Phantom Limb Pain and Painful Neuroma After Dysvascular Lower-Extremity Amputation: A Systematic Review and Meta-Analysis.

BACKGROUND: Phantom limb pain (PLP) and symptomatic neuroma can be debilitating and significantly impact the quality of life of amputees. However, the prevalence of PLP and symptomatic neuromas in patients following dysvascular lower limb amputation (LLA) has not been reliably established. This systematic review and meta-analysis evaluates the prevalence and incidence of phantom limb pain and symptomatic neuroma after dysvascular LLA. METHODS: Four databases (Embase, MEDLINE, Cochrane Central, and Web of Science) were searched on October 5th, 2022. Prospective or retrospective observational cohort studies or cross-sectional studies reporting either the prevalence or incidence of phantom limb pain and/or symptomatic neuroma following dysvascular LLA were identified. Two reviewers independently conducted the screening, data extraction, and the risk of bias assessment according to the PRISMA guidelines. To estimate the prevalence of phantom limb pain, a meta-analysis using a random effects model was performed. RESULTS: Twelve articles were included in the quantitative analysis, including 1924 amputees. A meta-analysis demonstrated that 69% of patients after dysvascular LLA experience phantom limb pain (95% CI 53-86%). The reported pain intensity on a scale from 0-10 in LLA patients ranged between 2.3 ± 1.4 and 5.5 ± .7. A single study reported an incidence of symptomatic neuroma following dysvascular LLA of 5%. CONCLUSIONS: This meta-analysis demonstrates the high prevalence of phantom limb pain after dysvascular LLA. Given the often prolonged and disabling nature of neuropathic pain and the difficulties managing it, more consideration needs to be given to strategies to prevent it at the time of amputation.

Pain and Functional Outcomes following Targeted Muscle Reinnervation: A Systematic Review.

BACKGROUND: It is estimated that by 2050, a total of 3.6 million patients will be living with an amputation in the United States. The objective of this systematic review is to evaluate the effect of targeted muscle reinnervation (TMR) on pain and physical functioning in amputees. METHODS: A literature search was performed on PubMed, Embase, and MEDLINE up to November 28, 2021. Clinical studies assessing the outcomes of TMR (pain, prosthesis control, life quality, limb function, and disability) were included. RESULTS: Thirty-nine articles were included. The total number of patients who underwent TMR was 449, and 716 were controls. Mean follow-up was 25 months. A total of 309 (66%) lower-limb and 159 (34%) upper-limb amputations took place in the TMR group, the most common being below-knee amputations (39%). The control group included a total of 557 (84%) lower-limb and 108 (16%) upper-limb amputations; the greatest proportion being below-knee amputations in this group as well (54%). Trauma was the most common indication for amputation. Phantom limb pain scores were lower by 10.2 points for intensity ( P = 0.01), 4.67 points for behavior ( P = 0.01), and 8.9 points for interference ( P = 0.09). Similarly, residual limb pain measures were lower for cases for intensity, behavior, and interference, but they failed to reach significance. Neuroma symptoms occurred less frequently, and functional and prosthesis control outcomes improved following TMR. CONCLUSION: The literature evidence suggests that TMR is a promising therapy for improving pain, prosthesis use, and functional outcomes after limb amputation.

[Treatment and prevention phantom pain syndrome in mine-explosive injuries]. / Analiz ispol'zovaniya sovremennykh metodov lecheniya i profilaktiki fantomnogo bolevogo sindroma pri minno-vzryvnykh travmakh.

Phantom pain syndrome significantly impairs the quality of life and effectiveness of surgical treatment after limb amputations. The authors consider possible strategies for treatment and prevention in elective surgical intervention and mine-explosive injuries.

Surgical treatments for postamputation pain: study protocol for an international, double-blind, randomised controlled trial.

