incision site around the 

residual limb or perceives the pain originating deep in the 

residual limb.4 Its incidence has been reported in up to 74% 

of individuals with limb amputation.5 This is different from 

phantom pain, which has been described as a painful or 

unpleasant sensation in the distribution of severed limb 

after amputation. It can be classified as either neuropathic-

like (sharp, shooting, electric shock type pain) or 

nociceptive-like (dull, squeezing, and cramping) or a 

combination of both. It has been reported in 85% of 

patients with limb amputation.4  

Although the mechanism of interaction is not fully 

understood, residual limb pain and phantom pain often 

coexist post-amputation and Montoya et al have reported 

a significant correlation between the severities of these two 

types of pain in individuals with limb amputation.6  

There is a paucity of studies in the literature concerning 

ultrasound-guided (US) radiofrequency ablation (RFA) as 

a treatment for residual limb neuroma pain in terms of its 

effectiveness in reducing pain and analgesic requirements, 

improving comfort when wearing prosthetic limbs and 

reducing the need for surgical intervention 

This study aims to investigate the effects of US-guided 

RFA as a treatment for residual limb neuroma- associated 

pain. After retrospectively reviewing the patient case notes, 

we retrieved data on the safety, efficacy, side effects, and 

complications of US-guided RFA in the treatment of painful 

residual limb neuroma. 

METHODOLOGY  

RETROSPECTIVE REVIEW 

The clinical notes and imaging of nine consecutive patients 

who underwent RFA for residual limb neuroma-associated 

pain during the period 2015 – 2019 were retrospectively 

reviewed. Information obtained included:  

1. Patient demographics 
2. Site of amputation 
3. Reason for amputation  
4. Size of neuroma and nerve involved 
5. Phantom pain (if any) 
6. RFA duration, temperature and pulsation (i.e. 

continuous versus alternating) 

7. Pain (Numerical Rating Scale – NRS) scores – at 3-8 
months pre-RFA, immediately pre and post RFA, 1 
day, 2 days, 2 weeks and 3 months post-RFA.  

8. Analgesic requirements pre- and post-RFA 
9. Adverse effects of RFA (if any) 

10. Comfort and ease of using prosthetic limb pre- and 
post-RFA. 
 

After obtained the NRS pain scores at the aforementioned 

intervals, statistical analysis was performed using 

MATLAB (MathWorks, MA, USA).  In order to assess the 

expected value and variation in pain scores amongst the 

patients, the mean pain score and standard deviation at 

the different time intervals (pre- and post-treatment) for all 

nine patients and for the six successfully treated patients 

were calculated.  

In order to determine the statistical significance of the 

change in pain scores, Wilcoxon signed-rank test was 

used to calculate the p-values when examining the change 

in pain scores from initial presentation and the different 

time intervals (pre- and post-treatment). Wilcoxon signed-

rank test was selected because of the small sample size 

and that pain scores cannot be assumed to be normally 

distributed. 

Written informed consent was obtained from each patient 

prior to the RFA procedure. As this is a retrospective 

review of past patient notes, ethical approval was not 

needed.  

Radiofrequency Ablation Assessment and Protocol 

1. The initial assessment in the outpatient clinic of the 

patients with limb amputation was performed by a 

Consultant Rehabilitation Physician (DHS) or a senior 

trainee under the supervision of the consultant at which 

initial pain scores were taken.  

2. Through magnetic resonance imaging (MRI), the 

presence a neuroma was confirmed as well as its site, 

size and nerve involved.  

3. The patients were then reviewed again post-MRI 

scanning by the Consultant Rehabilitation Physician 

and referred to a single Consultant Musculoskeletal 

Radiologist (RM) who performed US-guided RFA 

treatment. 

4. The patients waited between 3-8 months for their US-

guided RFA treatment.  

5. On the day of treatment, pain scores were taken again 

before the RFA. 

6. The patient was placed in a comfortable position 

(supine for the lower limb, sitting for the upper limb). 

The skin was then prepped with Isopropyl Alcohol 

solution and draped.  

7. The linear high-frequency ultrasonic transducer (5-

13MHz; VFX13-5, Siemens AG) was covered with a 

sterile transparent sticker and placed transversely over 

the area of focal tenderness as reported by the patient.  

