Zachary Paquette, MD: Ulnar-Distribution Phantom Limb Pain After Interscalene Brachial Plexus Block

January 16, 2023

Phantom limb pain has historically been a major barrier to recovery for patients after amputation. Here, Zachary Paquette, MD, CA-2 Resident Physician, analyzes "a case of ulnar-distribution phantom limb pain following an upper-extremity amputation despite the use of interscalene blockade for both intraoperative and postoperative management." This article was published as part of "The Frost Series" in Anesthesiology News. Special thank you to Karen Sibert, MD, for serving as Editor for the article and congratulations to Dr. Paquette on an excellent case study!

Case Presentation

"A 57-year-old woman with a 5.7×3×4.5-cm synovial sarcoma of the left humerus presented for left transhumeral amputation (Figures 1 and 2). Her medical history included hypothyroidism, chronic pain and fibromyalgia, for which she was taking gabapentin, methocarbamol and tramadol; body mass index was 25.3 kg/m2. A large component of her pain was related to the arm lesion itself and became progressively worse after her initial diagnosis. Additionally, the size of the tumor left her with limited function of the arm.

The anesthetic plan for surgery was a combination of general and regional anesthesia. However, our decision about the type of regional block to use—interscalene versus supraclavicular—was complicated by uncertainty regarding how far proximally (up the arm) the surgical resection would extend.

The choices for postoperative pain management of upper-extremity surgery may include brachial plexus block by any of these techniques: interscalene, supraclavicular, infraclavicular or axillary. Infraclavicular or axillary blocks were not considered appropriate in this case because of the proximal location of the tumor in the upper arm."

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