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The goal of amputation surgery is to remove an often painful, functionless limb and to rehabilitate the amputee to a painless, functional state. References J Bone Joint Surg [Br] ; However, a significant number of amputees will have persistent limb pain that interferes with prosthetic usage. Postamputation pain can be isolated to the residual limb or can occur as phantom pain. The physiologic mechanism for intrinsic stump pain and phantom pain is similar.
Reference Jensen T, Krebs B, Nielsen J, et al: Immediate and long term phantom limb pain in amputees: Incidence, clinical characteristics and relationship to preamputation limb pain. The treatment of chronic pain following an amputation is determined by the etiology of the pain. Obvious pathomechanical sources of pain such as degenerative arthritis of the knee in a transtibial amputation, ischemia in the residual limb in a dysvascular amputee, or a painful neuroma can be readily treated.
Psychiatric factors may amplify amputee pain syndromes, yet personality disorders do not absolutely correlate with the incidence of phantom pain syndromes. A large variety of surgical and nonsurgical methods exists for the treatment of postamputation pain. The survey of phantom pain treatment methods used by Veterans Administration hospitals, medical schools, and pain clinics showed that at least 50 different modalities are currently utilized for the treatment of amputee pain.
Pain is a phenomenon that consists of complex circuits of cellular communication and integration elicited by stimulation of peripheral tissues such as skin, joints, tendon, ligaments, and viscera. New York, Raven Press,pp Several types of peripheral nervous receptors have been identified: mechanoreceptors, thermoreceptors, and nociceptors, or pain receptors. References 3.
Bonica JJ: Neurophysiologic and pathologic aspect of acute and chronic pain. Arch Surg ; Impulses from these low-intensity receptors are carried by large myelinated fibers.
The thermoreceptors and mechanoreceptors are characterized by a low threshold for certain stimuli. For example, thermoreceptors have a distinct sensitivity to high and low skin temperatures but can be excited by firm pressure. On the other hand, nociceptors have a high threshold to an appropriate stimulus and a relatively small field of reception. There is considerable controversy regarding the existence of specific chemoreceptors.
Reference 3. Once depolarization is initiated, the generated action potential flows along sensory nerve fibers to superficial and deep cutaneous complexes and ultimately to the dorsal root ganglion, where cell bodies of the afferent neurons are located. The axons of the ganglion cells enter the apex of the dorsal horn of the spinal cord and terminate in a complex array of synaptic arrangements Fig The dorsal horn has been divided into six laminae on an anatomic and functional basis.
Phantom & Stump Pain
Rexed B: The cytoarchitecture organization of the spinal cord of the cat. The large myelinated fibers give off a collateral, which enters the dorsal horn and forms synaptic connections with cells and various laminae, especially laminae II and III. The small myelinated sensory afferent fibers proceed into the Lissauer tract, where they divide into ascending and descending divisions extending over one and two segments and establish synapses with marginal neurons and gelatinosa cells Fig Arch Surg ; 6.
Casey KL: Pain: A current view of neural mechanisms. Ami Sci ; It can even be difficult to localize the exact location of the pain after surgery. The pain can be the result of an incorrect initial diagnosis, inadequate surgical resection, or the occurrence of a stump neuroma.
Post-surgical Pain, Stump Neuroma Revision Surgery
Post-surgical pain can also be due to nerve degradation or just plain scar tissue formation or rarely, another post surgical complication. Post surgical pain usually becomes apparent between three and eight weeks postoperatively, or it may develop after months, or even years of a seemingly successful surgical intervention.
In general, if there is no improvement by three or four months after surgery there is probably little chance of further improvement. A stump neuroma is a traumatic, or amputation stump neuroma affecting the common digital nerve and is usually located just near proximal to the metatarsophalangeal joint. The stump, or traumatic neuroma develops as the budding nerve cells in the near section of the cut nerve trunk multiply and attempt to bridge the gap and grow towards the nerve trunk of the far segment of the cut nerve.
The newly budding nerve cells become entrapped in scar tissue and may stick to neighboring structures, such as the metatarsophalangeal joint capsule, the bone surface the periosteum of the metatarsal shaftand nearby tendons, ligaments, and muscle.
