Phantom Limb Pain- Mechanism and Evidence Based Management

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Vol 3 | Issue 1 | January-June 2022 | Page 08-12 | Rajendra Sahoo

DOI: 10.13107/ijra.2022.v03i01.47

Authors: Rajendra Sahoo [1]

[1] Department of Pain & Palliative Medicine, Kalinga Institute of Medical Sciences, KIIT Deemed University, Bhubaneswar, Odisha, India.

Address of Correspondence:
Dr. Rajendra Sahoo,
Senior Consultant, Department of Pain & Palliative Medicine, Kalinga Institute of Medical Sciences, KIIT Deemed University, Bhubaneswar, Odisha, India.
E-mail: sss.raaj@gmail.com

Abstract

Phantom limb pain (PLP) is a complex condition resulting in manifestation of pain in the missing body part. PLP is very common in post-amputated individuals and the prevalence rate of as high as 80% has been reported in amputees. PLP leads to a poor quality of life and has a tremendous impact on socioeconomic status of individuals. The mechanism of pain in PLP is still poorly understood despite significant research involving the molecular and neurobiology of the pain. Similarly, various pharmacological and non-pharmacological therapies are described in the literature. This article aims at briefly reviewing the existing literature pertaining to the PLP mechanism and evidence based treatment.

References

1. Ephraim PL, Wegener ST, MacKenzie EJ, et al. Phantom pain, residual limb pain, and back pain in amputees: results of a national survey. Arch Phys Med Rehabil 2005;86(10): 1910–1919.
2. Nikolajsen L and Jensen TS. Phantom limb pain. Br J Anesth 2001; 87(1): 107–16.
3. Whyte AS and Carroll LJ. A preliminary examination of the relationship between employment, pain and disability in an amputee population. Disabil Rehabil 2002;24(9): 462–470.
4. Barbin J, Seetha V, Casillas J-M, Paysant J, Perennou D. The effects of mirror therapy on pain and motor control of phantom limb in amputees: A systematic review. Ann Phys Rehabil Med. 2016;59(4):270–275.
5. Privitera R, Birch R, Sinisi M, Mihaylov IR, Leech R, Anand P. Capsaicin 8% patch treatment for amputation stump and phantom limb pain: a clinical and functional MRI study. J Pain Res. 2017;10:1623.
6. Bosmans JC, Geertzen JHB, Post WJ, et al. Factors associated with phantom limb pain: a 31/2-year prospective study. Clinical Rehabilitation 2010; 24(5): 444–453.
7. Davidson JH, Khor KE and Jones LE. A cross-sectional study of post-amputation pain in upper and lower limb amputees, experience of a tertiary referral amputee clinic. Disabil Rehabil 2010; 32(22): 1855–1862.
8. Dickinson BD, Head CA, Gitlow S, et al. Maldynia: pathophysiology and management of neuropathic and maladaptive pain – a report of the AMA council on science and public health. Pain Med 2010; 11(11): 1635–1653.
9. Baron R. Mechanisms of disease: neuropathic pain – a clinical perspective. Nat Clin Pract Neurol 2006; 2(2):95–106.
10. Ramachandran VS, Brang D and McGeoch PD. Dynamic reorganization of referred sensations by movements of phantom limbs. NeuroReport 2010; 21(10):727–730.
11. Chapman C. Neuromatrix theory. J Pain 1996; 5(2):139–142.
12. Robinson L, Czerniecki J, Ehde D, et al. Trial of amitriptyline for relief of pain in amputees: results of a randomized controlled study. Arch Phys Med Rehabil 2004;85(1): 1–6.
13. Spiegel DR, Lappinen E, Gottlieb M. A presumed case of phantom limb pain treated successfully with duloxetine and pregabalin. Gen Hosp Psychiatry. 2010;32(2):228.e5-7.
14. Bone M, Critchley P, Buggy DJ. Gabapentin in postamputation phantom limb pain: a randomized, double-blind, placebo-controlled, cross-over study. Reg Anesth Pain Med. 2002;27(5):481–486.
15. Smith DG, Ehde DM, Hanley MA, et al. Efficacy of gabapentin in treating chronic phantom limb and residual limb pain. J Rehabil Res Dev. 2005;42(5):645–654.
16. Nikolajsen L, Finnerup NB, Kramp S, et al. A randomized study of the effects of gabapentin on postamputation pain. Anesthesiology 2006; 105(5): 1008–1015
17. Abbass K. Efficacy of gabapentin for treatment of adults with phantom limb pain. Ann Pharmacother. 2012;46(12):1707–1711.
18. Harden RN, Houle TT, Remble TA, et al. Topiramate for phantom limb pain: a time-series analysis. Pain Med 2005; 6(5): 375–378.
19. Jaeger H and Maier C. Calcitonin in phantom limb pain: a double-blind study. Pain 1992; 48: 21–27.
20. Eichenberger U, Neff F, Sveticic G, et al. Chronic phantom limb pain: the effects of calcitonin, ketamine, and their combination on pain and sensory thresholds. Anesth Analg 2008; 106(4): 1265–1273.
21. Nikolajsen L, Hansen CL, Nielsen J, et al. The effect of ketamine on phantom pain: a central neuropathic disorder maintained by peripheral input. Pain 1996; 67(1): 69–77.
22. Ben Abraham R, Marouani N, Kollender Y, et al. Dextromethorphan for phantom pain attenuation in cancer amputees: a double-blind crossover trial involving three patients. Clin J Pain 2002; 18(5): 282–285.
23. Wiech K, Kiefer RT, Töpfner S, et al. A placebo-controlled randomized crossover trial
of the N-methyl-D-aspartic acid receptor antagonist, memantine, in patients with
chronic phantom limb pain. Anesth Analg 2004; 98(2): 408–413.
24. Schley M, Topfner S, Wiech K, et al. Continuous brachial plexus blockade in combination with the NMDA receptor antagonist memantine prevents phantom pain in acute traumatic upper limb amputees. Eur J Pain 2007; 11(3): 299–308.
25. Huse E, Larbig W, Flor H, et al. The effect of opioids on phantom limb pain and cortical reorganization. Pain 2001; 90(1–2): 47–55.
26. Wu C, Tella P, Staats P, et al. Analgesic effects of intravenous lidocaine and morphine on postamputation pain: a randomized double-blind, active placebocontrolled, crossover trial. Anesthesiology 2002; 96(2):841–848.
27. Wu C, Agarwal S, Tella P, et al. Morphine versus mexiletine for treatment of postamputation pain: a randomized, placebo-controlled, crossover trial. Anesthesiology 2008; 109(2): 289–296.
28. Barbin J, Seetha V, Casillas JM, Paysant J, Pérennou D. The effects of mirror therapy on pain and motor control of phantom limb in amputees: A systematic review. Ann Phys Rehabil Med. 2016 Sep;59(4):270-5.
29. Richardson C, Kulkarni J. A review of the management of phantom limb pain: challenges and solutions. J Pain Res. 2017;10:1861-1870.
30. Alviar MJ, Hale T, Dungca M. Pharmacologic interventions for treating phantom limb pain. Cochrane Database Syst Rev. 2016;10(10):CD006380.

