Case reportThe efficacy of postoperative perineural infusion of bupivacaine and clonidine after lower extremity amputation in preventing phantom limb and stump pain
Introduction
Pain after amputation is a significant problem among amputees. Phantom limb pain may appear in up to 85% of patients and is usually resistant to a wide variety of treatments [1], [2], [3], [4]. The mechanisms underlying this pain syndrome are still unknown. Complex multifactorial interactions involving peripheral nerves, central nervous system (CNS), sympathetic system, psychologic overlay [1], [2], [3], [4], and genetic predisposition [5] have all been implicated. Peripheral nerve transection results in an afferent nociceptive barrage that initiates spinal cord hyperexcitability with expansion of the receptive fields of dorsal horn neurons that respond to the nearest intact afferents [6]. These neuroplastic changes are believed to be responsible for the development of postsurgical chronic pain syndromes, including phantom limb and stump pain [7], [8]. It is believed that regional anesthesia, by preventing the establishment of central sensitization, may play a role in reducing the incidence of acute and chronic pain. In addition, because the surgical neurogenic inflammatory response may provide a source of nociceptive input into the CNS for a prolonged period, a continuous infusion of local anesthetic postoperatively may prevent the establishment of central sensitization [7]. Although perioperative epidural block may prevent the development of phantom limb pain [9], [10], [11], its use in the setting of anticoagulation is contraindicated. The perineural administration of clonidine, an α2-adrenergic receptor agonist, reduces neuropathic symptoms after nerve injury in a rat model [12]. Peripheral nerve block for intraoperative and postoperative analgesia with local anesthetics and clonidine not only prolongs and intensifies the block but may also help in preventing sensitization induced by nerve injury during surgery [13].
We report the efficacy of perioperative infusion of clonidine and bupivacaine for above-knee amputation (AKA) in providing effective postoperative analgesia and eliminating both stump and phantom limb pain in a patient with a previous history of this chronic pain syndrome in the same extremity.
Section snippets
Case report
A 68-year-old, 81-kg man presented for elective left AKA due to ischemic necrosis secondary to peripheral vascular disease. He had a left below-knee amputation two years earlier, after which he reported stump and phantom pain. His medical history was significant for hypertension, diabetes, chronic atrial fibrillation, and a St Jude aortic valve necessitating daily warfarin therapy. Warfarin was withheld 6 days before AKA surgery, and he received subcutaneous enoxaparin 80 mg (one mg/kg) every
Discussion
We report the efficacy of a perioperative perineural infusion of bupivacaine and clonidine for analgesia after AKA in a patient with a previous history of phantom limb and stump pain in the same extremity. This technique provided excellent postoperative analgesia with minimal supplementary opioid use while preventing the recurrence of both stump and phantom limb pain.
Although first described in 1649 [1], the etiology of phantom limb pain still remains unknown, and numerous analgesic techniques
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Cited by (28)
Systematic Review and Meta-analysis of the Efficacy of Perineural Local Anaesthetic Catheters after Major Lower Limb Amputation
2015, European Journal of Vascular and Endovascular SurgeryCitation Excerpt :The RCT proposed by Borghi et al. comparing postoperative PNC and opioids, to opioids alone, terminated after the first four patients were randomised, as all controls requested a PNC because of the apparent improvement in postoperative pain outcomes.33 A number of case series and reports have also highlighted the impressive analgesic effect of PNCs, with some patients requiring no postoperative opioid analgesia.30,39,40 PNC use demonstrated no appreciable effect on either phantom limb pain or stump pain.
Prevention of Chronic Pain After Surgical Nerve Injury: Amputation and Thoracotomy
2012, Surgical Clinics of North AmericaCitation Excerpt :Secondly, and more importantly, the catheters may be placed in a location proximal to the incision, improving postoperative analgesia. Previous studies gave sporadic reports of effective management of amputation pain using proximal perineural catheters.91–93 More recently, Borghi and colleagues94 evaluated this technique in a more systematic manner and found that prolonged perineural catheter use provided effective acute analgesia and long-term reduction of phantom limb pain.
Pre-emptive analgesia for chronic limb pain after amputation for peripheral vascular disease: A systematic review
2010, Annals of Vascular SurgeryAnesthesia and analgesia for cancer-related amputation
2010, Techniques in Regional Anesthesia and Pain ManagementCitation Excerpt :Another study examining intraoperative catheters placed during amputation or limb salvage resection resulted in 80% reduction in postoperative narcotic requirements.36 Madabhushi et al37 report a case of PLP symptoms absent for up to 12 months in a patient with preoperative PLP in the same limb after a 4-day perineural infusion of bupivacaine and clonidine. Such case reports illustrate the potential of perineural anesthesia, but a large randomized trial showing long-term pain reduction or the absence of PLP with a specific perineural technique or combination has yet to be performed.
Post amputation pain disorders
2009, Current Therapy in PainPost amputation pain disorders
2008, Current Therapy in Pain: Expert Consult