A case of phantom pain and stump pain that was effectively controlled by ultrasound-guided ulnar and median peripheral nerve blocks.

Phantom limb pain and stump pain are often intractable, and their incidences are relatively high. We report a case of a patient with phantom limb and stump pain of the finger, who was successfully treated by peripheral nerve blocks. The patient was a male truck driver in his fifties, who had his left annular finger amputated in an accident 2 years previously. Owing to poor pain control at the stump of his finger, he was referred to our department. The initial examination revealed pain about numerical rating scale (NRS) 6/10 in the left annular finger transection as well as allodynia. Although some pain relief had been observed with postoperative medication, he still had persistent resting pain of about NRS 4/10. Therefore, blocks of the ulnar nerve and median nerve were performed. After the blocks were performed, the pain improved to NRS 1 to 2/10, and pain upon movement also almost disappeared. Peripheral nerve blocks can be a useful treatment modality for phantom limb pain and stump pain in the fingers, as in this case.

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.

[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.

An Algorithm Approach to Phantom Limb Pain.

Phantom limb pain (PLP) is a common condition that occurs following both upper and lower limb amputation. First recognized and described in 1551 by Ambroise Pare, research into its underlying pathology and effective treatments remains a very active and growing field. To date, however, there is little consensus regarding the optimal management of phantom limb pain. With few large well-designed clinical trials of which to make treatment recommendations, as well as significant heterogeneity in clinical response to available treatments, the management of PLP remains challenging. Below we summarize the current state of knowledge in the field, as well as propose an algorithm for the approach to the treatment of PLP.

Effect of perioperative sciatic nerve block on chronic pain in patients undergoing below-knee amputation: A randomised controlled trial.

Background and Aims: Many pain syndromes such as chronic phantom limb pain (PLP) and stump pain (SP), involving nociceptive and neuropathic pain, develop after amputation. Recent literature suggests that the use of regional blocks reduces repeated stimulation of transected nerve roots and thus prevents central sensitisation. This randomised, double-blind study was conducted to evaluate the effect of pre-emptive ultrasound-guided single-shot lateral sciatic nerve block on the occurrence of chronic pain at six months after traumatic below-knee amputation. Methods: Thirty patients undergoing traumatic lower limb amputation under general anaesthesia were randomised into two groups: Group B received sciatic nerve block pre-emptively using ultrasound with 20 ml of 0.75% ropivacaine, whereas group C received 20 ml of normal saline. Follow-up of patients was done till six months post-amputation. The primary objective was to assess the occurrence of chronic pain at six months. Pain at 15 days and one month after surgery, post-operative morphine consumption and post-operative nausea and vomiting (PONV) were the secondary outcomes assessed. Results: The occurrence of PLP at six months was comparable in the two groups, group B (46.7%) and C (66.7%). None of the patients developed SP at six months. Median intensities of phantom pain were 1.0 (range, 1-2.0) versus 1.0 (range, 1-2.0) (P = 0.36), and median intensities of SP 2 (range, 2-3.0) versus 3 (range, 2-3.0) (P = 0.39) at 1 month. Conclusion: Pre-emptive sciatic nerve block did not decrease the occurrence or severity of chronic pain after traumatic below-knee amputation.

Post-amputation pain among lower limb amputees in a tertiary care hospital in Jeddah, Saudi Arabia: A retrospective study.

OBJECTIVES: To estimate the prevalence of post- amputation pain among lower-limb amputees and its burden on their lives. METHODS: A retrospective patients record review of lower limb amputation surgeries was carried out at King Abdulaziz University Hospital, Jeddah, Saudi Arabia, between 2008-2019. e collected data included: patients demographics, surgical operations, chronic pain characteristics, functional impairment, and treatment. RESULTS: A total of 645 lower-limb amputations carried out on 509 patients, 104 (20.4%) patients had more than one amputation surgery carried out, and 40 (7.9%) patients having bilateral amputations. The estimated prevalence of chronic post-amputation pain among the lower-limb amputees was approximately 61.5%. Persistent postoperative neuropathic pain was the most common type of pain following amputation, followed by residual limb pain, then phantom limb pain. The most common cause of amputation was diabetes and its related complications (76%). The mean age at surgery was 57.46±12.02 years. Although diabetes was a common comorbid illness (95.6%), it had no correlation with the development of chronic post-amputation pain. However, peripheral vascular disease had a strong association (p=0.009), especially with the development of phantom limb pain (54.5%; p=0.016). The most common reason for functional impairment among the amputees was disability (52.7%), while only 6.6% said it was secondary to pain. CONCLUSION: Post-amputation pain is one of the major consequences of amputation. Pain was poorly managed among these patients. Special considerations should be obtained to manage these patients' pain and reduce their suffering.

