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Optimum Management of Pre-amputation Pain Eliminates Phantom Pain at 6 Months: Presented at ASA

By W. A. Thomasson, PhD

CHICAGO, IL -- October 16, 2006 -- Patients scheduled for lower extremity amputation who receive optimum pain management before, during, and after surgery are unlikely to experience prolonged phantom limb pain, according to a paper presented here at the Annual Meeting of the American Society of Anesthesiologists (ASA).

Lead author Menelaos Karanikolas, MD, assistant professor, University of Patras, Patras, Greece, and colleagues randomized 35 patients into 5 treatment groups. Group 1 received epidural analgesia beginning approximately 48 hours prior to amputation and continuing for approximately 48 hours afterward. Groups 2 through 4 received patient-controlled intravenous analgesia during the preoperative period, with variations in intraoperative anesthesia and postoperative analgesia. Group 5 received intramuscular meperidine as needed plus oral acetaminophen/codeine during the preoperative and postoperative periods, with general anesthesia during surgery.

Of the 35 patients, 33 completed the 6 month follow-up; 2 patients died. There were no demographic differences between groups. The median (minimum, maximum) duration of treatment by protocol was 46.9 (41, 52) hours before and 46.8 (35, 58) hours after amputation.

The day before surgery, no patient in group 1 had limb pain; some patients in groups 2 through 4 were pain free, but others had values as high as 4 or 5 on the 10-point Visual Analog Scale. VAS values in group 5 ranged from 2 to 7.

Data were analyzed with the Kruskal-Wallis test.

Patients on optimized analgesia had lower scores on the Phantom pain Visual Analog Scale (VAS) and the Pain Rating Index - Affective (PRI) at all time points compared with controls. This effect was most pronounced in the group receiving preoperative epidural analgesia (group 1, P < .05) at 1 and 6 months.

At 6 months none of the 8 patients in group 1 had phantom pain, compared with 71% of 7 in group 5 (P < .007). There was no significant stump pain at 6 months in any group.

"My major concern is that it seems too good to be true," Dr. Karanikolas said in an interview.

Nevertheless, the major conclusion seems clear: The better the perioperative -- especially preoperative -- pain management, the less likely and less severe phantom limb pain becomes. And it appears that epidural analgesia may be somewhat better than intravenous analgesia for this purpose, providing more consistent assurance of freedom from pain in the long term.


[Presentation title: Optimized Perioperative Analgesia Decreases Phantom Pain after Lower Extremity Amputation. Abstract 336]

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