The vexing problem of post-amputation pain: What is the optimal perioperative pain management for below-knee amputation?
- Patricia K. Morley-Forster MD
- … show all 1 hide
Phantom pain, defined as intense throbbing or burning pain in the missing distal limb, is a common affliction after amputation. First described in 1872 by Ambroise Paré, the phenomenon is a common occurrence in 60–80% of amputees.1 Although some reports suggest abatement of phantom pain after a few years, others affirm it is long-lasting. In addition to phantom pain, the unfortunate patient may also experience pain in the residual leg (stump pain) for reasons such as osteomyelitis, excessive scar tissue, or neuroma formation. In numerous pharmacotherapy trials, opioids, ketamine, anticonvulsants, and tricyclic antidepressants have provided only inconsistent relief.
Intense pre-amputation pain is likely to be associated with the development of long-term phantom pain.2 In the 1970s, this observation led researchers to hypothesize that pain created a permanent imprint in the dorsal horn and in the pain-processing regions of the central nervous system. A number of investigations were undert
- Nikolajsen L, Jensen TS. Phantom limb pain. Br J Anaesth 2001; 87: 107–16. CrossRef
- Nikolajsen L, Ilkjaer S, Kroner K, Christensen JH, Jensen TS. The influence of preamputation pain on postamputation stump and phantom pain. Pain 1997; 72: 393–405. CrossRef
- Flor H, Birbaumer N. Phantom limb pain: cortical plasticity and novel therapeutic approaches. Curr Opin Anaesthesiol 2000; 13: 561–4. CrossRef
- Birbaumer N, Lutzenberger W, Montoya P, et al. Effects of regional anesthesia on phantom limb pain are mirrored in changes in cortical reorganization. J Neurosci 1997; 17: 5503–8.
- Roullet S, Nouette-Gaulain K, Biais M, et al. Preoperative opioid consumption increases morphine requirement after leg amputation. Can J Anesth 2009; 56(12).
- Bach S, Noreng MF, Tjellden NU. Phantom limb pain in amputees during the first 12 months following limb amputation, after preoperative lumbar epidural blockade. Pain 1988; 33: 297–301. CrossRef
- Jahangiri M, Jayatunga AP, Bradley JW, Dark CH. Prevention of phantom pain after lower limb amputation by epidural infusion of diamorphine, clonidine, and bupivacaine. Ann R Coll Surg Engl 1994; 76: 324–6.
- Nikolajsen L, Ilkjaer S, Christensen JH, Kroner K, Jensen TS. Randomised trial of epidural bupivacaine and morphine in prevention of stump and phantom pain in lower-limb amputation. Lancet 1997; 350: 1353–7. CrossRef
- Fisher A, Meller Y. Continuous postoperative regional analgesia by nerve sheath block for amputation surgery—a pilot study. Anesth Analg 1991; 72: 300–3. CrossRef
- Lambert AW, Dashfield AK, Cosgrove C, Wilkins DC, Walker AJ, Ashley S. Randomized prospective study comparing preoperative epidural and intraoperative perineural analgesia for the prevention of postoperative stump and phantom limb pain following major amputation. Reg Anesth Pain Med 2001; 26: 316–21.
- Pinzur MS, Garla PG, Pluth T, Vrbos L. Continuous postoperative infusion of a regional anesthetic after an amputation of the lower extremity. J Bone Joint Surg Am 1996; 78: 1501–5.
- Hanley MA, Jensen MP, Smith DG, Ehde DM, Edwards WT, Robinson LR. Preamputation pain and acute pain predict chronic pain after lower extremity amputation. J Pain 2007; 8: 102–9. CrossRef
- Rapp SE, Ready LB, Nessly ML. Acute pain management in patients with prior opioid consumption: a case-controlled retrospective review. Pain 1995; 61: 195–201. CrossRef
- deLeon-Casasola OA, Myers DP, Donaparthi S, et al. A comparison of postoperative epidural analgesia between patients with chronic cancer taking high doses of oral opioids versus opioid-naïve patients. Anesth Analg 1993; 7: 302–7.
- Ossipov MH, Lai J, King T, Vanderah TW, Porreca F. Underlying mechanisms of pronociceptive consequences of prolonged morphine exposure. Biopolymers 2005; 80: 319–24. CrossRef
- Angst MS, Clark JD. Opioid-induced hyperalgesia: a qualitative systematic review. Anesthesiology 2006; 104: 570–87. CrossRef
- Lotze M, Grodd W, Birbaumer N, Erb M, Huse E, Flor H. Does use of a myoelectric prosthesis prevent cortical reorganization and phantom limb pain? Nat Neurosci 1999; 2: 501–2. CrossRef
- The vexing problem of post-amputation pain: What is the optimal perioperative pain management for below-knee amputation?
Canadian Journal of Anesthesia/Journal canadien d'anesthésie
Volume 56, Issue 12 , pp 895-900
- Cover Date
- Print ISSN
- Online ISSN
- Additional Links
- Industry Sectors
- Author Affiliations
- 1. Department of Anesthesia and Perioperative Medicine, St. Joseph’s Health Centre, University of Western Ontario, 268 Grosvenor St., London, ON, N6A 4V2, Canada