How Common Are Chronic Residual Limb Pain, Phantom Pain, and Back Pain More Than 20 Years After Lower Limb Amputation for Malignant Tumors?

Abstract

Background After major lower limb amputation, persistent pain is common, with up to 85% of patients reporting recurring phantom or residual-limb pain. Although pain management is an important factor of quality of life in patients with lower limb amputations, there are few long-term data regarding the frequency of persistent pain and how it impacts prosthesis use. Questions/purposes (1) How prevalent are different types of pain at long-term follow-up after amputation for malignant tumors? (2) What association do different pain types have with daily prosthesis use? Methods Between 1961 and 1995, 124 major amputations for malignant tumors were performed at one center in Austria in patients (1) who spoke German and (2) whose surgical date resulted in the possibility of a minimum follow-up time of 20 years at the time of this survey; those patients were considered potentially eligible for this retrospective study. The indications for major amputation were to achieve local tumor control in limbs that the surgeon deemed unsalvageable without amputation. Of those 124 patients, 71% (88) had died, 9% (11) could not be reached, and 3% (4) declined to participate. Thus, 58% (21 of 36) of those living at the time of this study and who underwent lower limb amputation between 1961 and 1993 with a median (range) follow-up duration of 41 years (23 to 55) completed a standardized questionnaire, including an assessment of pain and daily prosthesis use during the year before the survey. Phantom pain, residual limb pain, and back pain were each further subclassified into pain frequency, intensity, and restrictions in activities of daily living (ADL) due to the specific pain form and rated on a 5- (pain frequency) and 10-point (pain intensity, restrictions in ADL) numerical rating scale. Before multivariate regression analysis, daily prosthesis use was correlated with pain parameters using Spearman correlation testing. Results Seventeen of 21 patients reported phantom limb and back pain, and 15 patients reported residual limb pain in the past year. Median (range) phantom pain intensity was 7 (1 to 10) points, median residual limb pain intensity was 4 (1 to 9) points, and median back pain intensity was 5 (1 to 10) points. After controlling for relevant confounding variables such as age at amputation, age at survey, and stump length, we found that less intense residual limb pain (defined on a 10-point scale with 1 representing no pain at all and 10 representing extremely strong pain [95% CI 0.3 to 1.0]; r = 0.8; p = 0.003) was associated with greater daily prosthesis use. Higher amputation levels showed a decreased daily prosthesis use compared with patients with lower amputation levels (defined as transfemoral amputation versus knee disarticulation versus transtibial amputation [95% CI 0.3 to 5.1]; r = 0.5; p = 0.03). Conclusion Decades after surgery, many patients with lower limb amputations experience pain that restricts them in terms of ADLs and decreases their daily prosthesis use. This information supports the need for regular residual limb inspections and careful prosthesis fitting even at long-term follow-up, as effective prosthesis fitting is a modifiable cause of residual limb pain. Future studies evaluating long-term treatment effects of pain relief surgery and therapeutic alternatives to conservative pain treatments should be performed, as these approaches may help alleviate pain in patients with refractory postamputation pain. Level of Evidence Level IV, therapeutic study.

Lower extremity amputation: the emerging role of targeted muscle reinnervation (TMR) and regenerative peripheral nerve interface (RPNI)

“…For amputees, the function of their shortened limb correlates closely with prosthetic use [9] . These results have also been corroborated in the LIMB-Q, a patient-reported outcome instrument in which numerous themes were extracted from direct interviews with patients who suffered high-energy lower extremity trauma [10] . Themes such as physical ability, psychological, and prosthesis were important to patients' daily quality of life [10] .…”

“…These results have also been corroborated in the LIMB-Q, a patient-reported outcome instrument in which numerous themes were extracted from direct interviews with patients who suffered high-energy lower extremity trauma [10] . Themes such as physical ability, psychological, and prosthesis were important to patients' daily quality of life [10] . As expected, a long-term study of patients over 20 years after their amputation demonstrated that higher amputation levels were associated with decreased prosthetic use while less intense residual limb pain was associated with greater daily prosthetic use [11] .…”

What’s New in Musculoskeletal Tumor Surgery

“…Long-term outcomes of amputations for oncologic reasons have also been an area of investigation. Geiger et al 17 and Döring et al 20 published functional and quality-of-life outcomes 20 to 40 years after the initial treatment for a limb sarcoma. The authors found that the cumulative incidence of amputation at 25 years after limb salvage was 18%, with periprosthetic joint infection as a risk factor for failure of limb salvage.…”

CORR Insights®: How Common Are Chronic Residual Limb Pain, Phantom Pain, and Back Pain More Than 20 Years After Lower Limb Amputation for Malignant Tumors?

“…The current study by Döring et al [2] is important because it focuses on the long-term outcomes and complications from the subset of patients who may not be good candidates for limb salvage.…”

“…We also need to determine the impact each technique has on long-term pain and amputee function. Döring et al [2] provide long-term functional and quality-of-life data for patients with amputation, which can serve as a A large proportion of amputationrelated studies focus on populations with the highest rates of amputation. This includes older patients with diabetes-or peripheral vascular disease-related complications [3,13] as well as military and traumatic amputations [4,11].…”