幻肢痛临床治疗研究进展

截肢后幻肢痛的危害逐渐受到重视.幻肢痛的发病机制尚未完全阐明,治疗仍很困难.该文综合分析了国内外近年研究进展,总结出一些常用、最新的治疗方法,包括药物治疗、物理治疗、手术治疗和心理治疗等.药物治疗中以三环类抗抑郁药、抗惊厥药、N-甲基-D天冬氨酸受体拮抗剂、镇痛药等最为常用,已证实它们对神经性疼痛有很好的疗效,但对幻肢痛的疗效仍存在争议,尚需作大样本研究.物理治疗似有较好的研究前景,具有操作方便、创伤小等优点,其中假肢使用及生物反馈疗法都有较好的临床效果.对一些特定病变引起的幻肢痛,手术治疗可能有效,但幻肢痛易复发、创伤大,其应用受到限制.心理治疗、行为治疗仍有较好的疗效,可能与逆转了大脑皮质功能重组有关.     

美金刚治疗严重幻肢痛缓解2例

本文报道2例因下肢严重创伤后并发难治性幻肢痛（PLP）大剂量阿片类药物和辅助镇痛药物治疗无效的病例。2例患者均接受大剂量口服美沙酮、静脉PCA二氢吗啡酮和辅助性药物（包括三环类抗抑郁药、非甾体抗炎药和抗癫痫类药物）的治疗,幻肢痛未得到控制。而口服NMDA受体拮抗剂美金刚后,幻肢痛得到缓解,且没有明显的副作用。     

幻肢痛的研究进展

随着交通事故、恶性疾病、自然灾害的不断增多,行截肢术的患者也越来越多。有资料显示,目前幻肢痛患者人数在不断增加,但发生机制还未完全阐明,治疗方法虽然不断更新但仍无重大突破。现就幻肢痛的研究进展作一综述。     

幻肢痛的研究进展

随着交通事故、恶性疾病、自然灾害的不断增多,行截肢术的患者也越来越多.有资料显示,目前幻肢痛患者人数在不断增加,但发生机制还未完全阐明,治疗方法虽然不断更新但仍无重大突破.现就幻肢痛的研究进展作一综述.     

幻肢与幻肢痛

1551年,法国外科军医Pare首先报告幻肢现象:一肢体或身体的某一部分 (如乳房,外生殖器等) 被截除后,已丧失的那一部分似乎仍与躯体联系着。而且有实际肢体的所有空间特征。当幻肢感伴有疼痛时,叫做幻肢痛。本文着重介绍幻肢痛的发生率、临床表现与治疗。一、发生率所报道的幻肢及肢痛的发生率差异较大,可能是由于判定标准不同。Ewalt观察了2200例截肢患者,幻肢痛占8％。Jouy在2700例截肢患者中发现无痛性幻肢占67％。幻肢痛为13％。Gillis指出:幻肢85％手术后立即出现,7％术后1个月发生,8％术后1年中发生。Sherman指出。实际上所有截肢患者都有数月幻肢痛。幻痛超过6个月转变为慢性,其发生率为0.4～50％。以后他们信访了1200名截肢的美国退伍军人,至少85％有持久而严重的疼痛。二、临床表现     

氯胺酮治疗幻肢痛

截肢病人术后往往仍有幻肢感觉并持续数月。文献报道幻肢痛的发生率最少2％,最高可达98％,而且治疗这种疼痛极其困难。其机理可能是由于患肢疼痛的躯体感觉输入的强度和时间过氏可造成中枢神经结构的变化。所以即使截肢,仍遗有痕迹作用而形成幻肢痛。作者报告3例经用氯胺酮治疗证明对幻肢痛有效。例1,男,31岁,交通事故后小腿多处骨折,因肿胀感染近两年而行右小腿膝上截肢术,术后残端触痛,并     