BACKGROUND: Painful conditions such as residual limb pain (RLP) and phantom limb pain (PLP) can manifest after amputation. The mechanisms underlying such postamputation pains are diverse and should be addressed accordingly. Different surgical treatment methods have shown potential for alleviating RLP due to neuroma formation - commonly known as neuroma pain - and to a lesser degree PLP. Two reconstructive surgical interventions, namely targeted muscle reinnervation (TMR) and regenerative peripheral nerve interface (RPNI), are gaining popularity in postamputation pain treatment with promising results. However, these two methods have not been directly compared in a randomised controlled trial (RCT). Here, we present a study protocol for an international, double-blind, RCT to assess the effectiveness of TMR, RPNI, and a non-reconstructive procedure called neuroma transposition (active control) in alleviating RLP, neuroma pain, and PLP. METHODS: One hundred ten upper and lower limb amputees suffering from RLP will be recruited and assigned randomly to one of the surgical interventions (TMR, RPNI, or neuroma transposition) in an equal allocation ratio. Complete evaluations will be performed during a baseline period prior to the surgical intervention, and follow-ups will be conducted in short term (1, 3, 6, and 12 months post-surgery) and in long term (2 and 4 years post-surgery). After the 12-month follow-up, the study will be unblinded for the evaluator and the participants. If the participant is unsatisfied with the outcome of the treatment at that time, further treatment including one of the other procedures will be discussed in consultation with the clinical investigator at that site. DISCUSSION: A double-blind RCT is necessary for the establishment of evidence-based procedures, hence the motivation for this work. In addition, studies on pain are challenging due to the subjectivity of the experience and the lack of objective evaluation methods. Here, we mitigate this problem by including different pain evaluation methods known to have clinical relevance. We plan to analyse the primary variable, mean change in NRS (0-10) between baseline and the 12-month follow-up, using the intention-to-treat (ITT) approach to minimise bias and keep the advantage of randomisation. The secondary outcomes will be analysed on both ITT and per-protocol (PP). An adherence protocol (PP population) analysis will be used for estimating a more realistic effect of treatment. TRIAL REGISTRATION: ClincialTrials.gov NCT05009394.

Mirror Therapy for the Management of Phantom Limb Pain: A Single- Center Experience.

BACKGROUND: Phantom limb pain (PLP) can have devastating consequences, affecting up to 90% of amputees. PLP is associated with analgesia dependence and impaired quality of life. Mirror therapy (MT) is a novel treatment that has been applied in other pain syndromes. We prospectively evaluated MT in the management of PLP. METHODS: A prospective study of patients recruited between 2008 and 2020 who underwent unilateral major limb amputation, with a healthy contralateral limb. Participants were invited to attend weekly MT sessions. Pain in the 7 days prior to each MT session was scored on a Visual Analog Scale (VAS: 0-10 mm) and the short form McGill pain questionnaire. RESULTS: Ninety eight patients (68 males and 30 females) aged 17-89 years were recruited over 12 years. Forty four percent of patients had amputations due to peripheral vascular disease. Over an average of 2.5 sessions, the final treatment score on the VAS scale was 2.6 (standard deviation ± 3.0) with a reduction of 4.5 points on VAS score. As a comparison using the short form McGill pain questionnaire scoring system, the average final treatment score was 3.2 (± 5.0) with 91% overall improvement. CONCLUSIONS: MT is a very powerful and effective intervention for PLP. It is an exciting addition to the armory of vascular surgeons in the management of this condition.

[Clinical updates on phantom limb pain : German version]. / Klinisches Update zu Phantomschmerz : Deutsche Fassung.

