1 / 29

Morning Report

Morning Report. Steven Hart. HPI. 45 year old female presents to clinic to establish new PMD CC: left leg pain Recent medical history Pain in left LE for 1 mo with several visits to ER left femoral thrombus and emboli to left lower extremity eventually diagnosed Left AKA required

yves
Download Presentation

Morning Report

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Morning Report Steven Hart

  2. HPI • 45 year old female presents to clinic to establish new PMD • CC: left leg pain • Recent medical history • Pain in left LE for 1 mo with several visits to ER • left femoral thrombus and emboli to left lower extremity eventually diagnosed • Left AKA required • Now (6 weeks later) c/o persistent pain where lower left leg was and sensations in left leg. • Started on coumadin prior to discharge

  3. Physical exam • C/w left AKA • Incisions clean and healing well • Non-tender, no erythema, skin intact • Exam otherwise unremarkable

  4. Topics • Phantom Limb Pain (PLP) • Definitions • Epidemiology • Etiology / Pathophysiology • Evaluation / Differential • Treatment • Prevention / Short term • Long term

  5. Definitions • Stump pain • Pain in the residual portion of the limb • Phantom Limb Pain (PLP) • A painful sensation perceived in a missing limb after amputation • Phantom Limb Sensation (PLS) • Any sensation of the missing limb (paresthesia, dysesthesia, hyperpathia) except pain.

  6. Epidemiology • Phantom Limb Sensation (PLS) • Occurs in 85% - 98% of amputees within 3 weeks of amputation • 8% may occur after 1-12 months • Usually resolves after 2 – 3 years spontaneously if PLP does not develop • Location affects intensity and likelihood of PLS • Proximal ie. Above the knees or elbows • Dominant extremity

  7. Epidemiology • Phantom Limb Pain (PLP) • 60-70% of amputes experience PLP • Location again an important factor • Proximal • 68-88% hemipelvectomy • 40-88% hip disarticulation • 51% upper limb • 20% AKA • 0-2% BKA

  8. Epidemiology • Phantom Limb Pain (PLP) – continued • Time • Occurs 1 week to decades after amputation • Pain onset after one year in < 10% • May diminish and eventually resolve with time • More likely, however, it will persist chronically • Pain in limb prior to amputation increases risk for PLP • Pains in other parts of the body • Headache • Joint pain • Sore throat • Abd pain • Back pain

  9. Epidemiology • Stump Pain • Occurs in about 50% of amputees • Frequently associated with phantom pain

  10. Etiology • Neuromas • Dominate theory until last 10-15 years • Irritation of the severed nerve endings • Inflammation resulted in anomalous signals to the brain perceived as pain. • Treatments included removal of nerve endings or further amputation. • Only resulted in temporary improvement • Eventually pain returned, frequently worse • Modern thought - One of many factors causing PLP

  11. Etiology • Neuroma – their role •  mechanical/neurostimulation  spontaneous and abnormal evoked activity   in sodium channel production   in sensitivity of neuromas to norepinephrine • Thus, pain with stress or other emotional states • A similar phenomenon occurs in the cell body of the dorsal root ganglia just upstream

  12. Etiology -spinal cord level •  signal from neuromas and doral root ganglia cell bodies   activity of neurons in dorsal horns   upregulation of several genes - especially receptive genes -  in N-methyl-D-aspartate (NDMA)

  13. Etiology -spinal cord level • Anatomical reorganization (rewiring) • Perph nerve transection  degeneration of afferent C-fiber terminals in Lamina II • These may replaced by A mechanoreceptive afferents • Results in pain evoked by simple touch

  14. Etiology - Central mechanism • Somatosensory cortex remapping • PLS/PLP evoked by touching face in a hand amputee • Verified by multiple neuroimaging studies in humans

  15. Etiology - Central mechanism • Plastic changes occur in the Thalamus • Stimulation of thalamus in amputees causes PLP and PLS • Similar stimulation does not cause any pain in non-amputees

  16. Differential Diagnosis of PLP • Radicular pain • Disk herniation • Angina • Post herpetic neuralgia • Metastatic cancer • Infection / poor wound healing

  17. Treatment of PLP -Overview • Poorly studied field • placebo effect common • Spontaneous resolution does happen • Fewer than 10% of PLP patients receive lasting relief • Frequently, neuropathic treatment recommended, but few studies to support this • Most neuropathic treatment trials do not include PLP • Prevention of PLP is a new area of interest

  18. Treatment of PLP -Overview • Multiple approaches • Prevention • Medical • Physical Therapy • Nerve Blocks • Nerve stimulation • Transcutaneous, spinal cord, deep brain, motor • ECT • Psychological Therapy

  19. Treatment of PLP -Prevention • Goal – avoid/control the changes that lead to chronic pain • Prevent or control pre, peri and post-operative pain • Use of pre, intra and post-op epidural blocks has been shown to reduce occurrence of PLP at 12 mo post-op • Mixed results in follow up studies

  20. Treatment of PLP -Prevention • Calcitonin infusions • Ketamine • Transcutaneous electrical stimulation

  21. Treatment of PLP -Medical Management • Anti-depressants • Tricyclic anti-depressants • Anti-convulsants • NMDA receptor antagonists • Opiates • Beta Blockers • Misc

  22. Treatment of PLP -Medical Management • Tricyclic anti-depressants • Frequently used • Well studied in other neuropathic pain syndromes • Diabetes, post herpetic neuralgia • Poorly studied in PLP • One randomized study showed no effect, other studies showed some benefit

  23. Treatment of PLP -Medical Management • Anti-convulsants • Carbamazepine • Effective for intense, brief, lancinating type of pain • Gabapentin • Effective in one small randomized trial • Topiramate • Small randomized study supported it effectiveness

  24. Treatment of PLP -Medical Management • Opiates • Effective for both stump pain and PLP • May affect cortical reorganization • Considered the mainstay of treatment • Tolerance/Addiction • Most amputees have a short life expectancy because of underlying disease. • Balance quality of life vs risk of opiate addiction/dependence

  25. Treatment of PLP -Medical Management • NMDA receptor antagonists • Ketamine – effective, must be IV • Memantine – oral, ineffective • Dextromethorphan • Small randomized studies have supported its use. • Improved feeling • No, small sedation • No increased side effects from placebo

  26. Treatment of PLP -Physical Therapy • Sensory discrimination training • Designed to alter the cortical map • Shown to significantly reduce PLP and cortical reorganization

  27. Treatment of PLP -Neurostimulation • Transcutaneous electrical nerve stimulation • Spinal Cord Stimulation • Deep brain stimulation • Motor cortex stimulation • All very preliminary

  28. Treatment of PLP • Acupuncture • May provide short term relief • ECT • Several case reports of pain resolution after treatment • Psychological Therapy • Relaxation training • hypnosis

  29. Conclusion • PLP is common in amputees • The cause is complicated and involves virtually all levels of the nervous system • Prevention of chronic pain may be possible but further investigation is needed • Chronic pain management is difficult and should be multifaceted • There is little evidence to guide therapy at this time.

More Related