Uso de toxina botulínica en el dolor tras amputación / Use of botulinum toxin for pain after amputation

Introducción: Una amputación es un suceso demoledor para todo paciente que lo sufre, puesto que presenta un cambio importante, interfiriendo en la esfera física, psíquica y social del individuo, requiriendo una adap­tación y reacondicionamiento progresivo. Uno de los puntos más importantes a controlar ante esta situación es el dolor del muñón, puesto que en muchas ocasiones será aquello que realmente determine la calidad de vida del paciente. En los últimos años, se ha estudiado la utilidad de la toxina botulínica para el tratamiento del dolor con resultados esperanzadores. Objetivo: Realizar una revisión sistemática de la litera­tura científica existente, sin restricción de año de publicación, sobre el empleo de la toxina botulínica en el dolor de los pacientes amputados, para agrupar los datos existentes. Métodos: La literatura se extrajo de PubMed, EMBASE, Cochrane, Clinical Key, Science Direct, Medes, Dialnet, Scielo y Google Schoolar. Se definió como único criterio de exclusión estudios realizados en no humanos. Se incluyeron todos los documentos relacionados con el objetivo de la búsqueda, independientemente de año, idioma, sexo, edad, tipo de amputación o toxina botulínica. De los 1795 estudios hallados tras la búsqueda inicial, se seleccionaron 19. Los niveles de evidencia corresponden a 2B, grado de recomendación B (2 estudios piloto, aleatorizados, doble ciego, con grupo control) y 4C (2 estudios observacionales longitudinales prospectivos, 15 casos clínicos). Resultados: Se estima una mejoría para el dolor resi­dual del muñón ± sensación del miembro fantasma del 80,43 % (74 pacientes) y un alivio del dolor del miembro fantasma ± dolor residual del 65,22 % (60). Se describe una ausencia de modificación del dolor del miembro fantasma para 32 pacientes (34,7 %) y ausencia de alivio del dolor residual en 18 pacientes (19,57 %). En ningún estudio se refleja un empeoramiento de la clínica...(AU)

Introduction: An amputation is a devastating event for all patients who suffer it. It introduces significant chan­ges in the patient's physical, psychic and social spheres. It requires progressive adaptation and reconditioning. Stump pain is one of the most important points in order to control this situation as, on many occasions, it will be what truly determines the patient's life quality. In the recent years, the usefulness of botulinum toxin was stu­died for pain treatment with encouraging results. Objetive: Provide a systematic review on existing scien­tific literature, with no restrictions on publication year, about the use of botulinum toxin for the pain of amputa­ted patients in order to compile the existing data. Methodology: Literature was retrieved from PubMed, EMBASE, Cochrane, Clinical Key, Science Direct, Medes, Dialnet, Scielo and Google Schoolar. The only exclusion criterium was studies carried out on non-human. All do­cuments related to the objective of this research were included independently of year, language, sex, age, type of amputation or botulinum toxin. From 1795 studies found after initial research, 19 studies were selected. The levels of evidence are pertained to 2b, degree of recommendation B (2 pilot studies, randomised, double-blind, with control group) and 4C (2 observational and longitudinal prospective studies, 15 clinical cases). Results: It is estimated that an 80.43 % (74 patients) improvement of stump residual pain and/or of the sensation on the phantom limb and a 65.22 % (60 patients) relief of the phantom limb pain and/or of the residual pain. An absence of change of the phantom limb pain was described by 32 patients (34.7 %) and an absence of relief of residual pain was reported on 18 patients (19.57 %). No studies reflect a deterioration of the disease...(AU)

Clinical updates on phantom limb pain.

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.

Coaptation of Cutaneous Nerves for Intractable Stump Pain and Phantom Limb Pain after Upper Limb Amputation.

