215: Incidence, Onset, and Predictors of Phantom Limb Pain Following Major Limb Amputation

Topic: Clinical Science
Subtopic: Pain category (ICD-11), Chronic postsurgical pain, Pain in Special Populations , Treatment/management

Background and Aims: Phantom limb pain (PLP) is a prevalent and disabling complication after major limb amputation, yet its mechanisms and predictors remain incompletely understood (1–3). High temporal-resolution longitudinal data characterizing pain quality in the weeks following amputation are scarce (4). Moreover, post-amputation pain is frequently not differentiated into stump pain and phantom limb pain, despite distinct underlying mechanisms and divergent therapeutic implications (5). Against this background, this prospective multicentre observational study aimed to (i) characterize the temporal onset of PLP following major limb amputation and to examine (ii) clinical as well as (iii) systemic inflammatory factors associated with its development.

Methods: In this prospective observational cohort study, adult patients undergoing major limb amputation were enrolled across eight German centres (DRKS00027853). Assessments were conducted preoperatively, daily until postoperative day 7, and weekly up to six months. PLP and stump pain (PainDETECT, TAPES-R) as well as factors such as depression (PHQ-8), anxiety (GAD-7), and quality of life (EQ-5D-5L) were assessed using validated instruments. Clinical variables included comorbidity burden (uCCI), ASA status, anaesthesia, and perioperative analgesia. The primary endpoint was time to first PLP onset. Logistic regression with backward AIC selection was used to identify predictors of severe PLP.

Results: Sixty patients were analysed included with a median age at 69 years (IQR 61–75.5); 71% were male and 83% ASA III. PLP occurred in 78%, with median onset on postoperative day 2 (IQR 1–12). Stump pain was reported by 62%. High-intensity PLP (“terrible/unbearable”) based on TAPES-R affected 42% of PLP patients and was frequently associated with functional limitation (55% ADL restriction). At onset, neuropathic pain was classified as likely in 29% (PD-Q ≥19). Lower preoperative EQ-5D and higher PHQ-8 scores independently predicted severe PLP, whereas systemic inflammatory markers were not associated.

Conclusions: PLP develops early and affects the majority of patients after major amputation, with substantial functional impact. Psychological distress and reduced preoperative quality of life are associated with severe PLP, whereas systemic inflammation does not appear to be a primary driver. A neuropathic component is present in a relevant subgroup. These findings support early biopsychosocial risk assessment and individualized perioperative pain management strategies.

References: 1. Erlenwein J, Diers M, Ernst J, Schulz F, Petzke F. Clinical updates on phantom limb pain. PAIN Rep [Internet]. 2021;6(1). Verfügbar unter: https://journals.lww.com/painrpts/Fulltext/2021/01000/Clinical_updates_on_phantom_limb_pain.7.aspx
2. Tafelski S. Perioperative Maßnahmen zur Prävention von Phantomschmerz: ein evidenzbasierter Ansatz zur Risikoreduktion. Anaesthesist. 1. September 2020;69(9):665–71.
3. Wandrey JD, Schäfer M, Erlenwein J, Tafelski S. [Practice of perioperative phantom limb pain prevention in Germany: a nationwide survey]. Anaesthesiol. November 2022;71(11):834–45.
4. Schone HR, Baker CI, Katz J, Nikolajsen L, Limakatso K, Flor H, u. a. Making sense of phantom limb pain. J Neurol Neurosurg Amp Psychiatry. 1. August 2022;93(8):833.
5. Neil M. Pain after amputation. BJA Educ. 1. März 2016;16(3):107–12.

Presenting Author: Jan Wandrey
Submitting Author: Jan Wandrey

Senior Author: Sascha Tafelski

IASP 2026 Global Year theme of Neuropathic Pain: Yes

• Oscar Andrés Retana Romero: Dr. med., MD - Charité - Universitätsmedizin Berlin
• Amelie Siegel: NA - Charité – Universitätsmedizin Berlin
• Bente Bierbaß: NA - Charité – Universitätsmedizin Berlin
• Malte Schwander-Tödt: MD - Charité – Universitätsmedizin Berlin
• Sascha Tafelski: PD Dr. med., MD - Charité – Universitätsmedizin Berlin