Incidence Of Phantom Limb Pain Research Articles

Charcot Neuroarthropathy Is Associated With Higher Rates of Phantom Limb After Lower Extremity Amputation.

The incidence of phantom limb pain in patients with Charcot neuroarthropathy who undergo major amputation is not well described. The purpose of this study was to determine whether patients with Charcot neuroarthropathy and diabetes who underwent either a below-knee amputation (BKA) or above-knee amputation (AKA) had an increased rate of phantom limb pain compared with those with a diagnosis of diabetes alone. Using international classification of disease (ICD) and common procedural terminology (CPT) codes, the TriNetX research database identified 10 239 patients who underwent BKA and 6122 who underwent AKA between 2012 and 2022. Diabetic patients with and without Charcot neuroarthropathy were compared in terms of demographics and relative risk of developing phantom limb pain after AKA or BKA. Age, sex, ethnicity, and race did not significantly differ between groups. Charcot neuroarthropathy was associated with significantly increased risk of phantom limb pain following both BKA (risk ratio [RR]: 1.2, 95% confidence interval [CI]: 1.1-1.3, P < .01) and AKA (RR: 1.6, 95% CI: 1.2-2.3, P < .0068). Our results indicate that patients with a coexisting diagnosis of Charcot neuroarthropathy who require BKA or AKA may have an increased risk of developing phantom limb pain. Level III.

Phantom Limb Pain and Painful Neuroma After Dysvascular Lower-Extremity Amputation: A Systematic Review and Meta-Analysis.

Phantom limb pain (PLP) and symptomatic neuroma can be debilitating and significantly impact the quality of life of amputees. However, the prevalence of PLP and symptomatic neuromas in patients following dysvascular lower limb amputation (LLA) has not been reliably established. This systematic review and meta-analysis evaluates the prevalence and incidence of phantom limb pain and symptomatic neuroma after dysvascular LLA. Four databases (Embase, MEDLINE, Cochrane Central, and Web of Science) were searched on October 5th, 2022. Prospective or retrospective observational cohort studies or cross-sectional studies reporting either the prevalence or incidence of phantom limb pain and/or symptomatic neuroma following dysvascular LLA were identified. Two reviewers independently conducted the screening, data extraction, and the risk of bias assessment according to the PRISMA guidelines. To estimate the prevalence of phantom limb pain, a meta-analysis using a random effects model was performed. Twelve articles were included in the quantitative analysis, including 1924 amputees. A meta-analysis demonstrated that 69% of patients after dysvascular LLA experience phantom limb pain (95% CI 53-86%). The reported pain intensity on a scale from 0-10 in LLA patients ranged between 2.3 ± 1.4 and 5.5 ± .7. A single study reported an incidence of symptomatic neuroma following dysvascular LLA of 5%. This meta-analysis demonstrates the high prevalence of phantom limb pain after dysvascular LLA. Given the often prolonged and disabling nature of neuropathic pain and the difficulties managing it, more consideration needs to be given to strategies to prevent it at the time of amputation.

Pre-operative sciatic nerve block vs postoperative surgeon-placed perineural stump catheter for prevention of phantom limb pain after below-knee amputation.

Pre-operative sciatic nerve block vs postoperative surgeon-placed perineural stump catheter for prevention of phantom limb pain after below-knee amputation.

Assessment of efficiency of mirror therapy in preventing phantom limb pain in patients undergoing below-knee amputation surgery-a randomized clinical trial.

Phantom limb pain (PLP) is a major cause of physical limitation and disability accounting for about 85% of amputated patients. Mirror therapy is used as a therapeutic modality for patients with phantom limb pain. Primary objective was to study the incidence of PLP at 6months following below-knee amputation between the mirror therapy group and control group. Patients posted for below-knee amputation surgery were randomized into two groups. Patients allocated to group M received mirror therapy in post-operative period. Two sessions of therapy were given per day for 7days and each session lasted for 20min. Patients who developed pain from the missing portion of the amputated limb were considered to have PLP. All patients were followed up for six months and the time of occurrence of PLP and intensity of the pain were recorded among other demographic factors. A total of 120 patients completed the study after recruitment. The demographic parameters were comparable between the two groups. Overall incidence of phantom limb pain was significantly higher in the control group (Group C) when compared to the mirror therapy (Group M) group [Group M = 7 (11.7%) vs Group C = 17 (28.3%); p = 0.022]. Intensity of PLP measured on the Numerical Rating Scale (NRS) was significantly lower at 3months in Group M compared to Group C among patients who developed PLP [NRS-median (Inter quartile range): Group M 5 (4,5) vs Group C 6 (5,6); p 0.001]. Mirror therapy reduced the incidence of phantom limb pain when administered pre-emptively in patients undergoing amputation surgeries. The severity of the pain was also found to be lower at 3months in patients who received pre-emptive mirror therapy. This prospective study was registered in the clinical trial registry of India. CTRI/2020/07/026488.

