Phantom Leg Pain Synd

[Noyac]

I know some of you get tired of hearing how things are done in PP. so I'll spare you. What I would like to emphasize is that in PP you are not just an anesthesiologist. You will be consulted by your peers on pain issues outside of the OR. Here's my latest consult.

63 yo male with S/P BKA X2 b/c of ischemia now with burning pain in his feet. He is on oxycodone 10mg TID, ativan up to 6mg at night for sleep among other meds. The consult was for help with treating Phantom Leg Pain (PLP). The goal is to get him out of the hospital and to a chronic care facility. he is also very confused.

Anyone want to tackle this one? Chronic pain guys are welcome as well. I'll tell you what I did later.

---

Members don't see this ad.

 

[Planktonmd]

I know some of you get tired of hearing how things are done in PP. so I'll spare you. What I would like to emphasize is that in PP you are not just an anesthesiologist. You will be consulted by your peers on pain issues outside of the OR. Here's my latest consult.

63 yo male with S/P BKA X2 b/c of ischemia now with burning pain in his feet. He is on oxycodone 10mg TID, ativan up to 6mg at night for sleep among other meds. The consult was for help with treating Phantom Leg Pain (PLP). The goal is to get him out of the hospital and to a chronic care facility. he is also very confused.

Anyone want to tackle this one? Chronic pain guys are welcome as well. I'll tell you what I did later.

I would gradually add a TCA and Gabapentin with gradual decrease of Lorazepam hoping the confusion will improve.

A good temporary solution could be an epidural catheter until the other drugs start working.

 

[Mman]

Perhaps pregabalin as opposed to gabapentin if insurance covers it (little better side effect profile, though I'm not sure on difference in efficacy). Agree with TCA as well.

 

[VentdependenT]

cymbalta plus lyrica or neurontin

TCA at night

high dose effexor (don't use if on cymbalta)

pain guys may try an epidural or a spinal nerve stimulator

you can throw a tens on somewhere but I don't know if those things are worth a damn

 

[N2b8]

Add Gabapentin; start with 100 mg tid and titrate up, tops 1600 mg tid

 

[nvrsumr]

Make sure the "basics" arent being missed. Stump shrinker socks, ace wrap or rigid removable device (RRD). The tactile stimulation often helps. Of course neuropathic agent of choice (lyrica may work faster than neurontin). Consider a trial with a lidoderm patch.

Long term the answer is to get this patient up and walking. His continued "confusion" will hinder his ability to receive prosthetic training which will seriously impact his phantom limb pain long term. Anything that can be done to resolve this will be of great benefit to this patient.

Of interest alot of research has been done on "mirror box" rehabilitation. This creates a mirage of the amputated limb fooling the patients "mind" into believing its there. This has been shown to significantly improve PLP and on fMRI to decrease areas of somatosensory cortex invasion by the the area represented by the amputated limb. This makes alot of sense if you believe PLP is a centralization problem.

 

[mille125]

Phantom limb pain is a central pain syndrome (ie pain is coming from the spinal cord). Peripheral techniques like epidural do not work and will fail. Do not do epidural steroids on a patient with phantom limb pain. Membrane stabilizing agents such as neurontin and lyrica are helpful. Cymbalta and elavil have efficacy as well. Ketamine, methadone, and other NMDA agents have a lot of promise. Spinal cord stimulation is helpful as well. If in doubt you should refer to a chronic pain management physician.

 

[Planktonmd]

Phantom limb pain is a central pain syndrome (ie pain is coming from the spinal cord). Peripheral techniques like epidural do not work and will fail. Do not do epidural steroids on a patient with phantom limb pain. Membrane stabilizing agents such as neurontin and lyrica are helpful. Cymbalta and elavil have efficacy as well. Ketamine, methadone, and other NMDA agents have a lot of promise. Spinal cord stimulation is helpful as well. If in doubt you should refer to a chronic pain management physician.

Yes it is most likely central pain, but a temporary epidural can work, and is worth a try, to help the patient in the beginning.
Who said an epidural is a "peripheral" technique?
Do you have data showing that an epidural wouldn't work?

