Chronic Stump Pain Research Articles

EP.WE.501The Role of Nerve Sheath Catheters after Major Lower Limb Amputations in Post-operative Pain Control

Abstract Aim Pain is a common post-operative complication after limb amputation. Though the evidence is mixed, current literature suggests nerve sheath catheters (NSC) have no effect on chronic stump pain, phantom limb pain or post-operative pain score but reduces opioid use. This study aims to compare pain outcomes in those with and without NSC after above knee amputations (AKA) and below knee amputations (BKA). Method This retrospective study collected information from 32 patients after lower-limb amputation from April 2014 - March 2017. Information regarding indication, anaesthetic and morphine requirement at 72 hours were collected from medical records and standardised questions used to assess phantom limb pain, chronic limb pain and pain intensity (1-10) at 24, 48 and 72 hours. Results Of the 11 patients who received a NSC catheter for pain control, 33% experienced no post-operative pain, 18% experienced phantom limb pain, 18% reported chronic limb pain and 62% required higher dosages of morphine at 72 hours. However, two patients used large amounts of morphine potentially giving spurious results. In comparison, of those patients without NCS, 43% experienced no pain, 9% experienced phantom limb pain, 33% reported chronic limb pain and only 47% required morphine at 72 hours and at lower doses compared to with NSC. The incidence of phantom limb pain was higher in those who had AKA regardless of the analgesic technique used. Conclusion Patients with NSC were less likely to experience chronic limb pain thus proving their role in post-operative pain control despite having higher morphine requirements.

488 An Evaluation of Pain Related Outcomes Following Nerve Sheath Catheter Insertion after Major Lower Limb Amputations

Abstract Aim Limb amputations have many post-op complications, including pain. The evidence supporting the use of nerve sheath catheters (NSC) to manage post-op pain is mixed. Current literature suggests NSC reduces post-op opioid requirements but does not reduce pain score, phantom limb pain or chronic stump pain. This study compared post-op pain in those with and without NSC after above knee amputations (AKA) and below knee amputations (BKA). Method Retrospective data from April 2014 – March 2017 was reviewed. Information regarding indication, anaesthetic, morphine requirement at 72 hours, phantom limb, chronic limb pain and a pain scale (1-10) at 24, 48 and 72 hours were collected. Results 32 patients were involved in the study. 11 had NSC for pain control. Of those patients without NSC, 43% experienced no pain. In comparison, 33% of those with NSC experienced no post-op pain. Phantom limb pain was experienced in a higher proportion of patients with NSC (18%) and in those with AKA (11%). 18% of patients with NSC experienced chronic limb pain, compared to 33% without NSC. 62% of patients with NSC required morphine at 72 hours and at higher dosages compared to those without. However, two patients used large amounts of morphine potentially giving spurious results. Conclusions Though limited by small patient group, patients with NSC were more likely to require morphine at 72 hours and at higher dosages but were less likely to experience chronic limb pain thus proving the role of NSC in post-op pain control.

Peripheral nerve stimulator for terminal sciatic nerve neuromas in an amputee.

Neuromas are a difficult-to-treat peripheral nerve pathology that can cause crippling pain. Optimal treatment is widely debated as pharmacological intervention frequently is not sufficient and surgical interventions are plagued with recurrence. The majority of amputees report severe and chronic stump pain. Avoiding complex surgery at the stump site would prevent infection or wound dehiscence. Recent advances in neuromodulation with external pulse emitters allow for pain relief with localized nerve stimulation. The authors describe the novel placement of a sciatic nerve stimulator in a 77-year-old man for painful stump neuromas of the common peroneal and tibial nerves.The video can be found here: https://youtu.be/96kKs3qjtqc

The Perineural Local Anaesthetic Catheter After Major Lower Limb Amputation Trial (Placement): A Randomised Controlled Feasibility Study

