Elsevier

Annals of Vascular Surgery

Volume 24, Issue 8, November 2010, Pages 1139-1146
Annals of Vascular Surgery

General Review
Pre-emptive Analgesia for Chronic Limb Pain After Amputation for Peripheral Vascular Disease: A Systematic Review

https://doi.org/10.1016/j.avsg.2010.03.026Get rights and content

Background

Chronic stump and phantom limb pain after amputation for critical ischemia significantly affect patients' quality of life and pose challenging clinical problems. Pre-emptive analgesia attempts to prevent chronic postoperative pain by minimizing painful stimuli before and during surgery.

Methods

This systematic literature review aimed to evaluate the evidence supporting the use of pre-emptive analgesia in minimizing the risk of chronic stump and phantom pain after lower limb amputation for critical ischemia of peripheral vascular disease.

Results

A total of 11 studies have been retrieved. Five different types of analgesic drugs were evaluated (local anesthetics, opiates, N-methyl-d-aspartate receptor antagonists, a2-agonist, and gamma-aminobutyric acid analogues), administered separately or in combinations, through the oral, intravenous, epidural, or regional (perineural) route. The beneficial effect of combined bupivacaine, diamorphine, and clonidine in reducing the risk of phantom limb pain was supported by only one study (level 3 evidence). Epidural and perineural infusions containing local anesthetic ± opiates are effective in treating acute perioperative pain, although not without potentially serious complications. Most studies were characterized by high drop-out rates because of disease-associated mortality.

Conclusions

There is no robust evidence supporting the use of pre-emptive analgesia to minimize the risk of chronic pain after amputation for critical ischemia of peripheral vascular disease. The methods used are, however, effective in treating acute postoperative pain.

Introduction

Chronic post-amputation pain affects a maximum of 80% of patients during the first year, in the form of stump pain or phantom limb pain (PLP, neuropathic pain perceived in the area of the amputated limb).1 It incurs significant impairment of patients' quality of life, work, sleep, and social and daily activities, which highlights the need for effective preventive and therapeutic strategies.2 Inadequate treatment of acute postoperative pain, excessive intra-operative painful stimuli, and high levels of established preoperative pain have been proposed as potential risk factors.3 Pre-emptive analgesia refers to the attempt to prevent chronic pain by early intervention before it occurs, that is, before and during surgery.4

Section snippets

Aims

The present review aims to evaluate the evidence underpinning the potential effect of pre-emptive analgesia in prevention of chronic pain after amputation for lower limb critical ischemia. Critique of the available evidence is attempted along with recommendations for clinical practice.

Search Strategy

The MEDLINE, CINHAL, OVID, and EMBASE databases and the Cochrane Collaboration Library were searched using keywords “pre-emptive,” “preventive,” “prevention,” “prophylaxis,” “chronic,” “stump,” “phantom,” “pain,” “amputation,” “lower limb,” and “critical ischemia” in various combinations to retrieve all relevant articles published in English language till year 2009. Cross-referencing from the bibliography of retrieved articles was also used to increase the yield of relevant publications. A

Mechanisms of Analgesic Action

Analgesic drugs from five different categories, used separately or in combinations, have been evaluated in the retrieved studies; local anesthetics (Bupivacaine, Ropivacaine), opiates (Morphine, Diamorphine), the N-methyl-d-aspartate (NMDA) receptor antagonist ketamine, the a2-agonist clonidine, and the gamma-aminobutyric acid analogue gabapentin. These drugs target mechanisms that have been proposed to contribute to chronic postamputation pain and include a constellation of central and

Results

The retrieved studies and their results are presented in the following paragraphs, classified according to mode of delivery of the analgesic agent.

Discussion

Patients with chronic stump pain and PLP after amputation for ischemic necrosis of peripheral vascular disease pose therapeutic challenges that dictate the need for further research on potential prophylactic regimes. The results of our systematic review reveal the paucity of well-designed randomized controlled trials that would be based on large patient numbers and would provide high levels of evidence. Most studies suffer from small sample sizes and postrandomization protocol violations. Most

Conclusions

Overall, it becomes evident that more well-designed randomized controlled trials including large patient populations are necessary to further evaluate the potential for pre-emptive analgesia for chronic postamputation pain. In the meantime, the use of those anesthetic regimes is justified that have proven effective in relieving acute postoperative stump pain.

References (26)

  • J.A. Wilson et al.

    A randomised double blind trial of the effect of pre-emptive epidural ketamine on persistent pain after lower limb amputation

    Pain

    (2008)
  • S. Reuben et al.

    Evaluating the analgesic effect of the perioperative perineural infiltration of bupivacaine and clonidine at the site of injury following lower extremity amputation

    Acute Pain (EMBASE)

    (2006)
  • A. Lambert et al.

    Randomized prospective study comparing preoperative epidural and intraoperative perineural analgesia for the prevention of postoperative stump and phantom limb pain following major amputation

    Reg Anesth Pain Med

    (2001)

    • Cited by (0)

    This review was submitted as a modular assignment for the first author's MSc Degree in Perioperative Care and Advanced Surgical Practice (Department of Anaesthetics, Cardiff University).

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