Phantom Pain - Pain Clinic. phantom pain phantom pain arises

Description:

Phantom limb pain is one of the most serious pain syndromes. They were first described in 1552 by Ambroise Pare, but so far the mechanisms underlying them have not been fully studied, and the prospects for their rapid elimination are very sad.

The percentage of people suffering from phantom pain is surprisingly high. In 72% of people, phantom pains occurred already in the first 8 days after surgery, after 6 months they were noted in 65%, two years later - in 60%. 60% of people continue to complain of pain in their phantom limb after 7 years. However, over time, pain attacks become less frequent.

Symptoms:

Phantom pain is one of the manifestations of a variety of phantom sensations. Pain refers to exteroceptive sensations, along with tactile, temperature, pressure sensations, itching, etc. Kinesthetic sensations may also occur, which include the perception of the position of the amputated limb, its length, volume, as well as kinetic sensations, including voluntary and involuntary movements in the limb. The most characteristic kinesthetic sensations are the perception of the unusual position of the limb, its shortening, and size distortion. All these sensations are most vivid immediately after the operation. Over time, the intensity of sensations weakens.

Causes of occurrence:

Classical phantom pain occurs after amputation of a limb, but the term is also applicable to pain that develops after amputation of any part of the body. In almost all patients who have undergone amputations of limbs, as well as some other organs (mammary gland, penis, anus, nose, ears), phantom sensations appear soon after nerve intersection, but they can appear at any time after denervation. These sensations are not always painful and sometimes do not cause complaints from patients. Most experts note that over time, pain decreases significantly in about half of patients.

Treatment:

For treatment appoint:

Phantom pains are difficult to treat, so it's best to try to prevent them. A decrease in the frequency and intensity of phantom pain in the postoperative period in patients with preoperative pain in the extremity is noted after epidural infusion of local anesthetics or morphine within 72 hours before surgery.

Medical treatment.
With a short history of phantom pain, analgesics show a positive effect. In some cases, long-term use of narcotic analgesics is indicated.

Nerve blockade.
Sympathetic blockade usually causes minimal or temporary improvement, but in some cases it is effective enough that even a small chance of persistent pain relief justifies sympathetic blockade in refractory pain syndrome. The probability of achieving a stable analgesic effect by blockade of sensory nerves is lower than with sympathetic blockades, even cases of paradoxical increase in pain after sensory blockades are described.

Chemical or surgical destruction.
Chemical or surgical disruption of the proximal somatosensory pathways is more risky than temporary blockade as it may worsen the condition and is therefore NOT suitable for the treatment of phantom pain.
Injections of local anesthetics into the stump have little effect on phantom pain.

Clinical case of treatment of a patient with post-traumatic amputation phantom pain syndrome

Patient F., 56 years old, an electrician, a resident of Novosibirsk, applied to the Pain Treatment Clinic of Professor Sokov E.L. 05/05/2009, with complaints of severe pain burning, shooting, boring, penetrating, debilitating nature, accompanied by a feeling of fear of pain in the fingers of the left completely amputated limb. Unbearable severe pain with an intensity of 10 points on a 10-point pain scale was provoked by touching the fabric of a shirt, a breath of wind, touching water, etc. Rehabilitation and prosthetics of the stump were impossible due to the maximum pain syndrome that could not be treated.

The patient constantly daily for 5 years takes a solution of diphenhydramine 1% up to 30 ml per day (3 packs of 10 ampoules), i.e. pregabalin 600 mg * 3 times a day, amitriptyline 25 mg * 6 tablets per day, tramal 1 ml * 3 once a day intramuscularly, tramala retard capsules 200 mg * 4 times a day inside, spasmalgon 10 tablets a day, solpadein 6 effervescent tablets a day, codeine + paracetamol tablets - 20 pcs. per day. The effect of the treatment is not noted. The pain syndrome decreases during the day slightly. The patient attempted suicide three times in the last year. Three times examined by MSEK, has 1 disability group, indefinitely.

