Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 9  |  Issue : 2  |  Page : 309-310

Exacerbation of phantom limb pain following spinal anaesthesia: A case report and review of the literatures


1 Department of Anaesthesiology, Institute of Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
2 Grande International Hospital, Kathmandu, Nepal

Date of Submission04-May-2015
Date of Acceptance20-Mar-2016
Date of Web Publication11-May-2016

Correspondence Address:
Gentle S Shrestha
Department of Anaesthesiology, Institute of Medicine, Tribhuvan University Teaching Hospital, Maharajgunj, 8975, Kathmandu
Nepal
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1687-7934.182289

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  Abstract 

Phantom limb pain has been reported in patients with lower limb amputation during subsequent spinal anaesthesia. No therapy has been proven to be uniformly effective. Here, we report a case managed successfully with ketamine and magnesium sulphate.

Keywords: ketamine, magnesium sulphate, phantom limb pain, spinal anaesthesia


How to cite this article:
Shrestha GS, Koirala S. Exacerbation of phantom limb pain following spinal anaesthesia: A case report and review of the literatures. Ain-Shams J Anaesthesiol 2016;9:309-10

How to cite this URL:
Shrestha GS, Koirala S. Exacerbation of phantom limb pain following spinal anaesthesia: A case report and review of the literatures. Ain-Shams J Anaesthesiol [serial online] 2016 [cited 2021 Apr 18];9:309-10. Available from: http://www.asja.eg.net/text.asp?2016/9/2/309/182289


  Introduction Top


Phantom limb pain in the missing limb is a well-recognized phenomenon after amputation [1]. It is present in about 80% of amputees. It can be severe, intractable and disabling, and is usually described as cramping, burning, tingling, sharp shooting to mixed-burning or burning-cramping in nature [2]. Exacerbation of phantom limb pain by spinal anaesthesia has also been described [3].


  Case history Top


A 33-year-old male presented with a history of a hit and run accident by a truck. The patient had traumatic occlusion of the left popliteal artery. Repair of the popliteal artery and vein was performed under general anaesthesia. However, the patient developed necrosis of the muscles of the left calf and foot region, and left knee disarticulation was performed 3 days later. After disarticulation, the patient complained of pain in the stump and a sensation of pain in the left foot, sole and toes (phantom limb sensation and pain). The stump pain was controlled with intravenous fentanyl and the patient had no stump pain after 48 h of disarticulation. However, the phantom limb pain persisted. It was of shooting nature and increased during the night, disturbing his sleep. Tab. gabapentin 300 mg orally twice daily, tab. paracetamol 500 mg orally four times daily, tab. diclofenac 75 mg orally twice daily and tab. alprazolam 0.25 mg orally at bed time (hs) were started. Pain was not adequately controlled and the patient frequently needed pethidine 50 mg intramuscular injection. Later, the patient developed stump infection and an above-knee amputation was planned. On preanaesthetic evaluation, the patient had persistent phantom limb sensation and pain. However, stump pain was absent. All medications were continued and tab. gabapentin 600 mg orally was administered at night before and 3 h before surgery. A subarachnoid block was performed with 3.5 ml of 0.5% hyperbaric bupivacaine. Sensory level of T6 and motor block of grade IV in the lower limbs were achieved. However, the patient complained of severe pain in the left lower limb that was of shooting nature. Inj. fentanyl 75 mg and inj. midazolam 2 mg intravenously were administered. This decreased the pain only slightly. Inj. ketamine 30 mg intravenous bolus was administered. Inj. magnesium sulphate 2 g (in 100 ml normal saline) was administered over 20 min. Pain was completely relieved in around 10 min and the surgery was started. The total duration of surgery was 150 min. After 1 h, on regression of sensory block, the patient complained of stump pain, which was managed with inj. fentanyl 30 mg intravenously. He did not complain of phantom limb pain. Postoperative analgesia was administered with inj. morphine 3.5 mg 4 h intravenously and inj. ketorolac 30 mg intravenously three times daily (tds). Gabapentin and alprazolam were continued. Tab. Amitriptyline 10 mg orally hs was administered.