BACKGROUND: Various surgical treatments have been advocated for stump pain and phantom limb pain after limb amputation but the most effective is unknown. We report a case of intractable stump pain and phantom limb pain of the upper limb, which was successfully treated by end-to-end coaptation of the cutaneous nerves after multimodal treatment failures. CASE DESCRIPTION: A 39-year-old man was referred to our department with a history of severe stump neuroma-related pain and phantom limb pain of his right upper limb. He had undergone multiple treatments over 26 years including medication, nerve blocks, and repeated surgeries. None had been successful for relief of pain. The clinical assessment showed a point of marked tenderness around the medial stump of the upper arm. Ultrasound-guided peripheral infiltration of local anaesthetic around the medial stump produced significant relief of his pain. Exploration around the medial limb stump revealed two stump neuromas of the medial cutaneous nerves of the forearm. Both stump neuromas were resected, and their stumps were coapted to each other. After 4 years, he was completely relieved of his pain and without any sensory deficit. CONCLUSION: Successful nerve coaptations for painful stump neuromas of the upper limb are reported rarely. This case suggests this method can be helpful. The patient burden was minimal because it involved the resection and coaptation of the two neuromas. This method should be encouraged for cases of intractable stump-related pain in the upper limb. HOW TO CITE THIS ARTICLE: Kadota H, Ishida K. Coaptation of Cutaneous Nerves for Intractable Stump Pain and Phantom Limb Pain after Upper Limb Amputation. Strategies Trauma Limb Reconstr 2020;15(1):50-53.

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.

Targeted muscle reinnervation for the management of pain in the setting of major limb amputation.

The life altering nature of major limb amputations may be further complicated by neuroma formation in up to 60% of the estimated 2 million major limb amputees in the United States. This can be a source of pain and functional limitation of the residual limb. Pain associated with neuromas may limit prosthetic limb use, require reoperation, lead to opioid dependence, and dramatically reduce quality of life. A number of management options have been described including excision alone, excision with repair, excision with transposition, and targeted muscle reinnervation. Targeted muscle reinnervation has been shown to reduce phantom limb and neuroma pain for patients with upper and lower extremity amputations. It may be performed at the time of initial amputation to prevent pain development or secondarily for the treatment of established pain. Encouraging outcomes have been reported, and targeted muscle reinnervation is emerging as a leading surgical technique for pain prevention in patients undergoing major limb amputations and pain management in patients with pre-existing amputations.

Mirror therapy for phantom limb and stump pain: a randomized controlled clinical trial in landmine amputees in Cambodia.

Background and aims The aim of the study was to examine the effect of mirror and tactile therapy on phantom and stump pain in patients with traumatic amputations, with particular reference to amputees in low-income communities. Methods The study was conducted with an open, randomized, semi-crossover case-control design in rural Cambodia. A study sample of 45 landmine victims with trans-tibial amputations was allocated to three treatment arms; mirror therapy, tactile therapy, and combined mirror-and-tactile therapy. Non-responders from the mono-therapy interventions were crossed over to the alternative intervention. The intervention consisted of 5 min of treatment every morning and evening for 4 weeks. Endpoint estimates of phantom limb pain (PLP), stump pain, and physical function were registered 3 months after the treatment. Results All three interventions were associated with more that 50% reduction in visual analogue scale (VAS)-rated PLP and stump pain. Combined mirror-tactile treatment had a significantly better effect on PLP and stump pain than mirror or tactile therapy alone. The difference between the three treatment arms were however slight, and hardly of clinical relevance. After treatment, the reduction of pain remained unchanged for an observation period of 3 months. Conclusions The study documents that a 4-week treatment period with mirror and/or tactile therapy significantly reduces PLP and stump pain after trans-tibial amputations. Implications The article reports for the first time a randomized controlled trial of mirror therapy in a homogenous sample of persons with traumatic amputations. The findings are of special relevance to amputees in low-resource communities.

Functional outcomes after the Sauvé-Kapandji procedure for distal radio-ulnar post-traumatic instability: a case-control comparison of three different operative methods of stabilization of the ulnar stump.

PURPOSE: This study was performed to elucidate the cause of proximal ulnar stump pain by comparing the clinical results and radiographic changes among three treatment groups involving different Sauvé-Kapandji procedures. METHODS: Thirty-seven patients (38 wrists) with distal radioulnar joint disorders followed up for ≥ six months post-operatively were investigated. Patients were treated by one of three Sauvé-Kapandji procedures. In group A (13 wrists), the original Sauvé-Kapandji procedure was performed. Groups B (13 wrists) and C (12 wrists) involved different modified Sauvé-Kapandji procedures with stabilization of the proximal ulnar stump using the extensor carpi ulnaris tendon. At the final examination, we evaluated wrist pain, proximal ulnar stump pain, the ranges of forearm pronation/supination, grip strength, the grip strength ratio between the affected and unaffected sides, and the clinical evaluation score. Standard posteroanterior and lateral radiographs during rest and during maximal gripping were taken for each patient at the final examination, and radiographic parameters were measured. RESULTS: Although significant differences in the frequency of ulnar stump pain were observed between group A and group B or C, no significant differences in wrist pain or the clinical evaluation score were observed. Moreover, no differences in the radiographic changes were noted among the three procedures. CONCLUSION: These findings suggest that proximal ulnar stump pain may be caused not by radial or dorsal deviation of the proximal ulnar stump but by other dynamic factors.

