Anaesthesia, 1992, Volume 47, pages 1053-1054 CASE REPORT
Phantom limb pain during labour
G. P. DUREJA
AND
SANDHYA
Summary We report the occurrence of severe phantom limb pain during labour. The patient, a 27-year-old. had had an above knee amputation perfiwmed 6 years earlier following a road traffic accident but had no previous history of phantom limb phenomena. However, during early labour, she complained of a severe phantom limb pain in her amputated leg; a continuous epidural block relieved her of the sensation and pain. The sensation did not return following delivery.
Key words Pain; phantom limb. Anaesthetic techniques, regional; epidural.
Phantom limb phenomena occur in the majority of patients with any kind of deafferentation such as surgical and traumatic amputation, peripheral nerve or spinal injury [I]. The occurrence of this phenomenon is usually seen immediately after the injury but may appear months or years later [2]. Reappearance of phantom limb pain has been reported during spinal anaesthesia [31, epidural anaesthesia (41 and in other stressful conditions. There are however, to our knowledge, no reports in the literature of phantom limb pain appearing during labour. Case history A 27-year-old nurse was admitted to the delivery suite in active labour with a full-term pregnancy. Her left leg had been amputated above the knee 6 years earlier following a road traffic accident and she had a prosthetic limb. She had had one live birth following an elective lower segment Caesarean section performed prior to the amputation. After the amputation, she achieved limited mobility with the help of a prosthesis and later continued her professional career. During the present pregnancy, she had an uneventful antenatal period reinforced with thorough psychological preparation. The attending obstetrician had decided to allow her to go into spontaneous labour at term. After about 4 h of labour, the patient complained of severe numbness and dysaesthesia in the amputated left leg stump followed by a phantom limb sensation. This gradually became painful and unbearable, the pain being
very intense and ‘crushing’ in quality. Due to the severity of pain, the patient demanded a termination of labour. In order to attempt to ease the pain it was decided to administer a continuous epidural analgesia. An epidural catheter was inserted at the L3-., vertebral interspace under aseptic conditions and 10 ml of 0.25% bupivacaine was administered. Within 10 min the patient had complete relief from the painful phantom limb as well as from labour pain. The phantom limb sensation reappeared after 2 h as the effect of the local anaesthetic wore off. Subsequently, three top-up doses of 8 ml of 0.25% bupivacaine were administered at regular intervals, the last dose being given with the patient in the sitting position. The fetus was delivered vaginally with the help of a midcavity forceps. Although the epidural catheter was not removed for 48 h following delivery, the patient did not require any top-up dose during this period. A follow-up was carried out 3 weeks after delivery and she did not have any recurrence of the ‘phantom limb’ sensation during that period. Discussion Phantom limb pain is one of the most distressing of all pain phenomena, yet its underlying mechanisms remain a mystery. Most amputees report a phantom limb sensation almost immediately after amputation of a limb. However, it is only about 35% of amputees who report pain in the phantom limb a t some time[2]. The pain may be continuous or occasional, and is described as cramping,
G.P. Dureja, MD, Associate Professor, Sandhya, MD, Senior Resident, Department of Anaesthesiology, All India Institute of Medical Sciences, New Delhi-I 10029 (India). Accepted 18 May 1992.
0003-2409/92/121053 +02 %08.00/0
@ 1992 The Association of Anaesthetists of G t Britain and Ireland
1053
1054
G .P . Dureja and Sandhya
shooting, burning or crushing. Emotional disturbance is reported to be one of the major factors which may trigger the pain in an amputee [I, 51. Use of a prosthesis and a lower age at amputation appears to be associated with a lower incidence of such pain [S]. Our patient used a prosthesis immediately following the amputation. The mechanisms underlying phantom limb pain have been the basis of controversy over the years. So far, no single mechanism has been able to explain the phenomenon. Peripheral, sympathetic, psychological and central mechanisms probably all play a role in producing the classical phantom pain [6]. Melzack [6, 71 has proposed a theory to explain the pain based on the gate control hypothesis of pain. It is believed that a portion of the brainstem reticular formation exerts a tonic inhibitory effect on transmission at all levels of the somatic projection system. When a large proportion of sensory fibres is destroyed by amputation of a limb, the tonic inhibition decreases. This results in self-sustained activity at all neural levels that can be triggered repeatedly by the remaining fibres. Pain occurs when the output of the self-sustaining neurone pools, which project to brain areas that subserve pain experience and behaviour, reaches or exceeds a critical level. The process of labour and the associated pain can result in strong psycho-emotional disturbances which may modulate the activity in the closed, self-sustaining neurone loops resulting in phantom limb pain in an amputee. Sensory input blockade by epidural block would result in cessation of activity in these self-sustaining neurone loops and so would produce pain relief [I]. Our patient had complete relief of ‘phantom limb’ pain following epidural block with 0.25% bupivacaine and there was a recurrence of pain as soon as the effect of the local anaesthetic wore off. However, the observation that spinal or epidural anaesthesia [3, 41 causes recurrence or appearance of phantom limb pain, even in patients who had previously suffered little or no pain, is difficult to explain. The decrease in somatic input after spinal or epidural block could lower
the level of inhibition of closed neurone loops and increase the probability of self-sustaining activity resulting in pain. During early labour, direct pressure of the downcoming fetal head on the visceral sensory fibres in the lower uterine segment and cervix could have contributed towards triggering the pain. The nociceptive impulses from the lower uterine segment travel through the pelvic and hypogastric plexus to the lumbar and lower thoracic sympathetic chains and the sensory stimuli from the cervix travel along the pelvic splanchnic nerves to the second to fourth sacral segments and the sacral portion of the sympathetic chain. Cronholm [8] has suggested that sensory inputs of this nature, or even a mild painful stimulus at effective sites in some normal areas of the body, can evoke ‘phantom limb’ pain in amputees. The fact that this patient’s pain was relieved by segmental epidural blockade supports this hypothesis.
