Phantom sensation in genital gender-affirming surgery: a narrative review.

PURPOSE OF REVIEW: To review findings related to phantom genital sensation, emphasizing phantom sensation in the transgender and gender diverse (TGD) population. We discuss prevalence, presentation and potential implications for sensory outcomes in genital gender-affirming surgery. RECENT FINDINGS: There is a high prevalence of phantom genital sensations in the TGD population. The prevalence varies by body part, approaching 50% in the most frequently reported transgender phantom - the phantom penis. Unlike genital phantoms that occur after trauma or surgery which are often painful, transgender phantoms are typically neutral and often erogenous in experience. Phantom sensation in the TGD population can be an affirming experience and important part of sexual well being and embodiment. SUMMARY: Recent studies have begun to characterize the prevalence and presentations of phantom genital sensations in TGD people, informing our evolving understanding of the sensory experiences of the transgender and gender diverse population. Targeting integration of these centrally-mediated phantom genital sensations with the peripherally generated sensation from genital stimulation may represent one potential avenue to improve sensation and embodiment following genital gender-affirming surgical procedures. Additionally, emerging techniques in modern peripheral nerve surgery targeting phantom pain may offer potential treatment options for painful phantom sensation seen after cases of genital surgery or trauma.

Analysis of amputations occurring in the earthquakes centered in Kahramanmaras: Adiyaman experience.

PURPOSE: Amputations are a common surgical procedure resulting from trauma during earthquakes, leading to severe disability. This study aims to investigate surgical outcomes specific to amputations that occurred in Adiyaman after the Kahramanmaras earthquakes. METHODS: This descriptive study included amputees who presented to Adiyaman University Training and Research Hospital. Between March 6, 2024 and March 29, 2024, amputees were contacted by phone and asked the questions in the form. Data analyzed included demographic information, number and level of amputated extremities, phantom limb pain, stump infection, extrication time, time to initiation of rehabilitation, number of revision, and whether a prosthesis was fitted. RESULTS: The study reached 75 amputees. The mean age was 37.9 ± 19.2, and the most frequently amputated age group was adults. Stump infection was observed in 40 amputees (53.3%), phantom limb pain in 47 (62.6%), and revision in 29 (38.7%). The median extrication time was 36 h and initiation of rehabilitation time was 45 days. It was noted that 35 amputees (62.5%) used prostheses. A statistically significant relationship was found between fasciotomy and stump infection (p = .000). Infection was detected in 65% of those who underwent fasciotomy. CONCLUSION: Earthquake-related amputations most frequently affected the adult age group and primarily involved lower extremity amputations, such as transfemoral and transtibial amputations. Phantom limb pain, need for revision, and infection are common in earthquake-induced amputations. Delayed fasciotomy increases the risk of stump infection. The data obtained in this study will help plan local health services to coordinate amputation care in disasters.

Assessment of efficiency of mirror therapy in preventing phantom limb pain in patients undergoing below-knee amputation surgery-a randomized clinical trial.

PURPOSE AND OBJECTIVES: Phantom limb pain (PLP) is a major cause of physical limitation and disability accounting for about 85% of amputated patients. Mirror therapy is used as a therapeutic modality for patients with phantom limb pain. Primary objective was to study the incidence of PLP at 6 months following below-knee amputation between the mirror therapy group and control group. METHODS: Patients posted for below-knee amputation surgery were randomized into two groups. Patients allocated to group M received mirror therapy in post-operative period. Two sessions of therapy were given per day for 7 days and each session lasted for 20 min. Patients who developed pain from the missing portion of the amputated limb were considered to have PLP. All patients were followed up for six months and the time of occurrence of PLP and intensity of the pain were recorded among other demographic factors. RESULTS: A total of 120 patients completed the study after recruitment. The demographic parameters were comparable between the two groups. Overall incidence of phantom limb pain was significantly higher in the control group (Group C) when compared to the mirror therapy (Group M) group [Group M = 7 (11.7%) vs Group C = 17 (28.3%); p = 0.022]. Intensity of PLP measured on the Numerical Rating Scale (NRS) was significantly lower at 3 months in Group M compared to Group C among patients who developed PLP [NRS - median (Inter quartile range): Group M 5 (4,5) vs Group C 6 (5,6); p 0.001]. CONCLUSION: Mirror therapy reduced the incidence of phantom limb pain when administered pre-emptively in patients undergoing amputation surgeries. The severity of the pain was also found to be lower at 3 months in patients who received pre-emptive mirror therapy. TRIAL REGISTRATION: This prospective study was registered in the clinical trial registry of India. TRIAL REGISTRATION NUMBER: CTRI/2020/07/026488.