Don't Suffer Any More. Get Help Now:. The remaining nearby nerve ending the proximal nerve stump should be moved and buried into surrounding muscle tissue i. Many surgeons use steroid, alcohol or dilute phenol infiltration into the proximal nerve stump to attempt to decrease the chance of a post surgical stump neuroma forming but these have not been proven to help.
Some surgeons cap the proximal nerve stump with silicone during the operation but this has also yielded inconsistent results and very often requires reoperation to remove the silicone capping and revise the surgery. Unfortunately, there is no way to accurately measure the adequacy of the nerve trunk resection at the time of surgery, and the surgeon can only hope for a clean, sharp cut, with accurate anatomic dissection, correct nerve placement, absolute hemostasis, and the avoidance of any wound complications.
The likelihood of the recurrence increases if the patient develops a postoperative infection or bruising. Symptoms are typically aggravated by weight bearing, walking, and wearing certain shoes usually shoes with high heels, narrow toe box, and thin soles. This finding, however, need not be present in all cases. Similarly, the web space may be numb or dull to touch.
The key finding is the reproduction of symptoms upon direct, deep palpation of the stump neuroma. Matt is from California. The diagnosis for a recurrent neuroma can be difficult and care should be taken to rule out other causes of metatarsalgia, especially if the pain is dull in nature. This usually requires a diagnostic local anesthetic injection done under ultrasound and preferably with nerve stimulator guidance beforehand, to ensure that the source of the pain can be accurately localized.
This diagnostic injection also tests that the pain is responsive to local anesthetic which is an indication that the pain will respond well to an ablation procedure.If you feel you cannot cope with your symptoms at home or your condition is worsening, please visit: www.
If you cannot get help online, please call Pain management after an amputation is challenging. Amputation of a limb may result in pain which is amongst the most severe a person may ever experience. The pain experienced after amputation is the result of direct damage to the bones and soft tissue as well as nerve related neural.
The neural pain is the result of injury to the peripheral nerves and loss of feedback to the central nervous system from the absent limb. These varied sources of pain leads to a very mixed form of pain which can require a very varied approach for treatment, including both surgical and non-surgical modalities.
Moreover, the burden of pain after amputation persists not only in the short term, but also in the years and decades after surgery. Fortunately, every patient is unique and not every patient who has an amputation suffers from significant pain requiring specific intervention.
In terms of nerve related pain, amputees may experience two types of stump pain. However, for most amputees, neuroma pain does not prevent them from using a standard, socket-fitted prosthesis and the pain is something they simply learn to tolerate. A neuroma is a painful lump of scar tissue that forms at the end of an amputated nerve. It represents a disorganised growth of nerve endings at the end of the nerve and can often occur after a nerve is partially or completely disrupted by an injury — either due to a cut, a crush, or excessive stretching this is the mechanism of a typical brachial plexus injury.
Typically, a neuroma is a ball-shaped mass which varies in size from a golf-ball to a pinhead, depending on the size of the nerve from which it arises which forms at the site of the injury.
Pain is caused by tapping the neuroma or by direct pressure, resulting in pain at that site accompanied by an uncomfortable sensation of electric shocks which may travel up the residual limb. Painful neuromas are particularly common after amputations in the hand and upper extremity arm and in the lower extremity leg but less so in the thigh. The therapeutic options for treatment of a neuroma are becoming increasingly clear.
The neuroma forms because of a thwarted attempt by the peripheral nerves to reconnect with the sensory and motor end organs in the amputated part. As a result, they become very sensitive. Traditional treatments have relied on burying the nerve ends to try and cushion or discourage formation of a neuroma.
Review of these traditional methods has shown that these options are not effective. This reduces the sensitivity of the peripheral nerves and prevents the neuroma from re-forming. Currently, there are only two ways in which to achieve this objective. Details of these surgical procedures are given elsewhere in this website.
All amputees experience phantom limb sensation the perception that the amputated part is still present. Risk factors predisposing to the development of PLP include; significant pain in the amputated part prior to the amputation, standard prosthesis use, lower limb amputations and bilateral amputations.