References BONICA JJ. The management ofpain. 2nd edn. Philadelphia: Lea and Febiger, 1990: 244-56. B, LUCE JC, LANGTONJNK. The influence of FEINSTEIN phantom limbs. In: KLOPSTEGP, WILSONP, eds. Human limbs and their substitutes. New York: McGraw Hill, 1954: 79-138. N. Phantom limb pain during spinal anaesthesia. MACKENZE Recurrence in amputees. Anaesthesia 1983; 38:886-7. MIHIC,DN. PINKERTE. Phantom limb pain during peridural anaesthesia. Pain 1981; 11: 269-72. ML, BURGESS EM. A survey of lowerKEGELB, CARPENTER limb amputees: prostheses, phantom sensations and psychosocial aspects. Bulletin of Prosthetics Research 1977; 1 0 43-60. MELZACK R. Phantom limb pain: implications for treatment of pathologic pain. Anesthesiology 1971; 35 409-19. MELZACKR. Central neural mechanisms in phantom limb pain. In: BONICAJJ, ed. Advances in neurology, Vol. 4. New York: Raven Press, 1974: 319-26. (81 CRONHOLM B. Phantom limbs in amputees: study of changes in integration of centripetal impulses with special reference to referred sensations. Acta Psychiatrica el Neurologica Scundinavica 1951; (Suppl. 72): 1-310.
Phantom limb pain during labour
G. P. DUREJA
AND
SANDHYA
Summary We report the occurrence of severe phantom limb pain during labour. The patient, a 27-year-old. had had an above knee amputation perfiwmed 6 years earlier following a road traffic accident but had no previous history of phantom limb phenomena. However, during early labour, she complained of a severe phantom limb pain in her amputated leg; a continuous epidural block relieved her of the sensation and pain. The sensation did not return following delivery.
Key words Pain; phantom limb. Anaesthetic techniques, regional; epidural.
Phantom limb phenomena occur in the majority of patients with any kind of deafferentation such as surgical and traumatic amputation, peripheral nerve or spinal injury [I]. The occurrence of this phenomenon is usually seen immediately after the injury but may appear months or years later [2]. Reappearance of phantom limb pain has been reported during spinal anaesthesia [31, epidural anaesthesia (41 and in other stressful conditions. There are however, to our knowledge, no reports in the literature of phantom limb pain appearing during labour. Case history A 27-year-old nurse was admitted to the delivery suite in active labour with a full-term pregnancy. Her left leg had been amputated above the knee 6 years earlier following a road traffic accident and she had a prosthetic limb. She had had one live birth following an elective lower segment Caesarean section performed prior to the amputation. After the amputation, she achieved limited mobility with the help of a prosthesis and later continued her professional career. During the present pregnancy, she had an uneventful antenatal period reinforced with thorough psychological preparation. The attending obstetrician had decided to allow her to go into spontaneous labour at term. After about 4 h of labour, the patient complained of severe numbness and dysaesthesia in the amputated left leg stump followed by a phantom limb sensation. This gradually became painful and unbearable, the pain being
very intense and ‘crushing’ in quality. Due to the severity of pain, the patient demanded a termination of labour. In order to attempt to ease the pain it was decided to administer a continuous epidural analgesia. An epidural catheter was inserted at the L3-., vertebral interspace under aseptic conditions and 10 ml of 0.25% bupivacaine was administered. Within 10 min the patient had complete relief from the painful phantom limb as well as from labour pain. The phantom limb sensation reappeared after 2 h as the effect of the local anaesthetic wore off. Subsequently, three top-up doses of 8 ml of 0.25% bupivacaine were administered at regular intervals, the last dose being given with the patient in the sitting position. The fetus was delivered vaginally with the help of a midcavity forceps. Although the epidural catheter was not removed for 48 h following delivery, the patient did not require any top-up dose during this period. A follow-up was carried out 3 weeks after delivery and she did not have any recurrence of the ‘phantom limb’ sensation during that period. Discussion Phantom limb pain is one of the most distressing of all pain phenomena, yet its underlying mechanisms remain a mystery. Most amputees report a phantom limb sensation almost immediately after amputation of a limb. However, it is only about 35% of amputees who report pain in the phantom limb a t some time[2]. The pain may be continuous or occasional, and is described as cramping,
G.P. Dureja, MD, Associate Professor, Sandhya, MD, Senior Resident, Department of Anaesthesiology, All India Institute of Medical Sciences, New Delhi-I 10029 (India). Accepted 18 May 1992.