From the history of the disease: In 2004, he received an industrial injury. During the repair of a de-energized high-voltage power line, which the patient held on to with his hand, someone turned on the switch and let an electric current of 6000 volts flow through the line. The patient received an electrical injury - the left arm burned up to the middle of the humerus in front of the patient's eyes, on the right arm there was a 3 degree burn of the hand. The patient then fell to the ground. In critical condition, the patient was taken to the surgical department, where an emergency operation was performed - amputation of the left humerus, amputations of 1-3 fingers of the right hand. Within a month the patient was in intensive care, then within 4 months he underwent repeated reconstructive operations on his hands, plastic surgery with a skin flap of the right hand. He was discharged home for outpatient rehabilitation. Pain in the fingers of the amputated left hand appeared and began to gradually increase after the healing of postoperative wounds. Analgesics were prescribed, which did not bring any effect. The patient began to experience problems in self-service: because of the pain syndrome, he could not wash himself, get dressed, refused to eat, and had difficulty going to the toilet. The slightest irritation of the skin or hair on the skin of the right hand began to provoke an attack of severe pain in the amputated left limb. It was decided to refrain from rehabilitation measures and prosthetics of the stump of the left hand. The patient gradually began to increase the dose of painkillers, then tramal was prescribed. In addition, the patient himself began to use painkillers uncontrollably. He became gloomy, taciturn, anxious, sometimes aggressive. Consulted by a psychiatrist repeatedly, the recommended treatment was ineffective.

When contacting the Pain Treatment Clinic, he stated that this is the last instance of hope, if at least some clinical effect is not achieved, then his life is over.

When examined by a neurologist of the Pain Treatment Clinic of Professor Sokov E.L. pain syndrome on a 10-point scale was 10 points, the patient was crying from pain.

On palpation, severe pain was determined in the area of ​​the spines of the shoulder blades, the stump of the left shoulder, the stump of the right hand.

On radiographs of the left shoulder joint - osteoporosis of the bones of the left shoulder blade, left clavicle.

In a day hospital, the patient underwent intraosseous blockades in the spine of the scapulae, heads of the clavicle, spinous processes of the cervical spine - a total of 26 blocks within 14 working days.

After the first procedure in the spine of the left and right shoulder blades, the pain syndrome decreased by 10-15%, the pains were no longer provoked by the touch of the shirt fabric, the mood improved somewhat, and he stopped expressing suicidal thoughts.

After the fifth procedure, the pain syndrome in the amputated limb regressed by 50% of the initial level. The patient completely refused tramal. I began to notice the effect of taking analgesics, my sleep and mood improved, I began to dress and eat on my own. I enjoyed walking around Moscow.

After the 10th procedure, the pain syndrome remained at the level of 50% of the initial level. However, the number of drugs taken was reduced by 2 times.

After the 14th procedure, the pain syndrome decreased by 80%, the patient refused all drugs except for 6 ml of diphenhydramine solution per day.

After 6 months, the patient called the Pain Clinic of Professor Sokov E.L. and reported that the pain syndrome in the amputated left limb is 4 points and is characterized as moderate, the patient visits the pool, prosthetic left limb. Does not take analgesics. There are no suicidal thoughts.

These pains are neuropathic. They are included in the deafferentation group, that is, unpleasant sensations arise due to pathological sensory processes in the central nervous system.

Phantom pain can occur after the amputation of any limbs, or the removal of any organ. They may appear immediately after surgery or after some time. Phantom pains cause severe discomfort. In some cases, they become a serious problem that is not so easy to solve. Pain, as a rule, begins unexpectedly and strongly, but weakens over time. In about half of patients, they remain for life.

Pain that appeared before amputation can easily develop into phantom pain. Often phantom pains haunt the elderly, they often occur in those people who have lost limbs not on the operating table, but as a result of some kind of accident, especially if everything happened abruptly and unexpectedly. We also note that they can develop against the background of any mental disorders.

Phantom pains are nothing more than one of the varieties of phantom sensations. Such sensations can be pressing, temperature, and so on. Often, after amputation, kinesthetic sensations also occur, that is, the person feels that he is still in his place. He even feels its volume and position. Often these feelings are distorted. For example, it seems to a person that the arm (amputated) is shorter than normal. All this is most pronounced after the operation, and weakens over time.

Pain in the cult

They differ from phantom pains in that they are caused by neuromas at the end of a severed nerve. Basically, patients complain that something pulsates in the stump, presses, pricks, and so on. Sometimes they feel like something is hitting them with electricity. These pains are less common than phantom pains. They go away a few months after the amputation.

