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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 35  |  Issue : 1  |  Page : 83-86

Continuous adductor canal block for the management of below-knee postamputation stump pain in a diabetic patient


1 Department of Anaesthesiology and Pain Medicine, Central Hospital, South Eastern Railway, Garden Reach, West Bengal, India
2 Senior Consultant Pain Management, Kolkata Pain Clinic, Kolkata, West Bengal, India

Date of Submission31-Jul-2020
Date of Decision18-Aug-2020
Date of Acceptance30-Oct-2020
Date of Web Publication27-Apr-2021

Correspondence Address:
Dr. Samir Basak
Flat 10C, Unit 4, BNR North Colony, 11 Garden Reach Road, Kolkata - 700 043, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpn.ijpn_107_20

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  Abstract 

Limb amputation surgery is one of the oldest surgical procedures. Below-knee amputation (BKA) surgery is indicated for advanced critical limb ischemia, diabetic foot sepsis, and major trauma. The majority of unplanned readmission after lower limb amputation surgery occurs mainly due to persistent postamputation stump pain. One of the important causes of postamputation stump pain is stump site infection. A higher rate of infection is seen in diabetic patients. Postamputation stump pain management is challenging due to the presence of mixed nociceptive and neuropathic pain component. Various modalities of treatment to control the stump pain are published in different articles. However, no single technique or drug is found superior to others. Here, we report a case of severe postamputation stump pain after BKA surgery in a diabetic patient with stump site infection. The pain was successfully managed by continuous infusion of analgesics via the adductor canal perineural catheter. After the stoppage of the infusion, the patient did not report any phantom limb pain syndrome during the 6-month follow-up.

Keywords: Below-knee amputation, continuous adductor canal block, postamputation stump pain, stump site infection


How to cite this article:
Basak S, Poddar K. Continuous adductor canal block for the management of below-knee postamputation stump pain in a diabetic patient. Indian J Pain 2021;35:83-6

How to cite this URL:
Basak S, Poddar K. Continuous adductor canal block for the management of below-knee postamputation stump pain in a diabetic patient. Indian J Pain [serial online] 2021 [cited 2021 Jun 15];35:83-6. Available from: https://www.indianjpain.org/text.asp?2021/35/1/83/314686


  Introduction Top

Limb amputation surgery is one of the oldest surgical procedures. Over 150,000 people undergo amputations of the lower extremity in the United States each year.[1] Below-knee amputation (BKA) or transtibial amputation is a surgical procedure that involves removing the ankle joint, foot and distal tibia and fibula with related soft-tissue structures. BKA is indicated for advanced critical limb ischemia, diabetic foot sepsis, and major trauma.[2] It is preferred over an above-knee amputation for better rehabilitation and functional outcomes. The majority of unplanned readmission after lower limb amputation surgery occurs mainly due to persistent postamputation stump pain.[3] One of the important causes of postamputation stump pain is stump site infection. A higher rate of infection is seen in diabetic patients.[4]

Postamputation stump pain is defined as pain originates from the residual portion of the amputated limb. It is comprising nociceptive pain due to soft tissue and bone damages, neuropathic pain due to direct nerve damage, and central sensitization.[4] Untreated pain, later on, develops phantom limb syndrome (stump pain, phantom limb pain, and phantom sensation).[5] Postamputation stump pain management is challenging due to the presence of mixed nociceptive and neuropathic pain component. Various modalities of treatment to control the stump pain are published in different articles.[5],[6],[7],[8] However, no single technique or drug is found superior to others.[9]

The Adductor canal block is a mainly sensory block of the saphenous nerve, which provides innervation to the medial malleolus, medial calf, and medial portion of the foot. It has been indicated for knee arthroplasty, anterior cruciate ligament reconstruction, distal lower extremity surgery such as debridement, fracture, and amputation.[10]

Here, we report a case of severe postamputation stump pain after BKA surgery in a diabetic patient with stump site infection. The pain was successfully managed by continuous infusion of analgesics via the adductor canal perineural catheter.


  Case Report Top

A 56-years-old male, weighing 66 kg was admitted with severe (numeric rating scale [NRS]:9/10) below-knee postamputation stump pain in the left leg. The pain was sharp, aching, and continuous. It was aggravated with the movement of the limb and was associated with sleep disturbance. The patient was suffering from the pain since after the amputation surgery under general anesthesia 10 days back in a different hospital. He was in moderately severe depression (patient health questionnaire-9 score-16). There was a history of uncontrolled diabetes for 5 years. The patient was now on insulin therapy for the past 1 year. He gave the history of cellulitis over the left lower leg, which was gradually progressed to severe form and resulted in amputation.