Estimating the Impact of Postamputation Pain.

BACKGROUND: Neuromas, neuralgia, and phantom limb pain commonly occur after lower-extremity amputations; however, incidence of these issues is poorly reported and understood. Present literature is limited to small cohort studies of amputees, and the reported incidence of chronic pain after amputation ranges as widely as 0% to 80%. We sought to objectively investigate the incidence of postamputation pain and nerve-related complications after lower-extremity amputation. METHODS: Patients who underwent lower-extremity amputation between 2007 and 2017 were identified using a national insurance-based claims database. Incidence of reporting of postoperative neuroma, neuralgia, and phantom limb pain were identified. Patient demographics and comorbidities were assessed. Average costs of treatment were determined in the year after lower-extremity amputation. Logistic regression analyses and resulting odds ratios were calculated to determine statistically significant increases in incidence of postamputation nerve-related pain complications in the setting of demographic factors and comorbidities. RESULTS: There were 29,507 lower amputations identified. Postoperative neuralgia occurred in 4.4% of all amputations, neuromas in 0.4%, and phantom limb pain in 10.9%. Nerve-related pain complications were most common in through knee amputations (20.3%) and below knee amputations (16.7%). Male sex, Charlson Comorbidity Index > 3, diabetes mellitus, diabetic neuropathy, diabetic angiopathy, diabetic retinopathy, obesity, peripheral vascular disease, and tobacco abuse were associated with statistically significant increases in incidence of 1-year nerve-related pain or phantom limb pain. CONCLUSIONS: Given the incidence of these complications after operative extremity amputations and associated increased treatment costs, future research regarding their pathophysiology, treatment, and prevention would be beneficial to both patients and providers.

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.

Sex-specific Differences in Multisite Pain Presentation among Adults with Lower-Limb Loss.

OBJECTIVES: Multisite pain remains significantly understudied following lower-limb loss (LLL), especially among females. This study aimed to explore sex-specific differences in the presentation of multisite pain post LLL. Hypotheses were multisite pain would be more prevalent among females post LLL as compared with males, and female sex would be significantly associated with multisite pain prevalence. METHODS: In this cross-sectional study, participants answered standardized questions regarding the presence of amputation-specific (ie, phantom-limb, residual-limb) and secondary (ie, contralateral-limb, low-back) pain. Multisite pain was defined as pain in ≥ 2 locations. Sex-specific differences in pain prevalence were evaluated using chi-square tests (P ≤ 0.050). Using logistic regression, the association between sex and multisite pain was examined after controlling for covariates (age, body mass index, time since amputation, amputation etiology and level). RESULTS: The sample included 303 adults (33% females) ≥ 1 year post unilateral LLL. More females than males reported pain in the residual limb (53.0% vs. 38.4%), low back (56.0% vs. 39.9%), contralateral knee (37.0% vs. 24.1%), and contralateral hip (25.0% vs. 12.3%; P < 0.050). More females than males were classified as having multisite pain (72.0% vs. 54.7%; P = 0.004). While patterns of multisite pain were similar (ie, pain affected both amputation-specific and secondary sites) between sexes, being female was independently associated with higher odds of having multisite pain (odds ratio: 2.40, 95% confidence interval: 1.40 to 4.12). DISCUSSION: Female sex appears to be associated with multisite pain ≥ 1 year after LLL. Future work is needed to identify mechanisms underlying sex-specific differences in pain presentation and evaluate the impact of sex on pain-related outcomes post amputation.

The demographics of persistent opioid consumption following limb amputation.

BACKGROUND: Patients who have limb amputation are at risk of chronic pain, including phantom limb pain that can be challenging to treat. The aim of this study was to describe the incidence of pre-operative opioid usage and the incidence and risk factors for new persistent post-operative opioid usage in opioid-naïve patients after limb amputation. METHODS: A retrospective study of all patients 18 years and older underwent upper or lower extremity amputations in Landspitali University Hospital between 2005 and 2015. Patients were considered to use opioids pre-operatively if they filled an opioid prescription 1-6 months prior to amputation and were considered to have persistent opioid use if opioid prescriptions were filled between post-operative months four to twenty-four. In addition to incidence estimate, uni- and multivariate analysis was performed to identify risk factors for persistent post-operative opioid usage. RESULTS: Of 328 total patients, 216 (66%) were opioid naïve and 112 (34%) were chronic opioid users. Of the opioid-naïve patients surviving more than 3 months 40 (20%) developed persistent post-operative opioid usage. In multivariate analysis, factors independently associated with persistent post-operative opioid usage were younger age, male gender, pre-operative use of neuropathic medications or benzodiazepines and lower (opposed to upper) extremity amputation. CONCLUSION: Opioid naïve patients undergoing major amputation had a 20% chance of having a persistent opioid requirement following surgery. This could represent new-onset phantom limb pain or other chronic pain. Our findings should encourage perioperative multimodal efforts to reduce the burden of chronic pain after limb amputations.