Phantom pains: treatment

Getting rid of them is not so easy. As a rule, doctors prescribe morphine or local anesthetics to eliminate them.

If phantom pains do not disappear, doctors prescribe analgesics. Their treatment is quite effective. In simple cases, the result will be noticeable very soon. In more complex ones, they have to be taken for a long period of time.

Sometimes pain is treated with a sympathetic nerve block. Sometimes it is effective, but in some cases there is only a temporary improvement. Also blockade of nerves can only weaken phantom pains. Yes, the probability of getting rid of this disease is small, but many doctors still resort to this method, because they know that there is a chance to save a person from troubles without long-term use of drugs that have many side effects.

Surgical or chemical removal of the proximal somatosensory pathways is another way to eliminate phantom pain. It is more risky than nerve blocks, but in some cases the effect is quite good. The bottom line is that chemistry can worsen the general condition of the body. Of course, surgical intervention is also not welcome.

Neurostimulation is one of the safest methods for eliminating phantom pain. Today, doctors know many ways to relieve a person of phantom pain by influencing the posterior columns of his spinal cord. The method has proven itself for a long time. Leading experts of the world declare its effectiveness. He is not conservative. For the most part, it is resorted to when everything else is ineffective.

Psychotherapy is often used for treatment. In this case, only a professional psychologist should deal with the patient - an amateur can only worsen the situation.

Amputation is a complex surgical operation. In the process of removing the leg, a large wound surface is created, in which there are nerves, bone and muscle tissue. Correct amputation technique minimizes painful complications in the postoperative period. Good healing of the stump without adhesions to nerves and bones quickly leads to pain relief. But unfortunately this is not always the case...

Pain relief is a necessary condition for the transition to the following rehabilitation measures. Pain resulting from surgery and tissue injury, usually, with appropriate treatment, disappears with the healing of the surgical wound.

Early pain after amputation

Most often they are associated with a rough operating technique, the lack of processing of the nerve trunks. Accumulation of fluid in the stump area (hematoma, lymphocele). These pains occur immediately after the operation and continue for a long time, gradually changing their character.

Inflammation or suppuration of the stump in the early postoperative period leads to an increase in temperature, profuse purulent discharge, wound dehiscence. The pains are bursting in nature and are relieved by anti-inflammatory drugs (analgin, diclofenac).

Ongoing critical ischemia of the stump. Incorrect choice of the level of amputation in the area of ​​poor circulation leads to the continuation of gangrene. The wound cannot heal and severe ischemic pain occurs. In this situation, only repeated amputation of the leg will help.

Phantom and late pains

During amputation, a different type of pain may occur that is not associated with tissue injury - phantom pain, which is sometimes difficult to treat with medication. Phantom sensations arise, as if in a remote limb (for example, itching in a missing finger, or a continuing sensation of rupture and crushing of tissues that arose at the time of the accident). The appearance of phantom pain after amputation is often associated with the formation of neuromas (dense painful rounded formations on the crossed nerve trunks associated with the growth of nerve tissues).

Our clinic successfully uses the method of treating phantom pains with the help of "mirror" therapy (Mirror therapy). Sometimes pain in the stump is associated with the formation of ulcers and abrasions in the process of using the prosthesis. This situation requires the joint efforts of the surgeon and prosthetist and sometimes requires elective amputation of the limb. The cause of later pain is mainly negligence in the care of the stump and improper use of prostheses. If, despite following all the rules for using the prosthesis in the stump, severe or phantom pain occurs, you should consult a doctor.

Treatment of late pain after amputation

If phantom pain becomes constant and reaches a level that prevents further rehabilitation, complex treatment is necessary. The reduction of phantom pain is facilitated by the moral acceptance of the fact of the loss of a limb, massage of the stump, uniform pressure created by the bandage, early start of physical exercise, the use of temporary prostheses and physiotherapy procedures. In rare and difficult cases, nerve blocks and surgery are required.

