Dr. Jeffries discusses pain experienced around the time of an amputation
While it is hoped that none of the people reading this article will ever experience an amputation in the future, the fact that many of you may be peer visitors for people about to undergo amputation makes it important to discuss pain around the time of an amputation.
The time when most people come in contact with the pain of amputation is the "perioperative" period. That is the period immediately preceding, during, and immediately following the amputation. It is becoming more and more apparent that the perioperative period is extremely important in the long-term pain picture. For that reason, we will discuss in some detail some of the important aspects of pain management during the perioperative period.
Unfortunately, some people experience significant pain in the preoperative period. This may be because of preoperative disease such as gangrene, ischemic vascular disease, tumor, infection, or trauma. These conditions can be highly painful right up to the moment when the person is anesthetized for the surgery. There are increasing suggestions in the medical literature that excellent pain relief (analgesia) for painful conditions in the preoperative period may result in a decreased incidence of ongoing postoperative pain.
This pain and anxiety relief may require the use of narcotic and non-narcotic pain medications, anti-anxiety medications, and other techniques that should be familiar to the physician, surgeon and anesthesiologist who are providing care. This is not a time to suffer in silence. The pain that is being experienced is using the chemicals produced by the brain to deal with pain and stress at a very rapid rate. If they remain depleted, they are not present in the postoperative period to assist with recovery. Going to the operating room for an amputation in a calm, relatively pain-free state is much more conducive to an easy recovery than going to the operating room after days or weeks of severe, unrelieved pain and/or anxiety. The person about to undergo amputation should ask for, and even demand if necessary, adequate relief of preoperative pain and anxiety.
As anyone can readily imagine, an amputation is an incredibly painful surgical procedure. Every type of tissue in the limb is cut or severed in doing the amputation including skin, muscle, bone, tendon, nerve, and blood vessels. Every one of these tissues has abundant nerve endings and all can hurt during and after the insult of the amputation. Anesthesia prevents the person from actually experiencing the pain during surgery but may not prevent pain patterns from being formed in the brain. As was mentioned with preoperative pain, intraoperative pain seems to correlate well with long-term post-amputation pain. Decrease of the severity of intraoperative pain may lead to diminished levels of long-term post-amputation pain.
It is obvious to everyone that an amputation is and is expected to be a very painful event. Anesthesia has been used for amputations when it was available ever since it was invented over 100 years ago. Usually that anesthesia has been a type of general anesthetic that puts the person to sleep, making them totally unaware of the amputation and its painful nature. Recently it has been found in several studies that interrupting the painful nerve impulses before they reach the brain may actually decrease the probability of long-term post-amputation pain.
It has been known for many years that the pain impulses could be prevented from reaching the brain by injecting in or around the nerves with chemicals known as local anesthetics. These include novocaine, cocaine, procaine, marcaine, lidocaine, and others. This could be done with either an injection into the nerve or nerve sheath itself, the spinal cord, or the area just outside the spinal cord, or a combination of these places.
When the anesthetic is injected into or near the nerve itself, this is referred to as a nerve block. These can be very useful when the nerve is easily located, such as in the finger and some other locations or during the actual amputation when it is seen. The anesthetic can last for several hours if a long acting anesthetic is used. This technique can be used for amputations anywhere and it is necessary to use direct nerve injections in the upper extremity where epidural anesthetics and analgesics are not feasible. This can be used either by itself or with a general anesthetic for the amputation. The anesthesia or analgesia can be prolonged by placing a small plastic tube into the area of the nerve sheaths and injecting it either continuously or repeatedly for several days post op.
When the anesthetic is injected just outside the spinal cord, but inside the spinal canal, it is referred to as an epidural block. These are very commonly used now for delivery of babies because they have few complications and can be prolonged for hours if needed. They are most often given by inserting a small flexible plastic tube through a needle into the epidural space. The needle is withdrawn and the small tube remains lying along side the spinal cord. Anesthetic and analgesic medications can be injected through the tube to relieve pain or completely anesthetize the area served by the nerves in the area. This can be used by itself for amputations or in conjunction with a general anesthetic. Since the plastic tube can be left in place for several days, the pain relief can be prolonged for several days. It is necessary for an anesthesia doctor to carefully monitor the epidural to make it safe, but they are highly effective, during and after surgery for excellent, complete pain relief for many people undergoing amputation. There are two small series of patients treated in this manner that reported no significant phantom pain in up to one year of follow up after the amputation. This appears to be one of the most exciting developments in management of amputation pain. The author has used the intraoperative and postoperative epidural technique for amputations that he has performed for several years and can report similar results in virtually no significant phantom pain.
The other technique for use of local anesthetic is by injecting it into the spinal cord to mix with the spinal fluid. This is referred to as a "spinal" block. These also give profound anesthesia and pain relief and can last for many hours after the surgery if long-acting agents are used; however, they cannot be prolonged for days without reinjection. Since there is suggestion that the long-term anesthesia or analgesia may prevent long term pain, the only real advantage to the "spinal" block it that it is technically easier to do than an epidural or nerve block.