INTRODUCTION: Most patients with amputation (up to 80 %) suffer from phantom limb pain postsurgery. These are often multimorbid patients who also have multiple risk factors for the development of chronic pain from a pain medicine perspective. Surgical removal of the body part and sectioning of peripheral nerves result in a lack of afferent feedback, followed by neuroplastic changes in the sensorimotor cortex. The experience of severe pain, peripheral, spinal, and cortical sensitization mechanisms, and changes in the body scheme contribute to chronic phantom limb pain. Psychosocial factors may also affect the course and the severity of the pain. Modern amputation medicine is an interdisciplinary responsibility. METHODS: This review aims to provide an interdisciplinary overview of recent evidence-based and clinical knowledge. RESULTS: The scientific evidence for best practice is weak and contrasted by various clinical reports describing the polypragmatic use of drugs and interventional techniques. Approaches to restore the body scheme and integration of sensorimotor input are of importance. Modern techniques, including apps and virtual reality, offer an exciting supplement to already established approaches based on mirror therapy. Targeted prosthesis care helps to obtain or restore limb function and at the same time plays an important role reshaping the body scheme. DISCUSSION: Consequent prevention and treatment of severe postoperative pain and early integration of pharmacological and nonpharmacological interventions are required to reduce severe phantom limb pain. To obtain or restore body function, foresighted surgical planning and technique as well as an appropriate interdisciplinary management is needed.

Deep brain stimulation for phantom limb pain.

Phantom limb pain is a rare cause of chronic pain in children but it is associated with extremely refractory pain and disability. The reason for limb amputation is often due to treatment for cancer or trauma and it has a lower incidence compared to adults. The mechanism of why phantom pain exists remains uncertain and may be a result of cortical reorganisation as well as ectopic peripheral input. Treatment is aimed at reducing both symptoms as well as managing pain related disability and functional restoration. Neuromodulatory approaches using deep brain stimulation for phantom limb pain is reserved for only the most refractory cases. The targets for brain stimulation include the thalamic nuclei and motor cortex. Novel targets such as the anterior cingulate cortex remain experimental as cases of serious adverse effects such as seziures have limited their widespread uptake. A multidisciplinary approach is crucial to successful rehabilitation using a biopsychosocial pain management approach.

Incidence and Nerve Distribution of Symptomatic Neuromas and Phantom Limb Pain after Below-Knee Amputation.

BACKGROUND: Patients with major lower limb amputations suffer from symptomatic neuromas and phantom-limb pain due to their transected nerves. Peripheral nerve surgery techniques, such as targeted muscle reinnervation and regenerative peripheral nerve interface, aim to physiologically prevent this nerve-specific pain. No studies have specifically reported on which nerves most frequently cause chronic pain. The authors studied the nerve-specific incidence of symptomatic neuroma formation and phantom limb pain in patients undergoing a below-knee amputation, to better tailor use of targeted muscle reinnervation and regenerative peripheral nerve interface. METHODS: This was a retrospective review of all patients undergoing a below-knee amputation from January 1, 2013, to December 31, 2018, at MedStar Georgetown University Hospital. All below-knee amputations were performed with a posterior skin flap, myotenodesis, and traction neurectomies of all nerves. Postoperative notes were reviewed for the presence of a symptomatic neuroma, defined as localized pain and a Tinel sign over a known sensory nerve, and nerve-specific phantom limb pain, defined as pain of the missing limb corresponding to a known dermatome. RESULTS: One hundred ninety-eight patients were included in this study. The rate of symptomatic neuroma formation was 14.6 percent (29 of 198), with the superficial peroneal and saphenous nerves most often involved. Diabetes and obesity were protective against symptomatic neuroma formation. The rate of nerve-specific phantom limb pain was 12.6 percent (25 of 198) and highly correlated with the presence of a symptomatic neuroma. CONCLUSION: To optimize outcomes for amputees, it is critical that surgeons best understand what nerves are more likely to form symptomatic neuromas and lead to nerve-specific phantom limb pain, so that surgeons can best tailor primary or secondary management of the major sensory nerves. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Statistical analysis plan for an international, double-blind, randomized controlled clinical trial on the use of phantom motor execution as a treatment for phantom limb pain.

