Phantomschmerzen – Pathomechanismen und Therapieansätze

 

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Nach Extremitätenamputation berichten ca. 80 % der Patienten über Phantomschmerzen. Abzugrenzen von Phantomschmerzen sind nicht schmerzhafte Phantomempfindungen und Stumpfschmerzen. Aktuelle Forschungsergebnisse zur Pathophysiologie von Phantomschmerzen unterstreichen die Bedeutung von kortikalen Veränderungen und von einer veränderten Körperwahrnehmung. Periphere und spinale Mechanismen sind eher von untergeordneter Bedeutung.

Wesentliche Bestandteile der Therapie von Phantomschmerzen sind die medikamentöse Behandlung und der Einsatz senso–motorischer Trainingsprogramme (Spiegeltherapie, Lateralisationstraining und Imaginationsverfahren). Antidepressiva und Antikonvulsiva sind vorrangig einzusetzende Medikamente – bei unzureichender Wirkung empfiehlt sich der Einsatz von retardierten Opioiden. Bei elektiven Amputationen ist präoperativ die Anlage eines Katheters zur epiduralen bzw. axillären Plexus–Anästhesie angezeigt. Die perioperative Gabe von Ketamin muss gegenwärtig als umstritten betrachtet werden.

Abstract:

About 80 % of all extremity amputations suffer from phantom limb pain following the operation. In this context, it is important to differentiate between painful phantom limb sensations, non–painful phantom limb sensations and residual limb pain.

The pathophysiology of phantom limb pain is not fully understood. Current research findings ascribe a major pathophysiological role to cortical changes as well as a disturbed body perception. Peripheral and spinal mechanisms appear less relevant in the development of phantom limb pain.

An essential part of the therapy is the pharmacological treatment with antidepressants, anticonvulsives and opioids. Another significant aspect of therapy is senso–motory training, important to mention here would be mirror therapy, lateralisation and motor imaging. In case of an elective amputation, an epidural or axiliar plexus catheter should be considered prior to the amputation. The perioperative treatment with ketamine is debated.

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Dr. med. Dr. phil. Andreas Schwarzer
Prof. Dr. med. Michael Zenz
Prof. Dr. med. Christoph Maier

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