Karsten Krøner

The influence of preamputation pain on postamputation stump and phantom pain

Abstract The significance of preamputation pain for the development of postamputation stump and phantom pain has been discussed over the years and is still a matter of dispute. It has been argued that preamputation pain increases the risk of phantom pain and that phantom pain is a revivification of pain experienced before the amputation. The purpose of this prospective study was to clarify the relation between preamputation pain and phantom pain. Fifty‐six patients scheduled for amputation of a lower limb were interviewed the day before the amputation about preamputation pain and about stump and phantom pain 1 week, 3 and 6 months after the amputation. Pain was quantitated and described using a visual analogue scale (VAS), 10 different word descriptors, the McGill Pain Questionnaire (MPQ) and the patients own words. If phantom pain was present patients were asked if the pain was similar to any pain experienced before the amputation. At each postoperative interview patients were asked to recall preamputation pain intensity. Location of pain and analgesic requirements were registered. Preamputation pain significantly increased the incidence of stump pain (P=0.04) and phantom pain (P=0.04) after 1 week and the incidence of phantom pain after 3 months (P=0.03). About 42% of the patients reported that their phantom pain resembled the pain they had experienced at the time of the amputation. However, there was no relation between the patients own opinion about similarity between preamputation pain and phantom pain and the actual similarity found when comparing pre‐ and postoperative recordings of pain. Patients significantly overestimated preamputation pain intensity after 6 months.

Randomised trial of epidural bupivacaine and morphine in prevention of stump and phantom pain in lower-limb amputation

BACKGROUNDnEpidural analgesia before limb amputation is commonly used to reduce postamputation pain. But there have been no controlled studies with large numbers of patients to prove such a pre-emptive effect. We investigated whether postamputation stump and phantom pain in the first year is reduced by preoperative epidural blockade with bupivacaine and morphine.nnnMETHODSnIn a randomised, double-blind trial, 60 patients scheduled for lower-limb amputation were randomly assigned epidural bupivacaine (0.25% 4-7 mL/h) and morphine (0.16-0.28 mg/h) for 18 h before and during the operation (29 patients; blockade group) or epidural saline (4-7 mL/h) and oral or intramuscular morphine (31 patients; control group). All patients had general anaesthesia for the amputation and were asked about stump and phantom pain after 1 week and then after 3, 6, and 12 months by two independent examiners. Study endpoints were rate of stump and phantom pain, intensity of stump and phantom pain, and consumption of opioids.nnnFINDINGSnTwo patients in each group were withdrawn before amputation. The groups were well matched in baseline characteristics. Median duration of preoperative saline treatment was 18.5 h (IQR 17-20). Median duration of preoperative epidural blockade in the blockade group was 18 h (15-20.3). The combined median duration of postoperative epidural pain treatment in both groups was 166 h (89.3-308.3). After 1 week, 14 (52%) patients in the blockade group and 15 (56%) in the control group had phantom pain (95% CI - 30.6 to 22.7, p = 0.9). The figures for blockade versus control group were: 14 (82%) vs ten (50%; 4.0 to 60.8, p = 0.09) at 3 months; 13 (81%) vs 11 (55%; -2.7 to 55.3, p = 0.2) at 6 months; and nine (75%) vs 11 (69%; -27.0 to 39.6, p = 1.0) at 12 months. Intensity of stump and phantom pain and consumption of opioids were similar in both groups at all four postoperative interviews.nnnINTERPRETATIONnPerioperative epidural blockade started a median of 18 h (15-20.3) before the amputation and continued into the postoperative period does not prevent phantom or stump pain.