Therapeutically, this type of pain is hard to control but there is increasing evidence that the root cause is the loss of normal feedback from the amputated part to the central nervous system.Pain management after amputation can be challenging due to the presence of mixed nociceptive and neuropathic pain. Prolonged analgesia via continuous perineural blockade provides optimal analgesia for early management of stump and phantom pain.
Amputation of a limb is one of the oldest recorded surgical procedures. Traumatic amputation and use of a prosthesis is found written in Sanskrit texts dating from to BC. Internationally, accurate numbers of limb amputations performed are very difficult to estimate as there is no recognized database or organization collecting this information.
Regardless of the indication for surgery, pain management after amputation is challenging. Amputation of a limb is one of the most severe pains in the human experience.
This is attributable to the magnitude of the tissue injury involved and the varying loci of centres responsible for pain generation; comprising peripheral, spinal, and cortical regions. Pain after amputation involves nociceptive pain, due to bone and soft tissue injury, and neuropathic pain from direct neural trauma and central sensitization.
This leads to a complicated, mixed, form of pain and a highly varied array of different postoperative pain syndromes. The burden of pain after amputation is therefore considerable, not just in the short term, but also in the years and decades after surgery. Severe post-amputation pains from phantom limbs have been recorded in survivors from World War II, some 50 yr after loss of a limb.
Pain management is often complicated in surgical amputees due to the presence of polypharmacy and severe co-morbidity including ischaemic heart disease and renal compromise. This article will discuss the different pain phenomena encountered after limb amputation and its management. This will include stump pain, acute phantom limb pain, and back pain. Different perioperative treatment modalities will be discussed aiming to inform practice in achieving optimal acute pain control and potentially preventing the chronicity of acute pain.
Acute pain management has been identified as a key priority in the management of patients undergoing amputation by a recent NCEPOD report.
In achieving good quality analgesia it is important to strike a balance between effective pain control and excess morbidity as a result of interventional or pharmacotherapy.
However, failure to optimize acute pain control not only leads to a detrimental pathophysiological stress response but impacts on a patient's psychology, functional recovery and predisposes to chronic stump and phantom pain. A number of different pain syndromes can present after amputation.
These shall be discussed as stump pain, phantom pain, and mechanical pain. It should be borne in mind however that each pain rarely exists in isolation and frequently contribute to one another.
A full assessment must therefore be made of each patient to try and identify the predominant pain at the time. The immediate aftermath of limb amputation in the first postoperative days is dominated by surgical wound pain. This pain is readily identifiable and confined to the surgical site.When you are recovering from an amputation, pain and strange sensations can linger. Fortunately, there are techniques that can help. Find five techniques to deal with phantom limb sensation and pain.
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5 Ways to Deal With Phantom Limb Pain After Amputation
After the initial post-surgical pain subsides, you may experience several types of sensations — some painful and unpleasant, others strange and disconcerting.
Doctors can help amputation patients control these sensations early on to limit long-term problems with post-amputation pain. Patients experiencing this sensation report an actual feeling of pain, ranging from mild to severe, in the missing body part.
Bolash says. This is not phantom pain, but pain originating from the stump. Poorly fitting prosthetics or limb bruising can cause residual limb pain as well. Bolash shares five of the most effective treatment techniques:. Bolash encourages anyone with post-amputation sensations to discuss it with their physician immediately.
No one will think the person is losing their sanity, he says. Share this article via email with one or more people using the form below. Send me expert insights each week in Health Essentials News. Advertising Policy. You have successfully subscribed to our newsletter. Related Articles. Diagnosed With Arthritic Ankles?
Trending Topics.Definition : Losing a limb is devastating. But, even after grieving the initial loss, you may continue to feel a sensation — phantom pain or discomfort — as if you still had the limb. Phantom pain in a limb that no longer exists is common after amputation. For some people, phantom pain gets better over time without treatment. For others, managing phantom pain can be challenging.