Removing a body part is a difficult process. In addition to the participation and support of family and relatives, the help of professional psychologists should not be neglected. In the first months after surgery, factors such as too low or high ambient temperature, depression, tension, lack of sleep, impaired circulation in the amputated limb, prolonged immobility, and infections (for example, flu or urinary tract infections) can lead to increased pain.

In cases where conservative treatment and blockade of the nerves does not lead to the elimination of the pain syndrome, it is necessary to perform reamputation with a full treatment of the nerve trunks and rational prosthetics. During the initial amputation, it is necessary to take care of the conditions for subsequent prosthetics and rehabilitation.

Clinical Cases

FAQ

Dobrii den!!! pishu vam s Gruzii ,pojalyista pomogite i posovetyite chto nam dleat ,u papi ...

Answer: Good afternoon. Send a photo of the leg in several projections and data from the study of the arteries of the leg (ultrasound or arteriography) by mail [email protected]

Hello. Recently, she was in the hospital in the gastro ward with suspected Crohn's disease. As a result, this disease was not found, but during the examination it was stated: GERD grade 0 against the background of cardia insufficiency...

Answer: Urgent stenting is not necessary, but if there are bowel symptoms, it is desirable to restore blood flow through the celiac trunk. Symptoms may be related.

Hello. Systemic vasculitis (Wegener's granulomatosis) has been in remission since 2009 on Rituximab. In 2015, a Chopart resection of the left foot was performed due to gangrene (a complication of vasculitis) and a popliteal-calcaneal...

Answer: Good afternoon. Make an appointment with our chief surgeon: Kalitko I.M.

Good afternoon. In early May, my dad had a stroke. He is 56 years old. Thank God, now he moves himself and talks. But when he was discharged, he underwent an ultrasound of the carotid arteries, which revealed...

Answer: Good afternoon. A completely closed carotid artery does not need to be operated on! Monitor the remaining carotid artery: do an ultrasound once every 6 months.

Good evening. My mother's leg was amputated after thrombosis. On the eighth day, the temperature is 38. Is this in the order of things or not?

Answer: Good afternoon. It is not normal.

There are watery blisters on the legs. Some of them started to leak. Very painful. What can be done than to anoint?

Answer: Perform an ultrasound of the vessels of the legs and show yourself to the surgeon.

Hello, on April 2, I had a hip replacement surgery, now I noticed that the big toe under the toenail began to darken, which could be

Answer: Good afternoon. Perform an ultrasound of the arteries of the legs - make sure that the blood flow in the legs is not impaired.

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Answer: Good afternoon. Without an additional start of blood flow to the foot, the wound will not heal. It is necessary to perform shunting of the arteries of the foot under a microscope. We are doing this successfully. Bring the patient with all examinations (including...

After aorto-femoral prosthesis surgery, the stitches in the groin are very sore and it is difficult to walk. The seams are clean. Will it pass or should I be concerned?

Answer: It is better to see the surgeon operating on you

Good afternoon My mother (73 years old) has diabetes. Injured 2 toes. On the advice of a surgeon from the clinic, she was treated with dioxidine and Levomekol for 2 months. \"Sores \" increased in diameter. Now they say...

Answer: Certainly. We save legs in 96% of cases of gangrene. Send data by mail [email protected]

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(FBS) - the occurrence of pain in a subjectively perceived limb. Classical FBS occurs after surgical or traumatic amputation of a limb, however, in a broad sense, it can develop after amputation of any part of the body (breast, nose, ears, tooth, eye).

In the post-amputation period, against the background of a body schema disorder, the formation of the so-called “phantom limb” (feeling of a lost part of the body) occurs, in which pain often develops. The incidence of FBS after amputation is estimated in the range from 45% to 90%. The need for timely and adequate correction of FBS is due to the high frequency and intensity of pain manifestations, as well as their significant impact on quality of life indicators.

FBS can develop in the early postoperative period (sometimes immediately after amputation), but in some cases, pain appears after a long time - weeks, months and even years. Over time, the intensity of sensations gradually weakens, pain attacks become less frequent and FBS may even disappear, but in 60% of individuals it persists after a year, and in some cases the intensity of pain may increase [back to contents].

Instrumental methods for diagnosing phantom pain are neuroimaging methods (positron emission tomography, functional magnetic resonance imaging, which reveal the generators of pathologically enhanced excitation, and also allow you to track the migration of the cortical representation of the missing limb, that is, to conduct pain mapping [back to contents].