Immediate and long-term phantom breast syndrome after mastectomy: incidence, clinical characteristics and relationship to pre-mastectomy breast pain

&NA; Phantom breast syndrome (PBS) following mastectomy has already been reported by other authors. The temporal course, character and extent of these phenomena, however, have not yet been elucidated. In a prospective study, we investigated the incidence, clinical picture and the temporal course of PBS. One hundred and twenty women who, during a 1 year period, embarked consecutively on post‐operative control or treatment at the department, were interviewed by a standard questionnaire 3 weeks after the operation. One year later 110 patients were interviewed again. The median age at the first interview was 54 years (Q1 = 45 years; Q3 = 62 years). The incidence of PBS was 25.8% at the first interview and 24.5% at the second. The incidence of phantom pain and non‐painful phantom sensations was 13.3% and 15.0%, respectively, 3 weeks after mastectomy and 12.7% and 11.8%, respectively after 1 year. We found significant relationships between pre‐operative pain and PBS, but no significant relation between age and the occurrence of PBS. Neither post‐operative sequelae nor cancer treatment including radiotherapy seemed to affect the occurrence of PBS. Exteroceptive‐like pain emerged as the most predominant type of pain from both interviews. At the time of the first interview, 35.0% of the patients experienced cicatrix pain which was clearly distinguishable from phantom pain; after 1 year, 22.7% of the patients had persistent cicatrix pain. The present incidence of PBS is close to the incidence reported by others. Persistent phantom pain may, however, be more common than usually expected. Also persistence of cicatrix pain seems to be more common than generally expected.

Codeine plus paracetamol versus paracetamol in longer-term treatment of chronic pain due to osteoarthritis of the hip. A randomised, double-blind, multi-centre study

&NA; This randomized, double‐blind, multi‐centre study was undertaken to evaluate the efficacy and safety of treatment for 4 weeks with codeine plus paracetamol versus paracetamol in relieving chronic pain due to osteoarthritis of the hip. A total of 158 outclinic patients entered the study. Eighty‐three patients (mean age 66 years) were treated with codeine 60 mg plus paracetamol 1 g 3 times daily, and 75 patients (mean age 67 years) with paracetamol 1 g 3 times daily. Ibuprofen 400 mg was prescribed as rescue medication. Due to an unexpected high rate of adverse drug reactions, the study was closed before the planned 400 patients had entered. Over weeks 1–4, 87%, 64%, 61% and 52% of patients in the codeine plus paracetamol group, and 38%, 31%, 22% and 29% of patients in the paracetamol group had one or more adverse drug reactions. Significantly more patients in the codeine plus paracetamol group had adverse drug reactions in each of the 4 weeks. Nausea, dizziness, vomiting and constipation were predominant adverse reactions in the codeine plus paracetamol group. During the first week of treatment, 30 patients (36%) in the codeine plus paracetamol group and 9 (12%) in the paracetamol group dropped out. As evaluated from patients completing the first week of treatment, the pain intensity during that week compared to their baseline pain was significantly lower in the codeine plus paracetamol group than in the paracetamol group. Moreover, during the first week the paracetamol group received rescue medicine significantly more frequently. In conclusion, when evaluated after 7 days of treatment, the daily addition of codeine 180 mg to paracetamol 3 g significantly reduced the intensity of chronic pain due to osteoarthritis of the hip joint. However, several adverse drug reactions, mainly of the gastrointestinal tract, and the larger number of patients withdrawing from treatment means that the addition of such doses of codeine cannot be recommended for longer‐term treatment of chronic pain in elderly patients.

Phantom-related phenomena after rectal amputation: prevalence and clinical characteristics

Phantom sensations are well known and almost inevitable sequels to limb amputation, whereas similar phenomena are only rarely described after rectum amputation (phantom rectum). Our study attempted to assess the frequency and character of phantom rectum. All surviving patients (n = 22), who had undergone abdominoperineal surgical resection of the rectum in the period 1980-1986 at our clinic, were interviewed by a standard questionnaire and underwent a physical examination. Sixty-eight per cent of the patients experienced a sensation of a missing rectum (phantom rectum), and in 27% of these or 18% of all patients this sensation was painful (phantom pain). The most common symptoms were sensations of flatus and/or faeces in a normal rectum, phantom flatus or phantom faeces. The phantom pains were described as either pricking and shooting or like haemorrhoids or hard stools that would rupture the rectum. Neither age, sex, preoperative pain, the Duke classification of the tumour nor the healing of the perineal wound seemed related to the likelihood of phantom rectum. The pathophysiological mechanisms underlying phantom-related phenomena following amputation have not yet been elucidated. This study describes a relatively unknown phantom-related clinical entity after amputation and may thus contribute to the understanding of this phenomenon.