颈部硬膜外药物冲击分离法加斜角肌间沟阻滞治疗幻肢痛1例报告

幻肢痛是截肢后病人感到已失去的肢体依然存在,且某一部分仍有疼痛。幻肢痛的发病率为50～90%、有2%的病人幻肢发生剧烈的疼痛,性质呈闪电样,烧灼样。常在情绪激动或精神异常时发生。目前对幻肢痛的发生机制有多种学说,治疗方法较多,但效果各异。国内杂志报道也较少,现将我们治疗的1例患者报告如下:1病历资料患者,男,53岁,1991年因车祸致左臂丛神经损伤,在上海长征医院行右腓神经移植左臂丛神经修复术,术后出现左上肢疼痛,并向前臂手指放射,伴有上肢功能障碍及前臂轻度肌肉萎缩。由于剧烈疼痛严重影响患者生活、工作,于2001年行左上肢截肢术…     

幻肢痛二例治疗体会

我院对两例断肢后幻肢痛的患者,采用以神经阻滞为主的综合疗法,取得满意的效果,现报告如下。例1,男,51岁。因左下肢血栓闭塞性脉管炎3年,左足剧痛1年,左足前部干性坏死3个月,于1986年9月行左大腿中下段截肢术。术后24h出现幻肢痛,4个多月来,虽常服用各种止痛药,但无明显好转。幻肢痛的时间、性质和程度与术前相似,时有阵发性刀割、针刺或灼痛。残端创面愈合良好、轻度肿胀、肌萎缩、压有麻痛感。X线照相示股骨残端萎缩硬     

神经阻滞法治疗幻肢痛

神经阻滞法治疗幻肢痛河南省洛阳正骨医院（４７１００２）康定坤，许建波，仝平欣作者自１９８９年元月以来，对较严重的幻肢痛患者１４例应用单纯神经阻滞法进行治疗，收到了满意的效果，现报告如下。临床资料１４例中，男９例，女５例；年龄１５～７５岁；上肢４例，下...     

下肢截肢术后持续周围神经阻滞的作用：对幻肢综合征症状的影响

背景达90％的截肢者在肢体截肢术后会产生幻肢综合征（phantom limb syndroms，PLS）。尽管现在有很多不同的治疗方法，但没有一种是显著有效的。因此，我们评估了高浓度的局麻药在外周神经的持续输注对预防PLS的效果。方法在术前或术中给71例行下肢截肢术的患者放置一周围神经导管，通过弹力输注泵（非电子）在术中开始以5ml／h的速率持续输注0．5％罗哌卡因，并且持续到术后的第4—83天。在术后的第1天，第1、2、3、4周和第3、6、9、12月评估PLS。为了评估患者在接受罗哌卡因输注时PLS是否存在及其严重程度，在每次评估前中断6—12小时的给药（即直至肢体感觉的恢复）。幻肢痛和残肢痛的程度由5分级的VRS评分系统来评分，其中0分代表无疼痛，4分代表不能忍受的疼痛，而幻肢的感觉被记录为存在或者不存在。如果VRS评分大干1分或者有显著的幻肢感觉出现，罗哌卡因立即以5ml／h的速率重新开始输注。如果患者的VRS评分持续为0或1分并且无幻肢感觉达48小时，则输注完全停止并移除导管。结果局麻药的持续输注时间的中位数是30天（95％的可信区间，25-30天）。在术后第1天，73％的患者主诉有严重的或者不能忍受的疼痛（VRS评分大于2分）。但是，在12个月的评估期的最后患者“严重到不能忍受”的幻肢痛的发生率仅为3％。在第12个月末，患者VRS疼痛评分的百分比：84％的患者为0分，10％的患者为1分，3％的患者为2分，3％的患者为3分，没有患者为4分。但是，在12个月的评估期的最后仍有39％的患者有幻肢感觉。所有患者都能在家中应用这种弹力输注系统。结论术后予以0．5％的罗哌卡因于神经周的持续输注可能是下肢截肢术后治疗幻肢痛和幻肢感觉的有效方法。     

Phantom limb pain

Almost everyone who has amputated a limb will experience a phantom limb. They have the vivid impression, that the limb is still present. 60 to 70% of these amputees will suffer from phantom limb pain. The present paper gives an overview of the incidence and the characteristics of the so called "post amputation syndrome". Possible mechanism of this phenomena are presented, including peripheral, spinal, and central theories. Treatment of phantom limb pain is sometimes very difficult. It includes drug therapy, psychological therapy, physiotherapy as well as the prevention of phantom limb pain with regional analgesia techniques.     

