Phantom limb syndrome induced by combined spinal and epidural anesthesia in patients undergoing elective open gynecological surgery.

BACKGROUND: During regional anesthesia, including combined spinal and epidural anesthesia (CSEA), patients may develop a perceptual alteration of limb position known as phantom limb syndrome (PLS). We aimed to identify factors that influence the PLS onset, to explore whether PLS predisposes to other postoperative symptoms, and to document the relationship between PLS and sensorimotor impairment during recovery. METHODS: Psychological questionnaires for anxiety and depression were completed beforehand, then multimodal tests of sensory and motor function, especially tests of proprioception, were performed regularly afterward. Two hundred participants undergoing elective gynecological surgery under CSEA reported their experiences of PLS and other symptoms using Likert rating scales. RESULTS: Prolonged preoperative fasting (odds ratio (OR) 2.34; 95% confidence intervals (CI) 1.21-4.52), and surgical history (OR 2.56; 95% CI 1.16-5.62) predisposed to PLS, but patients with more extensive anesthetic histories may be at lower risk (OR 0.57; 95% CI 0.31-1.08). Furthermore, significant correlations were observed between the recovery from PLS and the perception of joint movement within the deafferented area (R = 0.82, P < .01) and motor functions (R = 0.68). PLS increases the chance of experiencing postoperative fatigue, physical discomfort, and emotional upset. CONCLUSION: This study is the first to have identified the risk factors for PLS, assessed the relationship between PLS and postoperative sensorimotor impairment, and its influence on postoperative complications.

Comparación entre anestesia general con o sin bloqueo paravertebral preincisional con dosis única y dolor crónico postquirúrgico, en cirugía radical de cáncer de mama / Chronic postoperative pain after general anesthesia with or without a singledose preincisional paravertebral nerve block in radical breast cancer surgery

Objetivo: En la cirugía del cáncer de mama, en más del 50% de las pacientes con mastectomía y/o linfadenectomía persiste el dolor en el primer año. Nuestro objetivo fue determinar la asociación entre la técnica anestésica, la intensidad del dolor agudo postquirúrgico y el desarrollo del dolor crónico postquirúrgico. Pacientes y métodos: Cuarenta pacientes fueron asignadas aleatoriamente a recibir anestesia general o anestesia general con bloqueo paravertebral para mastectomía radical modificada. Se midió el dolor mediante escala visual analógica a los 60 minutos, a las 24 horas y a los 4-5 meses se realizó encuesta de dolor crónico postquirúrgico. Resultados: No hubo diferencias significativas respecto al dolor agudo. Veintinueve pacientes contestaron a la encuesta telefónica. En el grupo del bloqueo paravertebral sólo hubo un caso de dolor neuropático y ninguno de miembro fantasma mientras que en el grupo de anestesia general hubo 7 casos de dolor neuropático asociados a 3 casos de miembro fantasma [6,7% frente a 50%; test exacto de Fischer, p = 0,01, con un RR de 7,5 (IC95% 1,0-53,5)]. Hubo dolor miofascial (contracturas en cuello) en ambos grupos sin diferencias significativas. Conclusiones: A los 4-5 meses de la cirugía la anestesia general con bloqueo paravertebral preincisional presenta menos casos de dolor crónico que sí se utiliza anestesia general y analgesia con cloruro mórfico(AU)

Background and objective: Over 50% of patients still experience pain a year after mastectomy with or without lymphadenectomy. We aimed to determine the association between anesthetic technique, acute postoperative pain intensity, and the development of chronic postoperative pain. Patients and methods: Forty patients were randomly assigned to receive general anesthesia with or without a paravertebral nerve block for modified radical mastectomy. Postoperative pain was assessed on a visual analog scale at 60 minutes and 24 hours; the patients were also asked to respond to a telephone questionnaire on chronic pain 4 to 5 months later. Results: No significant differences in acute pain were observed. Twenty-nine responded to the telephone questionnaire. Only 1 patient in the paravertebral block group reported chronic neuropathic pain and none had phantom breast pain. Only 1 patient (6.7%) in the paravertebral block group reported chronic neuropathic pain and none had phantom breast pain. In the group that received general anesthesia alone, 1 patient reported phantom breast pain and 6 patients had neuropathic pain, associated with phantom breast pain in 2 cases (incidence of chronic pain 50%; P = .01, Fischer exact test; relative risk, 7.5, 95% confidence interval, 1.0-53.5). The incidences of myofascial pain (neck muscle tightness) were similar in the 2 groups. Conclusions: Four to 5 months after mastectomy, fewer cases of chronic pain developed in the group operated under general anesthesia with a preincisional paravertebral block than in the group that received only general anesthesia, with postoperative morphine chloride for analgesia(AU)

An unusual case of painful phantom-limb sensations during regional anesthesia.