BACKGROUND: Phantom limb pain (PLP) is a detrimental condition that can greatly diminish the quality of life. Purposeful control over the phantom limb activates the affected neural circuitry and leads to dissolution of the pathological relationship linking sensorimotor and pain processing (which gives rise to PLP). An international, double-blind, randomized controlled clinical trial (RCT) on the use of phantom motor execution (PME) as a treatment for PLP is currently undertaken, where PME is compared to an active placebo treatment, namely phantom motor imagery (PMI). METHODS AND DESIGN: Sixty-seven subjects suffering from PLP in upper or lower limbs are randomly assigned in 2:1 ratio to PME or PMI interventions respectively. Subjects allocated to either treatment receive 15 interventions where they are exposed to the same VR-AR environments using the same device. The only difference between interventions is whether phantom movements are performed (PME) or imagined (PMI). RESULTS: The primary outcome of the study is to examine whether 15 sessions of PME can induce a greater PLP relief, compared to PMI. The secondary objectives are to examine whether 15 sessions of PME provide a greater improvement in different aspects related to PLP compared to PMI, such as pain duration, pain intensity as measured by other metrics, and the patient's own impression about the effect of treatment. Long-term retention of treatment benefits will be assessed as change in all the variables (both primary and secondary) between baseline and follow-up timepoints (at 1, 3, and 6 months post-treatment). CONCLUSION: This manuscript serves as the formal statistical analysis plan (version 1.0) for the international, double-blind, randomized controlled clinical trial on the use of PME as a treatment for PLP. The statistical analysis plan was completed on 3 August 2021. TRIAL REGISTRATION: ClinicalTrials.gov NCT03112928 . Registered on April 13, 2017 SAP version: version: 1.0, date: 2021/08/03 Protocol version: This document has been written based on information contained in the study protocol published in Lendaro et al. (BMJ Open 8:e021039, 2018), in July 2018. SAP revisions: Not applicable.

A Systematic Review and Meta-analysis on the Incidence of Patients With Lower-Limb Amputations Who Developed Symptomatic Neuromata in the Residual Limb.

BACKGROUND: Neuromata developed after major extremity amputation can cause pain, limit the use of prosthetics, and negatively affect the quality of life. The frequency of postamputation neuroma varies widely. The objective of this study was to determine the incidence of patients who developed symptomatic neuromata after lower-limb amputation through a systematic review and meta-analysis. METHODS: A systematic review of the literature was performed on 4 major databases. Studies that reported the incidence of symptomatic neuroma in lower-limb amputees were included. A meta-analysis was performed to calculate the pooled incidence of neuromata. RESULTS: Thirteen studies consisting of 1329 patients were included in this meta-analysis. The reported incidence of patients who developed symptomatic neuromata ranged between 4% and 49%. The median duration of follow-up was 8.6 years (interquartile range, 2.0-17.4 years). The pooled percentage (95% confidence interval [CI]) of lower-limb amputees who developed symptomatic neuromata was 19% (12%-29%). In studies with a duration of follow-up at least 3 years, the pooled percentage (95% CI) of lower-limb amputees who developed symptomatic neuromata was 30% (22%-40%). In studies with a follow-up period of fewer than 3 years, the pooled percentage (95% CI) of neuroma incidence was 3% (2%-6%). CONCLUSIONS: In summary, the overall incidence of patients who developed symptomatic neuromata was 19% or approximately 1 in 5 lower-limb amputees. Symptomatic neuromata are more commonly diagnosed when the follow-up period is longer than 3 years. These findings suggest that neuroma after amputation might be underestimated in studies with a short duration of follow-up.

Common Spatial Pattern EEG decomposition for Phantom Limb Pain detection.

Phantom Limb Pain (PLP) is a chronic condition frequent among individuals with acquired amputation. PLP has been often investigated with the use of functional MRI focusing on the changes that take place in the sensorimotor cortex after amputation. In the present study, we investigated whether a different type of data, namely electroencephalographic (EEG) recordings, can be used to study the condition. We acquired resting state EEG data from people with and without PLP and then used machine learning for a binary classification task that differentiates the two. Common Spatial Pattern (CSP) decomposition was used as the feature extraction method and two validation schemes were followed for the classification task. Six classifiers (LDA, Log, QDA, LinearSVC, SVC and RF) were optimized through grid search and their performance compared. Two validation approaches, namely all-subjects validation and leave-one-out cross-validation (LOOCV), resulted in high classification accuracy. Most notably, the 93.7% accuracy achieved with SVC in LOOCV holds promise for good diagnostic capabilities using EEG biomarkers. In conclusion, our findings indicate that EEG data is a promising target for future research aiming at elucidating the neural mechanisms underlying PLP and its diagnosis.