. Treatment. FBS is still one of the most difficult tasks for a doctor, since this type of pain syndrome is quite difficult to treat. Differentiated therapy is needed, based on the characteristics of the clinical course of its various forms and the intensity of pain.

At the first manifestations of FBS, treatment begins with conservative measures, and only if they are unsuccessful, they resort to neurosurgical operations on the pain-conducting system of the brain and spinal cord. The exception is patients with amputation neuromas, who should be operated on as early as possible, thereby preventing the possibility of a pain dominant in the brain. However, the removal of neuromas often does not eliminate phantom pain that has already appeared.

Taking into account the peculiarities of the pathogenesis of FBS, the treatment of this pathology is aimed at suppressing the pathological activity of peripheral pacemakers and aggregates of hyperexcitable neurons and activating the antinociceptive system.

With a short history of FBS, drug treatment includes the use of non-narcotic and narcotic analgesics (ketamine, morphine, tramadol), which, however, give a short-term effect. The use of non-steroidal anti-inflammatory drugs (NSAIDs) is ineffective. There is evidence of the effective use of the transdermal route of administration of fentanyl.

There is also a scheme for the treatment of phantom pain, which consists in the joint appointment of clonidine, which stimulates descending antinociceptive pathways that suppress the conduction of pain impulses in the cells of the posterior horns of the spinal cord, and baclofen, which has a segmental inhibitory effect.

Some anticonvulsants also have an analgesic effect. In particular, carbamazepine is used, which provides inhibition of ectopic discharges that occur in a damaged nerve and reduces the excitability of central neurons. Gabapentin is a drug that reduces the excitability of nociceptive neurons in the spinal cord.

The mechanism of the analgesic action of antidepressants (amitriptyline) in FBS is the activation of descending supraspinal serotonin and norepinephrine antinociceptive systems. The analgesic effect may also be partially due to an indirect analgesic effect, since an improvement in mood and a decrease in emotional stress favorably affects the assessment of pain and reduces pain perception. Amitriptyline is also able to block channels for sodium ions both in peripheral nerve fibers and on neuronal membranes, which ensures inhibition of ectopic activity. To normalize the functional activity of the nervous system, its vegetative centers, complex treatment with baclofen, finlepsin, melipramine and haloperidol is used. However, pharmacological treatments for FBS are often only moderately effective.

Pain relief can be achieved both by reducing the flow of impulses from the peripheral nerves (injection of anesthetics into sensitive areas or nerves of the stump) and by increasing sensory impulses (injection of hypertonic solution into the corresponding areas causes a pain attack followed by partial or complete disappearance of pain). Novocaine blockades of sympathetic ganglia are also used. Successful use of blockade of the brachial plexus with an anesthetic in combination with oral administration of NMDA receptor antagonists that affect cortical reorganization has been reported.

One of the most promising directions in the treatment of FBS is neuromodulation. Methods from its arsenal are divided into neurostimulation (stimulation of nerve structures from nerves and plexuses to the cerebral cortex) and the method of chronic dosed automatic epidural or intrathecal (intrathecal, intraventricular) administration of analgesics and anesthetics (elimination of pathological pain impulses from the periphery and suppression of the activity of the primary generator pathologically). heightened arousal). The mechanism of the effect of neurostimulation is based on the principle that when exposed to electrical impulses at any level above the source of pain, these effects block the path for the passage of the pain impulse, which as a result does not reach the place of perception in the brain.

For the treatment of FBS, electrical stimulation of various structures of the nervous system is carried out - peripheral nerves, posterior columns of the spinal cord, deep structures of the brain, and the cerebral cortex. Allocate surface electrical stimulation of the nerves of the stump, as well as the contralateral (non-amputated) limb. The action of these techniques is aimed at eliminating the deficit of afferent influences and restoring inhibitory control from various parts of the central nervous system. Stimulation of the posterior columns of the spinal cord, in addition to the above-mentioned effect of electrophysiological blockade of pain impulses, implements the mechanism of "chemical blockade" of nociceptive signals, stimulating the production of endogenous antinociceptive substances - GABA, endorphin, serotonin, dopamine. In addition, electrical stimulation enhances the downward influence of the antinociceptive system.

