Randomized prospective study comparing pre‐emptive epidural and intraoperative perineural analgesia for the prevention of postoperative stump and phantom limb pain following major amputation

Background: The reported incidence of phantom limb pain (PLP) following amputation is up to 85 per cent. This study was designed to compare the efficacy of two perioperative analgesic techniques with respect to postoperative stump pain (POSP) and PLP. Methods: Patients were randomized prospectively. Group 1 received a pre‐emptive epidural for a minimum of 24 h before surgery which was continued after operation. Group 2 had intraoperative placement of a perineural catheter for the administration of local anaesthetic by infusion after operation. All amputations were performed under general anaesthesia. POSP was assessed by visual analogue score (VAS), ranging from 0 to 10. The presence of PLP was assessed 6 and 12 months after operation. Results: A total of 30 patients were recruited, 12 men and 18 women, of median age 74 (range 47–93) years. Each group was well matched for concurrent cardiovascular disease and the level of amputation. VAS at 6 h, 1, 2 and 3 days after operation was significantly less in group 1 than group 2 ( P < 0·05, two‐sample t test). Six patients died in each group and one was lost to follow‐up. The overall incidence of PLP was 75 per cent at 6 months and 44 per cent at 12 months, with no significant difference between the two groups. Conclusion: In this series, pre‐emptive epidural analgesia significantly reduced the severity of POSP. The incidence of PLP remains disappointingly high regardless of the analgesic technique used. © 2000 British Journal of Surgery Society Ltd