|Year : 2016 | Volume
| Issue : 2 | Page : 132-137
Effect of preamputation lumbar sympathectomy on stump pain of lower limbs in patients of thromboangitis obliterans (Buerger's disease)
Hammad Usmani1, Muazzam Hasan1, Muhammad Rehan Nazar Alam1, Syed Hasan Harris2, Tariq Mansoor2, Abdul Quadir1
1 Department of Anaesthesiology and Critical Care, Jawaharlal Nehru Medical College, Aligarh, Uttar Pradesh, India
2 Department of General Surgery, Jawaharlal Nehru Medical College, Aligarh, Uttar Pradesh, India
|Date of Web Publication||18-Jul-2016|
Department of Anaesthesiology and Critical Care, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh - 202 002, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
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.
Keywords: Lumbar sympathectomy, phantom limb pain, postamputation pain, stump pain, thromboangiitis obliterans
|How to cite this article:|
Usmani H, Hasan M, Alam MR, Harris SH, Mansoor T, Quadir A. Effect of preamputation lumbar sympathectomy on stump pain of lower limbs in patients of thromboangitis obliterans (Buerger's disease). Indian J Pain 2016;30:132-7
|How to cite this URL:|
Usmani H, Hasan M, Alam MR, Harris SH, Mansoor T, Quadir A. Effect of preamputation lumbar sympathectomy on stump pain of lower limbs in patients of thromboangitis obliterans (Buerger's disease). Indian J Pain [serial online] 2016 [cited 2020 May 30];30:132-7. Available from: http://www.indianjpain.org/text.asp?2016/30/2/132/186471
| Introduction|| |
Thromboangiitis obliterans (Buerger's disease) is a nonatherosclerotic inflammatory disorder primarily involving small and medium size vessels, mainly arteries of the extremities. The prevalence of this disease is very high, especially in India (45-63%) due to widespread habit of smoking and tobacco chewing in youths.  As the disease progresses; it could cause gangrene and amputation of limbs, eventually leading to persistent pain and disability.
A survey conducted at Mayo Clinic, USA, reported that the risk of major amputation in patients of Buerger's disease was 11% at 5 years, 21% at 10 years, and 23% at 20 years of tobacco exposure.  Postamputation pain further adds to poor quality of life.
Residual limb pain or stump pain is an acute nociceptive pain that is seen in early postamputation period and usually resolves as the wound heals. Persistent postamputation pain could be a result of abnormal triggering of nociceptors by unusual sympathetic discharges due to autonomic nervous system dysfunction. The studies also suggested that the incidence of pain is related to decreased blood flow to the residual limb. ,,
Persistent stump pain may be difficult to treat, and it often interferes with prosthetic use and rehabilitation. Persistent stump pain may be a risk factor for the development of phantom limb pain. Evidence indicate that the annual incidence of residual or stump pain may vary from 6% to 76% of amputees while the incidence of the phantom limb was reported to be 50-80% in patients of peripheral vascular disease. ,
Lumbar sympathectomy has been used for decades due to its proven beneficial effect on improving peripheral limb circulation and oxygenation in patients of peripheral vascular disease. ,, However, to the best of our knowledge, till date, none of the studies have evaluated the effects of preamputation lumbar sympathectomy on residual limb or stump pain in patients of Buerger's disease.
This study was conducted to evaluate the effects of preamputation lumbar sympathetic block, with respect to severity of residual limb pain of lower limbs and overall improvement in the quality of life of the patients of Buerger's disease.
| Materials and Methods|| |
Following due approval for conduct of the study from board of studies, the Department of Anesthesiology and Ethical Committee of Jawaharlal Nehru Medical College and Hospital, Aligarh Muslim University, Aligarh; fifty diagnosed cases of Buerger's disease with severe critical limb ischemic pain, planned for below knee amputation were enrolled for the study over a period of 1½ years. After completely explaining the procedure and written informed consent, patients were divided into two groups using computer-generated randomization technique; Group I (control group) and Group II (study group) each having 25 patients.
Residual limb pain was defined as pain in the residual limb postamputation. Phantom limb pain was defined as painful sensations perceived in the amputated/missing body part.
