Phantom Limb Pain

Woman in mist forest

In many ways phantom pain is like the shadowy image of the woman in this foggy scene; ghost-like and evanescent. But in other ways it is very different. When the pain is present it is usually sharp and clearly localized. Patients can usually tell you in exactly which part of their index finger the burning pain is and within seconds that it has moved to the tip of their thumb.

Phantom limb pain is a fascinating and luckily rare condition where a patient experiences pain in a part of the body, which is no longer physically present. This pain is usually described as sharp, electrical or burning in character. In most cases the pain comes in waves with a periodicity usually measured in minutes. In between these spikes the patient may be pain free, however, in severe cases there may be a background of burning disesthesias to torment the patient.

The pain of the phantom limb is usually present within minutes of the amputation (either surgical or traumatic) or the return of consciousness. Some fortunate individuals will experience a gradual diminution of the pain over a period of months, but for many the pain is either constant or becomes progressively worse.

Phantom limb pain like the pain of causalgia is neuropathic and responds poorly to conventional pain medications. It may respond partially to a combination of anticonvulsants and antidepressants, but side effects often limit the total dose. Some patients will respond to repeated sympathetic blocks, stellate ganglion blocks for the upper extremity and lumbar paravertebral blocks for the upper extremity. Others may benefit from a trial of nerve stimulation. This can sometimes be done externally in the upper extremity with transcutaneous electrical nerve stimulation (TENS) applied to the brachial plexus. In the lower extremity this is rarely possible because the nerves are much deeper. In cases where a trial of TENS therapy is unsuccessful a trial of spinal cord stimulation is indicated and often successful.

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