 

[Lizard1]

i'd also try a lumbar sympathetic block to the affected side to determine the sympathetic component. possible neuroma causing the pain that can be treated?

 

[mille125]

Yes it is most likely central pain, but a temporary epidural can work, and is worth a try, to help the patient in the beginning.
Who said an epidural is a "peripheral" technique?
Do you have data showing that an epidural wouldn't work?

do what you want...but dont give this as a board answer...you will fail

 

[Planktonmd]

do what you want...but dont give this as a board answer...you will fail

I passed my boards long time ago, thank you for the advice though.

 

[mille125]

Who said an epidural is a "peripheral" technique?




then as a board certified anesthesiologist I would assume that you would know that the nerve roots are a part of the peripheral nervous system and not the central............wait we learned that as an MS1

 

[Planktonmd]

Who said an epidural is a "peripheral" technique?




then as a board certified anesthesiologist I would assume that you would know that the nerve roots are a part of the peripheral nervous system and not the central............wait we learned that as an MS1

So in your opinion epidurals only site of action is nerve roots?
Look it up.
I hate to engage in this type of exchange, but some people are just too irritating.

 

[mille125]

My wife has said that I am not being very christian. Therefore I retract my last taunting criticism of plankton. Continuous epidural blockade has a "preemptive" role in preventing phantom limb pain when placed in a preoperative setting. However, once phantom limb pain has occurred (as in the case presentation) these blocks are of little value. This is my point. The reason that this irritates me is because I get numerous patients referred to me 3 to 6 mos later after someone tried some "epidural blocks". Time is very important in treating these patients and many times they have been "sentenced" to a prolonged period of intractable pain because of the delay in seeing someone who can actual help them. This is where my frustration lies and I took it out on plankton. This was wrong and I apologize.


PS: I am aware that the spinal root is the most prevalent but not the only site of action of epidural blockade.

 

[Noyac]

My wife has said that I am not being very christian. Therefore I retract my last taunting criticism of plankton. Continuous epidural blockade has a "preemptive" role in preventing phantom limb pain when placed in a preoperative setting. However, once phantom limb pain has occurred (as in the case presentation) these blocks are of little value. This is my point. The reason that this irritates me is because I get numerous patients referred to me 3 to 6 mos later after someone tried some "epidural blocks". Time is very important in treating these patients and many times they have been "sentenced" to a prolonged period of intractable pain because of the delay in seeing someone who can actual help them. This is where my frustration lies and I took it out on plankton. This was wrong and I apologize.


PS: I am aware that the spinal root is the most prevalent but not the only site of action of epidural blockade.

Very refreshing! Yes, someone here is able to counter someone without insulting them. What a change.

Mille, I totally agree, regional (even though it has some central effects) is useless at this point and has been well documented. There are studies countering this but the vast majority show very limited benefits once the insult has occurred.

I must add a few things that I forgot in my rushed state while posting this case. THe first BKA was 3 months earlier and the 2nd was 3 days earlier. The pt was on lovenox pre-op and I believe he was on it post-op but I don't remember at this point b/c it didn't matter to me since i wasn't going to do any regional technique. I wasn't performing a regional at this time since it is ineffective after the fact. Now it may make the pt more comfortable while initiating the pharm therapy but this is temporary at best and I want to know how things are working as I start Neurontin (formulary) Elavil, and calcitonin. Plus I am trying to get him out of the hospital. Nobody mentioned calcitonoin. What's up with that? Otherwise, the responses were great. You guys are good.

 

[Planktonmd]

I never said that an epidural was intended as a long term treatment, but an epidural with local anesthetic + narcotic will diffuse centrally and give you better analgesia than PO Narcotics and also less confusion (the patient was already confused), while in the hospital.
You could even place an intrathecal catheter and use narcotics through it.
These all are temporary measures to achieve less pain and less confusion.
The long term treatment as stated previously has to include multiple pharmacological and non pharmacological modalities, and sometimes is quite disappointing.
I have no experience with calcitonin for this indication.

