Residual limb pain

Not surprisingly, residual limb pain is common in the early postoperative period, but in most patients it subsides with healing. The prevalence of chronic residual limb pain is reported to vary between 5 and 100 percent (Table 31.1 ). Variations in the literature may reflect different methods of estimating pain and the fact that some amputees find it difficult to distinguish between residual limb and phantom pain. In a survey of 78 traumatic amputees, Pezzin et al.46 found that 14.1 percent suffered from severe and constant pain in the residual limb. Similar results have been found by others in patients who have undergone amputation for different reasons, including medical.16,22,23 In two recent studies, the mean prevalence of residual limb pain was reported to be 51.2 and 67.7 percent, respectively.24, 26 In the latter study, mean intensity of residual limb pain among those reporting pain was 5.1 (NRS, 0-10).24 Chronic residual limb pain is more likely to be present in war zones.2, 3

Residual limb pain may be described as pressing, throbbing, burning, squeezing, or stabbing.36 Some patients have spontaneous movements of the residual limb, ranging from slight, hardly visible jerks to severe contractions.

Residual limb pain and phantom pain are strongly correlated. Carlen et al.11 noted that phantom pain was decreased by the resolution of stump-end pathology. In a survey of 648 amputees, Sherman and Sherman14

found that residual limb pain was present in 61 percent of amputees with phantom pain, but in only 39 percent of those without phantom pain. Similar results have been found in at least four prospective studies.11,20,26,36 Other clinical studies have shown that temperature and muscle activity at the residual limb are related to phantom pain

Nikolajsen et al. studied 35 amputees and found that low mechanical thresholds (pressure algo-metry) at the residual limb were associated with residual limb and phantom pain one week after amputation.

The association between residual limb and phantom pain is consistent with experimental studies in amputees. Nystrom and Hagbarth58 observed abnormal activity in the peroneal and median nerve fibers of two amputees with ongoing pain in their phantom foot and hand, respectively. Percussion of neuromas in these two patients produced increased nerve fiber discharges and an augmentation of their phantom pain.

Careful sensory examination of amputation residual limbs may reveal areas with sensory abnormalities, such as hypoesthesia, hyperalgesia, or allodynia.59 However, it is not clear whether there is any correlation between phantom pain and the extent and degree of sensory abnormalities in the residual limb. Hunter et al.60 carefully examined the residual limb in 12 traumatic upper-limb amputees, but failed to find any simple relation between psychophysical thresholds and phantom phenomena.

Chronic residual limb pain can be very severe as illustrated by the following case study. A 48-year-old woman fractured her ankle in 1999. Healing was difficult and two years later the osteosynthesic material was removed because of infection. Physiotherapy was not possible due to pain, and the foot became fixed in an extended and pronated posture. Signs of chronic regional pain syndrome (CRPS) were evident. A below-knee amputation was performed in 2003 because of ulcers resistant to treatment. The patient subsequently developed severe residual limb pain. The pain was present constantly and described as shooting, burning, and scalding. The intensity of pain was 4-10 on a VAS. In addition to residual limb pain, the patient also experienced phantom pain. Medical treatment (TCAs, antiepileptic drugs, slow-release opioids) had only a modest effect on the pain. Physical examination of the residual limb revealed allodynia and hyperalgesia (Figure 31.2). In 2006, an epidural electrode was implanted for spinal cord stimulation (SCS). Within the first week after the implantation, the intensity of residual limb pain decreased to 2 on the VAS, and the allodynia at the residual limb was replaced by a feeling of numbness.

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