  Discussion Top


Three separate phenomena can occur after amputation of a body part: phantom sensation, stump pain and phantom pain. Phantom limb pain is common and difficult to treat. It can occur immediately after amputation in most cases, but their appearance can be delayed by days or even weeks. It can also occur in a patient with a previous lower limb amputation when spinal anaesthesia is administered for another procedure. Induction of phantom limb pain with regional anaesthesia has been reported in patients who have been symptom free for as long as 40 years and may occur during the onset or regression of the block [4]. The pathophysiology behind this phenomenon is not completely understood. A proposed mechanism is loss of segmental afferent input leading to decreased input to the brainstem, normally exerting an inhibitory influence on sensory transmission. Release from descending inhibition may allow upward transmission of abnormal neuronal activity. Other central mechanisms that may be involved in the aetiology of phantom limb pain are increased excitability of the dorsal-horn neurons, reduction of inhibitory processes and structural changes at the central nerve endings of the primary sensory neurons, the interneurons and the projection neurons. Other supraspinal changes such as cortical reorganization have also been postulated in the aetiology of phantom limb pain [5]. There are various risk factors for the development of phantom pain. These are preamputation pain, presence of persistent stump pain, bilateral limb amputation and lower limb amputation. Our patient had three of the above risk factors.

Phantom limb pain is a difficult-to-treat condition. A range of treatments for phantom limb pain have appeared in the literature; however, there is lack of evidence to support the efficacy of many agents. Different drugs used for the treatment of neuropathic pain (gabapentin, amitriptyline) can be used for the treatment of phantom pain, but most studies have not investigated phantom limb pain specifically [4]. Ketamine at a dose of 0.5 mg/kg intravenously is considered to significantly decrease the pain intensity in phantom limb pain [6]. Ketamine can be used alone or in combination with calcitonin to decrease pain intensity [7]. Mackenzie reported that intravenous administration of 10 mg diazepam, 100 or 150 mg fentanyl and nitrous oxide/oxygen could relieve recurring phantom pain effectively in two patients following spinal anaesthesia [8]. In our case, we initially used fentanyl and midazolam, but without much success. However, the use of intravenous ketamine at a dose of 0.5 mg/kg and magnesium sulphate relieved the pain completely. By virtue of calcium and NMDA (N-methyl d-aspartate) receptor antagonism, Magnesium sulphate has been show to be effective in the treatment of chronic [9] and postoperative [10] limb pain.

In summary, it is not uncommon for anaesthesiologists to encounter patients with phantom limb pain in their daily practice. The anaesthesiologist should be aware of the possibility of spinal anaesthesia-induced or spinal anaesthesia-exacerbated phantom pain in such patients and should be prepared to manage it. Intravenous ketamine at a dose of 0.5 mg/kg and magnesium sulphate may be effective in relieving severe phantom limb pain recurring during spinal anaesthesia.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Alivar MJM, Hael T, Dungca M. Pharmacologic interventions for treating phantom limb pain. Cochrane Database Syst Rev 2011; 12:CD006380.  Back to cited text no. 1
    
2.
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; 17:243-256.  Back to cited text no. 2
[PUBMED]    
3.
Harrison G. Phantom limb pain occurring during spinal anaesthesia. Anaesthesia 1951; 6:115-116.  Back to cited text no. 3
[PUBMED]    
4.
Jackson MA, Simpson KH. Pain after amputation. Continuing Education in Anaesthesia, Critical Care and Pain 2004; 4:20-23.  Back to cited text no. 4
    
5.
Herta F. Phantom limb pain: characteristics, causes and treatment. Lancet Neurol 2002; 2:182-189.  Back to cited text no. 5
    
6.
Nikolajsen L, Hansen C, Nielsen J, Keller J, Arendt-Nielsen L, Jensen T. The effect of ketamine on phantom pain: a central neuropathic disorder maintained by peripheral input. Pain 1996; 67:69-77.  Back to cited text no. 6
    
7.
Eichenberger U, Neff F, Sveticic G, Bjorgo S, Petersen-Felix S, Arendt-Nielsen L, et al. Chronic phantom limb pain: the effects of calcitonin, ketamine, and their combination on pain and sensory thresholds. Anesth Analg 2008; 106:1265-1273.  Back to cited text no. 7
    
8.
Mackenzie N. Phantom limb pain during spinal anesthesia. Anaesthesia 1983; 38:886-887.  Back to cited text no. 8
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9.
Tramer MR, Glynn CJ. Magnesium Bier's block for treatment of chronic limb pain: a randomised, double-blind, cross-over study. Pain 2002; 99:235-241.  Back to cited text no. 9
    
10.
Dabbagh A, Elyasi H, Razavi SS, Fathi M, Rajaei S. Inravenous magnesium sulphate for post-operative pain in patients undergoing lower limb orthopedic surgery. Acta Anaesthesiol Scand 2009; 53:1088-1091.  Back to cited text no. 10
    



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