Effect of a continuous perineural levobupivacaine infusion on pain after major lower limb amputation: a randomised double-blind placebo-controlled trial

ObjectivesRandomised controlled trial of the effect of a perineural infusion of levobupivacaine on moderate/severe phantom limb pain 6 months after major lower limb amputation.SettingSingle-centre, UK university hospital.ParticipantsNinety patients undergoing above-knee...

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.

Prevalence and incidence of phantom limb pain, phantom limb sensations and telescoping in amputees: A systematic rapid review.

This systematic, rapid review aimed to critically appraise and synthesize the recent literature (2014-2019) evaluating the incidence and prevalence of post-amputation phantom limb pain (PLP) and sensation (PLS). Five databases (Medline, Embase, Emcare, PsychInfo, Web of Science) and Google Scholar were searched, with two independent reviewers completing eligibility screening, risk of bias assessment and data extraction. The search identified 1,350 studies with 12 cross-sectional and 3 prospective studies included. Studies evaluated traumatic (n=5), atraumatic (n=4), and combined traumatic/atraumatic (n=6) amputee populations, ranging from 1month to 33years post-amputation. Study heterogeneity prevented data pooling. The majority of studies had a high risk of bias, primarily due to limited generalizability. Three studies evaluated PLP incidence, ranging from 2.2% (atraumatic; 1month) to 41% (combined; 3months) and 82% (combined; 12months). Only one study evaluated PLS/telescoping incidence. Across contrasting populations, PLP point prevalence was between 6.7%-88.1%, 1 to 3-month period prevalence was between 49%-93.5%, and lifetime prevalence was high at 76%-87%. Point prevalence of PLS was 32.4%-90%, period prevalence was 65% (1month) and 56.9% (3months), and lifetime prevalence was 87%. Telescoping was less prevalent, highest among traumatic amputees (24.6%) within a 1-month prevalence period. Variations in population type (e.g. amputation characteristics) and incidence and prevalence measures likely influence the large variability seen here. This review found that lifetime prevalence was the highest, with most individuals experiencing some type of phantom phenomena at some point post-amputation. This systematic rapid review provides a reference for clinicians to make informed prognosis estimates of phantom phenomena for patients undergoing amputation. Results show that most amputees will experience phantom limb pain (PLP) and phantom limb sensations (PLS): high PLP incidence 1-year post-amputation (82%); high lifetime prevalence for PLP (76%-87%) and PLS (87%). Approximately 25% of amputees will experience telescoping. Consideration of individual patient characteristics (cause, amputation site, pre-amputation pain) is pertinent given their likely contribution to incidence/prevalence of phantom phenomena.

Perioperative measures for prevention of phantom pain: an evidence-based approach to risk reduction

Prevention of phantom limb pain is one of the biggest and still largely unsolved challenges in perioperative medicine. Despite many study efforts and optimization of postoperative pain treatment over the last 30years, asignificant reduction in the incidence of phantom limb pain has not been achieved. Current studies have also shown that at least 50% of patients develop phantom pain after 6months. A possible approach could be to combine multiple synergistic interventions and implement them as aperioperative phantom pain management strategy bundle. In addition to regional anesthesia, NMDA antagonists, gabapentinoids, antidepressants and systemic lidocaine could play arelevant role. The aim of this pharmacological intervention was the modification of the pathophysiological changes in peripheral nerves and in the central nervous system after amputation.

Effects of different anesthetic techniques on the incidence of phantom limb pain after limb amputation: a population-based retrospective cohort study.

