Pembimbing : dr.

Imam Sudrajat, SpAn MSi Med

Penyusun : Ferry Afero Tanama (11.2011.084) Viona (11.2011.098) Rosalita (11.2011.109)
KEPANITERAAN KLINIK ILMU ANESTESIOLOGI FAKULTAS KEDOKTERAN UNIVERSITAS KRISTEN KRIDA WACANA PERIODE 12 NOVEMBER 2012 30 NOVEMBER 2012 RUMAH SAKIT BAYUKARTA KARAWANG

Received 8 October 2005; revised 23 March 2006; accepted 26 March 2006

Bill Y. Ong MD (Professor of Anesthesia)a Amarjit Arneja MD (Associate Professor of Medicine) Edmund W. Ong (Undergraduate Student)
DEPARTMENT of Anesthesia, University of Manitoba, Winnipeg, Manitoba, Canada R3A 1R9 Section of Rehabilitation Medicine, Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada R3A 1R9

Journal of Clinical Anesthesia (2006) 18, 600604

After lower-limb amputation, many amputees continue to have sensation in the stump and in the amputated portion of the limb. These sensations range from slight tingling to sharp, aching, or throbbing pain. Because phantom limb pain is often distressing and adversely affects patients after amputation , treatment to prevent or reduce it is needed.

Phantom limb pain might be influenced by preamputation pain. Jensen et al and Nikolajsen et al reported that phantom limb pain is more frequent in patients with preamputation pain. Katz and Melzack suggested that many patients had phantom limb pain that resembled their preamputation pain in quality and location. We assessed patients after their lower-limb amputation to determine if the choice of anesthesia had any effect on their subsequent stump and phantom limb sensations.

Stump pain was defined as a painful sensation or feeling from the stump or the remaining part of the leg but not from the removed part of the leg. Phantom sensation was defined as a nonpainful sensation or feeling from the removed part of the leg. Phantom limb pain was defined as a painful sensation or feeling from the removed part of the leg.

Inclusion criteria were the following: lowerlimb amputation within the past one to 24 months, minimum age of 18 years, ability to communicate in English, and completed medical records. Patients were asked to recall the average pain intensity that they felt before amputation and in the week after amputation. They were also asked if they had any stump pain, phantom sensation, or phantom limb pain in the week preceding the interview.

If a patient reported stump pain or phantom limb pain,that patient was asked as to which medication, if any, he or she had used to relieve the pain. The patient was also asked to describe the frequency of the pain symptoms. In addition, each patient was asked whether the pain affected his or her abilities to sleep at night, to concentrate, and to carry on with general activities.

Of these patients, 14% received epidural anesthesia, 54% received spinal anesthesia, and 32% received general anesthesia. There was no difference in patient characteristics among the three groups. Fifty percent or more of the patients had moderate-to-severe pain and used opioids for analgesia before their amputation.

Patients who had received epidural anesthesia and those who had received spinal anesthesia recalled significantly less pain in the first week after their surgery as compared with the patients who had received general anesthesia

The major finding of this study was that patients recalled significantly lower levels of pain during the first week after their amputation if they had received epidural or spinal anesthesia as compared with patients who received general anesthesia. Epidural analgesia/anesthesia might ameliorate phantom limb pain by preventing excessive stimulation of dorsal horn neurons before and immediately after lower-limb amputation

At 6 months after amputation, the patients who received epidural analgesia before surgery had a significantly lower incidence of phantom limb pain. At 7 days and one year after amputation, the rates of phantom limb pain were not significantly different. Jahangiri et al studied the use of epidural infusion containing bupivacaine, clonidine, and diamorphine in preventing phantom limb pain in a prospective controlled study

At 7 days, 6 months, and one year after amputation, there was a significantly lower frequency of phantom limb pain and phantom limb sensations among patients who had received epidural analgesia before amputation. There was no significant difference in frequency of stump pain.

Nikolajsen et al investigated preoperative epidural block with bupivacaine and morphine in a study on 60 patients. These investigators concluded that perioperative epidural block did not prevent phantom or stump pain.

did not find any difference at 14 months after amputation in the incidence or severity of stump pain, phantom limb sensation, and phantom limb pain between patients who received epidural anesthesia, those who received spinal anesthesia, and those who received general anesthesia for their lowerlimb amputation.

A weakness of the current study was the reliance on patients recall of pain severity. The bias in patients recall could have increased reported frequencies and severity of pain symptoms. The effect of spinal anesthesia on pain after amputation had not been examined previously. Katz and Melzack suggested that spinal anesthesia might reduce pain memories of the amputated limb.

Patients who received epidural anesthesia and those who received spinal anesthesia for amputation recalled less pain in the first week after their amputation. After 14 months, there was no significant difference in phantom limb pain and stump pain between patients who had received epidural anesthesia, those who had received spinal anesthesia, and those who had received general anesthesia.

Moderate-to-severe stump and phantom limb pain continued to be frequent despite the use of nonopioid analgesics, opioid analgesics, amitriptyline, and gabapentin by patients after their lower-limb amputation.