Post-amputation pain
- Core Classifications:
- Phantom Limb Pain (PLP): Painful sensation perceived in the absent/missing limb (burning, throbbing, shooting); onset within days-weeks post-op.
- Phantom Limb Sensation (PLS): Non-painful perception of the missing limb (warmth, tingling, itching); benign, highly common, requires reassurance only.
- Stump Neuroma (Terminal Neuroma): Localized residual limb pain + focal tender nodule + (+) Tinel sign (percussion reproduces radiating pain). c
- Residual Limb/Stump Pain (RLP): Pain localized to the anatomic stump due to mechanical (prosthesis fit), ischemic, or infectious causes.
- Key Risk Factors:
- Severe pre-operative pain (strongest predictor).
- Traumatic amputation.
- Lower extremity > upper extremity.
- Diagnostic Workup:
- Diagnosis: Primarily clinical (distinguishing PLP vs. neuroma vs. mechanical/infectious RLP).
- Stump US: Modality of choice for stump neuroma (hypoechoic nodule) or soft-tissue fluid collections.
- Stump X-ray: Evaluates for bone spurs, heterotopic ossification, or osteomyelitis.
- Labs (WBC, ESR, CRP): Indicated only if suspecting surgical site infection or osteomyelitis.
- Management:
- Phantom Limb Pain (PLP):
- First-line non-pharmacologic: Mirror therapy (promotes cortical reorganization).
- First-line pharmacologic: Gabapentin or Pregabalin; alternative: TCAs (Amitriptyline) or SNRIs (Duloxetine).
- Second-line/Refractory: TENS, Ketamine infusions, or Spinal Cord Stimulation (SCS).
- Stump Neuroma:
- Initial: Socket refitting / prosthetic adjustment.
- Interventional: Local anesthetic + corticosteroid injection.
- Refractory: Surgical excision with deep muscular/osseous transposition.
- Mechanical/Infectious RLP:
- Prosthetic realignment, skin care, or targeted Abx/drainage for infection.