Treating Intractable Phantom Limb Pain with Ambulatory Continuous Peripheral Nerve Blocks: A Pilot Study (original) (raw)
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Anesthesiology. 2011 May;114(5):1144-54, 2011
BACKGROUND: Severe preamputation pain is associated with phantom limb pain (PLP) development in limb amputees. We investigated whether optimized perioperative analgesia reduces PLP at 6-month follow-up. METHODS: A total of 65 patients underwent lower-limb amputation and were assigned to five analgesic regimens: (1) Epi/Epi/Epi patients received perioperative epidural analgesia and epidural anesthesia; (2) PCA/Epi/Epi patients received preoperative intravenous patient-controlled analgesia (PCA), postoperative epidural analgesia, and epidural anesthesia; (3) PCA/Epi/PCA patients received perioperative intravenous PCA and epidural anesthesia; (4) PCA/GA/PCA patients received perioperative intravenous PCA and general anesthesia (GA); (5) controls received conventional analgesia and GA. Epidural analgesia or intravenous PCA started 48 h preoperatively and continued 48 h postoperatively. The results of the visual analog scale and the McGill Pain Questionnaire were recorded perioperatively and at 1 and 6 months. RESULTS: At 6 months, median (minimum-maximum) PLP and P values (intervention groups vs. control group) for the visual analog scale were as follows: 0 (0-20) for Epi/Epi/Epi (P = 0.001), 0 (0-42) for PCA/Epi/Epi (P = 0.014), 20 (0-40) for PCA/Epi/PCA (P = 0.532), 0 (0-30) for PCA/GA/PCA (P = 0.008), and 20 (0-58) for controls. The values for the McGill Pain Questionnaire were as follows: 0 (0-7) for Epi/Epi/Epi (P < 0.001), 0 (0-9) for PCA/Epi/Epi (P = 0.003), 6 (0-11) for PCA/Epi/PCA (P = 0.208), 0 (0-9) for PCA/GA/PCA (P = 0.003), and 7 (0-15) for controls. At 6 months, PLP was present in 1 of 13 Epi/Epi/Epi, 4 of 13 PCA/Epi/Epi, and 3 of 13 PCA/GA/PCA patients versus 9 of 12 control patients (P = 0.001, P = 0.027, and P = 0.009, respectively). Residual limb pain at 6 months was insignificant. CONCLUSIONS: Optimized epidural analgesia or intravenous PCA, starting 48 h preoperatively and continuing for 48 h postoperatively, decreases PLP at 6 months.
Regional Anesthesia and Pain Medicine, 2023
Introduction We previously reported that a 6-day continuous peripheral nerve block reduces established postamputation phantom pain. To provide patients and providers with the information to best inform treatment decisions, here we reanalyze the data and present the results in a more patient-centered format. We also provide information on patient-defined clinically relevant benefits to facilitate evaluation of available studies and guide future trial design. Methods The original trial enrolled participants with a limb amputation and phantom pain who were randomized to receive a 6-day continuous peripheral nerve block(s) of either ropivacaine (n=71) or saline (n=73) in a double-masked fashion. Here we calculate the percentage of each treatment group that experienced a clinically relevant improvement as defined by previous studies as well as present what the participants of our study defined as small, medium, and large analgesic improvements using the 7-point ordinal Patient Global Impression of Change scale. Results Among patients who were given a 6-day ropivacaine infusion, 57% experienced at least a 2-point improvement on the 11-point numeric rating scale in their average and worst phantom pain 4 weeks postbaseline as compared with 26% (p<0.001) for average and 25% (p<0.001) for worst pain in patients given a placebo infusion. At 4 weeks, the percentage of participants rating their pain as improved was 53% for the active vs 30% for the placebo groups (95% CI 1.7 (1.1, 2.7), p=0.008). For all patients combined, the median (IQR) phantom pain Numeric Rating Scale improvements at 4 weeks considered small, medium, and large were 2 (0-2), 3 (2-5), and 5 (3-7), respectively. The median improvements in the Brief Pain Inventory interference subscale (0-70) associated with small, medium, and large analgesic changes were 8 (1-18), 22 (14-31), and 39 (26-47). Conclusions Among patients with postamputation phantom pain, a continuous peripheral nerve block more than doubles the chance of a clinically relevant improvement in pain intensity. Amputees with phantom and/or residual limb pain rate analgesic improvements as clinically relevant similarly to other chronic pain etiologies, although their smallest relevant improvement in the Brief Pain Inventory was significantly larger than previously published values. Trial registration number NCT01824082. HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY ⇒ Future patients and their caretakers will be able to make more-informed decisions regarding possible treatment of postamputation limb pain with continuous peripheral nerve blocks. ⇒ This information can facilitate evaluation of currently-published research, and enable future clinical researchers to improve study design and analysis.