[Perioperative measures for prevention of phantom pain: an evidence-based approach to risk reduction]. / Perioperative Maßnahmen zur Prävention von Phantomschmerz: ein evidenzbasierter Ansatz zur Risikoreduktion.

Prevention of phantom limb pain is one of the biggest and still largely unsolved challenges in perioperative medicine. Despite many study efforts and optimization of postoperative pain treatment over the last 30 years, a significant reduction in the incidence of phantom limb pain has not been achieved. Current studies have also shown that at least 50% of patients develop phantom pain after 6 months. A possible approach could be to combine multiple synergistic interventions and implement them as a perioperative phantom pain management strategy bundle. In addition to regional anesthesia, NMDA antagonists, gabapentinoids, antidepressants and systemic lidocaine could play a relevant role. The aim of this pharmacological intervention was the modification of the pathophysiological changes in peripheral nerves and in the central nervous system after amputation.

Factors affecting phantom limb pain in patients undergoing amputation: retrospective study.

PURPOSE: The efficacy of preemptive analgesia for prevention of phantom limb pain has been controversial although pain management before amputation is empirically important. The aim of this study was to determine the associated factors with perioperative phantom limb pain. METHODS: Following approval by the Medical Ethics Committee in our university, medical records of patients receiving limb amputation surgery in our hospital between April 1, 2013 and October 31, 2017 were retrospectively reviewed. To determine which pre-operative factors could affect the development of phantom limb pain, we performed univariate analysis to find candidate factors (p < 0.05), and then did multivariate regression analysis. RESULTS: Incidence of phantom limb pain was 50% (22/44). There was no difference between the groups in types of anesthesia and post-operative pain levels. The multivariate logistic regression including possible confounders suggested that diabetes mellitus and uncontrollable preoperative pain with non-steroidal anti-inflammatory drugs (NSAIDs) were independently associated with the development of phantom limb pain (Adjusted odds ratio (OR) 0.238 [95% confidential interval (CI) 0.0643-0.883], p = 0.032, Adjusted OR 6.360 [95% CI 1.280-31.50], p = 0.024, respectively). CONCLUSION: The types of anesthesia and the degree of postoperative pain were not related to the development of phantom limb pain. The present data suggest that insufficient preoperative pain with NSAIDs and diabetes mellitus would give an impact on the development of phantom limb pain.

Pain management in new amputees: a nursing perspective.

Phantom limb pain (PLP) is a widespread and challenging neuropathic pain problem, occurring after both surgical and traumatic amputation of a limb. It may occur immediately after surgery or some months later, however, most cases it presents within the first 7 postoperative days. Patients report a range of pain characteristics in the absent limb, including burning, cramping, tingling and electric shock sensation. The incidence of PLP has been reported to be between 50% and 85% following amputation. Its management is notoriously difficult, with no clear consensus on optimal treatment. It is often resistant to classic balanced analgesia and typical neuropathic pain medications. Taking into account these issues, the authors aimed to improve the management of patients undergoing amputation at their institution, by ensuring accurate and holistic assessment, the selection of suitable interventions through critical analysis and synthesis of available evidence, and the appropriate evaluation and adaptation of treatment plans, to ensure patients achieved their individualised goals.

Phantom Eye Syndrome: Patient Experiences after Enucleation for Uveal Melanoma.