On general examination, he was poorly built, conscious, and oriented. There was pallor but no cyanosis, clubbing, and edema. His vital parameters were within the normal limits. The wound site was infected and unhealthy. Vacuum-assisted closure of a wound therapy was started over the stump site [Figure 1]. On X-ray, surgical amputation through tibia and fibula was seen, and no heterotrophic calcification at the stump site was visible [Figure 2]. On admission, blood investigation had shown hemoglobin−7.8 g/dl (grams per deciliters), total leukocyte count−14,000/mm[3], serum albumin−2.4 g/dl, serum potassium−6.1 mEq/L, serum urea−69 mg/dl, serum creatinine−1.3 mg/dl, fasting blood sugar−139 mg/dl, postprandial blood sugar−228 mg/dl.

Figure 1: Below knee amputated left leg with vaccum assisted closure of the wound (dressing and splint opened)

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Figure 2: Chest X-ray (above) and left leg X-ray showing below-knee amputation through the tibia and fibula (below)

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For initial pain management, inj.-fentanyl was administered in a bolus dose of 50 micrograms intravenously, followed by a continuous infusion of fentanyl @ 25 mcg/h. However, the pain was not adequately controlled after 24 h of the infusion (NRS: 6/10). Then an infusion of injection ketamine 50 mg plus injection lignocaine hydrochloride preservative-free 200 mg in 100 ml normal saline was started for 1 h once daily. With those medications, the pain was controlled (NRS: 3/10) for only 3 days. After that, the patient again complained of stump pain with the same severity (NRS: 7/10) as previously. As there were persistent stump pain and infection, it was decided to place an ultrasound (USG)-guided perineural catheter in the adductor canal for continuous infusion of injection bupivacaine and injection. fentanyl.

Written informed consent and patient counseling were done on the day before the procedure. In the operation theater, intravenous access was secured and monitors for vital parameters were attached. Under the aseptic condition, a 13-6 MHz linear high-frequency USG transducer was placed horizontally on the medial aspect at the mid-thigh level. The sartorius muscle and the femoral artery were identified. An 18G echogenic peripheral nerve block needle was inserted near the femoral artery on the in-plane approach from medial to the lateral side [Figure 3]. The position was checked by injecting 1 ml of normal saline. Then perineural catheter (Transparent Polyamide catheter, approved material for prolonged implantation) was inserted via the needle 6 cm inside the skin, and a bolus dose of 20 ml 1% injection lignocaine hydrochloride was administered. The catheter was fixed by adhesive dressing and bandage. After the procedure, pain score was reduced to NRS: 2/10 within 30 min and vitals were normal. The patient was shifted to the surgical ward. In the ward, continuous infusion of injection bupivacaine 2.5 mg/ml plus injection fentanyl 2 mcg/ml @ 5 ml/hr was started by a syringe pump. The trained on-duty nurse performed the continuous monitoring of the vital parameters, the pain score, any adverse effect, and syringe refilling. The pain was well controlled (NRS: 1/10) [Figure 4]. Other supportive treatments were continued for hyperglycemia, anemia, hyperkalemia, and infection.

Figure 3: Ultrasound guided adductor canal cather insertion below sartorius muscle and near femoral artery

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Figure 4: Patient lying comfortably with adductor canal infusion of analgesics by a syringe pump

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On day-14, the surgeon performed the revision stump surgery and debridement of unhealthy granulation tissue under the subarachnoid block. The infection was controlled, and the wound site became healthy after another week. On day-22, we stopped continuous infusion of the analgesics in the adductor canal. Injection tramadol 50 mg intravenously was prescribed for rescue analgesia. After the stoppage of the infusion, the patient did not demand any rescue analgesics. The same catheter was retained for a total duration of 3 weeks. Then the catheter was removed on the day-23. After removal of the catheter, the patient was kept admitted for another 2 days. On the 25th day of hospital admission, the patient was discharged. The patient did not report any phantom limb pain syndrome during the 6-month follow-up after the discharge.


  Discussion Top

Our primary aim was to control the postamputation stump pain. For which we administered different analgesics like injection fentanyl, injection lignocaine, injection ketamine intravenously. However, the analgesic response was not adequate. Finally, the stump pain was controlled after perineural continuous infusion of injection bupivacaine and injection fentanyl for 3 weeks.

Systemic opioids are commonly used for postamputation pain management.[6] We tried intravenous fentanyl infusion with inadequate pain control. There is an established role of intravenous N-methyl D-aspartate-receptor blocker and sodium channel blockers for neuropathic pain management.[6],[11] Therefore, we started intravenous ketamine and lignocaine for 3 days. However, our findings were similar to the previous study by Hayes et al. that ketamine did not significantly reduce central sensitization or the incidence and severity of postamputation pain.[7]

According to Jahangiri et al., the perioperative epidural infusion of analgesics was effective in reducing the incidence of phantom pain after amputation surgery significantly compared to stump pain.[8] However, prolonged infusion through an epidural catheter is contraindicated in diabetes patients with stump site infection and concomitant anticoagulation therapy.[12]

Borghi et al., in their study, showed that prolonged perineural catheter infusion of 0.5% ropivacaine in combined sciatic and femoral nerve for a median duration of 30 days resulted in improved stump pain severity and phantom limb pain.[5] Placement of the femoral nerve catheter in the groin region for a prolonged duration carries an increased risk of bacterial colonization.[13] Moreover, simultaneous two catheter insertions and maintenance for a prolonged duration would be inconvenient to the patient. Therefore, we did not choose that technique.