Exclusion criteria included patients aged <18 years or more than 35 years, patients receiving anticoagulants, aspirin-containing nonsteroidal anti-inflammatory drugs, presence of hypersensitivity to local anesthetic agents, coagulopathies or prolonged bleeding time, autoimmune disease, diabetes mellitus, hyperlipidemia, ongoing septicemia as demonstrated by elevated white blood cells or infection overlying the entry area, uncontrolled psychiatric disorder or major depression, or other severe medical illness. Patients in both the groups were advised to stop smoking or tobacco chewing. Lumbar sympathectomy was carried out in patients of study group 1 week before amputation. Under all aseptic conditions, correct placement of needle was done under fluoroscopic guidance using radiopaque contrast. Injection phenol 8%, 2 ml was given cautiously in small aliquots at each L2 and L3 level into the region of lumbar sympathetic chain [Figure 1], with repeated aspirations to rule out the presence of any blood or cerebrospinal fluid. Patients were also asked for any neurological deficit during and postprocedure.
|Figure 1: Correct placement of needle seen in lateral view (a) and oblique view (b); spread of radioopaque contrast (c)|
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The difference in skin temperature before and after the procedure ≥2°C was regarded as a successful block.  After the procedure, all patients were monitored for any complications such as local pain, neurological deficits of limbs, headache, nausea and vomiting for 4 h in the recovery room. Patients in both the groups were advised to take a preparation of tramadol 37.5 mg and paracetamol 325 mg orally on a demand basis for breakthrough pain with a maximum of 6 tablets/day. Patients were advised to keep a record of number of tablets taken on weekly basis and maintained the same in a pain diary.
Patients of both groups were independently observed by a blinded observer for 12 weeks. The severity of stump pain was assessed by visual analog scale (VAS) of 0-10, where 0 = no pain and 10 = worst imaginable pain at 1 st , 3 rd , 6 th , and 12 th weeks. If however the patient did not turned up for any of the visits, the pain was assessed by telephonic communications. The incidence of phantom limb pain was also noted during the study period.
The quality of life of the patients was assessed using Short Form-36 scale (SF-36S) just before sympathectomy and then at 12 th week postamputation. Any complication occurring during or after the procedure was also recorded.
A sample size of 25 in each group was calculated on the basis of primary outcome that is the decrease in the VAS. The underlying hypothesis was assumed to be a "Continuous outcome superiority trial." A pilot study was done with ten patients in each group, and VAS was measured after 1 week after the intervention. The mean outcome (VAS) was found to be 9.4 and 8.1 in control and study group, respectively with a standard deviation of 1.5.
The significance level was taken as 5%, and power was taken as 80%. A minimum required sample size per group was calculated to be 21 and the minimum total required sample size was calculated to be 42. 
A total of 50 patients, 25 in each group were taken to avoid attritions, nonconsent, or drop outs. Statistical analysis of data was done with the help of appropriate statistical tests using the Statistical Package for the Social Sciences (SPSS) version 16 (SPSS Inc. Released 2007, SPSS for Windows, version 16.0. Chicago, Illinois, USA). The results were presented in number, percentage, mean, and standard deviation as appropriate. P < 0.05 was considered statistically significant.
| Results|| |
All patients in the study group underwent successful lumbar sympathectomy as shown by the rise in temperature of respective limb by ≥2°C. The demographic data and other preoperative parameters, i.e., number of smoking years, preamputation VAS, and SF-36 scores were similar in both groups [Table 1]. All the patients studied were males.
Preamputation lumbar sympathectomy significantly reduced the severity of stump pain which was reflected by decrease in VASs at 1 st , 3 rd , 6 th , and 12 th week in the study group as compared to patients of control group. However, the incidence of phantom limb pain was similar in both the groups [Table 2]. Consumption of analgesics was significantly reduced in patients after sympathectomy as compared to patients of control group [Table 3]. No major complication occurred in any of the patients of study group except one patient who had transient fall in blood pressure after sympathectomy, which was managed with intravenous fluid and vasopressors.
|Table 2: Visual analog scale scores at different time intervals and incidence of phantom limb pain in the two groups |
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The comparison of SF-36 scores between the study and control group at 12 th week after amputation showed that among eight different variables of SF-36 score, all except those related to physical functioning and social functioning had significantly better scores in patients of study group [Table 4]. Within the study group itself, SF-36 scores at 12 th week postamputation were significantly better when compared to presympathectomy period [Table 5].
|Table 4: SF - 36 scores of the two groups at the end of 12th week postamputation |
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|Table 5: SF - 36 scores of the patients in the study group before sympathectomy and at 12th week postamputation |
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| Discussion|| |
Limb amputation causes immense physical and mental trauma, often leading to serious psychosocial disturbances and poor quality of life. Persistent pain further adds to the sufferings of these patients. Various methods have been tried and proposed to decrease this traumatic experience and improve the quality of life in such patients. 