8. On imaging with a high-resolution sonography machine 

(Acuson Antares; Siemens AG, Munich, Germany), the 

presence of the neuroma was reconfirmed on both 

transverse and longitudinal views by rotating the 

transducer by 90 degrees. The neuroma was visualised 

https://doi.org/10.33137/cpoj.v2i1.33061
https://jps.library.utoronto.ca/index.php/cpoj/index


 

 

Guo S, Mansour R,  Henderson Slater D. Ultrasound-guided continuous radiofrequency ablation of painful residual limb neuroma in individuals with limb 

amputation- a retrospective case series. Canadian Prosthetics & Orthotics Journal. 2019; volume2, Issue1, No.4. https://doi.org/10.33137/cpoj.v2i1.33061 
3 

CONTINUOUS RADIOFREQUENCY ABLATION OF PAINFUL RESIDUAL LIMB NEUROMA 

Volume 2, Issue 1, Article No.4, November 2019 

 

 

https://jps.library.utoronto.ca/index.php/cpoj/index 

 

as a well-defined hypoechoic lesion involving the 

affected transected nerve (Figure 1, Figure 2).  

 

Figure 1: US image of 11x6mm neuroma along the ulnar nerve in 

the residual limb of a patient who had a trans-radial amputation 

(patient 1). 

 

Figure 2: US image of 10x7 mm neuroma along the common 

peroneal nerve in the residual limb of a patient who had a 

transtibial amputation (patient 2). 

9. After attaching to a radiofrequency generator 

(NeuroTherm NT1000; Morgan Innovation and 

Technology Ltd, Hampshire, UK) (Figure 3), a 10 cm 

disposable radiofrequency electrode was placed into a 

compatible 10 cm radiofrequency straight cannula (St 

Jude Medical, Plymouth, MN, USA) with a 5 mm active 

tip. With the transducer placed vertically to give a 

longitudinal view of the neuroma, this tip was advanced 

towards the nerve just proximal to the neuroma with the 

aim of reproducing the pain and confirming the site.  

Under direct imaging, 40 mg triamcinolone acetonide  

mixed with 2 mL 0.25% bupivacaine was injected 

around the nerve just proximal to the neuroma. Relief 

of the pain a few minutes after administration of the 

steroid confirmed the target neuroma. If neuroma-

associated pain was confirmed using this technique, 

the tip of the electrode-cannula would be advanced into 

the affected neuroma (Figure 4). RFA would then be 

carried out 90°Celsius continuously for 9 minutes.  

10. After undergoing RFA, pain scores were taken 

immediately post-procedure, via telephone follow up 1 

day, 2 days and 2 weeks post-RFA, and via face to face 

follow up in the rehabilitation clinic 3 months post-RFA. 

The patients were asked to give the maximum pain 

score that they felt on the day of assessment.  

  

Figure 3: NeuroTherm NT1000 Radiofrequency Generator 

 

Figure 4: Advancing the electrode-cannula (arrowed) into the 

neuroma for RFA under US guidance  

RESULTS 

 Pre-treatment data 

There were 9 patients (3 men and 6 women) aged between 

30 and 69 years (mean 45 years). Eight had lower limb 

amputations (5 had transtibial, 2 transfemoral, 1 hip 

disarticulation) and one had a trans-radial amputation.  

Four of these patients underwent amputation due to 

trauma, two due to peripheral vascular disease, two due to 

neoplasm and one due to infection. The patients 

underwent amputation between 1 and 26 years ago (mean 

7 years).   

https://doi.org/10.33137/cpoj.v2i1.33061
https://jps.library.utoronto.ca/index.php/cpoj/index


 

 

Guo S, Mansour R,  Henderson Slater D. Ultrasound-guided continuous radiofrequency ablation of painful residual limb neuroma in individuals with limb 

amputation- a retrospective case series. Canadian Prosthetics & Orthotics Journal. 2019; volume2, Issue1, No.4. https://doi.org/10.33137/cpoj.v2i1.33061 
4 

CONTINUOUS RADIOFREQUENCY ABLATION OF PAINFUL RESIDUAL LIMB NEUROMA 

Volume 2, Issue 1, Article No.4, November 2019 

 

 

https://jps.library.utoronto.ca/index.php/cpoj/index 

 

Table 1: Patient demographics, pre-RFA pain and neuroma characteristics. 

