Phantom-limb pain

Abstract

Author's replySir—H J McQuay and colleagues compare the study by Bach et al1Bach S Noreng MF Tjéllden NU Phantom limb pain in amputees during the first 12 months following limb amputation, after preoperative lumbar epidural blockage.Pain. 1988; 33: 297-301Summary Full Text PDF PubMed Scopus (478) Google Scholar with that of Lone Nikolajsen and colleagues.2Nikolajsen L Ilkjaer S Christensen JH Kroner K Jensen TS Randomised trial of epidural bupivacaine and morphine in prevention of stump and phantom pain in lower-limb amputation.Lancet. 1997; 350: 1351-1355Summary Full Text Full Text PDF Scopus (272) Google Scholar But these trials evaluated different hypotheses by use of different experimental designs, making it difficult to interpret the discrepant outcomes. As the figure in my commentary showed (see Department of Error, p 604 for correct figure), Nikolajsen's trial is the only one of its kind in design and outcome. The three other studies that evaluated preoperative epidural anaesthesia for patients undergoing amputation reported a reduced incidence of phantom limb pain relative to patients not given epidural anaesthesia4Jahangiri M Bradley JWP Jayatunga AP Dark CH Prevention of phantom limbpain after major lower limb amputation by epidural infusion of diamorphine, clonidine and bupivacaine.Ann R Coll Surg Engl. 1994; 76: 324-326PubMed Google Scholar, 5Schug SA Burrell R Payne J Tester P Pre-emptive epidural analgesia may prevent phantom limb pain.Regional Anesthesia. 1995; 20: 256PubMed Google Scholar or those given epidural anaesthesia during surgery.1Bach S Noreng MF Tjéllden NU Phantom limb pain in amputees during the first 12 months following limb amputation, after preoperative lumbar epidural blockage.Pain. 1988; 33: 297-301Summary Full Text PDF PubMed Scopus (478) Google Scholar To declare the issue resolved on the basis of a single negative study is premature—notwithstanding the quality of Nikolajsen's study. In their haste to declare this “dodo” extinct and to abandon research in this area, McQuay and colleagues would deprive those individuals undergoing amputation of the possibility of a future with less pain. We must continue to investigate methods to reduce the frequency and intensity of this very real and difficult pain problem. Author's reply Sir—H J McQuay and colleagues compare the study by Bach et al1Bach S Noreng MF Tjéllden NU Phantom limb pain in amputees during the first 12 months following limb amputation, after preoperative lumbar epidural blockage.Pain. 1988; 33: 297-301Summary Full Text PDF PubMed Scopus (478) Google Scholar with that of Lone Nikolajsen and colleagues.2Nikolajsen L Ilkjaer S Christensen JH Kroner K Jensen TS Randomised trial of epidural bupivacaine and morphine in prevention of stump and phantom pain in lower-limb amputation.Lancet. 1997; 350: 1351-1355Summary Full Text Full Text PDF Scopus (272) Google Scholar But these trials evaluated different hypotheses by use of different experimental designs, making it difficult to interpret the discrepant outcomes. As the figure in my commentary showed (see Department of Error, p 604 for correct figure), Nikolajsen's trial is the only one of its kind in design and outcome. The three other studies that evaluated preoperative epidural anaesthesia for patients undergoing amputation reported a reduced incidence of phantom limb pain relative to patients not given epidural anaesthesia4Jahangiri M Bradley JWP Jayatunga AP Dark CH Prevention of phantom limbpain after major lower limb amputation by epidural infusion of diamorphine, clonidine and bupivacaine.Ann R Coll Surg Engl. 1994; 76: 324-326PubMed Google Scholar, 5Schug SA Burrell R Payne J Tester P Pre-emptive epidural analgesia may prevent phantom limb pain.Regional Anesthesia. 1995; 20: 256PubMed Google Scholar or those given epidural anaesthesia during surgery.1Bach S Noreng MF Tjéllden NU Phantom limb pain in amputees during the first 12 months following limb amputation, after preoperative lumbar epidural blockage.Pain. 1988; 33: 297-301Summary Full Text PDF PubMed Scopus (478) Google Scholar To declare the issue resolved on the basis of a single negative study is premature—notwithstanding the quality of Nikolajsen's study. In their haste to declare this “dodo” extinct and to abandon research in this area, McQuay and colleagues would deprive those individuals undergoing amputation of the possibility of a future with less pain. We must continue to investigate methods to reduce the frequency and intensity of this very real and difficult pain problem.