Lumbar sympathectomy has been utilized to relieve intractable pain and healing of ischemic ulcers of the lower limbs in the patients of thromboangiitis obliterans (Buerger's disease). ,,, However, the role of preamputation lumbar sympathetic block in decreasing postamputation pain in lower limbs has not been highlighted in such patients. This prospective, randomized, single-blinded study was conducted to evaluate the effect of preamputation lumbar sympathectomy on postamputation stump pain and quality of life in patients of Buerger's disease.
Stump pain is an acute nociceptive pain, localized to the stump and is seen in early postamputation period. It usually subsides within the period of postsurgical wound healing. When stump pain is not controlled timely, it may become persistent and often interferes with quality of life and rehabilitation.  Persistent stump pain may contribute in the development of phantom limb pain among amputees.
Various spinal and supraspinal mechanisms have been implicated in the causation of postamputation pain. The increased afferent discharges from peripheral neuromas and dorsal root ganglionic cells might result into several morphological and chemical changes in the nervous system. Hyperexcitability and reorganization of the somatosensory cortex, central sensitization, and psychosocial factors could contribute in the development of postamputation pain. 
Apart from the changes in peripheral and central nervous system, the sympathetic nervous system plays a crucial role in the development of postamputation pain. Derangements involving sympathetic nervous system include abnormal sympathetic efferent-somatic afferent activity, ectopic sympathetic discharge from severed nerve endings, sympathetic sprouting in dorsal root ganglia, and increased responsiveness of injured nerves to catecholamines. , The studies have also reported that sympatholytic block abolishes neuropathic pain in amputees and pain reappears on administration of norepinephrine around the stump. ,,
The results of this study showed that patients who underwent preamputation lumbar sympathectomy had significantly better pain relief and quality of life in postamputation period. Reduction in pain severity was reflected by decreased VASs and lesser requirement of rescue analgesics in the patients of study group as compared to control group. A detailed assessment of quality of life was done using SF-36 score. The SF-36 score incorporates eight different sub-domains of patient health which includes physical functioning, social functioning, role limitations related to physical problems, role limitations related to emotional problems, mental health, vitality, bodily pain, and general health perception. There were significant improvements in most of the domains of SF-36 score in patients of study group as compared to control group in our study.
Lumbar sympathectomy interrupts sympathetic-nociceptive coupling and also has a direct neurolytic action on nociceptive fibers, thus attenuates postamputation stump pain. ,,, Researchers have demonstrated that the severity of postamputation may be inversely related to blood flow of the residual limb.  Lumbar sympathectomy also improves the blood circulation and tissue oxygenation of lower limbs; thus promotes early wound healing and prevents the development of persistent stump pain.
Preamputation pain is one of the important risk factors leading to postamputation pain.  Preamputation lumbar sympathetic block plays an important role in preventing the limb sensitization and subsequent development of stump and phantom limb pain.
Phantom limb pain is a persistent neuropathic pain that often resembles pain of the limb in preamputation period in both quality and location. , Although few studies have supported the role of sympathetic blocks in abolishing the phantom limb pain, , its effectiveness is not yet proven in well-controlled trials. We did not find any significant difference in the incidence of phantom limb pain in the two groups.
Since our study was not sufficiently powered to assess the same, we cannot ascertain the role of lumbar sympathectomy in attenuating the phantom limb pain. The relatively shorter duration of follow-up in our study could be another limitation as the onset of phantom limb pain may vary from weeks to years.  Further clinical trials of sufficiently longer duration are needed to investigate the role of lumbar sympathetic block in preventing the phantom limb pain.
| Conclusions|| |
We conclude that preamputation lumbar sympathectomy decreases the severity of postamputation stump pain and thus improves the overall quality of life in patients of Buerger's disease.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Arkkila PE. Thromboangiitis obliterans (Buerger's disease). Orphanet J Rare Dis 2006;1:14.
