Perioperative Pain Management for Major Limb Amputation - A Systematic-Narrative Hybrid Review

Post-amputation pain, including residual limb pain (RLP) and phantom limb pain (PLP), can affect the outcome of surgery and have an impact on quality of life. Effective management of acute post-amputation pain requires a multidisciplinary approach with collaboration among the surgical and anesthesia teams to optimize pain management. A systematic-narrative hybrid review was conducted to assess and report the effectiveness of various interventions in perioperative pain management for amputation surgery.

MEDLINE, Embase, CENTRAL, and ClinicalTrials.gov databases were searched for studies evaluating interventional and/or pharmacological approaches to managing perioperative pain in major extremity amputation surgery. The data collected included treatment options, average dosage and/or duration of treatments, and reported pain outcomes.

Of the 27 studies evaluating interventions, 8 addressed neuraxial or perineural analgesia, 16 focused on peripheral nerve blocks (PNB), 2 examined peripheral nerve stimulators (PNS), and 1 investigated transcutaneous electrical nerve stimulation. Preoperative epidural analgesia was associated with a reduced incidence of postoperative pain. PNS, PNB, and catheter-based infusions were found to be effective in managing postoperative pain. The role of ketamine in treating post-amputation pain yielded mixed results, while other pharmacological agents, such as valproic acid and gabapentin, demonstrated limited efficacy.

While numerous pain interventions are available, no single approach has been shown to be superior. A multimodal strategy, incorporating PNBs, preoperative pain control, and potentially ketamine, appears to provide the most comprehensive pain management strategy. Further long-term prospective studies are required to refine and optimize pain management techniques for major extremity amputation surgery.

III-Systematic reviews.