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Treating Intractable Phantom Limb Pain with Ambulatory Continuous Peripheral Nerve Blocks: A Pilot Study

Authors

  • Brian M. Ilfeld MD, MS (Clinical Investigation),

    Corresponding author
    • Department of Anesthesiology, University of California San Diego, San Diego, California, USA
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  • Tobias Moeller-Bertram MD, Dr. med, MAS,

    1. Department of Anesthesiology, University of California San Diego, San Diego, California, USA
    2. San Diego Veteran's Affairs Medical Center, San Diego, California, USA
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  • Steven R. Hanling MD,

    1. Department of Anesthesiology, Naval Medical Center, San Diego, California, USA
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  • Kyle Tokarz DO,

    1. Department of Anesthesiology, Naval Medical Center, San Diego, California, USA
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  • Edward R. Mariano MD, MAS (Clinical Research),

    1. Department of Anesthesiology, University of California San Diego, San Diego, California, USA
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    • The majority of study contributions of Drs. Mariano and Loland occurred while working at the University of Calfiornia San Diego, San Diego, California. Dr. Mariano has since moved to Stanford University, Stanford, California; and, Dr. Loland has since moved to the University of Washington, Seattle, Washington.
  • Vanessa J. Loland MD,

    1. Department of Anesthesiology, University of California San Diego, San Diego, California, USA
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    • The majority of study contributions of Drs. Mariano and Loland occurred while working at the University of Calfiornia San Diego, San Diego, California. Dr. Mariano has since moved to Stanford University, Stanford, California; and, Dr. Loland has since moved to the University of Washington, Seattle, Washington.
  • Sarah J. Madison MD,

    1. Department of Anesthesiology, University of California San Diego, San Diego, California, USA
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  • Eliza J. Ferguson BS,

    1. Department of Anesthesiology, University of California San Diego, San Diego, California, USA
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  • Anya C. Morgan MA, CCRC,

    1. Clinical and Translational Research Center, University of California San Diego, San Diego, California, USA
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  • Mark S. Wallace MD

    1. Department of Anesthesiology, University of California San Diego, San Diego, California, USA
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  • Financial Support: Funding for this project provided by the National Institutes of Health grant GM077026 (P.I.: Dr. Ilfeld) from the National Institute of General Medical Sciences (Bethesda, Maryland); the Clinical and Translational Research Institute, University of California, San Diego (San Diego, CA), with funding provided by the National Institutes of Health National Center for Research Resources grant UL1RR031980; the University of California Academic Senate (P.I.: Dr. Ilfeld; San Diego, CA); the Department of Anesthesiology, University of California San Diego (San Diego, California); and Summit Medical (Salt Lake City, Utah) provided both an unrestricted research grant and the infusion pumps used in this investigation. This company had no input into any aspect of study conceptualization, design, and implementation; data collection, analysis, and interpretation; or manuscript preparation. The contents of this article are solely the responsibility of the authors and do not necessarily represent the official views of the funding entities. The views expressed herein are the authors' own and do not necessarily reflect the official policy or position of the Department of Navy, Department of Defense, or the US Government.
  • Conflict of Interest: None.
  • Prior Presentation: Presented, in part, as a scientific abstract at the annual meeting of the American Society of Anesthesiologists in Washington DC (United States), October 13–17, 2012.

Reprint requests to: Brian M. Ilfeld, MD, MS, Department of Anesthesiology, 200 West Arbor Drive, MC 8770, San Diego, CA 92103-8770, USA. Tel: 858-657-7072; Fax: 858-683-2003; E-mail: bilfeld@ucsd.edu.

Abstract

Background.

There is currently no reliable treatment for phantom limb pain (PLP). Chronic PLP and associated cortical abnormalities may be maintained from abnormal peripheral input, raising the possibility that a continuous peripheral nerve block (CPNB) of extended duration may permanently reorganize cortical pain mapping, thus providing lasting relief.

Methods.

Three men with below-the-knee (2) or -elbow (1) amputations and intractable PLP received femoral/sciatic or infraclavicular perineural catheter(s), respectively. Subjects were randomized in a double-masked fashion to receive perineural ropivacaine (0.5%) or normal saline for over 6 days as outpatients using portable electronic infusion pumps. Four months later, subjects returned for repeated perineural catheter insertion and received an ambulatory infusion with the alternate solution (“crossover”). Subjects were followed for up to 1 year.

Results.

By chance, all three subjects received saline during their initial infusion and reported little change in their PLP. One subject did not receive crossover treatment, but the remaining two subjects reported complete resolution of their PLP during and immediately following treatment with ropivacaine. One subject experienced no PLP recurrence through the 52-week follow-up period and the other reported mild PLP occurring once each week of just a small fraction of his original pain (pretreatment: continuous PLP rated 10/10; posttreatment: no PLP at baseline with average of one PLP episode each week rated 2/10) for 12 weeks (lost to follow-up thereafter).

Conclusions.

A prolonged ambulatory CPNB may be a reliable treatment for intractable PLP. The results of this pilot study suggest that a large, randomized clinical trial is warranted.

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