 

On initial presentation to the outpatient rehabilitation clinic, 

seven patients reported a pain severity of 10/10 on the 

NRS score, one had a pain score of 9 and one had a pain 

score of 7. All nine patients reported pain around the 

residual limb, and six of these patients also complained of 

phantom pain in addition to their residual limb pain.  The 

residual limb condition in all these patients was stable with 

no local inflammation or acute skin or soft tissue changes. 

All patients reported discomfort and difficulty wearing their 

prosthetic limb due to pain.  Patient demographics, prosth-

eses suspension and weight-bearing characteristics,  

pre-RFA pain and neuroma characteristics are illustrated 

in Table1. The duration of pain symptoms from onset to 

initial presentation in clinic ranged from three months to six 

months with a mean of four months. Apart from simple 

and/or neuropathic analgesics, the patients had not 

received any other conservative pain-relieving interven-

tions.  

Through magnetic resonance imaging (MRI) and 

ultrasound scanning, three patients were found to have 

neuromas involving the tibial nerve, three involved the 

sciatic nerve, one involved the common peroneal nerve, 

one the superficial peroneal nerve and one the ulnar nerve. 

The largest neuroma was 30x30mm and involved the 

sciatic nerve (Figure 5). The smallest neuroma was 

10x6mm and involved the tibial nerve.  

The nine patients were consecutively referred from the 

prosthetic rehabilitation team to the radiology team for 

consideration for ultrasound-guided RFA. On the day of 

treatment, pain scores were taken again before the RFA – 

six patients reported a score 10/10 for their pain, two 

patients reported a score 8/10 and one patient reported a 
score 7/10.  

In all cases, the patient was able to point to a focal area of 

tenderness over the residual limb that was elicited on direct 

palpation. In the six patients with phantom pain, palpating 

over the focal area of tenderness led to a positive Tinel’s 

sign along the course of the affected nerve in the phantom 

limb.  On direct pressure from the transducer, the pain 

reported by the patient in all cases was able to be 

reproduced. 

Post-treatment results 

After undergoing RFA, pain scores were taken immediately 

post-procedure, via telephone follow up 1 day, 2 days and 

2 weeks post-RFA, and via face to face follow up in the 

rehabilitation clinic 3 months post-RFA (Table 2).  

All patients bar one underwent a diagnostic US-guided 

steroid injection to confirm that the neuroma was the 

source of the pain, prior to RFA. 

Six patients reported a significant reduction in pain NRS 

scores – defined as at least 50% reduction,7 sustained over 

at least 3 months with no adverse effects. Three of these 

six patients also reported a reduction in analgesic 

requirements, two patients did not have any analgesic pre- 

and post-RFA and one patient did not report any significant 

change in analgesic demands. All of the six patients 

reported an improvement in comfort in wearing their 

prosthetic limb. Amongst these six patients who reported 

significant pain relief, three of them also had pre-existing 

phantom pain and found that RFA also resolved their 

phantom pain completely.  

 

 

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1 F 67 Transradial 
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bearing 
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Ulnar 
nerve 

2 M 30 Transtibial Trauma 2 Sleeve 
Patellar Tendon 

Bearing 
7 + Yes 10x7 

Common 
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3 M 27 Transtibial Trauma 7 
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10 - Yes 14x8 
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4 F 37 Transtibial Trauma 10 
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5 M 47 
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Neoplasm 26 Strap 

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7 F 42 Transfemoral Neoplasm 1 Belt 
Ischial weight 

bearing 
10 - Yes 18x13 

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nerve 

8 F 69 Transtibial Infection 5 Sleeve 
Patellar Tendon 

Bearing 
10 + Yes 12x12 

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peroneal 

nerve 

9 F 36 Transfemoral Trauma 3 Lanyard 
Ischial weight 

bearing 
10 + Yes 19x15 

Sciatic 
nerve 

https://doi.org/10.33137/cpoj.v2i1.33061
https://jps.library.utoronto.ca/index.php/cpoj/index


 

 

