Phantom limb pain (PLP) is difficult to control, and patients frequently exhibit inadequate relief from medications or encounter unbearable side effects. We present here a novel application of erector spinae plane (ESP) block to manage PLP. Our patient is a 23-year-old, college student, diagnosed with high-grade osteosarcoma of the right humerus who underwent a right shoulder disarticulation. He reported PLP despite multimodal analgesia postoperatively. An ESP block using a high-frequency linear probe ultrasound was performed. A G23 spinal needle was advanced inplane toward the right T3 transverse process. After negative aspiration, 20 mL of therapeutic solution containing bupivacaine 0.25%, lidocaine 1%, epinephrine 5 mcg/ml, and 40 mg methylprednisolone was injected. After the procedure, the patient reported that his PLP went down to NRS 1/10. He consistently reported to have an NRS score of 0-1/10 on succeeding consultations despite discontinuation of opioid and pregabalin. In literature, ESP block has been used as a regional technique for shoulder disarticulation surgery and other neuropathic pain conditions, but no account has shown its use for PLP treatment. The procedure was successfully done to alleviate the upper extremity phantom limb pain, significantly reduce analgesic requirements, and improve tolerance of physical therapy and overall quality of life.
Phantom Limb ; Cancer Pain

BACKGROUND: We utilized diffusion tensor imaging (DTI) to evaluate the cerebral white matter changes that are associated with phantom limb pain in patients with unilateral arm amputation. It was anticipated that this would complement previous research in which we had shown that changes in cerebral blood volume were associated with the cerebral pain network. METHODS: Ten patients with phantom limb pain due to unilateral arm amputation and sixteen healthy age-matched controls were enrolled. The intensity of phantom limb pain was measured by the visual analogue scale (VAS) and depressive mood was assessed by the Hamilton depression rating scale. Diffusion tensor-derived parameters, including fractional anisotropy, mean diffusivity, axial diffusivity (AD), and radial diffusivity (RD), were computed from the DTI. RESULTS: Compared with controls, the cases had alterations in the cerebral white matter as a consequence of phantom limb pain, manifesting a higher AD of white matter in both hemispheres symmetrically after adjusting for individual depressive moods. In addition, there were associations between the RD of white matter and VAS scores primarily in the hemispheres related to the missing hand and in the corpus callosum. CONCLUSIONS: The phantom limb pain after unilateral arm amputation induced plasticity in the white matter. We conclude that loss of white matter integrity, particularly in the hemisphere connected with the missing hand, is significantly correlated with phantom limb pain.
Amputation ; Anisotropy ; Arm ; Blood Volume ; Brain ; Chronic Pain ; Complement System Proteins ; Corpus Callosum ; Depression ; Diffusion ; Diffusion Tensor Imaging ; Hand ; Humans ; Magnetic Resonance Imaging ; Neuronal Plasticity ; Phantom Limb ; Plastics ; White Matter

