This article explores a case of phantom limb pain and clearly demonstrates how engaging the right pain expert had a significant and positive impact on quality of life for the claimant. Dr Chris Jenner MB BS FRCA FFPMRCA, Consultant in Pain Medicine, is an expert witness in a wide variety of pain conditions. He begins this article by exploring a diagnosis and description of the causes of phantom limb pain, illustrated by a case study where his expert knowledge of phantom limb pain led him to recommend a different course of treatment to help a claimant avoid amputation of his leg.
What is Phantom Limb Syndrome?
Phantom Limb Syndrome is defined as the perception of sensations, usually including pain in a limb that has been amputated. Patients with this condition experience the limb as if it were still attached to the body.
Physicians believe that the brain continues to receive messages from nerves that originally carried impulses from the missing limb, thus causing the phantom limb syndrome.
Studies report that about 50-80% of people who have had an amputation experience phantom limb syndrome.
Phantom Limb Pain – Basic Facts
Phantom limb pain is the pain felt by an amputee that seems to be located in the missing limb. After amputation of a limb, an amputee continues to have an awareness of the limb and to experience sensations from it.
Other accompanying and induced sensations include warmth, cold, itching, squeezing and burning. Additionally, the missing limb often feels shorter and may feel as if it is in a distorted and painful position.
Phantom limb pain often occurs in people who are born without limbs and people who are paralysed. These sensations suggest that the perception of our limbs is ‘hard-wired’ into our brain.
This pain also has also been observed in cases where the brain gets disconnected from the body. Some situations can be peripheral nerve injuries and after a spinal cord injury, when an area becomes insentient and usually paralysed.
Causes of Phantom Limb Pain
Phantom limb pain is caused by a variety of different causes, including experience with pain prior to amputation, incorrect surgical procedure, stress, illness, blood clot, inactivity and neuroma. Episodes are often triggered by certain circumstances, such as the use of artificial limbs (prosthesis), pressure on the remaining part of the limb, stress, fatigue, weather changes, psychosocial and psychological factors.
Treatment of Phantom Limb Pain
The treatment of phantom limb pain is generally considered difficult, as it does not follow any single method. There are varied approaches that help different patients. These include drug therapy and other treatments, such as nerve blocks, spinal cord stimulation, hypnosis, biofeedback and other cognitive techniques. It is important before the start of any treatment that the physician clearly differentiates the symptoms of the phantom limb pain from that of stump pain.
In this case, the claimant (a young man) had been involved in a motorcycle accident in his work as a mechanic, resulting in serious injury to his right foot, where the forefoot had been traumatically disassociated from the hindfoot. The claimant had metalwork inserted into the ankle and numerous plastic surgery procedures, including skin grafts. However, the Claimant continued to experience debilitating pain in the area and found weight bearing impossible.
Two years on from the accident, with no cessation of the Claimant’s pain, an orthopaedic surgeon suspected damage to the posterior tibial nerve, which had regenerated with a hypersensitivity reaction. He concluded that this was very unlikely to improve, given the time that had passed since the injury and strongly recommended an elective below knee amputation to help resolve his pain, especially as a second round of minimally invasive pain management – Guanethidine block injections – had failed to help.
At the point of referral to Dr Chris Jenner, the claimant had already been assessed by a Prosthetist, and was seeking a final opinion from an expert in pain management, as to the consequences and prognosis of the amputation, as part of his medicolegal case.
On examining the claimant, Dr Jenner’s recommended treatment plan focused on the neuropathic pain with which he suffered. He opined that, even if the claimant were to undergo the elective amputation, there was a significant risk that he would continue to suffer with right lower limb neuropathic pain, and that there was a strong possibility that this could be a more intense pain than he was already experiencing. Not only would the claimant lose his right lower limb, but he would be susceptible to phantom neuropathic pain, other phantom sensations and stump pain as well as the psychological and practical challenges he was likely to face as an amputee.
Based on his experience of diagnosing and treating phantom limb pain, he diagnosed that the pain suffered by the claimant was neuropathic and therefore would not be resolved by removing the limb. Instead, x-ray guided pulsed radiofrequency and root and spinal cord stimulation were pursued, in order to ‘shut down’ the affected nerve and save the claimant’s lower limb. The treatment proved successful and the Claimant avoided amputation.
60-80% of amputees feel phantom pain following amputation. It is essential that all treatment options are considered before such a procedure is recommended as a last resort, as simply removing the affected limb is no guarantee to relieve pain and in cases of neuropathic pain this can in fact make things worse.
Consulting with the right expert provides not only the benefit of securing the best and most compelling opinion of an expert for your medicolegal case but can also provide the claimant with life changing clinical advice they might ordinarily not have received.
Dr Jenner is able to provide decisive opinion on the causation of neuropathic pain, such as phantom limb pain, and cutting-edge pain management treatment options, to ensure the best prognosis for your medicolegal claimants. To instruct Dr Jenner or discuss a case with him, please get in touch via Medicolegal Associates on 020 7118 0650 or firstname.lastname@example.org