Characterisation of Phantom Limb Pain in Traumatic Lower-Limb Amputees.

INTRODUCTION: There is no diagnosis for phantom limb pain (PLP), and its investigation is based on anamnesis, which is subject to several biases. Therefore, it is important to describe and standardize the diagnostic methodology for PLP. OBJECTIVE: To characterise PLP and, secondarily, to determine predictors for its diagnosis. Methodology. This is a cross-sectional study involving patients with unilateral traumatic lower-limb amputation aged over 18 years. Those with clinical decompensation or evidence of disease, trauma, or surgery in the central or peripheral nervous system were excluded. Sociodemographic and rehabilitative data were collected; PLP was characterised using the visual analogue scale (VAS), pain descriptors, and weekly frequency. RESULTS: A total of 55 eligible patients participated in the study; most were male, young, above-knee amputees in the preprosthetic phase of the rehabilitation. The median PLP VAS was 60 (50-79.3) mm characterised by 13 (6-20) different descriptors in the same patient, which coexist, alternate, and add up to a frequency of 3.94 (2.5-4.38) times per week. The most frequent descriptor was movement of the phantom limb (70.91%). Tingling, numbness, flushing, itchiness, spasm, tremor, and throbbing are statistically significant PLP descriptor numbers per patient predicted by above-knee amputation, prosthetic phase, higher education level, and greater PLP intensity by VAS (p < 0.05). CONCLUSION: PLP is not a single symptom, but a set with different sensations and perceptions that need directed and guided anamnesis for proper diagnosis.

Targeted Muscle Reinnervation Improves Pain and Ambulation Outcomes in Highly Comorbid Amputees.

BACKGROUND: Approximately 200,000 people undergo a lower extremity amputation each year. Following amputation, patients suffer from chronic pain, inability to ambulate, and high mortality rates. Targeted muscle reinnervation is a nerve transfer procedure that redirects transected sensory and mixed nerves into motor nerves to treat neuroma and phantom limb pain. This study evaluates outcomes with prophylactic targeted muscle reinnervation at the time of below-knee amputation. METHODS: This is a cohort study comparing 100 patients undergoing below-knee amputation with primary targeted muscle reinnervation and 100 patients undergoing below-knee amputation with standard traction neurectomy and muscle implantation. Outcome metrics included the presence of residual and phantom limb pain, pain severity, opioid use, ambulation ability, and mortality rates. RESULTS: The targeted muscle reinnervation group was on average 60 years old with a body mass index of 29 kg/m2. Eighty-four percent had diabetes, 55 percent had peripheral vascular disease, and 43 percent had end-stage renal disease. Average follow-up was 9.6 months for the targeted muscle reinnervation group and 18.5 months for the nontargeted muscle reinnervation group. Seventy-one percent of targeted muscle reinnervation patients were pain free, compared with 36 percent (p < 0.01). Fourteen percent of targeted muscle reinnervation patients had residual limb pain, compared with 57 percent (p < 0.01). Nineteen percent of targeted muscle reinnervation patients had phantom limb pain, compared with 47 percent (p < 0.01). Six percent of targeted muscle reinnervation patients were on opioids, compared with 26 percent (p < 0.01); and 90.9 percent of targeted muscle reinnervation patients were ambulatory, compared with 70.5 percent (p < 0.01). CONCLUSION: Targeted muscle reinnervation reduces pain and improves ambulation in patients undergoing below-knee amputation, which may be critical in improving morbidity and mortality rates in this comorbid patient population. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Immediate Effects of a Continuous Peripheral Nerve Block on Postamputation Phantom and Residual Limb Pain: Secondary Outcomes From a Multicenter Randomized Controlled Clinical Trial.

