373
PHANTOM
SU
P A I N TRE
D BY ELECTRICAL S T ~ U L A T I O N
ANY
p su nng Rom phantom l ~ b pain were assessed fer suit~reatmen~ b~ electrical stimulator ~ p t a n t to t e ~r~pherai nerve
tom limb :~nousty challenges his powers of imagination anci sympa~ ~yo The r e p o s e d incidence of pain,:in phantom timbs~ we believe~ reflects ~ much the attitude of the medical chronicler as the condition itself. Lhe~itte: [ 2
374
stump" when this was firstsuggested it horrifiedmost s ~ c a l mindsl It n o w appears less heretical. " -1 Electrical stimulation as a respectable form of treatment achtevea credIbi!ity following the work of Melzack and Wall [4], Its application
Nielson etal. [7] reported good relief in all 5 patients that they t r e a t e d , METHODS Since 1972 we have been using a system of an electrical stimulator implanted onto peripheral nerves or onto the posterior columns of the spinal
cord for the relief of various protracted pain syndromes [ 5]. It was immediately obvious that selection for this form of treatment by diagnosis alone provided a very unreliable guide to suitability. We have therefore subjected our patients to a battery of tests in addition to the more obvious clinical and neurological examination.
Pharmacological assessment
The determination of the existing analgesic regime and its modification if necessary. We withdra~ addictive drugs and add any other forms of medication such as psychotrcpic dru~s. The aim if possible is to obviate the need for surgery. In the group of! phantom limb pains it has proved of no value to modify the analgesic regime -- usually the patients have tried everything. Two patients were found to be addicted to Palfium. One was satisfacto~ly withdrawn and he wa; then implanted with success. The other would not satisfactorily withdra:~ and this helped decide against implantation. Antidepressant therapy has been necessary in two patients who were not implanted.
Psychiatric assessment
Psychiatric assessment by the surgeon and a psychiatrist suggested major psycho-neurotic disturbance i n t w o patients were not ~ p l ~ t e d . Minor disturbance was found in t w o athers which seemed co~ectable by medication and they were implanted, Psych ological assessme n t
Psychological assessment using the Cartel PQ !6 inventory has been made prior to operatior~. The analysis of these Lnventories ~ d (the co,elation o f personality factors w i t h the eventual r e s u l t after( implantation is now))the basis of a re~:rospective study. It is hoped that it logical ~aidance for implantation in the future.
375
Physiological tests These have included senso~y threshold and have not yet revealed anything of importance; it does not seem to be regularly elevated during stimulation. Assessment of the cerebral evoked potential has been used to indicate the So far. where no cerebral ents have not responded to electrical st[ nerve or spinal cord. Some suppression of the )c'curs during dorsal column sthmulation.
Therapeutic stimula tion tests These are directed to the peripheral nerve, the segment of the cord appr
PHANTOM
SU
P A I N TRE
D BY ELECTRICAL S T ~ U L A T I O N
ANY
p su nng Rom phantom l ~ b pain were assessed fer suit~reatmen~ b~ electrical stimulator ~ p t a n t to t e ~r~pherai nerve
tom limb :~nousty challenges his powers of imagination anci sympa~ ~yo The r e p o s e d incidence of pain,:in phantom timbs~ we believe~ reflects ~ much the attitude of the medical chronicler as the condition itself. Lhe~itte: [ 2
374
stump" when this was firstsuggested it horrifiedmost s ~ c a l mindsl It n o w appears less heretical. " -1 Electrical stimulation as a respectable form of treatment achtevea credIbi!ity following the work of Melzack and Wall [4], Its application
Nielson etal. [7] reported good relief in all 5 patients that they t r e a t e d , METHODS Since 1972 we have been using a system of an electrical stimulator implanted onto peripheral nerves or onto the posterior columns of the spinal
cord for the relief of various protracted pain syndromes [ 5]. It was immediately obvious that selection for this form of treatment by diagnosis alone provided a very unreliable guide to suitability. We have therefore subjected our patients to a battery of tests in addition to the more obvious clinical and neurological examination.
Pharmacological assessment
The determination of the existing analgesic regime and its modification if necessary. We withdra~ addictive drugs and add any other forms of medication such as psychotrcpic dru~s. The aim if possible is to obviate the need for surgery. In the group of! phantom limb pains it has proved of no value to modify the analgesic regime -- usually the patients have tried everything. Two patients were found to be addicted to Palfium. One was satisfacto~ly withdrawn and he wa; then implanted with success. The other would not satisfactorily withdra:~ and this helped decide against implantation. Antidepressant therapy has been necessary in two patients who were not implanted.
Psychiatric assessment
Psychiatric assessment by the surgeon and a psychiatrist suggested major psycho-neurotic disturbance i n t w o patients were not ~ p l ~ t e d . Minor disturbance was found in t w o athers which seemed co~ectable by medication and they were implanted, Psych ological assessme n t
Psychological assessment using the Cartel PQ !6 inventory has been made prior to operatior~. The analysis of these Lnventories ~ d (the co,elation o f personality factors w i t h the eventual r e s u l t after( implantation is now))the basis of a re~:rospective study. It is hoped that it logical ~aidance for implantation in the future.
375
Physiological tests These have included senso~y threshold and have not yet revealed anything of importance; it does not seem to be regularly elevated during stimulation. Assessment of the cerebral evoked potential has been used to indicate the So far. where no cerebral ents have not responded to electrical st[ nerve or spinal cord. Some suppression of the )c'curs during dorsal column sthmulation.
Therapeutic stimula tion tests These are directed to the peripheral nerve, the segment of the cord appr