Efficacy and safety of epidural, continuous perineural infusion and adjuvant analgesics for acute postoperative pain after major limb amputation - a systematic review.

BACKGROUND AND AIMS: Treatment of pain following major limb amputations is often a clinical challenge in a patient population consisting mainly of elderly with underlying diseases. Literature on management of acute post-amputation pain is scarce. We performed a systematic review on this topic to evaluate the efficacy and safety of analgesic interventions for acute pain following major limb amputation. METHODS: A literature search was performed in PubMed, Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews using the following key words: [(amputation) AND (pain OR analgesi* OR pain relief)] AND (acute OR postoperative). Randomized controlled studies (RCTs) and observational studies investigating treatment of acute pain following major amputations for any indication (peripheral vascular disease, malignant disease, trauma) were included. The review was performed according to the standards described in the PRISMA statement. The Cochrane quality assessment tool was used to evaluate the risk of bias in the RCTs. RESULTS: Nineteen studies with total of 949 patients were included. The studies were generally small and heterogeneous on outcomes, study designs and quality. There were 16 studies on epidural or continuous perineural analgesia (CPI). Based on five RCTs (n=268) and two observational studies (n=49), epidural analgesia decreased the intensity of acute stump pain as compared to systemic analgesics, during the first 24 h after the operation. Based on one study epidural analgesia caused more adverse effects like sedation, nausea and motor block than continuous perineural local anesthetic infusion. Based on one RCT (n=21) and eight observational studies (n=501) CPI seemed to decrease opioid consumption as compared to systemic analgesics only, on the first three postoperative days, and was well tolerated. Only three trials investigated systemic analgesics (oral memantine, oral gabapentine, iv ketamine). Ketamine did not decrease acute pain or opioid consumption after amputation as compared to other systemic analgesics. Gabapentin did not decrease acute pain when combined to epidural analgesia as compared to epidural analgesia and opioid treatment, and caused adverse effects. CONCLUSIONS: The main finding of this systematic review is that evidence regarding pain management after major limb amputation is very limited. Epidural analgesia may be effective, but firm evidence is lacking. Epidural causes more adverse effects than CPI. The results on efficacy of CPI are indecisive. The data on adjuvant medications combined to epidural analgesia or CPI is limited. Studies on efficacy and adverse effects of systemic analgesics for amputation pain, especially concentrating on elderly patients, are needed.

Chronic post-amputation pain: peri-operative management - Review.

STUDY DESIGN: Narrative review. METHOD: Eight bibliographic databases were searched for studies published in the (last five years up until Feb 2017). For the two database searches (Cochrane and DARE), the time frame was unlimited. The review involved keyword searches of the term 'Amputation' AND 'chronic pain'. Studies selected were interrogated for any association between peri-operative factors and the occurrence of chronic post amputation pain (CPAP). RESULTS: Heterogeneity of study populations and outcome measures prevented a systematic review and hence a narrative synthesis of results was undertaken. The presence of variation in two gene alleles (GCH1 and KCNS1) may be relevant for development of CPAP. There was little evidence to draw conclusions on the association between age, gender and CPAP. Pre-operative anxiety and depression influenced pain intensity post operatively and long-term post amputation pain (CPAP). The presence of pre-amputation pain is correlated to the development of acute and chronic post amputation pain while evidence for the association of post-operative pain with CPAP is modest. Regional anaesthesia and peri-neural catheters improve acute postoperative pain relief but evidence on their efficacy to prevent CPAP is limited. A suggested whole system pathway based on current evidence to optimize peri-operative amputation pain is described. CONCLUSION: The current evidence suggests that optimized peri-operative analgesia reduces the incidence of acute peri-operative pain but no firm conclusion can be drawn on reducing risk for CPAP.

Pulsed radiofrequency of brachial plexus under ultrasound guidance for refractory stump pain: a case report.

The post-amputation (pain) syndrome, including stump pain, phantom limb sensation, and phantom limb pain is common but difficult to treat. Refractory stump pain in the syndrome is an extremely challenging and troublesome clinical condition. Patients respond poorly to drugs, nerve blocks, and other effective treatments like spinal cord stimulation and surgery. Pulsed radiofrequency (PRF) technique has been shown to be effective in reducing neuropathic pain. This report describes a patient with persistent and refractory upper limb stump pain being successfully relieved with PRF of brachial plexus under ultrasound guidance after a 6-month follow-up period, suggesting that PRF may be considered as an alternative treatment for refractory stump-neuroma pain.