Guo S, Mansour R,  Henderson Slater D. Ultrasound-guided continuous radiofrequency ablation of painful residual limb neuroma in individuals with limb 

amputation- a retrospective case series. Canadian Prosthetics & Orthotics Journal. 2019; volume2, Issue1, No.4. https://doi.org/10.33137/cpoj.v2i1.33061 
5 

CONTINUOUS RADIOFREQUENCY ABLATION OF PAINFUL RESIDUAL LIMB NEUROMA 

Volume 2, Issue 1, Article No.4, November 2019 

 

 

https://jps.library.utoronto.ca/index.php/cpoj/index 

 

Table 2: Results of RFA treatment in terms of changes in pain, analgesic requirements and ease/comfort of prosthesis use. 

 

Of the three other patients who did not report a significant 

sustained reduction overall pain, one had a large sciatic 

nerve neuroma (Figure 5) which was eventually 

successfully treated with surgical excision. 

 

Figure 5: US image of 30x30 mm neuroma along the sciatic nerve 

in a patient who had a hip disarticulation (patient 5). 

Another patient was found to have a bony spur adjacent to 

the neuroma at the time of the ultrasound-guided RFA 

which could have contributed to her pain, whilst the third 

patient reported an initial reduction in pain for 1-week post 

RFA but then experienced a return of the pain including 

heightened phantom sensation. Interestingly, the third 

patient did not receive a routine diagnostic steroid injection 

prior to undertaking the RFA as we had confidently, but 

erroneously, assumed that the large neuroma was the 

cause of her pain. Apart from failure to relieve the pain in 

three of the patients, no complications of RFA were 

reported in all nine patients and no pathological changes 

were observed at the distal end of the targeted nerve 

during and after RFA. 

Routine regular follow up was carried out up the three-

month mark post-RFA, after which the patients were given 

the option to return to the clinic through a self-referral (via 

an open appointment) or re-referral via their general 

practitioner/family physician if there were any further 

problems with pain or discomfort. At the time of writing, 

none of the six successfully treated patients chose to return 

to clinic and thus we have not observed any reports of 

recurrence in the longer term.  

Statistical Analysis 

Statistical analysis was performed using MATLAB 

(MathWorks, MA, USA).  The mean pain score and 

standard deviation at the different time intervals (pre- and 

post-treatment) for all nine patients and for the six 

successfully treated patients were calculated. This data is 

tabulated in Table 3 (A and B) and graphically illustrated in 

Appendix.  

Wilcoxon signed-rank test calculated the p-values of the 

changes in pain scores at initial presentation and the 

different time intervals pre- and post-treatment 

(immediately before treatment, immediately after 

treatment, 1 day, 2 days, 2 weeks and 3 months post-

treatment) for all nine patients and for the six successfully 

treated patients (Table 3,A,B). The p-values comparing the 

change in pain scores at initial presentation and from Day 

1 post-treatment were consistently below 0.05, which is 

strongly against the null hypothesis and suggests a 

statistically significant reduction in pain scores.8 

Interestingly, the p-values for all nine patients were lower 

than the p-values for the six successfully treated patients. 

This could be explained by two factors. Firstly, Patient 1 

reported an initial complete resolution of her pain (from 10 

 

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1 10 0 0 0 10 10 + 
No change (still on gabapentin 

300mg TDS) 
No 

Did not have diagnostic 
steroid injection pre-RFA 

2 8 7 6 5 0 0 - 
Gabapentin reduced from 600mg 

TDS to 300mg TDS 
Yes None 

3 7 2 0 0 0 2 - 
Did not take analgesics pre- or 

post RFA 
Yes No 

4 10 0 0 0 0 0 - 
Did not take analgesics pre- or 

post RFA 
Yes No 

5 10 9 8 7 2 10 + 
Did not take analgesics pre- or 

post RFA 
No 

Required surgical 
excision of neuroma 

6 10 9 8 1 0 1 - 
Gabapentin reduced from 600mg 

TDS to 300mg TDS 
Yes None 

7 10 7 7 7 10 6 - 
No longer taking oxycodone 5mg 

BD 
No Adjacent bony spur 

8 8 8 8 8 6 3 - 
Paracetamol1g QDS moved to 

PRN 
Yes None 

9 10 5 1 1 unknown 0 + 
No change (still on pregabalin 
75mg ON, amitriptyline 25mg 