PURPOSE: Patients undergoing enucleation for uveal melanoma need to be informed of the possibility of phantom eye syndrome (PES). The number with uveal melanoma in PES studies has been small. Aims were to: (1) determine the prevalence, symptoms, and characteristics of PES and to test associations of PES symptoms with sociodemographic and clinical characteristics; (2) examine the interrelatedness of PES symptoms; and (3) explore the emotional valence of PES and the relationship to anxiety and depression. DESIGN: Cross-sectional questionnaire. PARTICIPANTS: Patients (n = 179) with uveal melanoma enucleated 4 to 52 months previously. METHODS: Questionnaire on PES. Responses to a routine audit of mood obtained from clinical records. MAIN OUTCOME MEASURES: Patients were asked about 3 symptoms: pain, visual sensations, and a feeling of seeing through the removed eye. Mood was assessed by the Hospital Anxiety and Depression Scale. RESULTS: Of 179 respondents, 108 (60.3%) experienced symptoms: 86 reported (48%) visual sensations, 50 reported (28%) seeing, and 42 reported (23%) pain; 14 (7.8%) reported all 3 symptoms. At the time of the questionnaire, 31 (17%) experienced 1 or more symptoms daily. Women were more likely to report pain (odds ratio [OR], 2.18; 95% confidence interval [CI], 1.08-4.40). Younger patients at enucleation were more likely to report pain (t = 4.13; degrees of freedom (df), 177; P < 0.001) and visual sensations (t = 2.11; df, 177; P < 0.05). Patients studied sooner after enucleation were more likely to report seeing (Mann-Whitney U, 2343; P < 0.05). Pain and seeing were intercorrelated (chi-square, 5.47; Φ = 0.18; df, 1; P < 0.05), pain with visual sensations (chi-square, 3.91; Φ = 0.15; df, 1; P < 0.05) and seeing with visual sensations (chi-square, 34.22; Φ = 0.45; df, 1; P < 0.001). Twenty of 108 patients (18.5%) found symptoms disturbing, and 21 of 108 (19.4%) pleasurable. Patients reporting pain were more anxious (OR, 3.53; 95% CI, 1.38-9.03) and depressed (OR, 13.26; 95% CI, 3.87-46.21). CONCLUSIONS: Patients should be informed of PES symptoms. Pain may indicate anxiety or depression; this needs research to determine cause and effect.

A Clinical Evaluation of Postamputation Phenomena Including Phantom Limb Pain after Lower Limb Amputation in Dysvascular Patients.

To explore the effects of phantom phenomena on a group of dysvascular lower limb amputees. This was a cross-sectional study of dysvascular lower limb amputees. A modified version of the phantom phenomena questionnaire was used to measure the prevalence of phantom phenomena and the effects of those phenomena on daily life. Eighty-nine amputees were recruited. The majority were inpatients (72%) and male (72%). Most had pain before amputation (83%). Sixty-three percent had phantom limb pain. No associations were found between phantom limb pain and preamputation pain (p = .397). Phantom limb pain was present immediately on waking from amputation in 23%. Phantom limb pain is highly fluctuant. It is more likely that phantom limb pain was present with more time passed since amputation (p = .002). Outpatients with unhealed wounds were less likely to have phantom limb pain (p = .007). The effects of postamputation phenomena include sleep loss and social restrictions. These results challenge the belief that phantom limb pain reduces over time as more outpatients reported phantom limb pain than inpatients. Preamputation pain is not linked to the presence of phantom limb pain. The fluctuant nature of phantom limb pain makes its treatment complex. Some may wish intensity to reduce, whereas others may prefer to reduce the number of episodes or duration of each episode instead. More research is needed to clarify the needs of amputees in relation to the postamputation phenomena.

[Amputations. A five-year epidemiological study in Buenos Aires City]. / Sujetos con amputaciones en la Ciudad de Buenos Aires. Estudio epidemiológico de cinco años.

An amputation is the removal of a limb by surgery or accident. The aim of this paper was to carry out an epidemiological analysis on patients with amputations treated at the Instituto de Rehabilitación Psicofísica between 2009 and 2013. This is a retrospective, observational and cross-sectional study. The analyzed data included a total of 262 patients: 180 men (68.7%) and 82 women (31.3%). Our population mainly included subjects with only one amputated lower limb (83.6%), of vascular etiology (mostly diabetics) and with an average age of 63.5 years. The second sample group comprised traumatic amputees (29.8%), with an average age of 37 years and with a higher frequency of phantom pain. The characteristics of these groups can make them to behave differently during rehabilitation.

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.

A systematic review of the prevalence of postamputation and chronic neuropathic pain associated with combat injury in military personnel.

