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Key messages
1. Continuous regional blockade via nerve sheath catheters provides effective postoperative
analgesia after amputation, but has no preventive effect on phantom limb pain (U)
(Level II).
2. Calcitonin, morphine, ketamine, gabapentin, amitriptyline and tramadol reduce phantom
limb pain (S) (Level II).
3. Sensory discrimination training and motor imagery reduce chronic phantom limb pain (S)
(Level II).
4. Ketamine, lignocaine (lidocaine), tramadol and amitriptyline reduce stump pain (S)
(Level II).
5. Perioperative epidural analgesia reduces the incidence of severe phantom limb pain (U)
(Level III‐2).
The following tick box represents conclusions based on clinical experience and expert
opinion.
Perioperative ketamine may prevent severe phantom limb pain (U).
9.1.3 Other postoperative pain syndromes
Increasing evidence for the development of postoperative chronic pain syndromes has led to
more detailed study of a number of them. The information below does not discuss aspects of
surgical techniques that may influence the incidence of chronic pain.
Risk factors that predispose to the development of chronic postsurgical pain include the
severity of pre and postoperative pain, intraoperative nerve injury (see Section 1.3). Again,
specific early analgesic interventions may reduce the incidence of chronic pain after some
operations.
Post-thoracotomy pain syndrome
Post‐thoracotomy pain syndrome is one of the most common chronic pain states. It is thought
to be caused primarily by trauma to intercostal nerves and most patients relate their pain
CHAPTER 9 directly to the site of surgery (Karmakar & Ho, 2004; Wildgaard et al, 2009). However, myofascial
pain syndromes as a consequence of thoracotomy have also been described (Hamada et al, 2000
Level IV).
Epidural analgesia initiated prior to thoracotomy and continued into the postoperative period
resulted in significantly fewer patients reporting pain 6 months later compared with patients
who had received IV PCA opioids for postoperative analgesia (45% vs 78% respectively)
(Senturk et al, 2002 Level II). There was no statistically significant difference in the incidence of
chronic pain between patients given pre‐emptive epidural analgesia (initiated prior to surgery)
and patients in whom epidural analgesia was commenced after surgery — 39.6% vs 48.6%
(Bong et al, 2005 Level I).
The addition of low‐dose IV ketamine to thoracic epidural analgesia reduced the severity and
need for treatment of post‐thoracotomy pain at 1 and 3 months postoperatively (Suzuki et al,
2006 Level II). However, another study showed that perioperative IV ketamine in addition to
interpleural local anaesthetic did not prevent chronic neuropathic pain up to 4 months after
thoracotomy (Duale et al, 2009 Level II).
Cryoanalgesia, which provides effective pain relief in the immediate postoperative period
(De Cosmo et al, 2008), caused an increased incidence of chronic pain (Ju et al, 2008 Level II).
236 Acute Pain Management: Scientific Evidence
