Randomized Prospective Study Comparing Preoperative Epidural and Intraoperative Perineural Analgesia for the Prevention of Postoperative Stump and Phantom Limb Pain Following Major Amputation

Lambert, A W; Dashfield, A. K.; Cosgrove, C.; Wilkins, David G.; Walker, A. J.; Ashley, S.

doi:10.1097/00115550-200107000-00007

Cited by 103 publications

(48 citation statements)

References 13 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…Placement of catheters directly into the severed nerve ends, aiming for the centre of the nerve, not the surrounding sheath, seems uncommon in the literature. In accord with other reports on lower extremity amputations using similar approaches (3–7), intraneural catheters provided a highly efficient analgesia in our patient. Even although the femoral and sciatic nerve do not exclusively provide sensory innervation of the leg, the necessity to block the lateral and posterior cutaneous nerve of the thigh and obturator nerve is not clear.…”

supporting

confidence: 92%

Intraneural catheter placement for post‐operative pain therapy in an amputee

Engelhardt¹,

Schaser²,

Fritzsche³

et al. 2006

Acta Anaesthesiol Scand

View full text Add to dashboard Cite

Sir,Regional anaesthesia is an effective means of providing postoperative pain therapy in amputees. We report our experience with a patient where excellent post-operative pain relief was obtained by continuous infusions of ropivacaine via stimulating catheters placed directly into the severed femoral and sciatic nerve ends.A 41-year-old male with neurofibromatosis type I (NF I) who required exarticulation of the hip joint as a result of neurofibrosarcoma was admitted to our hospital. Neuraxial regional anaesthesia or psoas compartment block was not performed because of an elevated activated partial thromboplastin time (aPTT) of unknown cause and extensive neurofibromata at intended puncture sites. Surgery was uneventful under general anaesthesia. For post-operative analgesia, two stimulating catheters were placed intra-operatively by directly inserting a 17-G Touhy cannula 9 cm into both the transsected ends of the femoral and sciatic nerve. Catheters were advanced through the Touhy needles to the same depth. Touhy needles were removed leaving both catheters 9 cm within the respective nerves. At the end of surgery, boluses of 25 ml of ropivacaine 0.2% each were administered through both catheters. Post-operative analgesia was provided with continuous infusions of ropivacaine 0.2% at rates of 6-8 ml/h for each catheter. Average pain score at rest was 0-1 (NRS). The highest score during mobilization amounted to three (NRS) on the first post-operative day. Catheter positions were checked on the 6th post-operative day. Under continuous administration of ropivacaine 0.2% 6 ml/h, stimulation of the sciatic nerve catheter (3.8 mA, 0.1 ms, 2 Hz) resulted in a twitching sensation in the amputated foot. Stimulation of the femoral nerve catheter did not cause any subjective twitching sensation even at 5 mA. Eight days after surgery, the catheters were removed. During the whole post-operative course, the use of opioids was not necessary. Ten months post-operatively, the patient did not complain of phantom pain.Continuous administration of local anaesthestics via catheters placed perineurally using differing surgical techniques has been described (1, 2). Placement of catheters directly into the severed nerve ends, aiming for the centre of the nerve, not the surrounding sheath, seems uncommon in the literature. In accord with other reports on lower extremity amputations using similar approaches (3-7), intraneural catheters provided a highly efficient analgesia in our patient. Even although the femoral and sciatic nerve do not exclusively provide sensory innervation of the leg, the necessity to block the lateral and posterior cutaneous nerve of the thigh and obturator nerve is not clear.Given the presence of infused ropivacaine, the observed current of 3.8 mA at 0.1 ms necessary to stimulate the sciatic nerve catheter is consistent with other reports (8,9). Stimulation of the femoral nerve was unsuccessful. However, to be clinically effective, the tip does not need to be electrically close to the femoral nerve (10).We conclude ...

show abstract

supporting

confidence: 92%

Intraneural catheter placement for post‐operative pain therapy in an amputee

Engelhardt¹,

Schaser²,

Fritzsche³

et al. 2006

Acta Anaesthesiol Scand

View full text Add to dashboard Cite

show abstract

“…The evidence in our cohort as well as other studies indicated the role of preemptive analgesia in preventing PLP. Current evidence is not in strong support of any one anesthetic technique of postoperative pain control is likely to provide a greater impact on preventing PLP [28–31]. Moreover, we found that patients who accepted postoperative analgesia were had almost a five times higher risk to experience PLP after the amputation, compared with the patients who did not have postoperative analgesia.…”

Section: Discussionmentioning

confidence: 61%

The pre-amputation pain and the postoperative deafferentation are the risk factors of phantom limb pain: a clinical survey in a sample of Chinese population

Yin

Zhang²,

Hong

et al. 2017

BMC Anesthesiol

View full text Add to dashboard Cite

BackgroundTo provide an overview of phantom limb pain (PLP) in China. This includes the prevalence of PLP and possible risk factors.MethodsIn a retrospective study, telephone interviews were conducted with 391 amputation patients who underwent extremity amputations at a tertiary hospital in China.ResultsPLP was found in 29% of the amputees. Pre-amputation pain (OR = 10.4, P = 0.002) and postoperative analgesia (OR = 4.9, P = 0.008) were identified as high-risk factors for PLP. 82.1% of PLP patients experienced pre-amputation pain. The average pain intensity of PLP was 5.1 ± 2.2, with 31.9% having severe intensity. The effects of PLP on the quality of the PLP patients were as follows: 7.8% of the patients had to limit their daily life and 29.0% of the patients had to limit their social activities. 17.3 and 25.7% of patients experienced depression and sleeping disorder respectively, while 18.9% had loss of interest and even 16.1% of PLP patients had attempted suicide. No effective treatments were found in 78.9% of these patients.ConclusionsPLP has markedly affected the lives of patients. Pre-amputation pain and postoperative epidural analgesia might be risk factors for the phantom limb pain after amputation. Prevention of pre-amputation pain and sudden post-amputation deafferentation should be recommended to the amputees.

show abstract

“…published on the use of peri‐operative epidurals to reduce the incidence of post amputation phantom limb pain [10], this approach has become standard in many institutions. More recent literature [11, 12] has, however, disputed this effect and, together with problems associated with epidural analgesia (e.g. hypotension, motor block and urinary retention) some doubt must be cast on this strategy.…”

Section: Discussionmentioning

confidence: 99%