ABSTRACT: Combat trauma can lead to widespread tissue damage and limb loss. This may result in chronic neuropathic and post amputation pain, including phantom limb pain (PLP) and residual limb pain (RLP). The military population is distinct with respect to demographic, injury, and social characteristics compared with other amputation and trauma cohorts. We undertook a systematic review of studies of military personnel, with a history of combat injury, that reported a prevalence of any type of postamputation pain or chronic neuropathic pain, identified from Embase and MEDLINE databases.Using the inverse variance method with a random-effects model, we undertook a meta-analysis to determine an overall prevalence and performed exploratory analyses to identify the effect of the type of pain, conflict, and time since injury on prevalence. Pain definitions and types of pain measurement tools used in studies were recorded. Thirty-one studies (14,738 participants) were included. The pooled prevalence of PLP, RLP, and chronic neuropathic pain were 57% (95% CI: 46-68), 61% (95% CI: 50-71), and 26% (95% CI: 10-54), respectively. Between-study heterogeneity was high (I 2 : 94%-98%). Characterisation of duration, frequency, and impact of pain was limited. Factors reported by included studies as being associated with PLP included the presence of RLP and psychological comorbidity. The prevalence of postamputation pain and chronic neuropathic pain after combat trauma is high. We highlight inconsistency of case definitions and terminology for pain and the need for consensus in future research of traumatic injury.

Prevalence and factors associated with psychological morbidity, phantom limb Pain in lower limb amputees.

BACKGROUND: Lower limb amputation can lead to psychological problems.There is a lack of data to evaluate the psychological problems and associated factors in lower limb amputees. AIM: Prevalence and factors associated with psychological disorder and phantom limb pain in lower limb amputees METHODS: It was a cross-sectional study with a consecutive sampling technique. Patients were assessed on the Hospital Anxiety and Depression Scale (HADS) for the presence of depression and anxiety disorder. DSM-5 diagnostic criteria for substance use disorder were used, andphantom limb pain was diagnosed as defined by Pare. RESULTS: 103 patients were included in the present study with a mean age of37.7 ± 14.5 yrs. The majorityof patients were males (87.4 %), married (69.9 %), on paid employment (95.1 %), and were of middle socioeconomic status (83.5 %). Most of the patients presented with roadside accident injuries (83.5 %)and had below-knee amputation (58.3 %). As per DSM-5, 38.8 % had a substance use disorder, out of which 35.9 % and 24.3 % had alcohol and tobacco use disorders, respectively. On HADS, 48.5 % had a presence of depressive disorder, and 30.1 % had anxiety disorder. The majority of patients (97.1 %) had phantom limb pain. Those from rural areas reported significantly more frequency of anxiety (x2-5.501; p-0.019) and depressive disorder (x2-7.009; p-0.008). Lower incomehad a significant positive association with depression (r-0.228; p-0.021) and phantom limb pain (U-22.500; p-0.008). CONCLUSION: The prevalence of psychiatric morbidity in lower-limb amputeeswas very high. The most common psychological morbidity was depression,followed by anxiety disorder and substance use disorders.Our findings reflect that we would benefit by including mental health professionals asintegral members of the multidisciplinary team to do an early psychological assessment and intervention, which would help prevent psychological illnesses and improve quality of life.

Pain and neurological sequelae of cluster munitions on children and adolescents in South Lebanon.

This paper aims at evaluating the neurological repercussions arising from injuries sustained due to cluster munitions in children up to 18 years in South Lebanon following the 2006 conflict. Data on neurological and pain symptoms suffered during and after treatment because of sub-munitions in South Lebanon from August 2006 till late 2011 were prospectively recorded. Patients were divided into subcategories; children aged 12 and under and adolescents aged between 13 and 18. During the study period, there were 407 casualties, 122 (30%) of which were aged 18 years or younger. There were 116 (95%) males and six (5%) females. Average age was 14 years. 10 (8.2%), all males, died as a result of their injuries. 42 (34.4%) were children and 80 (65.6%) were adolescents. 112 had surgical treatments for their injuries. 83 out of 112 patients (74%) with non-lethal injuries had amputations, 67% children and 78% adolescents. Among those who had amputations, 31 (37.4%) suffered from phantom limb pain and 71% suffered from stump/residual limb pain. 88% of patients were diagnosed with post-traumatic stress disorder (44% children and 77% adolescents) and 41% were diagnosed with post-concussion syndrome. Four patients (3.6%) suffered from traumatic brain injuries, both penetrating and closed. Pain syndromes were found in all patients who had amputation. The injury related comorbidities together with many post-concussion syndrome cases, and fewer traumatic brain injuries lead into a high level of physical, psychosocial and economic burdens on the community.

An observational descriptive study of the epidemiology and treatment of neuropathic pain in a UK general population.