Postoperative treatment of phantom pain and causalgias with calcitonin

Results of IV calcitonin treatment in patients suffering from postoperative phantom limb pain (n = 12) or causalgia following peripheral nerve lesions (n = 4) are reported. All patients were complained of severe pain after a traumatic event or amputation, with disturbed sleep in many cases. After only 1-2 infusions 10 patients with phantom limb pain (83%) were discharged from hospital pain-free. Pain was effectively reduced by up to 5 infusions in 2 patients (17%). A follow-up for maximally 24 months showed a recurrence of pain in only 4 patients with obvious stump problems or reamputations. Three patients with causalgia also profited from a remarkable but transitory pain reduction; in 1 patient therapy was ineffective. Recurrent pain due to causalgia could not be improved by repeated calcitonin infusion, although this was effective for phantom limb pain. The administration of calcitonin IV can be recommended as a valuable treatment for phantom limb pain and causalgias in the early postoperative period. Therapy was effective with negligible side-effects, and long-term follow-up revealed a long-lasting effect.     

Phantom limb pain: A literature review

Since the phantom limb sensation was first described by the French military surgeon Ambroise Pare in the 16th century, the number of studies surrounding phantom limb pain has increased every year. Especially in recent decades, scientists have achieved a better understanding of the mechanism and treatment of phantom limb pain. Although many hypotheses have been agreed and many treatments have been proven effective, scientists still do not have a very systematic understanding of the phantom limbs. The purpose of this review article is to summarize recent researches focusing on phantom limb in order to discuss its definition, mechanisms, and treatments.     

The care of patients with phantom limb pain in a pain clinic

Patients referred to the Pain Clinic at the University of Virginia Medical Center with genuine phantom pain rather than stump pain have been treated by a variety of technics. Simple revision of drug therapy has proved helpful in some instances, as has repeated injection of trigger areas or neuromata, though surgical excision has proved necessary in some patients. Mechanical stimulation by stump tapping, prosthetic application, or electrical transcutaneous stimulation also may be useful. Sympathetic nerve block is occasionally very rewarding. Most patients need some form of psychological therapy. Rarely is cordotomy or higher central nervous system surgery required. There is no single best mode of therapy for phantom limb pain, nor can patients be guaranteed a permanent cure.     

Postamputation phantom limb pain -- comes the solution into view?

About 70 % of amputees will suffer from phantom limb pain sooner or later. Nearly all of the amputees will feel some phantom sensations. Phantom limb pain not only impairs quality of life, but also impedes considerably social rehabilitation. Therefore effective strategies of prevention and treatment are urgently required. So far, none of the more than 40 treatment methods has proven to be really effective. It is to be expected that the latest theories regarding the emergence of phantom limb pain, which were developed on the basis of modern neuroimaging techniques, will lead to considerable progress. Accordingly the key to success is influencing cortical reorganization and preventing or extinguishing a pain memory. The demonstrable influence on central activities implicates several preventive and therapeutic modalities, i. e. absolute analgesia before amputation for a longer period of time and reduction of cortical reorganization by drugs, behaviour interventions and/or suggestion.     

