Phantom Limb Pain Still Not Understood After a Century

The November 7 issue of The Lancet focuses on the 1914 breakout of World War I as a pivotal time for the advancement of medical science — specifically, amputated limbs and associated pain.

The Lancet publishers reviewed their archives in order to determine any progress made in the last century. The efforts made by surgeons in World War I were used as building blocks to improve amputation process and treatment during the war and immediately after. However, they wrote, despite record patient numbers and growth in civilian medical expertise, little progress has been made in understanding this type of pain and its potential treatments.

“Amputation was used as a treatment in field hospitals to save lives; limb conservation was a secondary consideration,” the article noted. The authors continue that even today — 100 years later – musculoskeletal trauma and injury to peripheral nerves caused by improvised explosive devices are a common concern. A century ago, artillery munitions were the cause of this damage, and experts from the Imperial College London mentioned in the series that the injuries from the past and present are very similar.

What is similar between today’s conflicts and the World Wars of the past is post-amputation pain, which is still poorly understood with minimal effective treatments.

A BBC News article pointed out that phantom limb pain, as this condition is often called, is believed to affect about 60 percent of amputation patients.

The article continued by pointing out many articles in the medication archives mention insufferable pain of amputee patients. For example, Marmaduke Sheild, a senior consulting surgeon at hospitals which treated military casualties in London and Exeter in the United Kingdom wrote in 1916 that the post-amputation pain suffered by patients “a source of intolerable suffering and despair to those who fir them with artificial limbs.”

Sheild continued by suggesting surgeons not use what was termed “the guillotine method” — in which surgeons cut directly through the limb in a swift motion – because nerves remained exposed and likely caused additional pain and require further surgeries.

Emily R. Mayhew, PhD, who led the research, said half of men who had limbs amputated during World War I returned to the hospital for further treatment.

“After 3 years or so they often say the pain is starting to come back,” Mayhew told the BBC. “This can be pain in the actual stump that is left over or a phantom pain, which is a very odd sensation of the limb still being there, or the limb in pain still being there. It’s a bit like when your feet get very cold and feel numb, except that there is nothing there.”

Today, surgeons make efforts to amputate as little of the limb as necessary, which is a process termed debridement. The prongs of this effort are to stop the bleeding, take away the minimum amount of required damaged tissue, and to clean the injured area as much as is possible.

Treatments 100 years ago were ineffective by today’s standards, but today’s efforts are not as far along as many surgeons — and patients – would like them to be.