Strategies for prevention of lower limb post-amputation pain: A clinical narrative review
Journal of Anaesthesiology Clinical Pharmacology
Postamputation limb pain or phantom limb pain (PLP) develops due to the complex interplay of peripheral and central sensitization. The pain mechanisms are different during the initial phase following amputation as compared with the chronic PLP. The literature describes extensively about the management of established PLP, which may not be applicable as a preventive strategy for PLP. The novelty of the current narrative review is that it focuses on the preventive strategies of PLP. The institution of preoperative epidural catheter prior to amputation and its continuation in the immediate postoperative period reduced perioperative opioid consumption (Level II). Optimized preoperative epidural or intravenous patient-controlled analgesia starting 48 hours and continuing for 48 hours postoperatively decreased PLP at 6 months (Level II). Preventive role of epidural LA with ketamine (Level II) reduced persistent pain at 1 year and LA with calcitonin decreased PLP at 12 months (Level II). Peripheral nerve catheters have opioid sparing effect in the immediate postoperative period in postamputation patients (Level I), but evidence is low for the prevention of PLP (Level III). Gabapentin did not reduce the incidence or intensity of postamputation pain (Level II). The review in related context mentions evidence regarding therapeutic role of gabapentanoids, peripheral nerve catheters, and psychological therapy in established PLP. In future, randomized controlled trials with long-term follow-up of patients receiving epidural analgesia, perioperative peripheral nerve catheters, oral gabapentanoids, IV ketamine, or mechanism-based modality for prevention of PLP as primary outcome are required.
Turk Kardiyoloji Dernegi Arsivi-Archives of the Turkish Society of Cardiology
In recent years, percutaneous transluminal angioplasty has become the preferred revascularization option for chronic limb-threatening ischemia (CLTI) and infrapopliteal (IP) arterial disease. CLTI and IP disease require complex and lengthy procedures that necessitate multiple balloon inflations and frequent contrast injections. It will lead to severe discomfort if periprocedural pain control is inadequate. Conventional methods such as local anesthesia and systemic opioids are usually inadequate to provide pain control for complex IP arterial disease interventions. Ultrasound-guided peripheral nerve blockade (PNB) has been recently employed in peripheral procedures, with several small studies reporting favorable results in patients who underwent not complex interventions. In the present series, we report our experience of 4 patients who underwent PNB to relieve pain during endovascular treatment of complex IP disease, and in whom we have observed excellent periprocedural pain control that led to satisfactory postprocedural outcomes. Özet-Son yıllarda, perkütan translüminal anjiyoplasti, ekstremiteleri tehdit eden kronik iskemi (CLTI) ve infra-popliteal (İP) arter hastalığı için tercih edilen revaskülarizasyon seçeneği haline gelmiştir. CLTİ ve İP arter hastalığı; mükerrer balon dilatasyonu ve sık kontrast enjeksiyonunu gerektiren karmaşık ve uzun prosedürler gerektirir. Periprosedürel ağrı kontrolünün yetersiz kalması ciddi rahatsızlıklara yol açacaktır. Lokal anestezi ve sistemik opioidler gibi geleneksel yöntemler, kompleks İP girişimler sırasında ağrı kontrolünü sağlamak için genellikle yetersizdir. Ultrason rehberliğinde periferik sinir blokajı (PNB), son zamanlarda periferik prosedürlerde kullanılmıştır ve birkaç küçük çalışma, kompleks olmayan girişim yapılan hastalarda olumlu sonuçlar bildirmiştir. Bu seride, kompleks İP hastalığı olan dört hastada endovasküler tedavi sırasında ağrıyı azaltmak için PNB uygulanan, işlem sonrası tatmin edici sonuçlara yol açan ve mükemmel periprosedürel ağrı kontrolünü gözlemlediğimiz deneyimimizi bildirdik. RT, Walker JD, et al. Guidelines for performing ultrasound guided vascular cannulation: recommendations of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists.