0003-2409/92/121053 +02 %08.00/0
@ 1992 The Association of Anaesthetists of G t Britain and Ireland
1053
1054
G .P . Dureja and Sandhya
shooting, burning or crushing. Emotional disturbance is reported to be one of the major factors which may trigger the pain in an amputee [I, 51. Use of a prosthesis and a lower age at amputation appears to be associated with a lower incidence of such pain [S]. Our patient used a prosthesis immediately following the amputation. The mechanisms underlying phantom limb pain have been the basis of controversy over the years. So far, no single mechanism has been able to explain the phenomenon. Peripheral, sympathetic, psychological and central mechanisms probably all play a role in producing the classical phantom pain [6]. Melzack [6, 71 has proposed a theory to explain the pain based on the gate control hypothesis of pain. It is believed that a portion of the brainstem reticular formation exerts a tonic inhibitory effect on transmission at all levels of the somatic projection system. When a large proportion of sensory fibres is destroyed by amputation of a limb, the tonic inhibition decreases. This results in self-sustained activity at all neural levels that can be triggered repeatedly by the remaining fibres. Pain occurs when the output of the self-sustaining neurone pools, which project to brain areas that subserve pain experience and behaviour, reaches or exceeds a critical level. The process of labour and the associated pain can result in strong psycho-emotional disturbances which may modulate the activity in the closed, self-sustaining neurone loops resulting in phantom limb pain in an amputee. Sensory input blockade by epidural block would result in cessation of activity in these self-sustaining neurone loops and so would produce pain relief [I]. Our patient had complete relief of ‘phantom limb’ pain following epidural block with 0.25% bupivacaine and there was a recurrence of pain as soon as the effect of the local anaesthetic wore off. However, the observation that spinal or epidural anaesthesia [3, 41 causes recurrence or appearance of phantom limb pain, even in patients who had previously suffered little or no pain, is difficult to explain. The decrease in somatic input after spinal or epidural block could lower
the level of inhibition of closed neurone loops and increase the probability of self-sustaining activity resulting in pain. During early labour, direct pressure of the downcoming fetal head on the visceral sensory fibres in the lower uterine segment and cervix could have contributed towards triggering the pain. The nociceptive impulses from the lower uterine segment travel through the pelvic and hypogastric plexus to the lumbar and lower thoracic sympathetic chains and the sensory stimuli from the cervix travel along the pelvic splanchnic nerves to the second to fourth sacral segments and the sacral portion of the sympathetic chain. Cronholm [8] has suggested that sensory inputs of this nature, or even a mild painful stimulus at effective sites in some normal areas of the body, can evoke ‘phantom limb’ pain in amputees. The fact that this patient’s pain was relieved by segmental epidural blockade supports this hypothesis.
References BONICA JJ. The management ofpain. 2nd edn. Philadelphia: Lea and Febiger, 1990: 244-56. B, LUCE JC, LANGTONJNK. The influence of FEINSTEIN phantom limbs. In: KLOPSTEGP, WILSONP, eds. Human limbs and their substitutes. New York: McGraw Hill, 1954: 79-138. N. Phantom limb pain during spinal anaesthesia. MACKENZE Recurrence in amputees. Anaesthesia 1983; 38:886-7. MIHIC,DN. PINKERTE. Phantom limb pain during peridural anaesthesia. Pain 1981; 11: 269-72. ML, BURGESS EM. A survey of lowerKEGELB, CARPENTER limb amputees: prostheses, phantom sensations and psychosocial aspects. Bulletin of Prosthetics Research 1977; 1 0 43-60. MELZACK R. Phantom limb pain: implications for treatment of pathologic pain. Anesthesiology 1971; 35 409-19. MELZACKR. Central neural mechanisms in phantom limb pain. In: BONICAJJ, ed. Advances in neurology, Vol. 4. New York: Raven Press, 1974: 319-26. (81 CRONHOLM B. Phantom limbs in amputees: study of changes in integration of centripetal impulses with special reference to referred sensations. Acta Psychiatrica el Neurologica Scundinavica 1951; (Suppl. 72): 1-310.
