Postamputation limb pain

Following limb amputation a patient may experience residual limb pain, phantom pain and phantom sensation. Early recognition and management is important because it may prevent the transition from acute to chronic pain.

Residual limb pain (also known as stump pain) is pain localised to the site of limb amputation. It can be acute (usually nociceptive) or chronic (usually neuropathic). Evaluate patients with residual limb pain for local factors such as inflammation or irritation due to the prosthesis, and formation of a neuroma from the cut nerve endings.

Phantom pain is perceived as pain arising from the missing limb. Phantom pain is common after limb amputation (75% of patients will experience it within the first few days following limb amputation). It is often neuropathic and difficult to manage. Prevention and early treatment are important—strategies include:

• perioperative epidural anaesthesia and analgesia (evidence of efficacy is limited)
• postoperative calcitonin (intravenous or subcutaneous) may reduce acute phantom pain and prevent transition to chronic pain.

Drugs used for the management of phantom pain include ketamine (specialist only), gabapentinoids, tricyclic antidepressants or serotonin and noradrenaline reuptake inhibitors. Opioids are not a first-line treatment. Consider the role of adjuvants in chronic noncancer pain.

Graded motor imagery is also used; see Chronic pain management strategies.

If pain is refractory, spinal cord and peripheral nerve stimulation may be considered following multidisciplinary assessment and specialist input.

Phantom sensation is a sensation (excluding pain) perceived as arising from the missing limb. Nearly all patients have phantom sensations in the early months following limb amputation. These generally diminish with time but cannot be treated.