To investigate the role of p38MAPK signal pathway in spinal cord and dorsal root ganglion (DRG) in rats with phantom limb pain and the effects of specific inhibitors.
 Methods: Healthy adult male SD rats (n=48) were cut off one side of the sciatic under anesthesia to establish a model of phantom limb pain. In addition, the healthy rats were taken as a sham group (group S, n=24). The animals were scored by observing the action of chewing (0=no chewing, 13=the worst chewing) after the operation and were sacrificed on the following day after the operation. The successful model of phantom limb pain were randomly divided into 2 groups: a phantom limb pain group (group P, n=24) and a phantom limb pain plus inhibitor group (group P+I, n=24). SB203580 was given to the rat at 0.8 mg/kg on every Monday until the rats were sacrificed, the rest of the rats received an equal amount of saline. Eight rats from each group were randomly taken for the determination of levels of P-p38MAPK in spinal cord and DRG before administration and on the 4th, 6th, 8th weekend following the administration, respectively.
 Results: In the sham group, no animal developed chewing. Meanwhile, rats in successful model of phantom limb pain group began chewing from the 2nd day after operation with scores at eight to eleven. The chewing scores in the P+I group were reduced after the treatment. Compared with group S, P-p38MAPK levels were elevated in groups of P and P+I (P<0.05 or P<0.01). Compared with group P, P-p38MAPK level was decreased in the group P+I (P<0.05 or P<0.01).
 Conclusion: P38MAPK signal pathway involves in the development of phantom limb pain.
Animals ; Disease Models, Animal ; Enzyme Inhibitors ; pharmacology ; Ganglia, Spinal ; enzymology ; Imidazoles ; pharmacology ; Male ; Mastication ; physiology ; Phantom Limb ; enzymology ; etiology ; physiopathology ; Pyridines ; pharmacology ; Random Allocation ; Rats ; Rats, Sprague-Dawley ; Sciatic Nerve ; injuries ; Self Mutilation ; enzymology ; physiopathology ; Signal Transduction ; Spinal Cord ; enzymology ; p38 Mitogen-Activated Protein Kinases ; antagonists & inhibitors ; metabolism

Since the phantom limb sensation was first described by the French military surgeon Ambroise Pare in the 16th century, the number of studies surrounding phantom limb pain has increased every year. Especially in recent decades, scientists have achieved a better understanding of the mechanism and treatment of phantom limb pain. Although many hypotheses have been agreed and many treatments have been proven effective, scientists still do not have a very systematic understanding of the phantom limbs. The purpose of this review article is to summarize recent researches focusing on phantom limb in order to discuss its definition, mechanisms, and treatments.
Amputation ; Humans ; Lower Extremity ; Phantom Limb ; etiology ; therapy

Amputation stump pains can be developed in amputation sites after high voltage electrical burn injuries. We experienced one case of these severe stump pains in an upper extremity amputation patient. A 35-year-old man had a 38% total body surface area high voltage electrical burn. The patient underwent skin grafting and left shoulder disarticulation. During the rehabilitation period, he complained about severe stump area pains and phantom pains. We injected 0.5% Bupivacaine and Triamcinolone on the stump neuroma site but the pain sustained. After extracorporeal shock wave therapy (ESWT,) the pain subsided and did not recur. The patient was satisfied with functional and pain outcomes, so we report this case.
Adult ; Amputation ; Amputation Stumps ; Body Surface Area ; Bupivacaine ; Burns ; Disarticulation ; Humans ; Neuroma ; Phantom Limb ; Rehabilitation ; Shock* ; Shoulder ; Skin Transplantation ; Triamcinolone ; Upper Extremity

BACKGROUND AND PURPOSE: Neuropathic pain (NeuP) associated with traumatic brachial plexus injury (BPI) can be severe, persistent, and resistant to treatment. Moreover, comorbidity associated with NeuP may worsen the pain and quality of life. This study compared persistent NeuP after BPI between patients with and without co-morbid conditions (psychiatric dysfunction and other painful conditions) and tramadol usage as a second-line agent in combination with an antiepileptic and/or antidepressant during a 2-year follow-up. METHODS: The medical records of patients diagnosed with BPI referred to a pain center between 2006 and 2010 were reviewed for 2 years retrospectively. Data regarding patient demographics, injury and surgical profiles, characteristics of NeuP and its severity, and treatment received were compared between patients with and without manifesting co-morbid conditions. The NeuP and pain intensity assessments were based on the DN4 questionnaire and a numerical rating scale, respectively. RESULTS: Of the 45 patients studied, 24 patients presented with one of the following co-morbid conditions: myofascial pain (21%), psychiatric disorder (17%), phantom limb pain (4%), complex regional pain syndrome (21%), and insomnia (37%). Tramadol was required by 20 patients with co-morbidity and, 9 patients without co-morbidity (p<0.001). The mean pain score after 2 years was higher in patients with co-morbidity than in those without co-morbidity (p<0.05). CONCLUSIONS: Persistent pain following BPI was more common in patients manifesting other painful conditions or psychiatric co-morbidity. A higher proportion of the patients in the co-morbid group required tramadol as a second-line of agent for pain relief.
Adult* ; Brachial Plexus* ; Comorbidity ; Demography ; Follow-Up Studies ; Humans ; Medical Records ; Neuralgia* ; Pain Clinics ; Phantom Limb ; Quality of Life ; Retrospective Studies ; Sleep Initiation and Maintenance Disorders ; Tramadol