Electrical stimulation of the deep structures of the brain is carried out during the implantation of intracerebral electrodes. The sensory nuclei of the thalamus, periaqueductal, periventricular gray matter or internal capsule are stimulated. In addition, there are methods of electrical stimulation of the motor areas of the cerebral cortex, associated with the implantation of epidural electrodes, as well as non-invasive transcranial magnetic stimulation, stimulating the production of beta-endorphins.

From the arsenal of physiotherapeutic methods in the complex treatment of patients with FBS, laser therapy is also used - low-intensity laser radiation helps to eliminate the hyperactive determinant structure - the generator of pathologically enhanced excitation. A positive effect in the early stages of the development of the disease is given by vibration therapy - vibration massage of the tissues of the stump. The use of EHF-therapy in the treatment of phantom pain is associated with the ability of electromagnetic radiation in the millimeter wave range to harmonize the functions of the autonomic centers of the brain.

Also effective are such techniques as biofeedback (based on surface electromyography, temperature training), virtual reality technology, massage (point, massage of the stump scar), manual therapy, "mirror therapy". The use of reflexotherapy - acupuncture (acupuncture, electropuncture, laser puncture, etc.), transcutaneous electrical stimulation activates the endogenous anti-nociceptive system. The use of prostheses with a feedback device contributes to the reduction of phantom pain.

Psychotherapy is an important component in the complex treatment of phantom pain, since FBS can lead to the development of depressive states. Amputation may be accompanied by the development of a distress syndrome that exacerbates phantom pain, which makes the psychotherapeutic effect even more significant.

Surgical treatment of phantom pain began with the removal of neuromas that form on the cut nerve. The next step in the development of methods of analgesic operations was the selective destruction (microcoagulation) of the zone of entry of the posterior roots into the posterior horn - DREZ-operation, aimed at destroying the focus of pathologically increased excitation at the segmental level. However, in the presence of such foci in the "higher" parts of the nervous system or with an already established pathological algic system, this surgical intervention is ineffective. Sympathicotomy is also moderately effective. At the cerebral level, islet subpial resection of the cortex in the motor zone can be performed, as well as stereotaxic destruction of the sensory nuclei of the thalamus, designed to interrupt the flow of pain impulses to the overlying part of the nervous system [back to contents].

. Prevention. Phantom pains are difficult to treat, so it is best to take steps to prevent their development. With a prophylactic purpose at the stage of preoperative preparation of patients, it is advisable to eliminate pathological pain impulses from the periphery, and to provide adequate pain relief during surgery. Epidural or intravenous analgesia within 48 hours before surgery and within 48 hours after surgery can reduce the incidence of FBS. Epidural anesthesia directly affects the generator of pathologically increased excitation in the posterior horns of the spinal cord. The use of special means reduces the excitability of nervous structures. Among them, the anticonvulsant gabapentin is effective (2 days before surgery and for 2 weeks or more after surgery).

In the process of surgical intervention, in order to prevent the occurrence of FBS, the method of isolating the nerve according to Burdenko, resection of the neural trunks according to Molotkov are most often used. In addition, to prevent the development of FBS, the following methods of anesthesia of the nerve before its intersection are used: long-term periamputation blockade of the stump according to Speransky-Vishnevsky (novocaine 0.5%), intraosseous blockade according to Sokov (using lidocaine 1%).

One of the methods of prevention is the use of perfectly sharp instruments during amputation to separate tissues. For example, a radio wave scalpel, the use of which excludes contact mechanical action on tissues and is not accompanied by mechanical destruction of cells, and therefore necrosis of tissues adjacent to the incision is minimal. Treatment of the nerve using a radio wave scalpel accelerates the regeneration processes in the nerve stump, reduces the inflammatory response and scar deformity in the area of ​​intersection [back to contents].

Literature: data from studies by O.K. Chegurova, S.V. Kolesnikova, E.S. Kolesnikovaa, A.A. Skripnikova (Federal State Budgetary Institution "Russian Scientific Center "Restorative Traumatology and Orthopedics" named after Academician G.A. Ilizarov" of the Ministry of Health of Russia, Kurgan; 2014).

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