Along with the block techniques that have been mentioned, the use of a general anesthetic for sedation, amnesia, and general support is often used. A combination of techniques is often employed by the anesthesiologist. The patient about to undergo an amputation should always discuss the anesthetic plans with the anesthesiologist and surgeon and request information about the techniques mentioned in this article. Many highly qualified anesthesiologists may not be aware of the potential long-term benefits from intraoperative and postoperative epidural and nerve block techniques, even though they often utilize the epidural technique for delivering babies. Ask for them to discuss it in detail. If they have questions, they can call the Amputee Coalition for copies of the recent articles upon which these suggestions are based. Each patient has the right to ask for the optimum anesthetic and analgesic management. This is the time when an informed consumer is his/her own best advocate.
Immediate postoperative pain
The first 72 hours following an amputation is considered the immediate postoperative period. During this time swelling occurs, tissues are stretched, severed nerves are not sending normal afferent impulses to the spinal cord, and many other new realities are being experienced. Tension, fear, anger, and denial may be producing a strong emotional "stew" for the new amputee to experience. For most new amputees, this is physically the most difficult period with the most severe pain being experienced. There is clear evidence that adequate relief of pain and anxiety during this chaotic period is extremely important in determining long-term postoperative pain.
In addition to the previous discussion of epidural and nerve block techniques for pain relief, it is important to consider other types of pain relief in the postoperative period. These include narcotic and non-narcotic analgesic medications, anti-anxiety medications, anti-depressants, and others.
Narcotic pain medications such as morphine, Demerol, Fentanyl, and others have been used for many years for relief of severe pain. They can be injected intravenously, intramuscularly, epidurally, and subcutaneously as well as taken orally. The use of these strong pain medications has been the cornerstone of relieving pain following an amputation. There are some new medications available as well as a major new way of administering some of them that have made a significant impact on relief of pain. The new medications themselves won't be discussed since the new amputee cannot order his or her own medications; however, the new technique of administering them will be mentioned.
The new administration technique is referred to as Patient Controlled Analgesia (PCA). This means that the patient himself or herself actually controls the timing of the doses of pain medication. To do this, a small electric pump containing a syringe of pain medication is hooked to a switch. When the patient pushes a button, the pump gives a premeasured dose of the pain medicine. The doctor has determined how much medicine is safe to give and how often it can be given. The medicine is given through an intravenous tubing so that it enters the circulation immediately. A small amount can be given as often as every six to ten minutes. This has several benefits compared to the traditional injection in the muscle. It is much quicker to take effect. It does not have as much of a chance to over sedate the patient with a large dose of medicine. It does not require the nurse to come to the bedside each time pain medicine is needed. It usually actually takes less medicine to relieve pain in each 24-hour period.
In addition to narcotic pain medications, less potent non-narcotic analgesics include aspirin, acetaminophen, ibuprofen, and other non-steroidal anti-inflammatory drugs. These all have very useful roles when properly applied and should be used with guidance from the surgeon and anesthesiologist.
Other medications that can be helpful include tranquilizers such as Vistaril, anti-depressants such as Elavil, and anti-seizure medications such as Neruontin. A full discussion of these medications and their use is beyond the scope of this article since they are usually used more in the later postoperative period. They will be discussed in the next article in this series regarding post-amputation pain and its management.
First six weeks post-amputation
During the first six weeks following an amputation, many changes are occurring rapidly. Most of them are good changes with decrease of pain and swelling and increase of mobility and accommodation to the physical reality of amputation; however, there are many real problems in this period, physical as well as emotional.
There is typically decreasing need for pain medication but may be need for medicine to help with sleep or to deal with anxiety or depression. There is change in physical activity and the need to learn new methods of dealing with formerly routine tasks. Coming home from the hospital may be highly desired but also feared because it requires increased physical efforts and the emotional challenge of dealing with old relationships and demands despite a new physical reality.
Fears of dependency, inadequacy, and unacceptability may be the most important but unspoken part of the new amputee's thoughts. Questions about the ability to work or maintain physical independence may demand a share of the emotional resources being dedicated to achieving the ability to walk or to bathe independently.
While the physical pain may decrease dramatically, the emotional turmoil may spiral uncontrollably during the six or eight weeks after an amputation. This stress may significantly affect the amputee's ability and willingness to deal with the remaining physical pain. The chemicals in the brain that help deal with pain and stress may be used up by this time, making the amputee experience one of increased pain, anxiety, and stress.
The next article regarding post-amputation pain will discuss in detail the medical management of post-amputation pain during the months following an amputation.
Please send your questions and ideas to be incorporated into future articles. Send them to Editor, InMotion magazine, 900 E. Hill Avenue, Suite 295, Knoxville, TN 37915 or e-mail to Amputee CoalitionEdward@aol.com .