BackgroundGeneral anesthesia (GA) has been considered the anesthetic technique which most frequent leads to phantom limb pain (PLP) after a limb amputation. However, these prior reports were limited by small sample sizes. The aims of this study were to evaluate the incidence of PLP according to the various anesthetic techniques used for limb amputation and also to compare the occurrence of PLP according to amputation etiology using the Korean Health Insurance Review and Assessment Service for large-scale demographic information.MethodsThe claims of patients who underwent limb amputation were reviewed by analyzing the codes used to classify standardized medical behaviors. The patients were categorized into three groups—GA, neuraxial anesthesia (NA), and peripheral nerve block (PNB)—in accordance with the anesthetic technique. The recorded diagnosis was confirmed using the diagnostic codes for PLP registered within one year after the limb amputation.ResultsFinally, 7,613 individuals were analyzed. According to the recorded diagnoses, 362 patients (4.8%) developed PLP after amputation. Among the 2,992 patients exposed to GA, 191 (6.4%) were diagnosed with PLP, whereas 121 (4.3%) of the 2,840 patients anesthetized with NA, and 50 (2.8%) of the 1,781 patients anesthetized under PNB developed PLP. The relative risks were 0.67 (95% confidence interval [CI], 0.53–0.84; P < 0.001) for NA and 0.43 (95% CI, 0.32–0.59; P < 0.001) for PNB.ConclusionsIn this retrospective cohort study, using large-scale population-based databases, the incidence rates of PLP after limb amputations were, in the order of frequency, GA, NA, and PNB.

Pain management in new amputees: a nursing perspective.

Phantom limb pain (PLP) is a widespread and challenging neuropathic pain problem, occurring after both surgical and traumatic amputation of a limb. It may occur immediately after surgery or some months later, however, most cases it presents within the first 7 postoperative days. Patients report a range of pain characteristics in the absent limb, including burning, cramping, tingling and electric shock sensation. The incidence of PLP has been reported to be between 50% and 85% following amputation. Its management is notoriously difficult, with no clear consensus on optimal treatment. It is often resistant to classic balanced analgesia and typical neuropathic pain medications. Taking into account these issues, the authors aimed to improve the management of patients undergoing amputation at their institution, by ensuring accurate and holistic assessment, the selection of suitable interventions through critical analysis and synthesis of available evidence, and the appropriate evaluation and adaptation of treatment plans, to ensure patients achieved their individualised goals.

Factors affecting phantom limb pain in patients undergoing amputation: retrospective study.

The efficacy of preemptive analgesia for prevention of phantom limb pain has been controversial although pain management before amputation is empirically important. The aim of this study was to determine the associated factors with perioperative phantom limb pain. Following approval by the Medical Ethics Committee in our university, medical records of patients receiving limb amputation surgery in our hospital between April 1, 2013 and October 31, 2017 were retrospectively reviewed. To determine which pre-operative factors could affect the development of phantom limb pain, we performed univariate analysis to find candidate factors (p < 0.05), and then did multivariate regression analysis. Incidence of phantom limb pain was 50% (22/44). There was no difference between the groups in types of anesthesia and post-operative pain levels. The multivariate logistic regression including possible confounders suggested that diabetes mellitus and uncontrollable preoperative pain with non-steroidal anti-inflammatory drugs (NSAIDs) were independently associated with the development of phantom limb pain (Adjusted odds ratio (OR) 0.238 [95% confidential interval (CI) 0.0643-0.883], p = 0.032, Adjusted OR 6.360 [95% CI 1.280-31.50], p = 0.024, respectively). The types of anesthesia and the degree of postoperative pain were not related to the development of phantom limb pain. The present data suggest that insufficient preoperative pain with NSAIDs and diabetes mellitus would give an impact on the development of phantom limb pain.

Phantom limb pain: a review of pharmacological management.

Phantom limb pain (PLP) is a complex condition resulting in pain in the missing limb affecting 60-80% amputees. Increasing number of patients are undergoing amputations. Approximately 1 per every 1000 people in the United Kingdom is an amputee. Incidence of PLP can be as high as 80% following amputation. PLP can be severe and difficult to treat. A range of pharmacological interventions exist yet little is known about them in respect to PLP. This article will address the effectiveness of both single pharmacological, therapy as well as drug combination therapy. We reviewed all literature looking at the evidence for the efficacy of both single and combined pharmacological therapy in the management of phantom limb pain. Not all commonly prescribed analgesic agents have been studied in the use of PLP and in these cases, the evidence of their efficacy in neuropathic pain was reviewed. It is difficult to draw definitive conclusions on the pharmacological management of PLP based on current available evidence. Most trials involved small cohorts and were not specific to the PLP. The trials which looked specifically at the PLP population gave conflicting results. Only the N-methyl-d-aspartate (NMDA) receptor antagonist class demonstrated consistent positive results. Most notably ketamine did produce a reduction in pressure pain thresholds and pain windup associated with PLP, although the numbers in these studies remain small. This benefit was not demonstrated across all NMDA receptor antagonists. Combination therapy has demonstrated effectiveness in previous studies for neuropathic pain but this has never been tested specifically against a PLP cohort. Therefore, combination treatment of agents with proven efficacy in PLP such as opioid and gabapentin deserves a closer examination in a controlled study against a placebo as well as single drug therapy.