BACKGROUND: We recently reported that a 6-day continuous peripheral nerve block reduced established postamputation phantom pain 3 weeks after treatment ended. However, the immediate effects of perineural infusion (secondary outcomes) have yet to be reported. METHODS: Participants from 5 enrolling academic centers with an upper or lower limb amputation and established phantom pain received a single-injection ropivacaine peripheral nerve block(s) and perineural catheter insertion(s). They were subsequently randomized to receive a 6-day ambulatory perineural infusion of either ropivacaine 0.5% or normal saline in a double-masked fashion. Participants were contacted by telephone 1, 7, 14, 21, and 28 days after the infusion started, with pain measured using the Numeric Rating Scale. Treatment effects were assessed using the Wilcoxon rank-sum test at each time point. Adjusting for 4 time points (days 1, 7, 14, and 21), P < .0125 was deemed statistically significant. Significance at 28 days was reported using methods from the original, previously published article. RESULTS: Pretreatment average phantom and residual pain scores were balanced between the groups. The day after infusion initiation (day 1), average phantom, and residual limb pain intensity was lower in patients receiving local anesthetic (n = 71) versus placebo (n = 73): median [quartiles] of 0 [0-2.5] vs 3.3 [0-5.0], median difference (98.75% confidence interval [CI]) of -1.0 (-3.0 to 0) for phantom pain (P = .001) and 0 [0-0] vs 0 [0-4.3], and median difference 0.0 (-2.0 to 0.0) for residual limb pain (P < .001). Pain's interference with physical and emotional functioning as measured with the interference domain of the Brief Pain Inventory improved during the infusion on day 1 for patients receiving local anesthetic versus placebo: 0 [0-10] vs 10 [0-40], median difference (98.75% CI) of 0.0 (-16.0 to 0.0), P = .002. Following infusion discontinuation (day 6), a few differences were found between the active and placebo treatment groups between days 7 and 21. In general, sample medians for average phantom and residual limb pain scores gradually increased after catheter removal for both treatments, but to a greater degree in the control group until day 28, at which time the differences between the groups returned to statistical significance. CONCLUSIONS: This secondary analysis suggests that a continuous peripheral nerve block decreases phantom and residual limb pain during the infusion, although few improvements were again detected until day 28, 3 weeks following catheter removal.

Phantom eye syndrome. Case report / Síndrome de ojo fantasma. Reporte de caso

Abstract A frequent complication after limb amputation is the appearance of phantom limb syndrome, a phenomenon that has also been studied in the amputation of different body parts. Cases reported in relation to ophthalmologic surgery are few and evidence is limited in terms of specific management, which makes this a very important study. We report the case of a patient diagnosed with phantom eye syndrome in the post-operative period of an orbital exenteration surgery. A comprehensive approach was taken with multimodal symptom management, including intervention treatment. Significant improvement regarding the pain was achieved; however, non-painful phantom sensations persisted. Upon reviewing the available literature on the subject, its pathophysiology is not fully elucidated. Its incidence is highly variable, as well as the symptoms' appearance. The presence of headache and eye pain prior to surgery seem to be risk factors. Climate and psychological stress are exacerbating factors of the symptomatology. No high-quality evidence was found in terms of management guidelines, with the use of antidepressants, anticonvulsants and opioids being the most recommended. Interventional management is an option according to the characteristics of the pain and associated symptoms.

