Journal of Clinical Anesthesia (2006) 18, 600 604

Original contribution

Effects of anesthesia on pain after lower-limb amputationB

Bill Y. Ong MD (Professor of Anesthesia)a,*,
Amarjit Arneja MD (Associate Professor of Medicine)b,1,
Edmund W. Ong (Undergraduate Student)b,1
a

Department of Anesthesia, University of Manitoba, Winnipeg, Manitoba, Canada R3A 1R9

Section of Rehabilitation Medicine, Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba,
Canada R3A 1R9
b

Received 8 October 2005; revised 23 March 2006; accepted 26 March 2006

Keywords:
Amputation;
Anesthesia: epidural,
general, spinal;
Pain: phantom limb,
stump

Abstract
Objective: To evaluate the effects of epidural, spinal, and general anesthesia on pain after lowerlimb amputation.
Design: Cross-sectional survey.
Setting: Postamputation clinic.
Patients: 150 patients who were evaluated one to 24 months after their lower-limb amputation.
Interventions: Patients received epidural, spinal, or general anesthesia for their amputation.
Measurements: Standardized questions were used to assess stump pain, phantom sensation,
and phantom limb pain preoperatively and postoperatively. Pain intensity was assessed on a verbal rating
scale of 0 to 10. After the interview, each patients medical history and anesthetic record were assessed.
Results: Patients who had received epidural anesthesia and those who had received spinal anesthesia
recalled significantly less pain in the week after their surgery ( P b 0.05). After an average of 14 months,
there was no difference in stump pain, phantom limb sensation, or phantom limb pain between patients
who received epidural anesthesia, those who received spinal anesthesia, and those who received general
anesthesia for their amputation. Phantom limb pain continued to be frequent and severe despite patients
use of opioid analgesics, amitriptyline, and gabapentin.
Conclusions: Patients who received epidural anesthesia and those who received spinal anesthesia
recalled better analgesia in the first week after their amputation than did patients who received general
anesthesia. Anesthetic technique had no effect on stump pain, phantom limb sensation, or phantom limb
pain at 14 months after lower-limb amputation.
D 2006 Published by Elsevier Inc.

1. Introduction

This study was supported by a grant from the War Amps of Canada.
* Corresponding author.
E-mail address: billong@mts.net (B.Y. Ong).
1
Mailing address for Dr Arneja and E.W. Ong: RR139 Rehab Hospital,
820 Sherbrook St, Winnipeg, MB, Canada R3A 1R9.
0952-8180/$ see front matter D 2006 Published by Elsevier Inc.
doi:10.1016/j.jclinane.2006.03.021

After lower-limb amputation, many amputees continue to

have sensation in the stump and in the amputated portion of
the limb. These sensations range from slight tingling to
sharp, aching, or throbbing pain. Because phantom limb
pain is often distressing and adversely affects patients after
amputation [1], treatment to prevent or reduce it is needed.

Anesthesia and pain after amputation

Phantom limb pain might be influenced by preamputation pain. Jensen et al [2] and Nikolajsen et al [3] reported
that phantom limb pain is more frequent in patients with
preamputation pain. Katz and Melzack [4] suggested that
many patients had phantom limb pain that resembled their
preamputation pain in quality and location. Previous
studies [5-7] assessed the effects of epidural block before
and after amputation on subsequent phantom limb pain;
the results were not consistent. The effect of spinal
anesthesia on pain after amputation had not been examined
previously, however.
We assessed patients after their lower-limb amputation to
determine if the choice of anesthesia had any effect on their
subsequent stump and phantom limb sensations.

