Phantom Limb Pain and Amputation Pain

• Phantom pain: 50-80 percent of major limb amputees
• Residual limb pain: 20-50 percent, often prosthetic-related
• Stump neuroma pain: 10-25 percent, focal and surgically treatable
• Telescoping: 30-50 percent report phantom limb shortening over time

• Prosthetic abandonment: Pain is leading cause of non-use
• Depression and anxiety: Strongly associated with chronic pain
• Opioid dependence: Risk from repeated surgical interventions
• Quality of life: Profound effect on employment and social function

Peripheral: Ectopic firing from transected nerves and neuromas Spinal: Central sensitisation and disinhibition in dorsal horn Cortical: Reorganisation of S1 map, loss of inhibitory control Psychological: Memory of pre-amputation pain and emotional processing

Neuroma: Sprouting axons form tangled mass with ectopic pacemakers Residual limb: Ischaemia, scar tethering, prosthetic pressure Tinel sign: Mechanical provocation of neuroma generates distal paresthesia Prosthetic pain: Shear forces on skin, bone prominence, poor suspension

• Timing: Immediate vs delayed onset after amputation
• Location: Phantom (absent limb), residual (stump), neuroma (focal)
• Quality: Burning, cramping, electric, aching
• Triggers: Prosthetic use, weather, emotional stress, pressure
• Previous treatments: Mirror therapy compliance, medications, surgery

• Inspection: Stump healing, skin quality, prosthetic fit, volume
• Palpation: Tinel sign over neuroma, bone prominence, scar tethering
• Prosthetic assessment: Suspension, alignment, pressure points
• Functional: Phantom limb position sense, telescoping, movement control
• Neurological: Allodynia, hyperalgesia, sensory mapping

• Phantom pain prevalence 50-80 percent across all amputation aetiologies worldwide
• Trauma and vascular disease are leading causes in high- and low-resource settings
• Paediatric amputees have lower phantom pain rates due to greater cortical plasticity
• Upper limb amputees report higher pain intensity and prosthetic abandonment rates

• High-resource: TMR at index amputation, certified prosthetists, functional MRI research
• Limited-resource: Emphasis on early mirror therapy and continuous regional analgesia using low-cost catheters
• Universal principle: Prevention at amputation is more effective than late treatment regardless of setting
• Surgery: TMR and RPNI are increasingly adopted globally as evidence accumulates

The foundational evidence is conflicting. Nikolajsen 1997 (Lancet, n=60) found preoperative epidural blockade did NOT reduce phantom or stump pain, whereas Karanikolas 2011 (Anesthesiology, n=65) found optimized analgesia started 48 h pre-op significantly reduced 6-month phantom pain (1/13 vs 9/12 controls). The likely reconciliation is that earlier, more aggressive multimodal control matters more than the route. The 5-7 day duration commonly quoted is pragmatic, not trial-defined; continue while in hospital then transition to oral multimodal analgesia.

TMR clearly reduces neuroma pain. Its effect on pure cortical phantom pain without neuroma is less certain. Some series show benefit via altered peripheral input, but patient selection criteria remain undefined. Most surgeons reserve late TMR for patients with a clear neuroma component.

Both have case series support for refractory phantom pain. No head-to-head trials exist. Peripheral nerve stimulation may be more appropriate when pain is focal; spinal cord stimulation when pain is diffuse or bilateral. Cost and revision rates influence choice.

Graded motor imagery (laterality recognition then imagined movement then mirror) is popular in some centres. Randomised data are stronger for mirror therapy alone. The incremental benefit of the graded sequence is uncertain and may reflect therapist time rather than specific technique superiority.