Effect of preamputation lumbar sympathectomy on stump pain of lower limbs in patients of thromboangitis obliterans (Buerger′s disease)

Background: Thromboangiitis obliterans (Buerger's disease) is a nonatherosclerotic inflammatory disorder primarily involving small and medium sized vessels, mainly arteries of the extremities. As the disease progresses, it could cause gangrene and amputation of limbs, eventually leading to persistent pain and disability. Settings and Design: A prospective, randomized, single-blinded comparative study. Materials and Methods: Fifty patients of Buerger's disease planned for amputation below the knee were divided randomly into two equal groups of 25 each. Patients of both groups were advised to stop smoking. Lumbar (chemical) sympathectomy was carried out in patients of study group 1 week before amputation. The severity of postamputation stump pain was assessed using visual analog scale (VAS) and requirement of analgesics on weekly basis for 12 weeks. The incidence of phantom limb pain and overall quality of life was also evaluated using Short Form-36 (SF-36) scale. Results: VASs and requirement of analgesics were significantly less in patients who underwent lumbar sympathectomy as compared to patients of control group. The quality of life as reflected by SF-36 score was also significantly better in the study group. However, there was no significant difference in the incidence of phantom limb pain in the two groups. No major complications were reported following lumbar sympathectomy. Conclusions: Lumbar sympathectomy significantly decreases the severity of postamputation stump pain of lower limbs and thus improves the overall quality of life in patients of Buerger's disease.

Incidence of phantom limb phenomena after lower limb amputations in a Singapore tertiary hospital

Phantom limb sensations (PLS), phantom limb pain (PLP) and stump pain (SP) are well-recognised postamputation phenomena. However, there is a dearth of related epidemiological data in Asian populations. This study was conducted to fill the information gap. Telephone interviews were conducted with patients who underwent lower limb amputations at a tertiary hospital in Singapore. Information was obtained on phantom limb characteristics, perioperative pain and functional assessment. A total of 159 patients underwent amputations over a 31-month period. At the time of the interview, 47 patients had died and 66 were contactable, of whom 49 patients were interviewed. Of these, 31 (63%) patients experienced PLS. 22 patients had postoperative pain, with 9 having both PLP and SP, 3 having PLP alone and 10 having SP alone. Among the 12 patients with PLP, at least 6 (50%) experienced constant or daily pain and 7 (58%) scored their pain as moderate-to-severe. Among those with PLP and/or SP (n = 22), 5 were distressed by the pain, 11 were on analgesics and 3 received medical follow-up. 7 (32%) patients reported functional limitations secondary to PLP or SP. Altogether, 28 (57%) patients were wheelchair or bed bound. The incidence of PLP was 25% in our cohort. Although this is lower than that reported in other studies, it remains significant, as some patients suffered moderate-to-severe pain. The difference in incidence may be due to differences in the ethnic composition and/or indications for amputation in our group. Follow-up and care could improve the outcomes in these patients.

Phantom Limb Pain in Young Cancer-related Amputees

This study in children and young adults having cancer-related amputation aimed to examine the incidence of phantom limb pain (PLP) in the first year after amputation and also the proportion of patients who had preamputation pain. A retrospective review of medical records was undertaken. The proportion of patients with PLP was reported. Fisher exact test was used to examine the association between PLP and the presence of preamputation pain and between PLP and age (≤ 18 y vs. >18 y). Twenty-six amputations were performed on 25 patients. During the year after amputation, 76% of patients had experienced PLP at some time. After 1 year, though, only 10% still had PLP. Preamputation pain was present in 64% of patients. Although both of our patients with PLP at 1 year were young adults (older than or equal to 18 y) and both had preamputation pain, we found no statistically significant associations between age or the presence of preamputation pain with PLP. PLP after cancer-related amputation in children and young adults seems to be common but generally short lived in most patients.