2. Materials and methods

The University of Manitoba Health Research Ethics
Board approved this study. Participants were recruited from
among patients attending the postamputation clinic of the
Winnipeg Rehabilitation Hospital after their lower-limb
amputation. Inclusion criteria were the following: lowerlimb amputation within the past one to 24 months, minimum
age of 18 years, ability to communicate in English, and
completed medical records.
Patients who signed an informed consent form to
participate in the study were interviewed and assessed with
a standardized questionnaire and verbal rating scales for pain
in the amputated limb. Patients were asked to recall the
average pain intensity that they felt before amputation and in
the week after amputation. They were also asked if they had
any stump pain, phantom sensation, or phantom limb pain in
the week preceding the interview. In all cases, perceived pain
was rated on a verbal rating scale ranging from 1 to 10 (0 = no
pain; 10 = worst pain imaginable). Stump pain was defined
as a painful sensation or feeling from the stump or the
remaining part of the leg but not from the removed part of the
leg. Phantom sensation was defined as a nonpainful
sensation or feeling from the removed part of the leg.
Phantom limb pain was defined as a painful sensation or
feeling from the removed part of the leg.
If a patient reported stump pain or phantom limb pain,
that patient was asked as to which medication, if any, he or
she had used to relieve the pain. The patient was also asked
to describe the frequency of the pain symptoms. In
addition, each patient was asked whether the pain affected
his or her abilities to sleep at night, to concentrate, and to
carry on with general activities.
After the interview, the patients demographic information, date of amputation, associated medical conditions,
main reason for amputation, preoperative medications,
operative anesthesia, and level of amputation were determined from hospital records.
The demographic and verbal rating scale data were
evaluated by analysis of variance. Frequency of stump pain,

601
phantom limb sensation, or phantom limb pain and use of
analgesic medications were analyzed with v 2 analysis. P b
0.05 was considered to be statistically significant. The
results are presented as means F SD.

3. Results
One hundred fifty patients completed the study. Patient
characteristics are listed in Table 1. Of these patients, 14%
received epidural anesthesia, 54% received spinal anesthesia,
and 32% received general anesthesia. There was no
difference in patient characteristics among the three groups.
Diabetes mellitus was the most common associated medical
condition. There was no difference between the three groups
with regard to level of amputation and main reason for
amputation. Fifty percent or more of the patients had
moderate-to-severe pain and used opioids for analgesia
before their amputation.
Each patient and the attending anesthesiologist had
decided on the choice of anesthetic. Patients in the spinal
anesthesia group received a hyperbaric 0.75% spinal
bupivacaine solution. Those in the general anesthesia group
received a balanced technique with opioids and inhalational
Table 1 Patient characteristics, types of amputation, and pain
before amputation
Epidural
anesthesia
group
Patients (n)
Age (y;
mean F SD)
Gender (% male)
Mean time after
amputation (months;
mean F SD)
Associated medical
disorders (%)
Diabetes
Hypertension
MI/Stroke
Level of
amputation (%)
Below knee
Knee
Above knee
Main reason for
amputation (%)
Vascular infection
Trauma
Pain before
amputation (VRS;
mean F SD)
Use of opioid before
amputation (%)

Spinal
anesthesia
group

General
anesthesia
group

21
81
48
65.1 F 11.5 64.0 F 10.4 50.7 F 16.6
71.4
75.3
66.7
14.0 F 12.5 13.1 F 13.0 15.0 F 14.3

66.7
28.6
4.8

77.8
27.2
14.8

72.9
25.0
6.3

57.1
28.6
14.3

67.9
14.8
17.3

60.4
14.6
25.0

90.5
9.5
6.2 F 3.7

96.3
3.7
5.9 F 4.1

85.4
14.6
6.9 F 3.7

50.0

52.8

73.9

MI indicates myocardial infarction; VRS, verbal rating scale.

602

B.Y. Ong et al.

Table 2 Initial pain, phantom sensations, and use of

medications after amputation

Pain during the

first week after
amputation (VRS;
mean F SD)
Patients having
phantom limb
sensation (%)
Use of medications
at the time of
interview (%)
Nonopioid
analgesics (%)a
Opioid
analgesics (%)
Amitriptyline (%)
Gabapentin (%)

Epidural
anesthesia
group

Spinal
anesthesia
group

General
anesthesia
group

3.0 F 3.7

4.3 F 3.6

6.2 F 3.1*

80.9

76.5

81.3

42.9

38.4

37.5

14.3

13.6

20.8

18.2

28.6

29.2

4.5
22.7

3.6
4.8

8.3
12.5

VRS = Verbal Rating Scale.