Resumen Una complicación frecuente luego de la amputación de alguna extremidad es la aparición del síndrome de miembro fantasma, fenómeno que también se ha descrito en la amputación de diferentes partes del cuerpo. Los casos reportados en relación con cirugía oftalmológica son pocos y la evidencia es limitada en cuanto a manejo específico, lo cual justifica la descripción de este caso de interés. Reportamos el caso de una paciente a quien se diagnosticó síndrome de ojo fantasma en el periodo posoperatorio de una cirugía de exenteración orbitaria. Se realizó un enfoque integral con manejo multimodal de los síntomas, incluyendo tratamiento intervencionista. Se logró una notable mejoría del dolor; sin embargo, las sensaciones fantasma no dolorosas persistieron. Al revisar la literatura disponible sobre el tema, la fisiopatología no está totalmente dilucidada. La incidencia es muy variable, así como el tiempo de aparición de los síntomas. La presencia de cefalea y dolor ocular previos a la cirugía parecen ser factores de riesgo. El clima y el estrés psicológico son factores exacerbantes de la sintomatología. No se encontró evidencia de alta calidad en cuanto a pautas de manejo, siendo lo más recomendado el uso de antidepresivos, anticonvulsivantes y opioides. El manejo intervencionista es una opción de acuerdo a las características del dolor y síntomas asociados.

Comportamiento del dolor fantasma en pacientes amputados en Cárdenas. Periodo 2015-2019 / Phantom pain behavior in amputated patients in Cardenas. Period 2015-2019

RESUMEN Introducción: la amputación es un procedimiento quirúrgico y la incapacidad como consecuencia se puede considerar una entidad clínica. Toda respuesta a la amputación es altamente individual. Entre el 40 y 80 % de los amputados manifiestan dolor de la zona amputada o dolor de miembro fantasma. Entre todos los problemas que se pueden presentar tras la cirugía este es uno de los más graves. Objetivo: determinar el comportamiento del dolor fantasma en la población amputada en Cárdenas y la mejoría clínica de los síntomas con los diferentes tratamientos. Periodo comprendido entre 1-1-2015 al 31-12-2019. Materiales y métodos: se realizó un estudio descriptivo de corte transversal en el Hospital General "Julio Miguel Aristegui Villamil" de Cárdenas, en el período comprendido del 1-1-2015 al 31-12-2019. Con el fin de evaluar las variables clínicas y demográficas de pacientes con antecedentes de amputación unilateral de miembro y que acudieron al cuerpo de guardia y/o consultas externas de Ortopedia y Traumatología, de Angiológica y Cirugía Vascular por presentar dolor fantasma. Resultados: con respecto a la mejoría de los síntomas y del propio dolor fantasma, según la escala de evaluación del dolor (EVA), se demostró que hubo alivio muy discreto y en un 96 % de los pacientes se presentó persistencia de los mismos. Conclusiones: los resultados fueron insatisfactorios, a pesar de los tratamientos utilizados en el estudio (AU).

ABSTRACT Introduction: amputation is a surgical procedure and disability as its consequence can be considered a clinical entity. Any response to amputation is highly individual. Between 40 and 80% of amputees refer pain in the amputated area or phantom limb pain, and among all the problems that can occur after surgery, this is one of the most serious. Objective: to determine the behavior of phantom pain in the amputated population in Cárdenas from January 1st 2015 to December 31st 2019 and the clinical improvement of symptoms with the different treatments applied. Materials and methods: a descriptive cross-sectional study was conducted in the General Hospital Julio Miguel Aristegui Villamil of Cárdenas in the period from January 1st 2015 to December 31st 2019, with the aim of evaluating the clinical and demographic variables of patients with antecedents of unilateral limb amputation who attended the emergency department or outpatient Orthopedics and Traumatology, and Angiology and Vascular Surgery consultations for presenting phantom pain. Results: regarding the improvement of the symptoms and the phantom pain itself, according to the pain evaluation scale (VAS), it was shown that there was very discreet relief and its persistence in 96% of the patients. Conclusions: unsatisfactory results are observed instead of the treatments used in the study (AU).

Phantom eye pain: a multicentric study in 100 patients.