21. Phantom Pain

Phantom pain is pain caused by elimination or interruption of sensory nerve impulses by destroying or injuring the sensory nerve fibers after amputation or deafferentation. The reported incidence of phantom limb pain after trauma, injury or peripheral vascular diseases is 60% to 80%. Over half the patients with phantom pain have stump pain as well. Phantom pain can also occur in other parts of the body; it has been described after mastectomies and enucleation of the eye. Most patients with phantom pain have intermittent pain, with intervals that range from 1 day to several weeks. Even intervals of over a year have been reported. The pain often presents itself in the form of attacks that vary in duration from a few seconds to minutes or hours. In most cases, the pain is experienced distally in the missing limb, in places with the most extensive innervation density and cortical representation. Although there are still many questions as to the underlying mechanisms, peripheral as well as central neuronal mechanisms seem to be involved. Conservative therapy consists of drug treatment with amitriptyline, tramadol, carbamazepine, ketamine, or morphine. Based on the available evidence some effect may be expected from drug treatment. When conservative treatment fails, pulsed radiofrequency treatment of the stump neuroma or of the spinal ganglion (DRG) or spinal cord stimulation could be considered (evidence score 0). These treatments should only be applied in a study design.

Is preoperative opioid utilization an important factor in predicting phantom limb pain?

To the Editor, I was interested in reading the article by Roullet et al. published in the Journal. In a patient group suffering primarily from peripheral vascular disease, the authors observed that the incidence of phantom limb pain was higher in patients treated preoperatively with opioids. The study raises some questions that merit consideration. The study assessed the postoperative morphine requirements in patients who were receiving opioids preoperatively in the context of phantom limb pain. However, the patients were included in the study regardless of the reason for analgesic consumption. The knowledge that chronic opioid utilization in such patients is associated with tolerance and hyperalgesia and the need for increased postoperative opioids has been validated by other studies and described in another article in the same issue of the Journal. However, that knowledge alone cannot be the reason to infer that preoperative opioid consumption increases the risk of phantom limb pain and hence an increased need for postoperative opioids. Increased preamputation pain is also known to be a significant factor in determining the likelihood of phantom pain. This aspect was also observed in the same study and may have been the primary reason for the increased incidence of phantom pain in this cohort. Ketamine has been used effectively for phantom limb pain. Although ketamine was used in this study, its effect on the incidence of phantom limb pain was not evaluated in either group. One final issue to consider is whether sciatic nerve blockade alone was adequate to achieve complete sensory blockade during amputation. Wilson et al. achieved better results than observed in other studies employing regional analgesia and claim this difference was due to the ‘‘dense block of sensory input’’ by combining both spinal and epidural analgesia. An adequate reduction of the massively increased sensory input that occurs during amputation requires a block dense enough to prevent spinal or supraspinal responses. It has also been shown that local anesthetic administered via the epidural route does not abolish the peripheral sensory input completely. Sciatic nerve block may not be able to block all of the painful and non-painful impulses elicited during amputation. Functional magnetic resonance imaging has shown that electrical activity well below the threshold required to activate spinal responses may evoke neuronal impulses in the brainstem.

The vexing problem of post-amputation pain: What is the optimal perioperative pain management for below-knee amputation?