How to Cite this Article: Sahoo R | Phantom Limb Pain- Mechanism and Evidence Based Management | International Journal of Regional Anaesthesia | January-June 2022; 3(1): 08-12.

 

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Management of Patient with Limb Girdle Muscular Dystrophy for ERCP and Regional Anaesthesia for Laparoscopic Cholecystectomy: Case Report

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Vol 3 | Issue 1 | January-June 2022 | Page 27-30 | Shalini Saksena , Arnab Paul

DOI: 10.13107/ijra.2022.v03i01.051

Authors: Shalini Saksena [1], Arnab Paul [1]

[1] Department of Anaesthesia, PD Hinduja National Hospital & MRC, Mahim, Mumbai, Maharashtra, India.

Address of Correspondence:
Dr. Arnab Paul,
Department of Anaesthesia, PD Hinduja National Hospital & MRC, Mahim, Mumbai, Maharashtra, India.
E-mail: dr.arnabpaul88@gmail.com

Abstract

Limb-Girdle muscular dystrophies (LGMDs) are a clinically and genetically heterogeneous group of disorders characterized in general by predominantly limb-girdle weakness. It manifests as proximal muscle weakness involving the pelvic girdle and scapular girdle. We report the anaesthetic management of a patient who is a known case of limb-girdle muscular dystrophy, presented with cholecystitis to our institution. Patient underwent endoscopic retrograde cholangio pancreatography (ERCP) under total intravenous anaesthesia followed by laparoscopic cholecystectomy under spinal anaesthesia which were managed successfully.
Keywords: Muscular Dystrophies, Limb-Girdle, Malignant Hyperthermia, Anaesthesia

