Phantom Limb Pain: A Systematic Neuroanatomical-Based Review of Pharmacologic Treatment

Authors

  • Zachary McCormick MD,

    Corresponding author
    1. Department of Physical Medicine and Rehabilitation, The Rehabilitation Institute of Chicago/Northwestern McGaw Medical Center, Chicago, Illinois, USA
    • Reprint requests to: Zachary McCormick, MD, 780 S. Federal, Chicago, IL 60605, USA. Tel: 510-388-7084; Fax: 312-238-1035; E-mail: zmccormi@gmail.com.

    Search for more papers by this author
  • George Chang-Chien DO,

    1. Department of Physical Medicine and Rehabilitation, The Rehabilitation Institute of Chicago/Northwestern McGaw Medical Center, Chicago, Illinois, USA
    Search for more papers by this author
  • Benjamin Marshall DO,

    1. Department of Physical Medicine and Rehabilitation, The Rehabilitation Institute of Chicago/Northwestern McGaw Medical Center, Chicago, Illinois, USA
    Search for more papers by this author
  • Mark Huang MD,

    1. Department of Physical Medicine and Rehabilitation, The Rehabilitation Institute of Chicago/Northwestern McGaw Medical Center, Chicago, Illinois, USA
    Search for more papers by this author
  • R. Norman Harden MD

    1. Department of Physical Medicine and Rehabilitation, The Rehabilitation Institute of Chicago/Northwestern McGaw Medical Center, Chicago, Illinois, USA
    Search for more papers by this author

  • Disclosures: None of the authors have any conflicts of interest to report.
  • This research effort was not directly or indirectly financially supported.

Abstract

Objective

Review the current evidence-based pharmacotherapy for phantom limb pain (PLP) in the context of the current understanding of the pathophysiology of this condition.

Design

We conducted a systematic review of original research papers specifically investigating the pharmacologic treatment of PLP. Literature was sourced from PubMed, Embase, Scopus, and the Cochrane Central Register of Controlled Trials (CENTRAL). Studies with animals, “neuropathic” but not “phantom limb” pain, or without pain scores and/or functional measures as primary outcomes were excluded. A level of evidence 1–4 was ascribed to individual treatments. These levels included meta-analysis or systematic reviews (level 1), one or more well-powered randomized, controlled trials (level 2), retrospective studies, open-label trials, pilot studies (level 3), and anecdotes, case reports, or clinical experience (level 4).

Results

We found level 2 evidence for gabapentin, both oral (PO) and intravenous (IV) morphine, tramadol, intramuscular (IM) botulinum toxin, IV and epidural Ketamine, level 3 evidence for amitriptyline, dextromethorphan, topiramate, IV calcitonin, PO memantine, continuous perineural catheter analgesia with ropivacaine, and level 4 evidence for methadone, intrathecal (IT) buprenorphine, IT and epidural fentanyl, duloxetine, fluoxetine, mirtazapine, clonazepam, milnacipran, capsaicin, and pregabalin.

Conclusions

Currently, the best evidence (level 2) exists for the use of IV ketamine and IV morphine for the short-term perioperative treatment of PLP and PO morphine for an intermediate to long-term treatment effect (8 weeks to 1 year). Level 2 evidence is mixed for the efficacy of perioperative epidural anesthesia with morphine and bupivacaine for short to long-term pain relief (perioperatively up to 1 year) as well as for the use of gabapentin for pain relief of intermediate duration (6 weeks).

Ancillary