Phantom pain, defined as intense throbbing or burning pain in the missing distal limb, is a common affliction after amputation. First described in 1872 by Ambroise Pare, the phenomenon is a common occurrence in 60–80% of amputees. Although some reports suggest abatement of phantom pain after a few years, others affirm it is longlasting. In addition to phantom pain, the unfortunate patient may also experience pain in the residual leg (stump pain) for reasons such as osteomyelitis, excessive scar tissue, or neuroma formation. In numerous pharmacotherapy trials, opioids, ketamine, anticonvulsants, and tricyclic antidepressants have provided only inconsistent relief. Intense pre-amputation pain is likely to be associated with the development of long-term phantom pain. In the 1970s, this observation led researchers to hypothesize that pain created a permanent imprint in the dorsal horn and in the pain-processing regions of the central nervous system. A number of investigations were undertaken to reduce afferent input to the dorsal horn preoperatively and thus lessen the memory of pain in the central nervous system. The results of these trials, summarized below, have taught us a great deal about pain processing and have advanced knowledge in the field of regional analgesia. Nevertheless, pre-emptive analgesia yielded inconsistent results and does not appear to have made significant headway in reducing the vexing problem of long-term post-amputation pain. The conclusion, based on new insights from animal and neuroimaging studies into the mechanism of phantom pain, is that reorganization in the somatosensory cortex is at least as important as events in the periphery. Reorganization may also occur at the dorsal horn and at the thalamic level and may be influenced by peripheral input. The mechanism of phantom limb pain remains obscure. It has the clinical characteristics of a neuropathic pain syndrome with a complex interplay between peripheral and central components, and it displays considerable variability among individuals. For example, when brachial plexus anesthesia was administered to prevent peripheral input from the amputation stump, both phantom pain and cortical reorganization were eliminated in 50% of upper-limb amputees, whereas the phantom pain remained unchanged in the remaining 50% of subjects. In order to attenuate the undesirable cortical reorganization, both sensory stimulation therapy and centrallyacting drugs, such as ketamine and gabapentin, have been proposed as preemptive therapies that could be used in the perioperative period for patients identified at high risk for phantom pain. What criteria should we use to determine those at highest risk? The observational study in this issue of the Journal is the first to suggest that pre-amputation use of prescribed opioids may be a risk factor for developing phantom pain. Since a landmark clinical trial published in 1988 by Bach et al., anesthesiologists have been interested in the role of perioperative neuraxial blockade as a pre-emptive treatment for phantom pain. Patients with vascular disease scheduled for amputation were randomized to receive either epidural bupivacaine for three days preand postprocedure or an epidural with placebo infusion plus conventional morphine analgesia postoperatively. After 6 months, the incidence of phantom limb pain was significantly lower in the epidural-treated group than in the morphine group. In 1994, this finding was confirmed in another randomized trial where an epidural was P. K. Morley-Forster, MD (&) Department of Anesthesia and Perioperative Medicine, St. Joseph’s Health Centre, University of Western Ontario, 268 Grosvenor St., London, ON N6A 4V2, Canada e-mail: pat.morley-forster@sjhc.london.on.ca

Primary care incidence and treatment of four neuropathic pain conditions: a descriptive study, 2002-2005.

BackgroundBetween 1992 and 2001 the UK general practice incidence of post-herpetic neuralgia and trigeminal neuralgia declined, whilst the incidence of painful diabetic neuropathy increased. The most common first line treatments were compound analgesics. As therapeutic options have subsequently changed, this study presents updated data on incidence and prescribing patterns in neuropathic pain.MethodsA descriptive analysis of the epidemiology and prescription treatment at diagnosis of incident post-herpetic neuralgia (n = 1,923); trigeminal neuralgia (1,862); phantom limb pain (57) and painful diabetic neuropathy (1,444) using computerised UK general practice records (THIN): May 2002 to July 2005.ResultsPrimary care incidences per 100,000 person years observation of 28 (95% confidence interval (CI) 27–30) for post-herpetic neuralgia, 27 (95%CI 26–29) for trigeminal neuralgia, 0.8 (95%CI 0.6–1.1) for phantom limb pain and 21 (95%CI 20–22) for painful diabetic neuropathy are reported. The most common initial treatments were tricyclic antidepressants (post-herpetic neuralgia) or antiepileptics (trigeminal neuralgia and painful diabetic neuropathy) and opioid analgesics (phantom limb pain). The mean number of changes before a stable drug regimen was 1.2 to 1.5 for trigeminal neuralgia, painful diabetic neuropathy and post-herpetic neuralgia, and 2.4 for phantom limb pain.ConclusionThe incidence of phantom limb pain and post-herpetic neuralgia are decreasing whilst painful diabetic neuropathy plateaued and trigeminal neuralgia remained constant. Despite more frequent use of antidepressants and antiepileptics for first line treatment, as opposed to conventional non-opioid analgesics, changes to therapy are common before a stable regimen is reached.

Incidence and Management of Phantom Limb Pain According to World Health Organization Analgesic Ladder in Amputees of Malignant Origin

Antidepressants and anticonvulsants are currently considered to be the drug treatment of choice for neuropathic pain. Opioids are effective in relieving neuropathic pain, including phantom pain in the early postoperative course. The present study of 42 cancer patients with limb amputation was conducted to determine the incidence of phantom limb pain and phantom sensation and to test the utility of the World Health Organization 3-step analgesic ladder in phantom limb pain management. Patients were monitored monthly for the first 2 months postoperatively and every 2 months thereafter for 2 years. The World Health Organization analgesic ladder was followed for pain management. The patients complaining of phantom sensation, phantom pain, and stump pain decreased from 69%, 60%, and 31%, respectively, at 1 month to 32%, 32%, and 5%, at the end of 2 years with the addition of opioids. The World Health Organization analgesic ladder played significant role in phantom limb pain management.