ON) 
Yes None 

https://doi.org/10.33137/cpoj.v2i1.33061
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Guo S, Mansour R,  Henderson Slater D. Ultrasound-guided continuous radiofrequency ablation of painful residual limb neuroma in individuals with limb 

amputation- a retrospective case series. Canadian Prosthetics & Orthotics Journal. 2019; volume2, Issue1, No.4. https://doi.org/10.33137/cpoj.v2i1.33061 
6 

CONTINUOUS RADIOFREQUENCY ABLATION OF PAINFUL RESIDUAL LIMB NEUROMA 

Volume 2, Issue 1, Article No.4, November 2019 

 

 

https://jps.library.utoronto.ca/index.php/cpoj/index 

 

to 0 on the NRS) followed by a full return of her pain two 

weeks later. This outlier may have unduly influenced the 

p-value calculations. Secondly, reducing the already small 

sample size from nine patients to an even smaller sample 

of six patients could also have increased the p-values. 

Table 3: Mean pain score, standard deviation (SD) and p-values 

at different time intervals pre- and post-RFA of all nine patients (A) 

and six successfully treated patients (B).   

  A   B  

Time interval Mean SD 
p-
value 

Mean  SD 
p-
value 

At presentation 9.56 1.01 1.0000 9.33 1.21 1.0000 

Immediately pre-
RFA 

9.22 1.20 0.6250 8.83 1.32 0.6250 

Immediately 
post-RFA 

5.22 3.67 0.0156 5.17 3.55 0.1250 

Day 1 4.22 3.83 0.0039 3.83 3.92 0.0313 

Day 2 3.22 3.46 0.0039 2.50 3.27 0.0313 

2 weeks 3.50 4.21 0.0156 1.58 2.58 0.0313 

3 months  3.56 4.13 0.0156 1.00 1.26 0.0313 

 

DISCUSSION  

Neuroma formation is common after limb amputation. The 

type commonly found post-amputation are terminal 

neuromas which can occur when the proximal nerve 

terminal is severed during the surgery, after which 

apoptosis occurs in the distal axons of the nerve.9 In order 

to maintain the congruity of the axon, Schwann cells 

stimulate new growth of adjacent axons. However, in 

cases where the defect of the axon is too long to overcome 

by the aforementioned mechanism, the proximal axons will 

growth in multiple directions to overcome the defect, giving 

a bulbous appearance to the neuroma that is visualised on 

MRI and ultrasound imaging.9  

Residual limb neuroma-associated pain can be difficult to 

treat. A multidisciplinary approach is often required in 

terms of adjustments to the liner and socket by the 

prosthetists, psychological input, gait retraining by 

physiotherapy, oral analgesic changes, specialist input by 

the pain team and ultimately surgical excision with its 

associated operative risks and risk of recurrence.10 

There is a paucity of studies in the literature concerning 

ultrasound-guided RFA in the treatment of residual limb 

neuroma-associated pain in individuals with limb 

amputation. These have mainly been isolated case 

reports.10-12 There has been one previous case series 

carried out by Zhang et al of 13 patients exploring the use 

of alcohol neurolysis in combination with RFA in residual 

limb neuroma associated pain.13 The authors found that in 

patients whose neuroma pain was resistant to alcohol 

neurolysis, RFA provided an effective alternative in terms 

of pain relief. RFA may be continuous or pulsed. 

Continuous RFA uses high-frequency alternating current 

which leads to coagulative necrosis of the neuroma. 

Pulsed RFA utilises the current in short 20 millisecond 

bursts with a half-second respite in between to allow for 

heat dissipation.14  

In these isolated case reports, pulsed RFA was performed 

at 42°C for 120-240 seconds each in two to three separate 

intervals, whereas in Zhang et al case series pulsed RFA 

was carried out at 80°C for 240 seconds each in two 

separate intervals. and the authors suggested this gave 

more consistent favourable results in terms of longer-term 

improvements in pain scores up to 6 months post-

procedure.  