Association between phantom limb complex and the level of amputation in lower limb amputee.

OBJECTIVE: The aim of this study was to evaluate the natural course of phantom limb complex without any treatment after lower limb amputation. METHODS: The study design was consisted of a combination of retrospective review and cross-sectional interview. 101 patients with lower limb amputation were included into the study. Patients were divided into three groups according to the amputation level: i) from hip disarticulation to knee disarticulation (including knee disarticulation) (25 patients, mean age: 55.9, 19 males, 6 females) ii) transtibial amputation (below knee to ankle including ankle disarticulation) (41 patients, mean age: 58.6, 33 males, 8 females) iii) below ankle to toe amputation (35 patients, mean age: 58.7, 26 males, 9 females). The patients were evaluated on both early postoperative period (EPP) and sixth months after the surgery (ASM). The data related amputation including amputation date, level, cause, stump pain (SP), phantom limb pain (PLP), components of PLP, phantom sensation (PS) were recorded based on the information obtained from patients' and hospital files. RESULTS: Statistically significant differences were found for pain intensity (VAS) between groups for SP and PLP at EPP (p < 0.001, p = 0.036; respectively). The mean VAS score in Group I for SP and PLP was higher than other groups. This differences for SP and PLP did not continue at ASM assessment (p = 0.242, p = 0.580; respectively). CONCLUSION: VAS scores for SP in above knee amputations and VAS scores for PLP in above knee amputations and below ankle amputations were higher at EPP. But these high scores had disappeared over time. Management strategies have to be considered particularly in the early postoperative period in patients who had undergone above knee amputation. LEVEL OF EVIDENCE: Level III Prognostic study.

Prevalence of Phantom Limb Pain, Stump Pain, and Phantom Limb Sensation among the Amputated Cancer Patients in India: A Prospective, Observational Study.

INTRODUCTION: The phantom limb pain (PLP) and phantom limb sensation (PLS) are very common among amputated cancer patients, and they lead to considerable morbidity. In spite of this, there is a lack of epidemiological data of this phenomenon among the Asian population. This study was done to provide the data from Indian population. METHODS: The prevalence of PLP, stump pain (SP), and PLS was prospectively analyzed from the amputated cancer patients over a period of 2 years in Dr. B.R.A. Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi. The risk factors and the impact of phantom phenomenon on patients were also noted. RESULTS: The prevalence of PLP was 41% at 3 and 12 months and 45.3% at 6 months, whereas that of SP and PLS was 14.4% and 71.2% at 3 months, 18.75% and 37.1% at 6 months, 15.8% and 32.4% at 12 months, respectively. There was higher prevalence of PLP and PLS among the patients with history of preamputation pain, smoking with proximal level of amputation, receiving general anesthesia, receiving intravenous (IV) opioid postoperative analgesia, and developing neuroma or infection. CONCLUSION: The prevalence of PLP and PLS was higher among the cancer amputees as compared to SP, and a few risk factors responsible for their higher prevalence were found in our study. The PLP and PLS lead to considerable morbidity in terms of sleep disturbance and depression.

Coblation of Femoral and Sciatic Nerve for Stump Pain and Phantom Limb Pain: A Case Report.

BACKGROUND: There is currently no reliable treatment for stump pain and phantom limb pain. Peripheral factors play a significant role in the pathophysiology of stump pain and phantom limb pain. Coblation technology is a relatively new technology that has shown promise in treating neuropathic pain. CASE REPORT: This report describes the use of coblation technology on femoral and sciatic nerve for stump pain and phantom limb pain. An ultrasound-guided perineural infiltration anesthesia surrounding the neuroma was first performed and achieved approximately 60% stump pain relief that lasted for 2 hours, but no relief of the phantom limb pain. An ultrasound-guided femoral and sciatic nerve block was performed to obtain longer pain relief. The patient reported approximately 80% pain relief in both stump pain and phantom limb pain that lasted for 40 hours. This finding suggested other factors in addition to the ultrasound-detected neuroma in the residual limb generating pain for this patient. Coblation of femoral and sciatic nerves was performed. The stump pain was completely relieved immediately after operation. At 1, 3, and 6 months postoperative review, 80% relief of both stump and phantom limb pain was achieved. Overall activity was improved and there was no need for pain medications. The analgesic effect was stable during the 6-month follow-up period. CONCLUSION: Our report suggests that coblation technology may be useful treatment for stump pain and phantom limb pain. Treatments focusing on peripheral nerves may be more effective than those focusing on the neuroma. This finding needs additional study for confirmation.