Introduction - Pain control after major lower limb amputation for peripheral vascular disease is a significant problem, due to the multifactorial nature of post-amputation pain, contra-indication of epidural anaesthesia in many patients and side effects of opioid analgesics and patient frailty. A perineural catheter is a thin plastic tube which may be placed adjacent to the sciatic or tibial nerve at the time of amputation, through which a continuous local anaesthetic infusion can be given. Although low quality observational data suggest that perineural catheter usage reduces postoperative opioid requirements, little data are available regarding their effect on pain. PLACEMENT is a randomised controlled feasibility study to explore the feasibility of running a multi-centre effectiveness trial to assess the impact of perineural catheter usage on short and medium term postoperative outcomes. Methods - Fifty patients undergoing major lower limb amputation (at below or above knee level) for peripheral vascular disease were recruited from two centres. Patients were randomised in a 1:1 ratio to receive standard postoperative analgesia, with or without insertion of a perineural catheter and local anaesthetic infusion for up to 5 postoperative days. The primary effectiveness outcome was pain measured on a verbal rating scale in the first five post-operative days. Secondary effectiveness outcomes included quality of life and the prevalence of phantom limb and chronic stump pain assessed 2 and 6 months after surgery as well as total healthcare costs. Key feasibility outcomes included the proportion of eligible patients successfully recruited and the feasibility of using pain scores as a primary outcome measure as well as a preliminary estimate of the effect size. Full ethical approval has been granted (Wales REC 3 reference number 16/WA/0353). The trial is registered as ISRCTN85710690 with EudraCT number 2016-003544-37 and is funded by Health and Care Research Wales (grant number RfPPb-16-1198). Results - Recruitment commenced on 15th February 2017 and 50 patients were successfully enrolled in the study across two centres by 15th November 2017. Follow-up is due to complete in May 2018, and results of the primary effectiveness and key feasibility outcomes will be available in time for the annual meeting of the European Society for Vascular Surgery, where they will be made publically available for the first time. Conclusion - PLACEMENT is a multi-centre randomised controlled feasibility study which is the first to explore the feasibility of running an effectiveness trial on perineural catheter usage for postoperative pain in amputees. Recruitment is complete and full trial results will be available in time for the annual meeting of the European Society for Vascular Surgery.

Perineural local anaesthetic catheter after major lower limb amputation trial (PLACEMENT): study protocol for a randomised controlled pilot study

BackgroundPain after major lower limb amputation for peripheral arterial disease (PAD) is a significant problem. A perineural catheter (PNC) can be placed adjacent to the major nerve at the time of amputation with a continuous local anaesthetic infusion given postoperatively to try and reduce pain. Although low-quality observational data suggest that PNC usage reduces postoperative opioid requirements, there are limited data regarding its effect on pain. The aim of PLACEMENT is to explore the feasibility of running an effectiveness trial to assess the impact of a PNC with continuous local anaesthetic infusion, inserted at the time of amputation, on short and medium-term postoperative outcomes.Methods/designFifty patients undergoing a major lower limb amputation (below or above the knee) for PAD will be recruited from two centres. Patients will be randomised in a 1:1 ratio to receive standard postoperative analgesia, with or without insertion of a PNC and local anaesthetic infusion for the first 5 postoperative days. Outcome data will be captured for the first 5 days, including pain scores (primary outcome, captured three times a day), opioid use, nausea or vomiting, itching, dizziness and complications. Patients will be contacted 2 and 6 months after surgery to assess quality of life, phantom limb pain, chronic stump pain and total healthcare costs. Semi-structured interviews will be conducted with at least 10 patients (dependent on saturation of analytic themes on preliminary coding) purposefully sampled to achieve variation in site and study arm. Interviews will explore patients’ perception of post-amputation pain and its treatment, and experience of study processes. Semi-structured interviews with 5–10 health professionals will explore feasibility, fidelity, and acceptability of the study. Data from this pilot will be used to assess feasibility of, and estimate parameters to calculate the sample size for an effectiveness trial. Full ethical approval has been granted (Wales Research Ethics Committee 3 reference number 16/WA/0353).DiscussionPLACEMENT will be the first study to explore the feasibility of running an effectiveness trial on PNC usage for postoperative pain in amputees, and provide parameters to calculate the appropriate sample size for this study.Trial registrationISRCTN.com, ISRCTN85710690. Registered on 21 October 2016.European Clinical Trials Database (EudraCT), 2016-003544-37. Registered on 24 August 2016.