BACKGROUND: This study updated our knowledge of UK primary care neuropathic pain incidence rates and prescribing practices. METHODS: Patients with a first diagnosis of post-herpetic neuralgia (PHN), painful diabetic neuropathy (PDN) or phantom limb pain (PLP) were identified from the General Practice Research Database (2006 - 2010) and incidence rates were calculated. Prescription records were searched for pain treatments from diagnosis of these conditions and the duration and daily dose estimated for first-line and subsequent treatment regimens. Recording of neuropathic back and post-operative pain was investigated. RESULTS: The study included 5,920 patients with PHN, 5,340 with PDN, and 185 with PLP. The incidence per 10,000 person-years was 3.4 (95% CI 3.4, 3.5) for PHN; and 0.11 (95% CI 0.09, 0.12) for PLP. Validation of the PDN case definition suggested that was not sensitive. Incident PHN increased over the study period. The most common first-line treatments were amitriptyline or gabapentin in the PDN and PLP cohorts, and amitriptyline or co-codamol (codeine-paracetamol) in PHN. Paracetamol, co-dydramol (paracetamol-dihydrocodeine) and capsaicin were also often prescribed in one or more condition. Most first-line treatments comprised only one therapeutic class. Use of antiepileptics licensed for neuropathic pain treatment had increased since 2002-2005. Amitriptyline was the only antidepressant prescribed commonly as a first-line treatment. CONCLUSION: The UK incidence of diagnosed PHN has increased with the incidence of back-pain and post-operative pain unclear. While use of licensed antiepileptics increased, prescribing of therapy with little evidence of efficacy in neuropathic pain is still common and consequently treatment was often not in-line with current guidance.

Calcitonin in the Treatment of Phantom Limb Pain: A Systematic Review.

INTRODUCTION: Phantom limb pain (PLP) refers to pain perceived in a part of the body removed by amputation or trauma. Despite the high prevalence of PLP following amputation and the significant morbidity associated with it, robust therapeutic approaches are currently lacking. Calcitonin, a polypeptide hormone, has recently emerged as a novel analgesic with documented benefits in the treatment of several pain-related conditions. METHODS: We present a systematic review that comprehensively evaluates the analgesic effects of calcitonin for patients with PLP. We searched MEDLINE, OLDMEDLINE, and PubMed Central databases with the key words "calcitonin" "phantom limb pain" and "phantom pain" to identify clinical studies evaluating the efficacy or effectiveness of calcitonin administration, in any form and dose, for the treatment of PLP. Additionally, Google Scholar was searched manually with the search term "calcitonin phantom limb pain". All four databases were searched from inception until 1 December 2022. The methodological quality of each included study was assessed using the Downs and Black checklist and the GRADE criteria were used to assess effect certainty and risk of bias. RESULTS: Our search identified 4108 citations, of which six ultimately met the criteria for inclusion in the synthesis. The included articles described a mix of open-label (n = 2), prospective observational cohort (n = 1), and randomized clinical trials (n = 3). The most common treatment regimen in the current literature is a single intravenous infusion of 200 IU salmon-derived calcitonin. CONCLUSION: The available evidence supported the use of calcitonin as either monotherapy or adjuvant therapy in the treatment of PLP during the acute phase, while the evidence surrounding calcitonin treatment in chronic PLP is heterogeneous. Given the limited treatment options for the management of PLP and calcitonin's relatively wide therapeutic index, further research is warranted to determine the role that calcitonin may play in the treatment of PLP and other pain disorders.

Evolving techniques for reducing phantom limb pain.

At least two million people in the United States of America live with lost limbs, and the number is expected to double by 2050, although the incidence of amputations is significantly greater in other parts of the world. Within days to weeks of the amputation, up to 90% of these individuals develop neuropathic pain, presenting as phantom limb pain (PLP). The pain level increases significantly within one year and remains chronic and severe for about 10%. Amputation-induced changes are considered to underlie the causation of PLP. Techniques applied to the central nervous system (CNS) and peripheral nervous system (PNS) are designed to reverse amputation-induced changes, thereby reducing/eliminating PLP. The primary treatment for PLP is the administration of pharmacological agents, some of which are considered but provide no more than short-term pain relief. Alternative techniques are also discussed, which provide only short-term pain relief. Changes induced by various cells and the factors they release are required to change neurons and their environment to reduce/eliminate PLP. It is concluded that novel techniques that utilize autologous platelet-rich plasma (PRP) may provide long-term PLP reduction/elimination.