Department of Orthopaedic Surgery, Medical University of Vienna, Vienna, Austria.
Austrian Doctors for the Disabled, Vienna, Austria.
Clin Orthop Relat Res. 2021 Sep 1;479(9):2036-2044. doi: 10.1097/CORR.0000000000001725.
After major lower limb amputation, persistent pain is common, with up to 85% of patients reporting recurring phantom or residual-limb pain. Although pain management is an important factor of quality of life in patients with lower limb amputations, there are few long-term data regarding the frequency of persistent pain and how it impacts prosthesis use.
QUESTIONS/PURPOSES: (1) How prevalent are different types of pain at long-term follow-up after amputation for malignant tumors? (2) What association do different pain types have with daily prosthesis use?
Between 1961 and 1995, 124 major amputations for malignant tumors were performed at one center in Austria in patients (1) who spoke German and (2) whose surgical date resulted in the possibility of a minimum follow-up time of 20 years at the time of this survey; those patients were considered potentially eligible for this retrospective study. The indications for major amputation were to achieve local tumor control in limbs that the surgeon deemed unsalvageable without amputation. Of those 124 patients, 71% (88) had died, 9% (11) could not be reached, and 3% (4) declined to participate. Thus, 58% (21 of 36) of those living at the time of this study and who underwent lower limb amputation between 1961 and 1993 with a median (range) follow-up duration of 41 years (23 to 55) completed a standardized questionnaire, including an assessment of pain and daily prosthesis use during the year before the survey. Phantom pain, residual limb pain, and back pain were each further subclassified into pain frequency, intensity, and restrictions in activities of daily living (ADL) due to the specific pain form and rated on a 5- (pain frequency) and 10-point (pain intensity, restrictions in ADL) numerical rating scale. Before multivariate regression analysis, daily prosthesis use was correlated with pain parameters using Spearman correlation testing.
Seventeen of 21 patients reported phantom limb and back pain, and 15 patients reported residual limb pain in the past year. Median (range) phantom pain intensity was 7 (1 to 10) points, median residual limb pain intensity was 4 (1 to 9) points, and median back pain intensity was 5 (1 to 10) points. After controlling for relevant confounding variables such as age at amputation, age at survey, and stump length, we found that less intense residual limb pain (defined on a 10-point scale with 1 representing no pain at all and 10 representing extremely strong pain [95% CI 0.3 to 1.0]; r = 0.8; p = 0.003) was associated with greater daily prosthesis use. Higher amputation levels showed a decreased daily prosthesis use compared with patients with lower amputation levels (defined as transfemoral amputation versus knee disarticulation versus transtibial amputation [95% CI 0.3 to 5.1]; r = 0.5; p = 0.03).
Decades after surgery, many patients with lower limb amputations experience pain that restricts them in terms of ADLs and decreases their daily prosthesis use. This information supports the need for regular residual limb inspections and careful prosthesis fitting even at long-term follow-up, as effective prosthesis fitting is a modifiable cause of residual limb pain. Future studies evaluating long-term treatment effects of pain relief surgery and therapeutic alternatives to conservative pain treatments should be performed, as these approaches may help alleviate pain in patients with refractory postamputation pain.
Level IV, therapeutic study.
在下肢大截肢后，持续性疼痛很常见，高达 85%的患者报告存在反复出现的幻肢或残肢痛。尽管疼痛管理是下肢截肢患者生活质量的一个重要因素，但关于持续性疼痛的频率以及它如何影响假肢使用的长期数据很少。
问题/目的：（1）在恶性肿瘤截肢后长期随访中，不同类型的疼痛有多常见？（2）不同类型的疼痛与日常假肢使用有何关联？
在奥地利的一个中心，1961 年至 1995 年间，对 124 例恶性肿瘤进行了主要截肢手术，这些患者符合以下条件：（1）讲德语，（2）手术日期使得在进行本次调查时，至少有 20 年的随访时间；这些患者被认为有资格参加这项回顾性研究。主要截肢的指征是为了在外科医生认为无法保留肢体而截肢的情况下，实现肢体的局部肿瘤控制。在这 124 名患者中，71%（88 例）死亡，9%（11 例）无法联系到，3%（4 例）拒绝参与。因此，在这项研究中，58%（21/36）的生活在当时并在 1961 年至 1993 年间接受了下肢截肢手术的患者完成了一份标准化问卷，其中包括在调查前一年评估疼痛和日常假肢使用情况。幻肢痛、残肢痛和背痛均进一步分为疼痛频率、强度和由于特定疼痛形式而导致的日常生活活动（ADL）受限程度，并使用 5 分（疼痛频率）和 10 分（疼痛强度、ADL 受限程度）数字评分量表进行评分。在进行多变量回归分析之前，使用 Spearman 相关检验来分析日常假肢使用与疼痛参数之间的相关性。
21 名患者中有 17 名报告存在幻肢和背痛，15 名患者报告在过去一年中存在残肢痛。中位数（范围）幻肢疼痛强度为 7（1 至 10）分，中位数残肢疼痛强度为 4（1 至 9）分，中位数背痛强度为 5（1 至 10）分。在控制了年龄、调查时的年龄和残肢长度等相关混杂变量后，我们发现，残肢疼痛强度较弱（定义为 10 分制，1 代表完全无痛，10 代表极度疼痛[95%CI 0.3 至 1.0]；r=0.8；p=0.003）与更大的日常假肢使用相关。与低位截肢（定义为股骨截肢与膝关节离断术与胫骨截肢术[95%CI 0.3 至 5.1]；r=0.5；p=0.03）相比，高位截肢患者日常假肢使用减少。
手术后几十年，许多下肢截肢患者仍经历疼痛，这些疼痛会限制他们的日常生活活动能力，并减少他们日常使用假肢的频率。这些信息支持在长期随访中定期进行残肢检查和仔细的假肢适配的需要，因为有效的假肢适配是残肢疼痛的一个可改变的原因。应该进行评估缓解疼痛手术长期治疗效果和替代保守疼痛治疗的治疗方法的未来研究，因为这些方法可能有助于减轻有顽固性截肢后疼痛的患者的疼痛。
IV 级，治疗性研究。