Cooper LT, Tse TS, Mikhail MA, McBane RD, Stanson AW, Ballman KV. Long-term survival and amputation risk in thromboangiitis obliterans (Buerger's disease). J Am Coll Cardiol 2004;44:2410-1.
Cohen SP, Gambel JM, Raja SN, Galvagno S. The contribution of sympathetic mechanisms to postamputation phantom and residual limb pain: A pilot study. J Pain 2011;12:859-67.
Lin EE, Horasek S, Agarwal S, Wu CL, Raja SN. Local administration of norepinephrine in the stump evokes dose-dependent pain in amputees. Clin J Pain 2006;22:482-6.
Sherman RA, Arena JG, Sherman CJ, Ernst JL. The mystery of phantom pain: Growing evidence for psychophysiological mechanisms. Biofeedback Self Regul 1989;14:267-80.
Richardson C, Glenn S, Nurmikko T, Horgan M. Incidence of phantom phenomena including phantom limb pain 6 months after major lower limb amputation in patients with peripheral vascular disease. Clin J Pain 2006;22:353-8.
Jensen TS, Krebs B, Nielsen J, Rasmussen P. Phantom limb, phantom pain and stump pain in amputees during the first 6 months following limb amputation. Pain 1983;17:243-56.
Singh R, Shukla A, Kang LS, Verma AP. Chemical lumbar sympathetic plexus block in Buerger's disease: Current scenario. Indian J Pain 2014;28:24-8.
Mashiah A, Soroker D, Pasik S, Mashiah T. Phenol lumbar sympathetic block in diabetic lower limb ischemia. J Cardiovasc Risk 1995;2:467-9.
Carroll I, Clark JD, Mackey S. Sympathetic block with botulinum toxin to treat complex regional pain syndrome. Ann Neurol 2009;65:348-51.
Stevens RA, Stotz A, Kao TC, Powar M, Burgess S, Kleinman B. The relative increase in skin temperature after stellate ganglion block is predictive of a complete sympathectomy of the hand. Reg Anesth Pain Med 1998;23:266-70.
Power Calculator for Continuous Outcome Superiority Trial. Sealed Envelope Ltd.; 2012. Available from: https://www. sealedenvelope.com/power/continuous-superiority. [Last accessed on 2014 Nov 04].
Nikolajsen L, Jensen TS. Phantom limb pain. Br J Anaesth 2001;87:107-16.
Manjunath PS, Jayalakshmi TS, Dureja GP, Prevost AT. Management of lower limb complex regional pain syndrome type 1: An evaluation of percutaneous radiofrequency thermal lumbar sympathectomy versus phenol lumbar sympathetic neurolysis - A pilot study. Anesth Analg 2008;106:647-9.
Abramov R. Lumbar sympathetic treatment in the management of lower limb pain. Curr Pain Headache Rep 2014;18:403.
Sanni A, Hamid A, Dunning J. Is sympathectomy of benefit in critical leg ischaemia not amenable to revascularisation? Interact Cardiovasc Thorac Surg 2005;4:478-83.
Nesargikar PN, Ajit MK, Eyers PS, Nichols BJ, Chester JF. Lumbar chemical sympathectomy in peripheral vascular disease: Does it still have a role? Int J Surg 2009;7:145-9.
Schley MT, Wilms P, Toepfner S, Schaller HP, Schmelz M, Konrad CJ, et al.
Painful and nonpainful phantom and stump sensations in acute traumatic amputees. J Trauma 2008;65:858-64.
Nikolajsen L. Postamputation pain: Studies on mechanisms. Dan Med J 2012;59:B4527.
Torebjörk E, Wahren L, Wallin G, Hallin R, Koltzenburg M. Noradrenaline-evoked pain in neuralgia. Pain 1995;63:11-20.
Chabal C, Jacobson L, Russell LC, Burchiel KJ. Pain response to perineuromal injection of normal saline, epinephrine, and lidocaine in humans. Pain 1992;49:9-12.
Nikolajsen L, Ilkjaer S, Krøner K, Christensen JH, Jensen TS. The influence of preamputation pain on postamputation stump and phantom pain. Pain 1997;72:393-405.
Hill A, Niven CA, Knussen C. Pain memories in phantom limbs: A case study. Pain 1996;66:381-4.
Katz J, Melzack R. Pain "memories" in phantom limbs: Review and clinical observations. Pain 1990;43:319-36.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]