Successful use pulsed radiofrequency spinal ganglions in patient with chronic stump pain. Case report

About 50-85% of patients suffer from stump and phantom pain after amputations. These chronic pain conditions are often debilitating and result in disability, sleep and psychosocial disorders, impairment of day-work and the substantial decline in the quality of life. In some patients pharmaceutical therapy may fail to bring satisfactory pain relief or follows severe adverse events. Operations such as rhizotomy, cordotomy and stump revision are often unsuccessful in treating post-amputation chronic pain. The solitary case reports about the using of minimally invasive technique of pulsed radiofrequency (PRF) for treatment of chronic stump and phantom pain have been published only. Our current clinical observation is about successful using of the PRF spinal ganglions in patient with chronic pharmaceutical-resistant post-amputation stump pain.

High-frequency peripheral electric nerve block to treat postamputation pain

Postamputation residual limb pain is often a disabling chronic pain condition. Oftentimes, patients are left with a chronic stump pain that is refractory to current pain management modalities, such as medications, peripheral nerve blocks or denervation techniques, nerve or spinal cord stimulation, or surgical revision. Using high-frequency alternating current via a peripheral nerve cuff electrode creates a complete depolarizing nerve block, which blocks painful or unwanted nerve transmission of pain signals; the cuff is placed proximal to the neuroma at the end of the severed nerve. This article demonstrates the technique of placing a peripheral nerve cuff surgically around the peripheral nerves of patients who suffer from debilitating stump pain with lower extremity amputations. In total, 10 patients were implanted with the nerve cuff with 9 patients receiving in-clinic testing and 7 patients progressing onto long-term home-use. The average numerical rating scale pain scale for tested patients decreased from 5.7-1.4 (out of 10) after high-frequency alternating current electrical nerve block therapy with 85% of all testing sessions yielding a >50% pain reduction. Additionally, patients noted improved ability to maintain activity of daily living, as well as noted improvement of quality of life scores, and a reduction in overall pain medication use. Although the study’s initial endpoint was 90 days, we have continued to follow our implanted patients who have now reached 36 months.

Ultrasound Demonstration of Vascularity Changes With Changes in Pain Perception in a Stump Neuroma

Pain in the residual limb after an amputation has posed many challenges in treatment. Ultrasound (US) imaging has helped in the visualization of neuroma and its selective targeting for interventions. A 58-year-old man presented to the pain clinic with chronic stump pain after a below knee amputation during the Vietnam war. After multiple similar steroid injections around the area of pain in the following months, we decided to use the US to better target the stump neuroma. Color flow Doppler showed extensive vascularity around the posterior aspect of the neuroma where there was scar tissue. During a follow-up visit for intra-articular steroid injection to the L5-S1 left lumbar facet for coincidental lumbar facet arthropathy, an US scan of the stump neuroma with color flow Doppler was performed out of curiosity. Multiple US views of the neuroma with color flow Doppler was performed and all showed a significant decrease in vascularity. Similar absence of vascularity was noted after a spinal cord stimulator placement. This is a case report of US demonstration of increased vascularity in a stump neuroma coinciding with the patient's pain. This serendipitous demonstration makes the need for US visualization useful in the evaluation of neuroma. It is also useful to use US guidance to avoid the vascular structures when testing the beneficial response to various medications. Larger randomized controlled studies are needed to further correlate the US demonstration of vascularity and neuroma pain.

Immediate response of phantom limb pain to calcitonin

We applied calcitonin in a single-shot treatment to 10 patients with persistent or acute phantom limb pain. Nine patients responded immediately and noted a clear analgesic effect. In contrast a group of non-phantom pain patients of heterogeneous composition did not respond at all, except 1 patient with chronic stump pain. We believe that this could be an exciting new approach to the treatment of phantom limb pain.