Phantom limb pain is a phenomenon in which patients experience pain in a part of the body that no longer exists. In several treatment modalities, spinal cord stimulation (SCS) has been introduced for the management of intractable post-amputation pain. A 46-year-old male patient complained of severe ankle and foot pain, following above-the-knee amputation surgery on the right side amputation surgery three years earlier. Despite undergoing treatment with multiple modalities for pain management involving numerous oral and intravenous medications, nerve blocks, and pulsed radiofrequency (RF) treatment, the effect duration was temporary and the decreases in the patient's pain score were not acceptable. Even the use of SCS did not provide completely satisfactory pain management. However, the trial lead positioning in the cauda equina was able to stimulate the site of the severe pain, and the patient's pain score was dramatically decreased. We report a case of successful pain management with spinal cauda equina stimulation following the failure of SCS in the treatment of intractable phantom limb pain.
Amputation ; Ankle ; Cauda Equina* ; Foot ; Humans ; Male ; Middle Aged ; Nerve Block ; Pain Management ; Phantom Limb* ; Spinal Cord Stimulation* ; Spinal Cord*

A 37-year-old man with a right transfemoral amputation suffered from severe phantom limb pain (PLP). After targeting the affected supplementary motor complex (SMC) or primary motor cortex (PMC) using a neuro-navigation system with 800 stimuli of 1 Hz repetitive transcranial magnetic stimulation (rTMS) at 85% of resting motor threshold, the 1 Hz rTMS over SMC dramatically reduced his visual analog scale (VAS) of PLP from 7 to 0. However, the 1 Hz rTMS over PMC failed to reduce pain. To our knowledge, this is the first case report of a successfully treated severe PLP with a low frequency rTMS over SMC in affected hemisphere.
Adult ; Amputation ; Humans ; Motor Cortex ; Phantom Limb* ; Transcranial Magnetic Stimulation* ; Visual Analog Scale

A majority of patients who sustain injuries to the peripheral sensory nerves of the face and jaws experience a slow but gradual return of sensation that is functional and tolerable, if not the same as before the injuries. However, long-term effects of such injuries are aggravating for many patients, and a few patients experience significant suffering. In some of these patients, posttraumatic symptoms become pathological and are painful. The predominant painful components are (1) numbing anesthesia dolorosa pain, (2) triggered neuralgiaform pain, (3) burning and aching causalgiaform pain, and (4) phantom pain. This is a case report of conservative management of traumatic neuralgia and neuritis as part of posttraumatic pain syndromes in geriatric patients who have undergone the teeth extraction and alveoloplasty.
Alveoloplasty* ; Anesthesia ; Burns ; Humans ; Jaw ; Neuralgia* ; Neuritis ; Phantom Limb ; Sensation ; Tooth Extraction ; Tooth*

Tinnitus is a phantom sensation of sound in the absence of external stimulation. Since the mechanism of tinnitus is not clearly discovered, no currently available treatments are ideal. There have been many published studies which report that electrical stimulation has a suppressive effect on tinnitus. Although there is no consensus stimulation method and regimen, electrical stimulation has emerged as an interesting and promising modality for tinnitus relief. In this review, authors collected and analyzed articles on electrical stimulation and outlined various methods of noninvasive and invasive stimulation.
Consensus ; Electric Stimulation Therapy ; Electric Stimulation* ; Phantom Limb ; Tinnitus*