References

1. Jayadev S. Muscular Dystrophies. Brenner’s Encyclopedia of Genetics 2013; 2: 522-4.
2. Allen T, Maguire S. Anaesthetic management of a woman with autosomal recessive limb-girdle muscular dystrophy for emergency caesarean section. Int J Obstet Anesth 2007; 16:370–374.
3. Iyadurai SJ, Kissel JT. The Limb-Girdle Muscular Dystrophies and the Dystrophinopathies. Continuum (Minneap Minn). 2016;22(6, Muscle and Neuromuscular Junction Disorders):1954–77
4. Chu ML, Moran E. The limb-girdle muscular dystrophies: is treatment on the horizon? Neurotherapeutics. 2018; 15:849–62.
5. Richa FC. Anaesthetic management of a patient with limb-girdle muscular dystrophy for laparoscopic cholecystectomy. Eur J Anaesthesiol 2011; 28:72–73.
6. Segura LG, Lorenz JD, Weingarten TN, et al. Anaesthesia and Duchenne or Becker muscular dystrophy: review of 117 anesthetic exposures. Paediatr Anaesth 2013; 23:855–864.
7. Kim TW, Nemergut ME. Preparation of modern Anaesthesia workstations for malignant hyperthermia-susceptible patients: a review of past and present practice. Anesthesiology. 2011;114(1):205–12.
8. Wappler F. Anaesthesia for patients with a history of malignant hyperthermia. Curr Opin Anaesthesiol. 2010;23(3):417–22.
9. Bajwa SJ, Kulshrestha A. Anaesthesia for laparoscopic surgery: General vs regional anaesthesia. J Min Access Surg 2016; 12:4-9.
10. Catani M, Guerricchio R, De Milito R, et al. ‘Low-pressure’ laparoscopic cholecystectomy in high-risk patients (ASA III and IV): our experience. Chir Ital 2004; 56:71–80.
11. Van Obbergh LJ, Corteel J, Papadopoulos J, et al. Anaesthesia for a child suffering from a deletion in the Xp21 loci resulting in Duchenne disease, glycerol kinase deficiency and congenital adrenal hypoplasia. Paediatr Anaesth 2011; 21:1085–87.

How to Cite this Article: Saksena S, Paul A | Management of Patient With Limb Girdle Muscular Dystrophy for ERCP and Regional Anaesthesia for Laparoscopic Cholecystectomy: Case Report | International Journal of Regional Anaesthesia | January-June 2022; 3(1): 27-30.

 

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Dual Guidance in the Era of Ultrasound: An Overlooked Necessity or a Luxury!

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Vol 3 | Issue 1 | January-June 2022 | Page 35-36 | Vedhika Shanker, Tuhin Mistry, Gurumoorthi Palanichamy, Jagannathan Balavenkatasubramanian

DOI: 10.13107/ijra.2022.v03i01.53

Authors: Vedhika Shanker [1], Tuhin Mistry [1], Gurumoorthi Palanichamy [1], Jagannathan Balavenkatasubramanian [1]

[1] Department of Anaesthesiology, Ganga Medical Centre & Hospitals Pvt Ltd, Coimbatore, India.

Address of Correspondence
Dr. Tuhin Mistry,
Department of Anaesthesiology, Ganga Medical Centre & Hospitals Pvt Ltd, Coimbatore, India.
E-mail: tm.tuhin87@gmail.com

