|Year : 2016 | Volume
| Issue : 2 | Page : 138-139
Appearance of phantom limb pain after spinal anesthesia
Rajmala Jaiswal, Arnab Banerjee, Arjun Pirkad, Naresh Kumar
Department of Anesthesiology, Pt. B.D. Sharma PGIMS, Rohtak, Haryana, India
|Date of Web Publication||18-Jul-2016|
Department of Anesthesiology, Pt. B.D. Sharma PGIMS, Rohtak, Haryana
Source of Support: None, Conflict of Interest: None
Phantom limb pain which is basically neuropathic in nature resulting from functional changes in peripheral and central pain pathways subsequent to amputation, is challenging to treat. We report an interesting case of phantom limb pain during the regression phase of spinal anesthesia in a patient to be operated for revision amputation for chronic ulcer.
Keywords: Neuropathic pain, phantom limb pain, subarachnoid block
|How to cite this article:|
Jaiswal R, Banerjee A, Pirkad A, Kumar N. Appearance of phantom limb pain after spinal anesthesia. Indian J Pain 2016;30:138-9
| Introduction|| |
The term phantom-limb pain was coined by Mitchell in 1872.  Ambroise Paré had postulated in 1552 that peripheral factors as well as a central pain memory might be causing phantom-limb pain and was the first to describe it.  Phantom pain, a neuropathic pain resulting from functional changes in peripheral and central pain pathways subsequent to amputation, is challenging to treat.  Central changes seem to be a major determinant, occurring in 80% of patients who undergo the procedure. Furthermore, phantom breasts and uterus in women, penis in man, visceral organs, eyes, teeth, and part of the chest have been reported. Phantom pain appearing in the lower limb immediately after spinal anesthesia have been reported.  However, the occurrence of phantom pain during regression of subarachnoid blockade has not been reported yet. Here, we report the onset of severe phantom limb pain during the regression phase of spinal anesthesia in a patient operated for revision amputation for a chronic ulcer.
| Case Report|| |
A 65-year-old male, 50 kg body weight, suffered traumatic amputation of left lower limb in March 2015. The patient came for revision amputation for a chronic ulcer. Physical examination, laboratory investigations, family and past medical history were unremarkable. In operation theater, routine monitors were attached, 18G intravenous catheter was placed, and ringer lactate drip started. In sitting position under aseptic precaution spinal anesthesia given in L3-L4 interspaces with 23G Quienke's spinal needle and 2.2 ml hyperbaric bupivacaine (0.5%) given. Sensory blockade of T 8 and motor blockade of T 9 achieved. Duration of surgery was 1.5 h. The intraoperative period was uneventful, and the patient did not receive any sedatives or analgesics. After completion of surgery, the patient was shifted to the recovery room where he complained severe burning, excruciating, and intolerable pain sensation (visual analog pain score [VAS 10]) arising from the left anatomically absent limb. On examination, the sensory blockade had receded up to T10 and sensation to pin-prick test was absent in normal limb, but in the amputee limb, pin-prick test could not be elicited as there was severe pain. Injection tramadol (50 mg + 50 mg) was given, but no pain relief was achieved. As the patient was restless and incorporative because of his excruciating pain, injection fentanyl 50 mcg was given and after 5 min there was complete pain relief (VAS 3). No further episodes of any pain in the postoperative period were noted.
| Discussion|| |
The proposed mechanism of phantom limb pain is either spinal or central in origin.  Reports of excruciating phantom limb pain immediately after subarachnoid blockade are reported, but the exact mechanism remains unclear.  In our case, there was phantom limb pain occurred during the regression phase of spinal anesthesia. During spinal anesthesia, there is a blockade of both inhibitory and excitatory control over the deafferented nerve cells in the amputated stump. The occurrence of phantom pain during the regression phase of the subarachnoid block may depend on the dominance of either inhibitory or excitatory pathways. In our case, the excitatory pathways at the level of spinal cord dominate leading to the perception of severe excruciating pain, final common pathway which results from the integration of painful input into the somatosensory and limbic cortices. Intravenous fentanyl acts on the common pathway and blocks the sudden spontaneous free transmission of high-frequency burst activity in these neurons leading to pain relief.  In our case, one dose of intravenous fentanyl (1 μ/kg) was sufficient to control the pain. He received an injection diclofenac i.m. b.d. as advised by the surgeon for initial 2 postoperative days. The patient was observed in the ward and was discharged on the 3 rd postoperative day with no recurrence of such severe excruciating pain.
Thus, we can conclude that reappearance of phantom pain may be possible during the regression phase of spinal anesthesia in patients with previous lower limb amputation, and it should be treated immediately. Intravenous fentanyl can be used as to treat such excruciating phantom limb pain.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Mitchell SW. Injuries of Nerves and their Consequences. Philadelphia: Lippincott; 1872.
Keil G. So-called initial description of phantom pain by Ambroise Paré. "Chose digne d'admiration et quasi incredible": The "douleur ès parties mortes et amputées". Fortschr Med 1990;108:62-6.
Flor H. Phantom-limb pain: Characteristics, causes, and treatment. Lancet Neurol 2002;1:182-9.
Mackenzie N. Phantom limb pain during spinal anaesthesia. Recurrence in amputees. Anaesthesia 1983;38:886-7.
Fiddler DS, Hindman BJ. Intravenous calcitonin alleviates spinal anesthesia-induced phantom limb pain. Anesthesiology 1991;74:187-9.
Sellick BC. Phantom limb pain and spinal anesthesia. Anesthesiology 1985;62:801-2.