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November 6, 2000 Newsletter

Phantom Pain Can Get Your Ghost

Many of our readers have asked for my opinion about pain after amputation of a limb- most commonly the lower leg.

Amputation of the lower leg, also known as below knee amputation or BKA for short is increasingly more common as a result of diabetes and the following leg infections. As a result, doctors often have to treat with a below knee amputation. The result is often successful but most will develop a form of pain in the absent leg, commonly known as phantom limb pain.

I have seen several patients with a diagnosis of phantom limb pain or pain after BKA. I have found that many suffer leg pain as a result of low back neuropathy referring down into the absent leg. Although the leg is absent, the pain can be felt because of the presence of sensation of pain in the spinal nerve roots. The pain occurs often on the BKA side but often creates back and leg pain in "both legs." It is probable that the amputation changes the dynamics of the whole spine but particularly at the base of the low back on the side of the BKA.

Many of my patients have had success with regular chiropractic treatment of the low back and regular stretching but many do achieve good benefit from injection therapy or intramuscular stimulation (IMS) of the low back and legs.

Headaches Can be a Headache

The patient with chronic headaches can be very difficult to treat for any physician. I have found that treating them more aggressively when their headaches are actually  minor, helps many severe chronic headache sufferers. 

This sounds obvious but I did not do this myself until I became more involved with chronic pain. As a general rule, I will typically inform a headache sufferer that headaches are generally proven to be a neck generated phenomenon, or cervicogenic. 

Patients are often surprised and cannot believe their headaches (even migraine) originate in their neck, when they seem to have no neck pain, at least early on in the headache cycle. However, I painstakingly go through the mechanisms, neck triggers and stages of treatment. I rarely differentiate between migraine, tension, PMS or hormone headaches because I believe they all will have a cervicogenic nature to them. 

Although, there are clearly other triggers that aggravate headaches, these will typically not trigger a headache until a person develops a significant neck condition. It is still important to investigate all chronic headache patients and some may need tests that include CT scan, MRI, Neck X-ray or MRI, EMG (if there are associated limb symptoms), neurological consult, and of course, my examination. 

Some of the early stage treatments for minor headaches include the addition of a good chronic NSAID, such as Celebrex. For OTC, Advil and Motrin can also be good but they may have a higher risk of GI bleeding. I will then add either in combination or separately, physiotherapy with traction, chiropractic, and personal stretching (Lamb Program ™). I may also add inversion therapy, topical pain creams, heat therapy for the neck and /or massage therapy. 

If these treatments cause an increase in headaches, then a form of injection therapy may be required (IMS). The addition of sleep enhancing agents may also make a big difference, as sleep deprivation or inefficiency to sleep may trigger more neck dysfunction and resulting headaches. Nortriptylline, Elavil, Trazadone may help sleep. Actual sleeping medications that can help include Ambien (US) and Starnoc (Canada). 

Inefficiency to sleep, is probably why many headache sufferers awaken with headaches (the neck muscles contract at night). Very often this stepwise therapy will benefit mild, moderate and severe headache sufferers. 

As always, keep long and strong.