Phantom pain in major lower limb amputation : primary ligation cauterization vs traction neurectomy (phapilla)

Abstract

Phantom Limb Pain (PLP) is bothering amputees in silent. Neuroma hyperexcitability is one of the popular peripheral theories which can be addressed during primary amputation by Orthopaedic surgeons. No study comparing the type of neurectomy association with PLP. The objective is to compare the incidence of PLP in conventional and alternative techniques of neurectomy in major lower limb amputation. This is a prospective, randomized, interventional study involving 98 patients in Hospital Kuala Lumpur, requiring major lower limb amputation due to the diabetic complication, tumor, trauma and inotropic complications from October to June 2017. Patients were evenly randomized into two groups; Group A - conventional traction neurectomy (CTN) and Group B - ligation and cauterization neurectomy (LCN). The endpoint of the study is the outcome of PLP which was assessed clinically at post-operative Day 3, 14 and 6-month. The results are analyzed using univariate and multivariate simple logistic regression. Group A and B have 47 and 46 patients respectively after 5 patients dropped out. 70.2% in Group A (n=33) and 28.3% in Group B (n=13) end up with PLP (p<0.001). 69% of patients who underwent amputation above knee level (n=20) suffered from PLP (p<0.05). Group B have higher mean PLP pain score (3.31 and 2.94) but not statistically significant. 69.6% of patients with pre-operative pain (n=32) and 43.5% with peripheral vascular disease (n=20) developed PLP (p<0.05). LCN is as superior as CTN. LCN has 90% lower rate to develop PLP compared to CTN. Other significant factors in those who developed PLP include proximal levels of amputation, pre-operative pain, and peripheral vascular disease.