a
Nonopioid analgesics included aspirin, acetaminophen, and
nonsteroidal anti-inflammatory drugs.
* P = 0.0337.

anesthetics. Patients in the epidural anesthesia group

received local anesthetics through epidural catheters in the
lumbar region for surgical anesthesia. The spinal and
general anesthesia patients received intravenous or intramuscular opioids for postoperative analgesia. Epidural
patients received a continuous infusion of diluted bupivacaine and hydromorphone for analgesia for 24 to 120 hours
postoperatively. Anesthesiologists from the acute pain
service supervised the epidural infusions.
Patients who had received epidural anesthesia and those
who had received spinal anesthesia recalled significantly
less pain in the first week after their surgery as compared
with the patients who had received general anesthesia ( P b
0.05). There was no difference between the three groups of
patients regarding frequency of nonopioid analgesic, opioid
analgesic, amitriptyline, or gabapentin use (Table 2). Nonopioid analgesics included aspirin, acetaminophen, and
nonsteroidal anti-inflammatory drugs.
A significant number of patients reported experiencing
stump pain and phantom limb pain. Stump pain parameters
were similar between the three groups (Table 3). There was
no difference in phantom limb pain parameters among the
three anesthesia groups (Table 3). Severity and frequency of
stump pain and phantom limb pain were similar (Table 3).

4. Discussion
The major finding of this study was that patients recalled
significantly lower levels of pain during the first week after
their amputation if they had received epidural or spinal

anesthesia as compared with patients who received general anesthesia.

In a randomized, prospective trial of 30 patients
undergoing lower-limb amputation, Lambert et al [8]
randomly assigned 14 patients to receive epidural bupivacaine and diamorphine for 24 hours preoperatively, perioperatively, and three days postoperatively. The other
16 patients were given an intraoperatively placed perineural
catheter for intraoperative and postoperative infusions of
bupivacaine. All patients received general anesthesia for
their amputation. Epidural block gave better relief from
stump pain in the immediate postoperative period. Gottschalk and Frank [9] found that intraoperative attenuation of
noxious stimuli with epidural block reduced pain and
wound hyperalgesia for three weeks after surgery in one
patient. Flisberg et al [10] and Dahl et al [11] reported that
epidural analgesia started in the postoperative period was as
effective as epidural analgesia started preoperatively and
continued into the postoperative period.
Jensen et al [2] as well as Katz and Melzack [4]
suggested that pain sensations in the limb before amputation
might play a role in phantom pain after amputation. Animal
models of nerve injury showed that repeated stimulation of
peripheral nociceptors produced changes in the dorsal horn
Table 3

Stump and phantom limb pain after amputation

Patients with
stump pain (%)
Among patients
with stump pain
(mean F SD)
Severity of stump
pain (VRS)
Days per month
with stump pain
Patients with
phantom limb
pain (%)
Among patients
with phantom
limb pain
(mean F SD)
Severity of phantom
limb pain
Days per month
with phantom
limb pain
Functions affected
by stump and
phantom limb
pain (%)
Sleep
Concentration
Daily activities

