Diagnosis and treatment of pain after amputation surgery

November 07, 2022 10:00 a.m

After amputation, some patients may experience pain in their residual limbs. Post-amputation pain—categorized as phantom pain or stump pain—can be a challenging condition to treat.

Phantom pain is different from stump pain, but they often occur together. Describing amputation pain can help your doctor accurately diagnose and treat these two conditions.

Phantom limb pain

The feeling that the phantom pain in the limb is coming from a part of the body that is no longer there. Doctors once believed that this post-amputation phenomenon was a psychological problem, but now experts recognize that it is a real sensation originating in the spinal cord and brain. “Many levels are involved in determining what causes phantom limb pain,” says Colby Hansen, MD, associate professor in the Department of Physical Medicine and Rehabilitation at UT Health. “A combination of central (brain and spinal cord) and peripheral (nerves in the affected limb) nervous system may contribute to phantom limb pain.”

Symptoms

Symptoms of phantom limb pain may begin within the first week, be delayed for months after amputation, come and go, or be continuous. Amputees describe phantom limb pain as stabbing, stabbing, gripping, crushing, throbbing, or burning. For many, this may resemble the type of pain they may have experienced in their limb prior to the amputation.

Diagnosis

Although there is no medical test to diagnose phantom pain, doctors identify the condition based on your symptoms and the knowledge that phantom pain may be caused by miscommunication between the brain, spinal cord, and nerves that continues after the amputation. Your doctor will ask about other causes that may make your pain worse, including stress, anxiety, depression, and pain in the limb before amputation.

Treatment

In some people, phantom pain improves over time without treatment. For others, managing phantom pain can be challenging. Hansen says a team effort of healthcare professionals, including physical therapists, psychologists, surgeons and prosthetists, results in effective phantom pain relief by:

  • Over-the-counter pain relievers and some stronger drugs
  • Antidepressants
  • Physical and occupational therapy
  • injections
  • Residual Limb and Nerve Surgery
  • Electrical stimulation
  • Wearing a prosthesis more often
  • Mirror therapy
  • Standard relaxation techniques such as mindfulness, guided imagery, gentle massage and listening to music

Pain in the stump

Stump pain, also called residual limb pain, is a type of pain felt in the part of the limb that remains after amputation. It occurs in about half of people within the first week after an amputation, but it can also persist without healing.

Symptoms

Residual pain in the limb varies in severity, but you may feel discomfort such as pressure, throbbing, burning, squeezing, or stabbing.

Diagnosis

Tests and procedures used to diagnose stump pain include:

  • Physical examination: Checks for skin breakdown, pressure sores, bone problems, signs of infection and growths. Your doctor can detect a neuroma — a tangle of nerve endings that can form after an amputation — and complications with fitting or using a prosthesis.
  • Image Tests: An MRI, CT scan, X-rays, or ultrasound help rule out other causes of your pain and identify fractures, bone abnormalities, tumors, and infection.
  • Blood tests: Find out about other medical conditions that can cause pain.
Treatment

Treatment for stump pain focuses on treating the underlying cause of the pain. Stump pain eventually improves without treatment in about half of patients. Pain relief options include medications (pain relievers, antidepressants, and anticonvulsants), physical and occupational therapy, massage, hypnosis, nerve blocks, and neuromodulation.

At the University of Utah, Hansen and other doctors use the most advanced techniques to restore strength, function, control and avoid pain. One such approach is targeted muscle reinnervation (TMR) surgery to separate nerve endings and insert them into muscles where they will grow into new muscles. TMR surgery can prevent pain and allow prosthetic limbs to read signals from muscles.

An amputee in Hansen’s care had no residual pain about eight years after having his leg amputated due to a traumatic injury. However, during a clinic visit, the amputated patient reported burning and tingling pain that may have been caused by the neuroma formed by his sciatic nerve. He was treated for delayed stump pain using medication, injections, and ultrasound-guided radiofrequency ablation for post-amputation pain relief. Hansen found that a combination of strategies like these worked to ease the amputee’s occasional residual pain when it reoccurred.

“Sorting out the causes of pain can be difficult, but with patient and health care provider persistence, many amputees can be pain-free through psychological and therapeutic strategies,” says Hansen.

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