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The Treatment Of Painful Phantom Limb: A Follow-up Study
THE TREATMENT OF PAINFUL PHANTOM LIMB
A Follow-up Study C.
G. DE GUITERREZ-MAHONEY, M.D.,
F.A.C.S.'*
PAINFUL phantom limb has long been a very trying problem to treat, and because of the need for a method of managing the more difficult cases the suggestion was made in 19441 that resection of the postcentral cortex corresponding to the amputated limb would alleviate the condition. The present report is intended to review the patients treated by the author with this method. There have been several notices of the application of the method, some of which have been favorable and others unsuccessful, and it is hoped that in the future a composite report of all these cases might be made which will give a more adequate impression than the few cases now submitted.
ILLUSTRATIVE CASE HISTORIES
The first patient was a 40 year old man who had lost parts of the middle and ring fingers of the right hand and subsequently suffered distracting pain in the phantom fingers. The left postcentral cortex for these fingers was removed with the result that he was relieved of his pain so that he was able to work. When last seen two years after his operation he was leaving to enter the Merchant Marine. Nothing has been heard of him since then. The second patient was a 24 year old man who had injured and destroyed his left brachial plexus in a crushing truck accident. No repair was possible. He suffered a painful phantom limb, and a section of his right postcentral cortex ,corresponding to the limb was removed. This relieved him of pain which had necessitated using morphine at frequent intervals. He was last seen six months after the cortical operation. He had experienced some painful sensation in the old phantom limb but it required nothing more powerful than salicylates for relief. He complained principally of the uselessness of the paralyzed arm, due to the brachial plexus. destruction. The arm was subsequently amputated after his discharge from military service. He must have continued to complain, for a chorodotomy at the third cervical level was later done at a Veterans' Hospital. A neurosurgeon's report three years after the cortical resection indicated that ,this man was "not having sufficient pain to justify any further major surgery." This had From the Neurological Division, St. Vincent's Hospital, New York City. '* Neurosurgeon-in-Chief, St. Vincent's Hospital, New York City.
481
482
~
C. G. DE GUITERREZ-MAHONEY
also been my opinion when he was last seen sometime before the amputation ancl chordotomy. So, it would seem that considet:able relief had been obtained by this man from the resection of the postcentral cortex. The third patient was a 56 year old man who had sustained an amputation at midthigh, following which he had a painful phantom limb. For this three operations (chordotomies) had been performed, the last a year before he was first seen by me. A variation in the cerebral operation was made in this instance, the left precentral as well as the postcentral corte]!: corresponding to the right lower extremity and trunk being removed, since he had complained of severe pain in the right hip as well as in the phantom limb. The immediate effect was most satisfactory but within six months he complained again of pain, principally in the hip. This has varied and has been less bothersome when traveling than when resting at home. The f01ll'th patient was a man 68 years of age who had had the left leg amputated just below the knee fifty years previously. He had had persistent painful phantom sensations for twenty years and he had become a severe morphine addict. The right postcentral cortex corresponding to the left leg was removed; a year later he stilI had pain in the stump and some phantom sensations but he had relief of his painful phantom phenomena after operation. SUMMARY
These four cases indicate that removal of the postcentral cortex corresponding to a painful phantom is only partially effective in controlling the discomfort associated with the phenomenon. The procedure was developed with the intent of eliminating the point of registration of impulses beginning in the amputation stump. The hypothesis that such sensations registered only in the postcentral coitex and in specific areas for specific parts has thus been shown to be false. More attention should probably have been paid to the early studies of Dusser de Barenne2 who showed in monkeys that the cortical sensory representation extended for a considerable distance anterior and posterior to the central fissure, More recent observations by WoolseySand others also have shown that cortical sensory representation is more extensive than previously localized in the postcentral cortex, through the discovery of the so-called second sensory cortex. Thus it would seem that the possibility of eliminating all sensation from a part by removal of cerebral cortex is not feasible since the cortical sensory representation is too extensive. The excision of adequate corte]!: to desensitize a part would be associated with other
TREATMENT OF PAINFUL PHANTOM LIMB
483
unjustifiable resulting disabilities. In some instances, removal of the precentral and postceptral cortex concerned with an amputated limb might give adequate partial relief to recommend the procedure but for the more difficult patients, frontal leucotomy will probably have to be the operation of choice.
REFERENCES 1. de Gutierrez-Mahoney, C. G.: The Treatment of Painful Phantom Limb by
Removal of Post-central Cortex. J. Neurosurg. 1: 156--162, 1944. 2. Dusser de Barenne, J. G.: Experimental Researches on Sensory Localization in the Cerebral Cortex of the Monkey (Macacus). Proc. Roy. Soc. B. 96: 271291,1924. 3. Woolsey, Clinton N.: "Second" Somatic Receiving Areas in the Cerebral Cortex of Cat, Dog and Monkey. Federation Bull. 2: 55-56, 1943.