 

[Noyac]

I never said that an epidural was intended as a long term treatment, but an epidural with local anesthetic + narcotic will diffuse centrally and give you better analgesia than PO Narcotics and also less confusion (the patient was already confused), while in the hospital.
You could even place an intrathecal catheter and use narcotics through it.
These all are temporary measures to achieve less pain and less confusion.
The long term treatment as stated previously has to include multiple pharmacological and non pharmacological modalities, and sometimes is quite disappointing.
I have no experience with calcitonin for this indication.

Very true Plank however, my goal was to get this pt to the extended care facility as soon as possible and an epidural would delay this at least for 2-3days. Plus lovenox is on board.
The confusion dissipated completely when I stopped the ativan and started Elavil. Ketamine was an option i considered but again I was trying to get this pt to the next facility. Therefore, I went with the calcitonin 200IU SQ TID.

 

[militarymd]

How does the Calcitonin work?

 

[militarymd]

My wife has said that I am not being very christian. Therefore I retract my last taunting criticism of plankton. Continuous epidural blockade has a "preemptive" role in preventing phantom limb pain when placed in a preoperative setting. However, once phantom limb pain has occurred (as in the case presentation) these blocks are of little value. This is my point. The reason that this irritates me is because I get numerous patients referred to me 3 to 6 mos later after someone tried some "epidural blocks". Time is very important in treating these patients and many times they have been "sentenced" to a prolonged period of intractable pain because of the delay in seeing someone who can actual help them. This is where my frustration lies and I took it out on plankton. This was wrong and I apologize.


PS: I am aware that the spinal root is the most prevalent but not the only site of action of epidural blockade.

What about a subarachnoid block?

 

[Noyac]

How does the Calcitonin work?

I don't know. But this article has a few theories: http://www.turner-white.com/pdf/hp_jun03_treat.pdf


Its definitely not the cure all but nothing is and it was in my opinion my best option.

 

[Noyac]

What about a subarachnoid block?

Yes, but temporary at this point. And there is that lovenox if that concerns you.

 

[IN2B8R]

Theorized to be similar in action as Substance-P.

How does the Calcitonin work?

 

[Lizard1]

Ironically I was consulted on a pt in the ER today who c/o phantom leg pain that was excruciating. He had failed a SCS, was "allergic" to membrane stabilizers and the only thing that helped him was methadone 320mg qd, morphine 240md qd and "oxydose" 220mg qd. He reported that he was being given to him by his private pain doc who all of the sudden fired him today and didn't give him any Rx's to go out on or try a taper. Well, I know I'm calling bs on this guy and look in his records and of course see drug seeking behavior for the last 15yrs as well at different pain clinics that we rotate at.

So I basically tell him he's out of luck, I don't feel comfortable prescribing him these meds on my DEA # and set him up in mental health for methadone detox, chronic pain rehab and with a pain psychologist for coping skills. I also recommended(i.e. i did not accept him ) that his PCP could try calcitonin therapy if they wanted to admit him and I'd help out with that. I do believe he has chronic pain but also believe he is abusing opioids. I hope to get the chance to try calcitonin on this guy......

 

[Noyac]

I hope to get the chance to try calcitonin on this guy......

I wouldn't be surprised if it didn't work in this case. I"ll bet nothing will work with the exception of narcotics. This guy is doomed without rehab IMHO. But I wouldn't hesitate to try it.

 

[VolatileAgent]

ketamine "holiday". works almost like magic. there is also mounting evidence that escalating doses of mu-receptor drugs (opioids) exacerbate pain syndromes over the long haul.

http://www.sciencedirect.com/scienc...serid=10&md5=a1cd64cfceb22dd1256427da0ff4fade

 

[mille125]

there is also mounting evidence that escalating doses of mu-receptor drugs (opioids)





this has been known for sometime...called opioid induced hyperalogesia

 

[mille125]

Ironically I was consulted on a pt in the ER today who c/o phantom leg pain that was excruciating. He had failed a SCS, was "allergic" to membrane stabilizers and the only thing that helped him was methadone 320mg qd, morphine 240md qd and "oxydose" 220mg qd. He reported that he was being given to him by his private pain doc who all of the sudden fired him today and didn't give him any Rx's to go out on or try a taper. Well, I know I'm calling bs on this guy and look in his records and of course see drug seeking behavior for the last 15yrs as well at different pain clinics that we rotate at.

