chapter 28

Phantom Syndromes

Laxmaiah Manchikanti, Vijay Singh, and Mark V. Boswell

■ HISTORICAL CONSIDERATIONS without treatment, except in the cases where phantom pain develops. Phantom sensation or pain is the persistent that a The incidence of pain has been reported to body part exists or is painful after it has been removed by vary from 0% to 88%.16-32 Prospective evaluations31,37 sug- or trauma. The first medical description of post- gested that in the year after amputation, 60% to 70% of amputation phenomena was reported by Ambrose Paré, a amputees experience phantom limb pain, but it diminishes French military surgeon, in 1551 (Fig. 28–1).1,2 He noticed with time.14,31 The incidence of phantom limb pain increases that amputees complained of severe pain in the missing limb with more proximal . The reports of phantom long after amputation. Civil War surgeon Silas Weir Mitchell3 limb pain after hemipelvectomy ranged from 68% to 88% popularized the concept of phantom limb pain and coined the and following hip disarticulation 40% to 88%.28,30 However, term phantom limb with publication of a long-term study on wide variations exist with reports of phantom limb pain the fate of Civil War amputees in 1871 (Fig. 28–2). Herman after lower extremity amputation as high as 72%21 and as Melville immortalized phantom limb pain in American liter- low as 51% after upper limb amputation.22 Further, 0% preva- ature, with graphic descriptions of Captain Ahab’s phantom lence was reported in below-knee amputations compared to limb in Moby Dick (Fig. 28–3). 19% in above-knee amputations.30 Phantom limb pain has The three most commonly used terms are phantom sen- been reported to occur as early as 1 week after amputation sation, phantom pain, and stump pain. Phantom sensation and as late as 40 years after amputation.4,33,34 Although refers to any sensation of the missing limb or organ except phantom pain may diminish with time and eventually fade pain. In contrast, phantom pain refers to painful sensations away, some prospective studies indicate that even 2 years after referred to the missing organ or limb. Stump pain refers to the amputation, the incidence is almost the same as at onset.31,37 pain in the stump. It is reported that nearly 60% of patients continue to have Phantom sensations may occur in any part of the body but phantom limb pain24,31 after 1 year, whereas in the first month are most often described in the extremities. Phantom sensa- following amputation, 85% to 97% of patients experience tion of the tongue, nose, breast, bladder, uterus, rectum, penis, phantom limb pain.24,29,30 Although phantom limb pain may and other organs have been described in the literature.4-11 begin months to years after an amputation, pain starting after 1 year following amputation occurs in fewer than 10% of patients.4 Stump pain is reported with a prevalence of up to ■ THE CLINICAL SYNDROME 50% of the amputees.16,18,21-23,35,36 Stump pain results in disuse of the limb prosthesis in approximately 50% of the Epidemiology patients.16,18,21-23,35,36 The stump pain usually coincides with the development of phantom limb pain.37 In one study, it was Phantom limb sensation is an almost universal occurrence at shown that 88% of the patients with phantom pain also some time during the first month following surgery. Patients reported stump pain.23 In another study, it was reported in only generally describe the limb in terms of definite volume and 50% of the patients.30 length and may try to reach out with or stand on the phantom Phantom limb pain is also associated with multiple pain limb.4 Phantom limb sensation is strongest in amputations 12 problems in other areas of the body, with reports indicating above the elbow and weakest in amputations below the knee, or pain in joints in 35% of the patients, and is more frequent in the dominant limb of double 13 in 28% of the patients, abdominal pain in 18%, and amputees. The incidence of phantom limb sensation in 13%.38 increases with the age of the amputee.4 Phantom limb sensa- tion in 85% to 98% of the amputees is seen in the first 3 weeks 14 after amputation, whereas in a small proportion of the Disability and Risk Factors patients (approximately 8%), phantom limb sensation may not occur until 1 to 12 months following amputation.15 Most Multiple risk factors identified for phantom pain include phantom sensations generally resolve after 2 to 3 years phantom sensations, stump pain, pain prior to the amputation,

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