The Adductor canal block has emerged as a promising alternative to femoral nerve block in managing postoperative pain after distal lower extremity surgery.[10] On that basis, we assumed that the adductor canal block could reduce the below-knee postamputation stump pain. We have selected the adductor canal block site at mid-thigh level, below the sartorius muscle, and near the femoral artery as described by Tsai et al. in their case series.[14] Our needle insertion site was quite far away from the infected stump site. Adherence to aseptic technique, minimal handling of the catheter, optimum glycemic control, and course of antibiotics had prevented any catheter-related infection in our case.

There was a paucity of literature on using adductor canal analgesia for postamputation stump pain management. We have performed only one case of continuous adductor canal analgesia for the postamputation stump pain management. Further randomized controlled trials are required in which the adductor canal catheter will be inserted before the amputation surgery and kept for a prolonged duration. Then assessment should be done after long-term follow-up on the development of phantom limb syndrome.


  Conclusion Top

Post amputation pain is complex and should be managed effectively. Placement of an adductor canal catheter for continuous analgesia is a good option for the management of postamputation stump pain in a diabetic patient with stump site infection. Moreover, it prevents the development of phantom limb syndrome.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal for academic purposes. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Acknowledgement

The authors thank Dr. Amita Acharjee, Professor and Head of the Department of Anaesthesiology, Bangur Institute of Neuroscience, Kolkata.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Dillingham TR, Pezzin LE, Shore AD. Reamputation, mortality, and health care costs among persons with dysvascular lower-limb amputations. Arch Phys Med Rehabil 2005;86:480-6.  Back to cited text no. 1
    
2.
Adams CT, Lakra A. Below Knee Amputation (BKA). 2020 Sep 7. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2020. Available from: https://www.ncbi.nlm.nih.gov/books/NBK534773/ [last accessed on 2020 Aug 17].  Back to cited text no. 2
    
3.
Phair J, DeCarlo C, Scher L, Koleilat I, Shariff S, Lipsitz EC, et al. Risk factors for unplanned readmission and stump complications after major lower extremity amputation. J Vasc Surg 2018;67:848-56.  Back to cited text no. 3
    
4.
Neil M. Pain after amputation. BJA Educ 2016;16:107-12.  Back to cited text no. 4
    
5.
Borghi B, D'Addabbo M, White PF, Gallerani P, Toccaceli L, Raffaeli W, et al. The use of prolonged peripheral neural blockade after lower extremity amputation: The effect on symptoms associated with phantom limb syndrome. Anesth Analg 2010;111:1308-15.  Back to cited text no. 5
    
6.
McCormick Z, Chang-Chien G, Marshall B, Huang M, Harden RN. Phantom limb pain: A systematic neuroanatomical-based review of pharmacologic treatment. Pain Med 2014;15:292-305.  Back to cited text no. 6
    
7.
Hayes C, Armstrong-Brown A, Burstal R. Perioperative intravenous ketamine infusion for the prevention of persistent post-amputation pain: A randomized, controlled trial. Anaesth Intensive Care 2004;32:330-8.  Back to cited text no. 7
    
8.
Jahangiri M, Jayatunga AP, Bradley JW, Dark CH. Prevention of phantom pain after major lower limb amputation by epidural infusion of diamorphine, clonidine and bupivacaine. Ann R Coll Surg Engl 1994;76:324-6.  Back to cited text no. 8
    
9.
Ahuja V, Thapa D, Ghai B. Strategies for prevention of lower limb post-amputation pain: A clinical narrative review. J Anaesthesiol Clin Pharmacol 2018;34:439-49.  Back to cited text no. 9
    
10.
Waldman SD. Saphenous Nerve Block at the Knee. Atlas of Interventional Pain Management. 4th ed. Philadelphia: Elsevier; 2015. p. 746-52.  Back to cited text no. 10
    
11.
Wren K, Lancaster RJ, Walesh M, Margelosky K, Leavitt K, Hudson A, et al. Intravenous lidocaine for relief of chronic neuropathic pain. AANA J 2019;87:351-5.  Back to cited text no. 11
    
12.
Bomberg H, Kubulus C, List F, Albert N, Schmitt K, Gräber S, et al. Diabetes: A risk factor for catheter-associated infections. Reg Anesth Pain Med 2015;40:16-21.  Back to cited text no. 12
    
13.
Capdevila X, Bringuier S, Borgeat A. Infectious risk of continuous peripheral nerve blocks. Anesthesiology 2009;110:182-8.  Back to cited text no. 13
    
14.
Tsai PB, Karnwal A, Kakazu C, Tokhner V, Julka IS. Efficacy of an ultrasound-guided subsartorial approach to saphenous nerve block: A case series. Can J Anaesth 2010;57:683-8.   Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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