Short Communication

Real-time ultrasonography (USG) guidance has revolutionized the practice of regional anesthesia (RA). As an adjunct to USG, nerve stimulation has been advocated for accurate and safe delivery of local anesthetic (LA) while performing peripheral nerve blocks [1]. This letter highlights the importance of dual guidance infraclavicular brachial plexus block (BPB) in a polytrauma patient for forearm surgery.
A 54-year-old male was brought to the emergency with an alleged history of a road traffic accident and multiple injuries, including left middle third clavicle fracture, bilateral multiple rib fractures, closed distal third both bones fracture of right forearm, scalp hematoma of the left parietal area, and left-sided pneumothorax. On arrival at the resuscitation bay, the overall pain score was 9/10 on a numeric rating scale. An intercostal drain was inserted, and he had been placed on noninvasive ventilation (NIV). A multimodal analgesia regimen was started, including continuous thoracic epidural, intravenous paracetamol 15 mg/kg, tramadol 2 mg/kg, and transdermal 10 mg buprenorphine patch. The patient has been on regular treatment for type 2 diabetes mellitus and hypertension for 15 years. He had suffered two episodes of myocardial infarction 8 years ago, for which he had undergone percutaneous transluminal coronary angioplasty and was on dual antiplatelet therapy. The transthoracic echocardiography revealed mild left ventricular hypertrophy, hypokinetic posterior, lateral, and inferior walls with a left ventricular ejection fraction of 40%. He also suffered an ischemic cerebrovascular accident involving the left middle cerebral artery 6 years ago. The patient had residual weakness of the right-sided hemiparesis, dysphagia, and slurring of speech. He was scheduled for open reduction and internal fixation with plating both right forearm bones 3 days after admission. The plan was to provide surgical anesthesia with a right-sided diaphragm sparing BPB. The anesthesia plan was explained to the patient and relatives, and informed written consent was obtained.
The patient was positioned supine with head-end elevation at 30° in the operation theater, and the ipsilateral arm was abducted. Standard monitors were attached, and a scout scan was performed with a high-frequency linear array transducer (Sonosite HFL 38xp/13–6 MHz; Fujifilm SonoSite Inc., Bothell, WA, USA) to assess the viability of the anesthetic plan (Fig. 1a). The right infraclavicular BPB was performed under dual guidance (USG and electrostimulatilation) with a 100 mm nerve block needle and 15 ml 0.75% ropivacaine and 4 mg dexamethasone was administered (Fig. 1b). Each cord of the brachial plexus was simulated separately, and 5 ml of LA was deposited after obtaining desired responses at <0.5 mA current, 0.1 ms impulse duration, and a frequency of 2 Hz. The lateral, posterior, and medial cords were identified by elbow flexion, wrist extension, and wrist flexion, respectively. The block was successful, and the procedure went off without any complications.
BPB above the clavicle is widely practiced for various upper limb surgeries. We ruled out this option to avoid inadvertent phrenic nerve palsy. Our patient was on intermittent NIV, and the procedure was undertaken once the patient could tolerate NIV-free periods without any respiratory distress. However, the challenge of the patient’s inability to lie supine remained. The costoclavicular approach could not be instituted as the patient had a right-sided subclavian central venous catheter. Hence, correct transducer placement and proper visualization of the brachial plexus were not possible (Fig. 1c). We also excluded the possibility of axillary BPB due to the presence of fungal skin infection. We opted for USG guided infraclavicular BPB, but discrimination of individual cords was not feasible. Hence, we used a combination of ultrasound and nerve stimulation for a sure-fire successful RA technique.
A successful infraclavicular BPB can be achieved either with electrostimulation or ultrasound guidance in experienced hands. However, USG shortens performance time compared to the dual-motor endpoint stimulation [2]. Although the LA deposition at a single point, cranioposterior to the axillary artery, could result in successful infraclavicular BPB, the success rate was reported to be higher with multiple-injection (53–100%) [4]. Gurkan et al. reported a similar success rate between dual guidance (95%) and single motor endpoint stimulation (93%) [5]. Hence, the use of ultrasound without neurostimulation may be sufficient to achieve a successful infraclavicular BPB. However, in particular cases, electrostimulation as an adjunct may help in the identification of individual cords based on the motor response as well as act as a safety monitor to prevent intraneural injection [1].
To conclude, Dual guidance was necessary for our patient to perform the infraclavicular BPB. Ultrasound helped in real-time visualization of spread and reduced the LA volume, while peripheral nerve stimulation aided in accurate localization of cords with evoked motor responses.

References

1. Gadsden JC. The role of peripheral nerve stimulation in the era of ultrasound-guided regional anaesthesia. Anaesthesia 2021;76 Suppl 1:65-73.
2. Brull R, Lupu M, Perlas A, Chan VW, McCartney CJ. Compared with dual nerve stimulation, ultrasound guidance shortens the time for infraclavicular block performance. Can J Anaesth 2009;56:812-8.
3. Dingemans E, Williams SR, Arcand G, Chouinard P, Harris P, Ruel M, et al. Neurostimulation in ultrasound-guided infraclavicular block: A prospective randomized trial. Anesth Analg 2007;104:1275-80.
4. Sauter AR, Dodgson MS, Stubhaug A, Halstensen AM, Klaastad Ø. Electrical nerve stimulation or ultrasound guidance for lateral sagittal infraclavicular blocks: A randomized, controlled, observer-blinded, comparative study. Anesth Analg 2008;106:1910-5.
5. Gurkan Y, Acar S, Solak M, Toker K. Comparison of nerve stimulation vs. ultrasound-guided lateral sagittal infraclavicular block. Acta Anaesthesiol Scand 2008;52:851-5.

How to Cite this Article: Shanker V, Mistry M, Palanichamy G, Balavenkatasubramanian J | Dual Guidance in the Era of Ultrasound: An Overlooked Necessity or a Luxury! | International Journal of Regional Anaesthesia | January-June 2022; 3(1): 35-36.

 

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