Phantom limb pain

K K Jain MD (Dr. Jain is a consultant in neurology and has no relevant financial relationships to disclose.)
Originally released January 13, 2000; last updated January 8, 2017; expires January 8, 2020

This article includes discussion of phantom limb pain, deafferentation pain, pseudoesthesia, and stump hallucination. The foregoing terms may include synonyms, similar disorders, variations in usage, and abbreviations.

Overview

“Phantom limb” is a term used to designate the sensation of the presence of an extremity following its amputation, which may be painful. This article discusses the pathogenesis and strategies for prevention and treatment of phantom limb pain. Although it is possible to reduce the incidence of phantom limb pain through proper management after amputation, most of the drugs used for treatment are not effective. Among surgical procedures, deep brain stimulation has been reported to have some success.

Key points

 

• Loss of a limb is followed by phantom limb phenomena that may be both painful and nonpainful.

 

• Although there is no consensus on the pathomechanism of phantom limb pain, a strong relationship has been reported between the magnitude of the phantom limb pain and the amount of cortical reorganization.

 

• A wide variety of methods--pharmacological, nonpharmacological and surgical--have been used for the management of phantom limb pan.

 

• There is no entirely satisfactory treatment, but phantom limb pain can be prevented or partially reversed by adequate analgesic use in the perioperative period associated with limb amputation.

Historical note and terminology

“Phantom limb” is a term used to designate the sensation of the presence of an extremity following its amputation. This is also referred to as deafferentation pain. Pain and dysesthesia in a phantom limb may incapacitate a patient. The early descriptions by Ambroise Pare, Rene Descartes, Aaron Lemos, Charles Bell, and then Mitchell of this strange consequence of amputation have been reviewed in historical and cultural context (Finger and Hustwit 2003). More than 4 centuries ago, the French surgeon Ambroise Pare was aware of phantom limb pain when he wrote in 1551 about "the patients who have, many months after cutting away of the leg, grievously complained that they still felt great pain of the leg so cut off. . . the patients imagine they have their members yet entire" (Keynes 1952). Although these were secondhand descriptions, William Porterfield, a prominent Scottish physician who lived from 1696 to 1771, was possibly the first physician to write about his own experiences after having a leg amputated (Wade and Finger 2003). Phantom limb pain is described in Herman Melville's novel Moby Dick, which was first published in 1851. Captain Ahab, who had lost his leg in a skirmish with the great white whale, stated, "A dismasted man never entirely loses the feeling of his old spar. . . And I still feel the smart of my crushed leg, though it be now so long dissolved" (Melville 1987). The classical description of phantom limb pain, the most detailed available in the English language, is that by Weir Mitchell in 1872 (Mitchell 1872). He used the term “sensory hallucinations” to characterize this phenomenon. Mitchell applied faradic current to the stumps and was able to “conjure” up a phantom and induce movements in its digits. These observations on the phantom limb by Mitchell excited the interest of Hughling Jackson towards the end of the 19th century; he interpreted the dominance of hand or foot in the phantom limb on the basis of the order in which the lost parts remain most vividly in the consciousness. The “movements” of the lost limb were considered to be the result of excitation of motor centers roused into activity by incoming currents from the sensory nerves in the limb stump (Jackson 1932). Despite all the available information, phantom limb pain was not generally recognized by the medical profession until 1941, when Bailey and Moersch published their classical paper on this subject based on their clinical study of 50 patients at the Mayo Clinic (Bailey and Moersch 1941). Bailey and Moersch were rather pessimistic about the efficacy of surgery in relieving this pain, but in the same year Riddoch demonstrated that anterolateral cordotomy could relieve phantom limb pain (Riddock 1941). Nevertheless, Riddock agreed that no relief could be expected when the pain had become indelibly stamped on the cerebral cortex. The concept of pathophysiology at that time was that phantom limb pain was an example of facilitation due to central excitatory states at the highest integrative level (Hardy et al 1952).

The Index Medicus recognized this term in 1954. As of January 2017, over 397 citations in MEDLINE have “phantom limb pain” as a title word, and 796 have this term in any field. Besides the limbs, painful phantoms have been described for eyes, nose, teeth, tongue, breast, bladder, and genital organs. In a variant of this phenomenon, supernumerary phantom limb, the patient experiences the presence of an additional limb. This has been reported in patients following a right hemispheric stroke. There has been no real breakthrough in the understanding of the pathomechanism or management of phantom limb pain during the past half century.

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