Epidural
anesthesia
group

Spinal
anesthesia
group

General
anesthesia
group

33.3

32.1

32.5

4.5 F 2.6

5.4 F 2.4

5.4 F 1.6

14.6 F 12.8 17.7 F 12.1 15.5 F 8.8

66.7

58.0

64.6

5.1 F 2.2

5.2 F 2.5

5.6 F 2.6

12.3 F 10.9 12.7 F 11.0 16.7 F 10.7

28.6
23.8
23.8

25.9
15.0
14.8

33.3
25.0
18.8

Anesthesia and pain after amputation

neurons of the spinal cord. Epidural analgesia/anesthesia
might ameliorate phantom limb pain by preventing excessive stimulation of dorsal horn neurons before and
immediately after lower-limb amputation [12]. This might
reduce the risk for phantom limb pain.
Bach et al [5] provided lumbar epidural block with
bupivacaine and morphine for 72 hours preoperatively to 11
patients. Fourteen control subjects received other analgesics
without local anesthetic before amputation. All patients
received epidural or spinal analgesia for their amputation.
At 6 months after amputation, the patients who received
epidural analgesia before surgery had a significantly lower
incidence of phantom limb pain. At 7 days and one year
after amputation, the rates of phantom limb pain were not
significantly different. All patients in the study by Bach et al
[5] received epidural or spinal anesthesia for their amputation. The lack of difference at 7 days could be explained by
the epidural or spinal analgesia during surgery.
Jahangiri et al [6] studied the use of epidural infusion
containing bupivacaine, clonidine, and diamorphine in
preventing phantom limb pain in a prospective controlled
study on 24 patients undergoing lower-limb amputation.
Epidural infusion was given for 24 to 48 hours preoperatively and maintained for at least three days postoperatively.
At 7 days, 6 months, and one year after amputation, there
was a significantly lower frequency of phantom limb pain
and phantom limb sensations among patients who had
received epidural analgesia before amputation. There was
no significant difference in frequency of stump pain. Our
results are consistent with the lower observed incidence of
pain at 7 days after amputation in the epidural group. Our
results at 14 months differed. The study by Jahangiri et al [5]
had a limited number of participants, and the investigators
were not blinded to the treatments received by the patients.
Nikolajsen et al [7] investigated preoperative epidural
block with bupivacaine and morphine in a study on
60 patients. Patients scheduled for lower-limb amputation
were randomly assigned to receive either epidural bupivacaine and morphine for 18 hours before and during the
operation (29 patients in the blockade group) or epidural
saline and oral or intramuscular morphine (31 patients in the
control group). All patients received epidural and general
anesthesia for amputation and epidural analgesia after
amputation. There was no difference in the frequency or
intensity of stump and phantom pain between the epidural
and control groups after one week, three months, 6 months,
or 12 months. These investigators concluded that perioperative epidural block did not prevent phantom or stump pain.
All patients in the study and control groups received
epidural analgesia during the amputation surgery. The
results of our study are consistent with the findings of
Nikolajsen et al [7] beyond one week after amputation.
We did not find any difference at 14 months after
amputation in the incidence or severity of stump pain,
phantom limb sensation, and phantom limb pain between
patients who received epidural anesthesia, those who

603
received spinal anesthesia, and those who received general
anesthesia for their lower-limb amputation. These results are
consistent with the observations of Nikolajsen et al [7]. We
found incidence rates of phantom limb pain to be between
58.0% and 66.7% among the three groups. These results are
higher than those by Bach et al [5] but similar to those
observed by Jahangiri et al [6] in their control subjects and
by Nikolajsen et al [7] in their control subjects and study
patients. The intensities of stump and phantom limb pain
were similar, as were the frequencies of stump and phantom
limb pain. These findings are consistent with the observations of frequent stump and phantom limb pain by Ehde et al
[1] in a community population of amputees.
A weakness of the current study was the reliance on
patients recall of pain severity. The bias in patients recall
could have increased reported frequencies and severity of
pain symptoms. Our results are, however, consistent with
the prospectively corrected data of Nikolajsen et al [3]. Our
findings are also similar to previous observations [5-8]. The
similarity of our data with those of other investigators led us
to believe that the recall bias had not altered our results to a
significant degree.
The effect of spinal anesthesia on pain after amputation
had not been examined previously. Katz and Melzack [4]
suggested that spinal anesthesia might reduce pain memories
of the amputated limb. We observed only a short-term
beneficial effect of spinal anesthesia on pain after amputation.
In conclusion, we found that patients who received
epidural anesthesia and those who received spinal anesthesia for amputation recalled less pain in the first week
after their amputation. After 14 months, there was no
significant difference in phantom limb pain and stump pain
between patients who had received epidural anesthesia,
those who had received spinal anesthesia, and those who
had received general anesthesia. Moderate-to-severe stump
and phantom limb pain continued to be frequent despite
the use of nonopioid analgesics, opioid analgesics, amitriptyline, and gabapentin by patients after their lowerlimb amputation.

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