So I basically tell him he's out of luck, I don't feel comfortable prescribing him these meds on my DEA # and set him up in mental health for methadone detox, chronic pain rehab and with a pain psychologist for coping skills. I also recommended(i.e. i did not accept him ) that his PCP could try calcitonin therapy if they wanted to admit him and I'd help out with that. I do believe he has chronic pain but also believe he is abusing opioids. I hope to get the chance to try calcitonin on this guy......

it would take a lot for me to "fire" a phantom limb pain patient...he must have been abusing or diverting his medications

 

[Noyac]

ketamine "holiday". works almost like magic. there is also mounting evidence that escalating doses of mu-receptor drugs (opioids) exacerbate pain syndromes over the long haul.

http://www.sciencedirect.com/scienc...serid=10&md5=a1cd64cfceb22dd1256427da0ff4fade

Yes Ketamine works well and I spoke with pharmacy about a ketamine infusion should my plan not work. If you remember, this guy was confused most likely from all the ativan and I didn't want to add to the confusion. Mostly, I wanted the confusion to go away. This is one reason to avoid ketamine. The other was that I was trying to get him out of the hospital. A ketamine infusion would mean he stays.

 

[VolatileAgent]

Yes Ketamine works well and I spoke with pharmacy about a ketamine infusion should my plan not work. If you remember, this guy was confused most likely from all the ativan and I didn't want to add to the confusion. Mostly, I wanted the confusion to go away. This is one reason to avoid ketamine. The other was that I was trying to get him out of the hospital. A ketamine infusion would mean he stays.

agreed. those are obstacles. you have to commit to a low dose infusion over a few days. we used to have a guy here who cured many patients from persistent phantom limb pain and CRPS using low dose ketamine infusion. it was done as an intermediate care admission. i can't remember the exact protocol, but his patients treated him like he walked on water after they went through it.

 

[urgewrx]

how about iv lidocaine drip? Change it to po mexiletine in a few days.
​

 

[mille125]

how about iv lidocaine drip? Change it to po mexiletine in a few days.
​

i have not had a lot of success with mexilitine. i think that it is fourth line at best...

 

[Planktonmd]

how about iv lidocaine drip? Change it to po mexiletine in a few days.
​

Are people still doing this?
If I remember correctly there was some disappointing data when this was used for post herpetic neuralgia.

 

[Noyac]

Are people still doing this?
If I remember correctly there was some disappointing data when this was used for post herpetic neuralgia.

Some of the data was disappointing and some of it was encouraging. Mostly, I think it is a practice of the past.

 

[2ndyear]

Yes Ketamine works well and I spoke with pharmacy about a ketamine infusion should my plan not work. If you remember, this guy was confused most likely from all the ativan and I didn't want to add to the confusion. Mostly, I wanted the confusion to go away. This is one reason to avoid ketamine. The other was that I was trying to get him out of the hospital. A ketamine infusion would mean he stays.

My anecdotal experience with low dose ketamine infusions (n=5) shows little to no confusion. These were all really low dose though, about 0.2-25 mg/kg/hr. On my pain rotation we did send one patient home on ketamine, but there was a visiting nurse service in place and the diadnosis was terminal cancer and bone pain mets.

 

[VentdependenT]

We use ketamine over at Rush for CRPS patients. They receive a series of 3hr infusions intermittently with blocks. Dunno the dosing however.

I don't see how it would hurt in the case of phantom limb pain as it is centrally mediated as well.

 

[mille125]

We use ketamine over at Rush for CRPS patients. They receive a series of 3hr infusions intermittently with blocks. Dunno the dosing however.

I don't see how it would hurt in the case of phantom limb pain as it is centrally mediated as well.

you can also get your pharmacy to compound ketamine in a topical/cream form. this works well for CRPS. I have several CRPS patients that swear by it. KAN (ketamine/amitriptyline/neurontin) cream works well.

 

[Noyac]

you can also get your pharmacy to compound ketamine in a topical/cream form. this works well for CRPS. I have several CRPS patients that swear by it. KAN (ketamine/amitriptyline/neurontin) cream works well.

Dude thats awesome. I have never heard of this. How is it used?