A Follow-up Study C.
G. DE GUITERREZ-MAHONEY, M.D.,
F.A.C.S.'*
PAINFUL phantom limb has long been a very trying problem to treat, and because of the need for a method of managing the more difficult cases the suggestion was made in 19441 that resection of the postcentral cortex corresponding to the amputated limb would alleviate the condition. The present report is intended to review the patients treated by the author with this method. There have been several notices of the application of the method, some of which have been favorable and others unsuccessful, and it is hoped that in the future a composite report of all these cases might be made which will give a more adequate impression than the few cases now submitted.
ILLUSTRATIVE CASE HISTORIES
The first patient was a 40 year old man who had lost parts of the middle and ring fingers of the right hand and subsequently suffered distracting pain in the phantom fingers. The left postcentral cortex for these fingers was removed with the result that he was relieved of his pain so that he was able to work. When last seen two years after his operation he was leaving to enter the Merchant Marine. Nothing has been heard of him since then. The second patient was a 24 year old man who had injured and destroyed his left brachial plexus in a crushing truck accident. No repair was possible. He suffered a painful phantom limb, and a section of his right postcentral cortex ,corresponding to the limb was removed. This relieved him of pain which had necessitated using morphine at frequent intervals. He was last seen six months after the cortical operation. He had experienced some painful sensation in the old phantom limb but it required nothing more powerful than salicylates for relief. He complained principally of the uselessness of the paralyzed arm, due to the brachial plexus. destruction. The arm was subsequently amputated after his discharge from military service. He must have continued to complain, for a chorodotomy at the third cervical level was later done at a Veterans' Hospital. A neurosurgeon's report three years after the cortical resection indicated that ,this man was "not having sufficient pain to justify any further major surgery." This had From the Neurological Division, St. Vincent's Hospital, New York City. '* Neurosurgeon-in-Chief, St. Vincent's Hospital, New York City.
481
482
~
C. G. DE GUITERREZ-MAHONEY
also been my opinion when he was last seen sometime before the amputation ancl chordotomy. So, it would seem that considet:able relief had been obtained by this man from the resection of the postcentral cortex. The third patient was a 56 year old man who had sustained an amputation at midthigh, following which he had a painful phantom limb. For this three operations (chordotomies) had been performed, the last a year before he was first seen by me. A variation in the cerebral operation was made in this instance, the left precentral as well as the postcentral corte]!: corresponding to the right lower extremity and trunk being removed, since he had complained of severe pain in the right hip as well as in the phantom limb. The immediate effect was most satisfactory but within six months he complained again of pain, principally in the hip. This has varied and has been less bothersome when traveling than when resting at home. The f01ll'th patient was a man 68 years of age who had had the left leg amputated just below the knee fifty years previously. He had had persistent painful phantom sensations for twenty years and he had become a severe morphine addict. The right postcentral cortex corresponding to the left leg was removed; a year later he stilI had pain in the stump and some phantom sensations but he had relief of his painful phantom phenomena after operation. SUMMARY
These four cases indicate that removal of the postcentral cortex corresponding to a painful phantom is only partially effective in controlling the discomfort associated with the phenomenon. The procedure was developed with the intent of eliminating the point of registration of impulses beginning in the amputation stump. The hypothesis that such sensations registered only in the postcentral coitex and in specific areas for specific parts has thus been shown to be false. More attention should probably have been paid to the early studies of Dusser de Barenne2 who showed in monkeys that the cortical sensory representation extended for a considerable distance anterior and posterior to the central fissure, More recent observations by WoolseySand others also have shown that cortical sensory representation is more extensive than previously localized in the postcentral cortex, through the discovery of the so-called second sensory cortex. Thus it would seem that the possibility of eliminating all sensation from a part by removal of cerebral cortex is not feasible since the cortical sensory representation is too extensive. The excision of adequate corte]!: to desensitize a part would be associated with other
TREATMENT OF PAINFUL PHANTOM LIMB
483
unjustifiable resulting disabilities. In some instances, removal of the precentral and postceptral cortex concerned with an amputated limb might give adequate partial relief to recommend the procedure but for the more difficult patients, frontal leucotomy will probably have to be the operation of choice.
REFERENCES 1. de Gutierrez-Mahoney, C. G.: The Treatment of Painful Phantom Limb by
Removal of Post-central Cortex. J. Neurosurg. 1: 156--162, 1944. 2. Dusser de Barenne, J. G.: Experimental Researches on Sensory Localization in the Cerebral Cortex of the Monkey (Macacus). Proc. Roy. Soc. B. 96: 271291,1924. 3. Woolsey, Clinton N.: "Second" Somatic Receiving Areas in the Cerebral Cortex of Cat, Dog and Monkey. Federation Bull. 2: 55-56, 1943.