OBJECTIVE: The objective of this article is to describe a late-onset phantom-limb pain during a continuous analgesic popliteal nerve block after foot surgery and its alleviation and recurrence when stopping and resuming the local anesthetic infusion. CASE REPORT: A 29-year-old woman undergoing a left hallux valgus repair received a continuous popliteal sciatic nerve block for postoperative analgesia. Postoperatively, 6 hours after the commencement of a ropivacaine 0.2% infusion, she reported feelings of tingling, clenching pain, and missing-limb sensation below the ankle. The surgical site remained painless. Sensation elicited by touch and propioception were normally perceived. Only sensations for pinprick and heat were impaired. The ropivacaine infusion was stopped, followed 2.5 hours later by the complete regression of any abnormal sensation. Meanwhile, pain at the surgical site was scored at 50 mm on a 100-mm visual analogic scale. As the infusion of ropivacaine was resumed, the abnormal sensations reappeared. The catheter was removed, and abnormal sensations again disappeared. The patient was discharged from hospital without further complications. CONCLUSIONS: This observation suggests that phantom-limb pain can be of late-onset and might occur during a continuous infusion of low-concentration local anesthetic responsible only for an analgesic block, as shown by the fact that only thermal and pinprick sensations, known to depend on Adelta-fibers and C-fibers, were altered. Therefore, this case contradicts the usual belief that a profound block is necessary to elicit phantom-limb pain.

Phantom limb pain as a manifestation of paclitaxel neurotoxicity.

Paclitaxel is a chemotherapeutic agent with activity directed against several malignancies. It has multiple adverse effects including neurotoxicity. We describe 2 patients with prior amputation who experienced phantom limb pain (PLP) after receiving paclitaxel therapy. A third patient experienced disabling neurotoxicity in the extremity of a prior ulnar nerve and tendon transposition after receiving paclitaxel. This unique syndrome should be identified as a direct causal effect of paclitaxel. In this report, we review the pathophysiology of PLP and treatment options. Physicians should be aware that PLP can occur after initiation of paclitaxel.

Regulation of proprioceptive memory by subarachnoid regional anesthesia.

BACKGROUND: Patient perception of limb position during regional anesthesia is frequently incorrect. The existing model ascribes this misperception, or phantom sensation, as a reversion to a fixed, slightly flexed, body schema. A model was developed to evaluate the influence of limb position changes on the incidence of incorrect or phantom sensations during regional anesthesia. METHODS: Forty American Society of Anesthesiologists physical status I-III adult patients undergoing genitourinary procedures under subarachnoid anesthesia were assigned to a lidocaine or bupivacaine treatment group and randomly assigned to one of four time groups (1, 4, 7, and 10 min). After blockade, patients were placed supine and blinded to limb positioning manipulations. One leg was flexed and the contralateral leg extended, with leg positions subsequently reversed at the assigned time point. At 10 min, patients were asked to identify the position of each leg. Percentage of incorrect response was analyzed using a logistic regression model with two independent variables: treatment and time. A supplemental study was undertaken to evaluate the observed difference in incorrect perceptions relative to flexed first versus extended limb first sequencing. RESULTS: The inability to perceive a change in limb position under regional anesthesia is dependent on the time after the block that the position change is initiated in relation to the onset characteristics of the local anesthetic. A phantom sensation of an extended leg position clearly exists. The flexed-first limb has a significantly higher incidence of incorrect or phantom perceptions. CONCLUSION: Proprioceptive memory involves a dynamic neuroplastic imprinting process that is influenced by limb or joint position prior to onset of regional anesthesia. This contrasts with previously held beliefs of a purely fixed body schema.

Phantom limb experiences in congenital limb-deficient adults.

This case report describes phantom limbs in four adults with congenital limb deficiency. Case 1, with congenital absence of the left arm below the elbow, received a minor injury of the stump at age 16 and subsequently developed a full-length phantom arm, hand and fingers. Cases 2 and 3, at the ages of 26 and 30, underwent minor surgery of the lower limbs and subsequently developed vivid, full-length phantoms of their legs. Case 4, aged 31, was born with a shortened and deformed right leg, and underwent amputation of the foot and deformed part of the leg at age 3. Beginning at age 6, she developed a full-length phantom leg and foot that touched the floor, which persisted for more than 20 years. The descriptions by these four adults lend credibility to earlier reports of phantom limbs in congenital limb-deficient children. They also indicate that these phantoms may persist into adulthood.

[Phantom phenomena during regional anesthesia]. / Phantom-Erscheinungen während regionaler Anaesthesie.

Phantom phenomena were studied following the administration of peridural (PDA), spinal (SA) and brachial plexus anaesthesia (PB) to 200 patients undergoing a peripheral surgical procedure. 18% of the subjects in PDA, 40% in SA and 63% in the PB group reported a typical, phantom of lower, respect. upper extremities as already described in the literature. Various additional (atypical) forms of phantoms were observed: 10% in PDA, 24% in SA and 6% in PB group. Sex, age, tourniquet, premedication and type of local anaesthetic did not influence substantially the occurrence of phantom. The latter was however directly related to the total dose (mg) of local anaesthetic administered. The appearance of phantom was not always a guarantee of successful block. The possible mechanisms of painless phantoms are discussed.