A review of clinical evidence supporting techniques to prevent chronic postoperative pain syndromes

OBJECTIVE: To conduct a systematic review to evaluate the level of evidence for using acute postoperative pain management techniques with a view to pre-empting the later development of chronic pain syndromes. MATERIAL AND METHODS: Systematic review of the literature on the treatment of acute postoperative pain and its usefulness in preventing postoperative chronic pain syndromes. RESULTS: Fifteen studies focusing on 3 conditions were examined: chronic postmastectomy pain syndrome, chronic postthoracotomy pain syndrome, and chronic phantom limb pain. Four clinical trials provided no clear evidence of benefit from preoperative injections of local anesthetic in decreasing the incidence of chronic postmastectomy pain. Continuous thoracic epidural analgesia started before surgery has been shown to have a clearly beneficial effect in preventing chronic pain 3, 6, and 12 months after thoracotomy. Chronic phantom limb pain syndromes have not been found to be prevented by the use of continuous epidural analgesia started before or after surgery in comparison with the injection of local anesthetics through a perineural catheter or the oral or intramuscular administration of morphine-like drugs. CONCLUSIONS: Only chronic pain following thoracotomy has been found to be preempted by acute pain management and only by continuous thoracic epidural analgesia started before surgery. There is no solid evidence demonstrating that other techniques used to relieve acute postoperative pain have a beneficial effect in preempting chronic postoperative pain syndromes.     

Implicit memory formation in children during anesthesia

The purpose of this retrospective study in children and young adults having cancer‐related amputation was to examine the incidence and factors associated with phantom limb pain. Of the 27 patients studied, most had osteosarcoma (59.3%), followed by the Ewing sarcoma family of tumors (14.8%). During the year following amputation, 70.4% of patients had experienced phantom limb pain at some time. After 1 year, though, only 8.7% still had phantom limb pain. Patients 18 and older were somewhat more likely to have phantom limb pain after 1 year (P = 0.060). There was no statistically significant difference in the number of patients who had phantom limb pain between the groups that did and did not have pre‐amputation pain, but the patients with pre‐amputation pain tended to have higher rates of moderate or severe pain.     

Phantom limb pain--a complication of lower extremity wound management

Amputation is one treatment option for patients with critical limb ischemia, diabetic foot wounds, and occasionally, even venous leg ulcers. Amputation of the whole limb or part of it or the digits can cause complications including pain. Post-amputation pain, and especially phantom limb pain (PLP), is a poorly understood phenomenon. Effective management of established pain is a major challenge. This review is for wound workers who are a multiprofessional group. Any amputated limb, appendage, or viscera can be affected by PLP,though the focus of this article will be the treatment of PLP following limb loss. The pathophysiology is still not fully understood. The size of the problem of PLP, possible underlying physiological mechanisms, and potential preventative measures are presented in this article.     

Phantom limb pain: aspects of neuroplasticity and intervention

Phantom-limb pain is a common sequel of amputation, occurring in up to 80 % of the amputee population. It must be differentiated from non-painful phantom phenomena, residual-limb pain, and non-painful residual-limb phenomena. A comprehensive model of phantom-limb pain is presented that assigns a major role to pain occurring before the amputation and to central as well as peripheral changes related to it. Special emphasis is put on the role of cortical reorganization in the development of phantom limb pain. Finally, new approaches to the prevention and treatment of phantom limb pain are presented that have a positive influence on phantom limb pain by preventing or reversing cortical reorganization.     

Phantom limb, residual limb, and back pain after lower extremity amputations

This study describes the sensations and pain reported by persons with unilateral lower extremity amputations. Participants (n = 92) were recruited from two hospitals to complete the Prosthesis Evaluation Questionnaire which included questions about amputation related sensations and pain. Using a visual analog scale, participants reported the frequency, intensity, and bothersomeness of phantom limb, residual limb, and back pain and nonpainful phantom limb sensations. A survey of medication use for each category of sensations also was included. Statistical analyses revealed that nonpainful phantom limb sensations were common and more frequent than phantom limb pain. Residual limb pain and back pain were also common after amputation. Back pain surprisingly was rated as more bothersome than phantom limb pain or residual limb pain. Back pain was significantly more common in persons with above knee amputations. These results support the importance of looking at pain as a multidimensional rather than a unidimensional construct. They also suggest that back pain after lower extremity amputation may be an overlooked but very important pain problem warranting additional clinical attention and study.