You and your doctor can work together to treat phantom pain effectively with medication or other therapies. Although doctors know something about the situations in which phantom pain occurs, the cause is still unclear. Phantom pain can affect a person who has had an amputation or someone born without a limb. In some cases, a poor-fitting artificial limb prosthesis may cause pain. Talk to your doctor to be sure you're putting your artificial limb on correctly and that it fits right. If you think your artificial limb may not fit properly, or is causing pain, talk to your doctor.
Triggers of phantom pain You also may find that certain circumstances seem to trigger an episode of phantom pain, such as :. When to seek medical advice : Phantom pain often begins within a few days after surgery.
Some people find that phantom pain goes away over time, whereas others have pain for many years.
Pain that has gone untreated for more than six months to a year tends to be more difficult to treat. So, be sure to report pain to your doctor right away for more effective treatment.
Phantom limb pain, stump pain and phantom limb sensation describe conditions that commonly affect people who have lost a limb :. You may find that you can't predict what type of pain you'll have, when an episode will occur, how intense it will be or how long it will last. Diagnosis : Although there's no medical test to diagnose phantom pain, doctors can identify the condition by collecting information such as your symptoms and the circumstances such as trauma or surgery that occurred before the pain started.
Be sure to speak up about your pain symptoms. Only you can describe your pain to your doctor.Amputation Stump Pain
Tell your doctor how much pain you have, if it's getting better or worse, and what, if anything, seems to help it or make it worse. Keeping a pain diary may help you and your doctor sort out the circumstances that may trigger your pain and how best to treat the pain. If you know what triggers your pain, you might be able to avoid it, start treatment early, or tailor treatment based on your trigger.
For example, if exercise triggers your pain, you can try taking medication ahead of time. If use or lack of use of your artificial limb triggers pain, a change to the prosthesis may help. Treatment: Doctors may use one or more of a variety of approaches to treat phantom limb pain.
Medications Doctors often try medications first. Although there are no medications specifically for phantom pain, several are used to help chronic pain of any origin. Keep in mind that no single drug works for everyone, and not everyone benefits from medications.
You may need to try several different drugs to find one that works for you. Nonsurgical approaches As with medications, treating phantom pain with nonsurgical therapies is a matter of trial and observation. The following techniques may relieve phantom pain :. Other experimental treatments include other nerve blocks and destruction of nerve tissue nerve tissue ablation.
No clear evidence has yet shown these treatments to be helpful. Surgery Surgery may be an option if other treatments have not helped.Anyone who undergoes an amputation can develop phantom pain or stump pain. Phantom limb pain feels like it is coming from the body part that is no longer there, although it is actually caused by nerve endings at the site of the amputation that continue to send pain signals to the brain.
There are many types of cancer pain. Our Pain and Spine Specialists can help you discover the type and cause of the pain so it can be effectively treated. Symptoms include:. Although there are no medical tests to diagnose phantom and stump pain, the conditions can be identified by collecting information about the symptoms and through clinical examination.
Non-invasive treatment for phantom pain and stump pain is often a matter of trial and observation. Quite often, multiple treatments may be used. Yes, subscribe me! Sign me up for the PMIR newsletter. About Our Doctors Alexander P. Hersel, M. Bradley Spiegel, M. Phantom pain normally occurs within the first week after an amputation, although in some cases, it can develop months or even years after the amputation.
Phantom pain may be a response to mixed signals from the brain as areas of the spinal cord and brain lose input from the missing limb and adjust in unpredictable ways. Phantom pain may be caused by damaged nerve endings, scar tissue at the site of the amputation, and the physical memory of pre-amputation pain in the affected area.
Symptoms There are many types of cancer pain. Symptoms of Phantom Pain Include: An onset within the first few days of amputation. A tendency to come and go rather than be constant. Often described as shooting, stabbing, boring, squeezing, throbbing or burning.
May also include feelings of coldness, warmth, itchiness or tingling. May be triggered by weather changes, pressure on the remaining part of the limb or emotional stress.
Stump pain is often described as sharp, burning and electric. Diagnosis Although there are no medical tests to diagnose phantom and stump pain, the conditions can be identified by collecting information about the symptoms and through clinical examination. Treatment Options Non-invasive treatment for phantom pain and stump pain is often a matter of trial and observation.