21 - Post-amputation pain

Summary

INTRODUCTION

The phenomenon of pain in a missing limb has puzzled patients, doctors and the lay public for centuries. In the 16th century the French military surgeon Ambroise paré published a medical description of the enigmatic affliction, while in the 17th century the great philosopher Rene Descartes looked at its potential pathophysiology. The most famous ‘first’ description of the condition is attributed to the great neurologist charles Bell, but it was only in the later part of 19th century, that the US military surgeon Silas Weir Mitchell introduced the term ‘phantom limb’: ‘There is something almost tragical, something ghastly, in the notion of these thousands of spirit limbs, haunting as many good soldiers, and every now and then tormenting them …’

We now know that post-amputation syndromes can occur with any amputated body part apart from limbs e.g. breast, tongue, teeth, genitalia and even inner organs such as the rectum.

CLASSIFICATION AND INCIDENCE OF POST-AMPUTATION PAIN SYNDROMES

Following amputation (or deafferentiation injury such as brachial plexus avulsion) a number of phenomena can develop, which require differentiation.

Stump Pain

Stump pain is pain localized to the site of amputation. Stump pain can be acute (usually nociceptive) or chronic (usually neuropathic). Stump pain is most common in the immediate post-operative period. The overall incidence of chronic stump pain is in the range of 45%. The incidence of early stump pain is increased by the presence of severe pre-amputation pain and severe acute stump pain.