There is currently no consensus on the temperature and 

duration for RFA or whether it should be continuous or 

pulsed.  Our study differs from the existing literature in that 

we have used continuous RFA at 90°C for nine minutes 

(540 seconds) which is in line with our local hospital 

practice.  In addition to the higher temperature and longer 

duration, we have found that a single intervention of 

continuous RFA was sufficient in most of our patients in 

terms of sustained long-term pain relief without the need 

for multiple RFA treatments as seen Zhang et al’s study 

involving pulsed RFA. Continuous RFA is known to be 

more effective than pulsed RFA in the treatment of facet 

joint-related low back pain 14-16 and a similar trend may 

also be apparent in residual limb neuroma associated pain 

in individuals with limb amputation.  

In the six patients who reported significant pain relief post-

RFA, three of them also had pre-existing phantom pain and 

found that RFA also resolved their phantom pain 

completely. There are many theories as to where phantom 

pain originates including peripheral, spinal and central 

nervous system contributors. Our study supports the 

theories that there is a peripheral contribution. This is also 

supported by as Zhang et al who note that in clinical 

practice residual limb pain and phantom pain are often 

intertwined and can be difficult to separate. Severing of 

peripheral nerves during amputation can lead to 

hyperexcitability and spontaneous generation of action 

potentials from the cut nerve, which in turn can cause 

phantom pain. This theory could explain the growing use 

of peripheral nerve blocks to treat phantom limb pain.17-19 

Undergoing a diagnostic steroid injection prior to the RFA 

may be a confounding factor in terms of the patient’s pain 

relief. US-guided steroid injections have been used to treat 

painful residual limb neuroma with promising early results 

in a few isolated case reports and a small case series.20-22 

But again, like with RFA and residual limb neuromas, the 

number of studies and the number of patients treated could 

be too small to infer any concrete consensus.  

As mentioned, of the three other patients who did not report 

a significant reduction in pain, one had a large sciatic nerve 

neuroma that was eventually successfully treated with 

surgical excision, one had confounding pain from an 

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Guo S, Mansour R,  Henderson Slater D. Ultrasound-guided continuous radiofrequency ablation of painful residual limb neuroma in individuals with limb 

amputation- a retrospective case series. Canadian Prosthetics & Orthotics Journal. 2019; volume2, Issue1, No.4. https://doi.org/10.33137/cpoj.v2i1.33061 
7 

CONTINUOUS RADIOFREQUENCY ABLATION OF PAINFUL RESIDUAL LIMB NEUROMA 

Volume 2, Issue 1, Article No.4, November 2019 

 

 

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adjacent bony spur (Figure 6) that was also eventually 

surgically excised, whilst the third patient did not receive a 

routine diagnostic steroid injection confirming the neuroma 

as the source of the pain prior to undertaking  RFA.  

This sciatic nerve neuroma (30 x 30 mm) was almost 

double the size of the second-largest neuroma in our study. 

This might suggest that RFA would be better suited to 

treating pain originating from small to medium size 

neuromas. 