Neuropathic pain after orthopaedic surgery with continuous peripheral nerve block
Danish medical journal, 2024
INTRODUCTION. INTRODUCTION. Continuous peripheral nerve blocks (cPNBs) have shown favourable post-operative pain control results but may be associated with a risk for long-term neurological complications. This study sought to examine factors associated with persistent post-operative pain and potential neuropathy after orthopaedic lower-limb surgery with the use of post-operative cPNB. METHODS. METHODS. Patients who underwent lower limb orthopaedic procedures with cPNBs between November 2021 to May 2022 were included. Patient demographics and perioperative data were noted. At discharge, patients completed the PainDetect (PD) questionnaire and were followed up six months after discharge. RESULTS. RESULTS. Seventy-seven patients with a total of 171 catheters completed the follow up. The median time to follow-up was 214 days after catheter removal, and 18 patients (23%) had a PD score ≥ 13. Univariate analysis showed that multiple variables were associated with a PD score ≥ 13 at the six-month follow-up. Multiple logistic regression showed that a high PD score at discharge, high BMI and longer duration of cPNBs were associated with higher risk of having a PD score ≥ 13 at the six-month follow-up. CONCLUSION. CONCLUSION. Several factors were associated with a higher risk of having possible neuropathy after six months. BMI, duration of catheter and PD score at discharge were correlated with risk of possible neuropathic pain. FUNDING. FUNDING. None. TRIAL REGISTRATION. TRIAL REGISTRATION. The study was a quality control project and therefore did not require registration under Danish law.. Regional anaesthesia using peripheral nerve blocks (PNBs) has been shown to effectively control post-operative pain in lower-extremity procedures, yielding reduced opioid consumption, shorter hospital stays and high patient satisfaction [1]. Continuous PNBs (cPNBs) can provide long-lasting analgesia by placing the catheters near the peripheral nerve or plexus and conducting continuous infusion of anaesthetics [1]. However, studies comparing the efficacy of cPNBs to single-injection PNBs have produced inconsistent findings, with some showing a preference for cPNBs owing to their longer duration of action and lower opioid consumption [1-3], whereas others have raised concerns about potential long-term neurological complications associated with cPNBs [4]. Although cPNBs have proven useful in orthopaedic lower-limb surgery, knowledge is limited of their potential DANISH MEDICAL JOURNAL DANISH MEDICAL JOURNAL Open Access under Creative Commons License CC BY-NC-ND 4.0 1/10 Persistent post-operative pain with possible neuropathy six months after lower-limb orthopaedic surgery using cPNB was associated with a high PD score at discharge, preoperative analgesic intake (opioid and non-opioid), longer duration of cPNBs, higher BMI and previous smoking. Possible neuropathic pain after six months warrants further investigations (e.g., electrodiagnostic testing) and, if needed, initiation of relevant pharmacologic and/or non-pharmacologic interventions for chronic neuropathic pain.
PM&R, 2021
Background: Phantom limb pain (PLP) is common and often accompanied by serious suffering. Current systematic-review evidence suggests that recommended treatments are no more effective than placebo for reducing PLP. Given the difficulty in conducting a meta-analysis for nonpharmacological treatments and the weak evidence for pharmacological treatments for PLP, consensus on the first-line management of PLP needs to be reached using alternative methods. Objective: To reach expert consensus and make recommendations on the effective management of PLP. Design: A three-round Delphi design was used. Setting: The study was conducted using e-mail and Google survey tool as the main methods of communication and providing feedback. Participants: The study included 27 clinicians and researchers from various health disciplines who are experts in PLP management. Method: Data were collected using three sequential rounds of anonymous online questionnaires where experts proposed and ranked the treatments for PLP. A consensus was reached on the treatments that were endorsed by 50% or more of the experts. Results: Thirty-seven treatments were proposed for the management of PLP at the beginning of the study. Consensus was reached on seven treatments that were considered effective for managing PLP and on two treatments that were considered ineffective. Graded motor imagery, mirror therapy, amitriptyline, sensory discrimination training, and use of a functional prosthesis were endorsed by most experts because of the available backing scientific evidence and their reported efficacy in clinical practice. Cognitive behavioral therapy and virtual reality training were endorsed by most experts because of their reported efficacy in clinical practice despite indicating a dearth of scientific evidence to support their ranking. Citalopram and dorsal root ganglion pulsed radiofrequency were rejected owing to a lack of relevant scientific evidence. Conclusion: The results of this study suggest that the nonpharmacological treatments endorsed in this study may have an important role in the management of PLP.