Strength Pattern of Cancellous Bone at the Ankle Joint

The strength pattern of cancellous bone was examined in 17 ankles by a cylinder compression test and in eight distal tibial specimens by an osteopenetration test.With the compression test, 6 mm lev...

Distribution of bone strength at the distal tibia and fibula

Abstract A study on the topographical variation of penetration strength of the malleoli and the central tibia in levels parallel to the joint surface was carried out. Eight distal tibial specimens were obtained at autopsy (mean age 72 years, range 49–87 years). The bone strength profile at level 1 on the tibia showed maxima at the anterolateral and posteromedial areas. At the lateral malleolus, a high strength region was located in the central area. No constant strength pattern could be recognized at the medial malleolus. The average strength ratio between both malleoli and the central tibia was 0·9:1. There was a statistically significant reduction in bone strength with depth at nearly all locations.

Codeine plus paracetamol versus paracetamol in longer-term treatment of chronic pain due to coxarthrosis. a randomized, double-blind, multi-centre study

CODEINE PLUS PARACETAMOL VERSUS PARACETAMOL IN LONGER-TERM TREATMENT OF CHRONIC PAIN DUE TO COXARTHROSIS. A RANDOMIZED, DOUBLE-BLIND, MULnTf-CENTRE.4TUDY. P. Kiaersaaard-Anderse , A. Nafer , 0. Skovf3, F. Madsen*‘, H. M. Andersen*4, K. Krraner’, I. Hvass ‘, 0. Gjederum*7, L. Pedersen**, P. E. Branebjerg**. ‘O

Phantom related phenomena after mastectomy

opaedic Hospital, 8200 Aarhus N., Denmark; Depts. of Orthop. Surg. in ‘Holstebro, Kolding, 4Haderslev, 5Horsens, ‘&.bjerg, 7Aalborg; and*DAK-laboratoriet a/s, Copenhagen, Denmark. ACC Hall C

Phantom limb phenomena in amputees 7 years after amputation

School of Medicine, Yonago, Tottori, Japan 683 Aim of Investigation: It is very difficult and controversial to decide the proper management of tic douloureux in the elderly, especially when they are over 70 years old. At the beginning of our experiences in microvascular decompression(MVD) for tic douloureux, it appeared impossible to accomplish it without any trouble in the elderly. So, we selected radiofrequency coagulation as a first procedure in the aged. But experiences and technical advances changed our strategy to select MVD as a first choice for tic douloureux even in the elderly. The aim of the paper is to present our technical details and results of MVD for the elderly(> 70). Methods: The patient was placed in lateral decubitus position and a small craniectomy (1.5 2 cm) was palced at the junction of the transverse and sigmoid sinus. The trigeminal nerve was decompressd with small pieces of teflon strands without sacrifice of petrosal veins. Results: Among 37 patients who had been performed MVD in our clinic, 9 patients were over 70 years old including 5 patients over 80 with the longest follow-up period 3.5 years (mean 19.8 months). There has been no recurrence so far contrasting with frequent recurrences in short term in radiofrequency gasserian coagulation procedures. Conclusions: In the management of tic douloureux, MVD should be the first choice procedure even if the patient is over 80 years old. At the operation, the cerebellum is slack, easy to retract, and rapid to access to the trigeminal root entry zone. And the compressive structures (including 1 epidermoid) had been clearly identified and decompressed in all cases over 70 years old.