For larger neuromas, surgical intervention may be an 

inevitability. Dumanian et al carried out a randomised 

controlled trial of 28 individuals with limb amputation with 

painful residual limb neuroma assigned to either traditional 

surgical excision or Target Muscle Reinnervation (TMR).23 

During surgical excision of a neuroma, TMR involves 

identifying using a nerve stimulator nearby sensory and 

motor nerves innervating surrounding muscle and suturing 

the nerves to a surgically divided distal nerve (e.g. tibial 

nerve sutured to the distal segment of the motor nerve to 

the soleus). This nerve transfer technique aims to facilitate 

reinnervation as close as possible to resembling 

physiological innervation thus potentially inhibiting the 

pathological central reorganisation of neuropathic pain 

mechanisms.24 The authors found that TMR provided 

greater pain relief for both residual limb pain and phantom 

pain on the NRS compared with traditional surgical 

excision of the neuroma.23 The same research group also 

conducted a multicentre cohort study comparing 51 

patients undergoing major limb amputation with immediate 

TMR with 438 unselected standard major limb amputation 

patients. The authors found that immediate TMR at 

amputation reduced both phantom and residual limb pain 

on the NRS and may also reduce the formation of 

neuromas in the first place.24  

Traditional surgical excision has also been criticised in 

terms of the invasiveness of the dissection. A large and 

invasive dissection can lead to delayed wound healing as 

well as excessive adhesions and scar tissue formation, 

which can cause pain and discomfort during prosthesis 

fitting. This, in turn, can lead to delays in weight-bearing 

and rehabilitation, A large and invasive dissection of the 

neuroma can also be associated with higher recurrence 

rates.25 It is for these reasons that less invasive surgical 

excision techniques have been explored. Thomas et al 

conducted a case series of 10 patients with limb 

amputation who underwent ultrasound-guided needle 

localisation of their painful neuroma prior to surgical 

excision. The authors found that pre-operative US-guided 

localisation of the neuroma facilitate less invasive surgical 

dissections and thus potentially a reduction in the 

aforementioned complications.25  

Limitations to our study include the relatively small sample 

size and lack of a control group, and thus prospective 

cohort studies with a larger sample size may be needed to 

confirm our results before it can be generalised to the 

larger population of individuals with limb amputation with 

residual limb neuroma.   

 

Figure 6: US image of a bony spur (arrowed) adjacent to a 

18x13mm neuroma along the sciatic nerve in a patient who had a 

transfemoral amputation (patient 7). 

CONCLUSION 

Our retrospective case series suggests that US-guided 

continuous RFA is a safe and effective treatment for 

residual limb neuroma associated pain and phantom pain 

in individuals with limb amputation. US-guided RFA can 

reduce pain and analgesic requirements, improve comfort 

and ease of wearing the prosthesis and reduce the 

potential need for surgical excision of the neuroma and its 

associated surgical risks. 

We recommend all patients undergo a diagnostic steroid 

injection prior to RFA to confirm that the residual limb 

neuroma is the source of the pain. 

Further studies are needed to study the co-factors that 

could determine the residual limb pain and could affect the 

RFA treatment. This could facilitate a pre-selection of the 

responders to the treatment. We plan on conducting a 

prospective longitudinal series study with a larger sample 

size to investigate further the effect of RFA treatment of 

neuroma-associated residual limb and phantom pain in 

individuals with limb amputation including comparing 

different temperatures, durations, continuous versus 

pulsed RFA, as well as exploring combined RFA and 

phenol / alcohol injections (neurolysis).  

DECLARATION OF CONFLICTING 

INTERESTS 

The authors declare no conflict of interest. 

SOURCES OF SUPPORT 

The authors received no financial or other sources of 

support for this study. 

https://doi.org/10.33137/cpoj.v2i1.33061
https://jps.library.utoronto.ca/index.php/cpoj/index


 

 

Guo S, Mansour R,  Henderson Slater D. Ultrasound-guided continuous radiofrequency ablation of painful residual limb neuroma in individuals with limb 

amputation- a retrospective case series. Canadian Prosthetics & Orthotics Journal. 2019; volume2, Issue1, No.4. https://doi.org/10.33137/cpoj.v2i1.33061 
8 

CONTINUOUS RADIOFREQUENCY ABLATION OF PAINFUL RESIDUAL LIMB NEUROMA 

Volume 2, Issue 1, Article No.4, November 2019 

 

 

https://jps.library.utoronto.ca/index.php/cpoj/index 

 

AUTHOR CONTRIBUTION 

Dr Henderson Slater and Dr Mansour initially thought of 

the study. All three authors devised the study design. Dr 

Mansour devised the local protocol for RFA practice, 

collected pain scores up to 2 weeks post-treatment and the 

sonographic images. Dr Guo retrieved the clinical data 

from the patient notes, analysed and interpreted the data, 

and performed the statistical analysis. Dr Guo wrote and 

revised the manuscript with advice from Dr Henderson 

Slater.  

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https://doi.org/10.33137/cpoj.v2i1.33061
https://jps.library.utoronto.ca/index.php/cpoj/index


 

 

Guo S, Mansour R,  Henderson Slater D. Ultrasound-guided continuous radiofrequency ablation of painful residual limb neuroma in individuals with limb 

amputation- a retrospective case series. Canadian Prosthetics & Orthotics Journal. 2019; volume2, Issue1, No.4. 

https://doi.org/10.33137/cpoj.v2i1.33061 

10 

APPENDIX 

Mean ± Standard deviation (SD) of pain scores at different time intervals pre- and post-RFA  

 

https://doi.org/10.33137/cpoj.v2i1.33061