Phantom Limb Pain in Daily Practice-Still a Lot of Work to Do!
Pain Medicine, 2012
Objectives. Effective treatment of phantom limb pain (PLP, pain felt in the part of the body of an amputated limb) is still difficult to achieve, and improved treatment is needed. It is therefore of paramount interest to understand the current practice of PLP therapy outside pain centers. Design. As a part of a nationwide survey, 537 amputees were asked 11 questions related to their treatment experiences and the pain relief. Furthermore, the patients' opinion about the quality of medical care was also asked. Results. Five hundred thirty-seven out of 1088 amputees returned the questionnaire (49.4%). Four hundred (74.5%) suffered from PLP. The patients rated their caregivers' knowledge about PLP lower than their own. Many (41.6%) of PLP patients had never been informed about the possibility of occurrence and mechanisms of PLP. The vast majority of the PLP patients did not try any treatment. Among those treated, more than 30% consulted more than three physicians for beneficial treatment. A >50% pain reduction was achieved in only 12.7% of PLP patients. The most successful treatments were opioids (67.4%) and anticonvulsants (51.7%). Surgery was performed in 46.4% of all PLP patients and in 29.7% due to a clinically suspected neuroma. After surgery, pain was worse or unchanged in 50% and improved in 41.6%, and 7.4% were pain-free. Conclusions. Our results suggest that there are primary needs for better information about PLP pathophysiology and treatment not only for patients but also for caregivers. Limited therapeutic success reveals a further need for increased research in PLP management.
Postamputation pain: epidemiology, mechanisms, and treatment
Journal of Pain Research, 2013
Postamputation pain (PAP) is highly prevalent after limb amputation but remains an extremely challenging pain condition to treat. A large part of its intractability stems from the myriad pathophysiological mechanisms. A state-of-art understanding of the pathophysiologic basis underlying postamputation phenomena can be broadly categorized in terms of supraspinal, spinal, and peripheral mechanisms. Supraspinal mechanisms involve somatosensory cortical reorganization of the area representing the deafferentated limb and are predominant in phantom limb pain and phantom sensations. Spinal reorganization in the dorsal horn occurs after deafferentation from a peripheral nerve injury. Peripherally, axonal nerve damage initiates inflammation, regenerative sprouting, and increased "ectopic" afferent input which is thought by many to be the predominant mechanism involved in residual limb pain or neuroma pain, but may also contribute to phantom phenomena. To optimize treatment outcomes, therapy should be individually tailored and mechanism based. Treatment modalities include injection therapy, pharmacotherapy, complementary and alternative therapy, surgical therapy, and interventions aimed at prevention. Unfortunately, there is a lack of high quality clinical trials to support most of these treatments. Most of the randomized controlled trials in PAP have evaluated medications, with a trend for short-term efficacy noted for ketamine and opioids. Evidence for peripheral injection therapy with botulinum toxin and pulsed radiofrequency for residual limb pain is limited to very small trials and case series. Mirror therapy is a safe and cost-effective alternative treatment modality for PAP. Neuromodulation using implanted motor cortex stimulation has shown a trend toward effectiveness for refractory phantom limb pain, though the evidence is largely anecdotal. Studies that aim to prevent PAP using epidural and perineural catheters have yielded inconsistent results, though there may be some benefit for epidural prevention when the infusions are started more than 24 hours preoperatively and compared with nonoptimized alternatives. Further investigation into the mechanisms responsible for and the factors associated with the development of PAP is needed to provide an evidence-based foundation to guide current and future treatment approaches.