PURPOSE: Phantom eye syndrome (PES) is an underestimated complication of eye amputation (EA) characterized by phantom eye pain (PEP), phantom visions and/or phantom sensations. The aim of this study was to assess PEP prevalence, features, risk factors, social and psychological consequences and associated quality of life. METHODS: A questionnaire study was conducted in three oculoplastic departments between April 2016 and July 2017. Patients >18 years who had undergone EA ≥3 months earlier were included and asked to complete a prestamped questionnaire. Patient's characteristics, preoperative, surgical and postoperative data were collected. RESULTS: Of the 185 questionnaires given, 115 (62%) were returned for analysis. Hundred patients with a mean age of 65.1 years (29-92; SD = 13.0) were included. Eye amputation (EA) indications were uveal melanoma (n = 24, 24%), trauma (n = 20, 20%), retinal detachment (n = 20, 20%), glaucoma (n = 14, 14%) and endophthalmitis (n = 12, 12%). Forty-seven (47%), 30 (30%) and 38 (38%) patients experienced PEP, phantom visions and phantom sensations, respectively. Anxiety and depression [Hospital Anxiety Depression scale (HADS) score ≥8 for both] were diagnosed in 34 (34%) and 42 (42%) patients, respectively. The mean EQ-5D-3L and EQ-5D visual analogue scale scores were 0.8 (0.06-1; SD = 0.2) and 68 (0-100; SD = 22), respectively. Preoperative eye pain (p = 0.031), glaucoma (p = 0.027), postoperative anxiety with HADS score ≥8 (p = 0.012) and ≥11 (p = 0.014), aesthetic discomfort (p = 0.002) and EQ-5D-3L score <0.8 (p < 0.001) were significantly associated with PEP in the univariate analysis. In the multivariate analysis, only anxiety (HADS score ≥8) was significantly associated with PEP (p = 0.009). CONCLUSION: Phantom eye pain (PEP) is a common complication of EA strongly associated with postoperative anxiety.

Targeted Muscle Reinnervation as a Solution for Nerve Pain.

LEARNING OBJECTIVES: After reading this article, the participants should be able to: 1. List current nonsurgical and surgical strategies for addressing postamputation neuroma pain and discuss their limitations. 2. Summarize the indications and rationale for targeted muscle reinnervation. 3. Develop an operative plan for targeted muscle reinnervation in an acute or delayed fashion for upper and lower extremity amputations. 4. Propose a management algorithm for treatment of symptomatic neuromas in an intact limb. 5. Discuss the risk of neuroma development after primary revision digital amputation or secondary surgery for a digital neuroma. 6. Compare and contrast targeted muscle reinnervation to the historical gold standard neuroma treatment of excision and burying the involved nerve in muscle, bone, or vein graft. 7. Interpret and discuss the evidence that targeted muscle reinnervation improves postamputation neuroma and phantom pain when performed either acutely or in a delayed fashion to treat existing pain. SUMMARY: Symptomatic injured nerves resulting from amputations, extremity trauma, or prior surgery are common and can decrease patient quality of life, thus necessitating an effective strategy for management. Targeted muscle reinnervation is a modern surgical strategy for prevention and treatment of neuroma pain that promotes nerve regeneration and healing rather than neuroma formation. Targeted muscle reinnervation involves the transfer of cut peripheral nerves to small motor nerves of adjacent, newly denervated segments of muscle and can be easily performed without specialized equipment. Targeted muscle reinnervation strategies exist for both upper and lower extremity amputations and for symptomatic neuromas of intact limbs. Targeted muscle reinnervation has been shown in a prospective, randomized, controlled trial to result in lower neuroma and phantom pain when compared to the historical gold standard of burying cut nerves in muscle.

Residual limb pain: An evidence-based review.

Acquired limb loss, whether from accident or amputation, occurs with an incidence of greater than 175,000 per year in the United States. Current prevalence is estimated at greater than 1.5 million and is expected to double within 30 years. While many patients with amputations may have no significant pain or sensory issues after healing from the initial loss, one-quarter to one-half of patients may have ongoing difficulties with residual limb pain, phantom limb pain, or phantom limb sensation. This review explores the potential etiologies of those symptoms, as well as a variety of treatment options that a practitioner may consider when approaching this condition.