A 49-year-old man with a history of traumatic left above-elbow amputation was hospitalized for surgical management of a phantom pain syndrome Evaluation revealed a history of exertional chest pain radiating into the phantom limb.

A 49-year-old man with a history of traumatic left above-elbow amputation was hospitalized for surgical management of a phantom pain syndrome Evaluation revealed a history of exertional chest pain radiating into the phantom limb. Exercise testing reproduc the pain symptoms and demonstrated electrocardiographic ischemic S-T portion depression. Coronary angiography revealed harsh three-vessel coronary artery disease. The patient underwent coronary artery bypass graft surgery which eliminated the anginal constituting of his phantom pain syndrome and abolished evidence of exercise-induced myocardial ischemia. This case illustrates that myocardial ischemia can breed phantom pain with the characteristics of typical angina and indicates the ne for thorough evaluation of patients presenting with unusual features of phantom pain.

Patients who have had amputations becoming to trauma or peripheral vascular disease commonly describe both painless and painful sensation referr to the amputated limb. The differential diagnosis of these symptoms includes phantom pain syndrome and reflective sympathetic dystrophy. Both disorders have a relatively short latency of onset[12] and a highly variable prevalence ranging from 01 to 85 percent[3] In this report, we describe a unique case of phantom limb pain presenting with the characteristics of angina pectoris.

CASE REPORT

A 49-year-old white man was admitted to the University of California (Davis) Medical Center for surgical relief of phantom limb pain. At age 21 years, a proximal left above-elbow amputation was performed because of a crush injury. The patient did well post-amputation, noting painless phantom limb sensation for more than 25 years. pair years before this hospital admission, he reported the storm of severe recurrent pain in the residual left upper extremity radiating down the phantom limb into the hand. Outpatient evaluation through a neurosurgeon revealed tenderness throughout the medial aspect of the residual left upper extremity, diminished left axillary oscillation and decreased left shoulder skin temperature. Differential diagnosis included reflected sympathetic dystrophy, phantom limb pain syndrome and stub neuroma. The patient was referr to the Department of Anesthesiology where exploration with lidocaine infiltration of the residual limb was performed in an unprosperous attempt to localize a peripheral neuroma. Lidocaine provided solely mild reduction in the patient's pain. after injection of the left stellate ganglion produc similar inferences Two weeks later, in a follow-up evaluation, the patient was hyperesthetic to touch in the axillary region of the residual limb and was admitted for a dorsal bottom entry-zone surgical procedure.

A preoperative ECG revealed of the present day T wave changes. Cardiac serum enzyme were normal. Cardiology consultation was obtained. Further history revealed that the left upper extremity pain included the left anterior area of the chest, was exertional, associated with activities as it is as climbing stairs or performing yard work, and abated with quietness Cardiac risk factors included an 8-month history of diabetes mellitus, a 10 pack-year history of cigarette smoking, and mother with a fatal myocardial infarction at age 63 years. The patient underwent treadmill exercise testing (Bruce protocol) which induced chest discomfort and left upper extremity phantom pain distal to the site of amputation associated with 2-mm electrocardiographic S-T portion depression at 3- min (maximum heart rate, 127 beats by minute, 78 percent of age-predicted maximum) at which time the proof was terminated. Coronary angiography revealed strict three-vessel disease: subtotal occlusion of the left anterior descending artery, 80 percent stenosis of the circumflex artery, and total occlusion of the right coronary artery which was supplied according to left-to-right collateral vessels. Left ventriculography demonstrated normal contractile pattern. During this hospitalization the patient underwent elective coronary bypass graft surgery with five grafts and had an uncomplicated postoperative course.

Four month postoperatively, thallium 201 myocardial exercise scintigraphy demonstrated no exertional symptoms and no perfusion flaws or electrocardiographic abnormalities at a maximum heart rate of 150 beats for minute. Eight months following surgery the patient reported continued ability to perform his activities of daily living without exertional chest discomfort or phantom limb pain.

COMMENT

This patient illustrates the ne for comprehensive multisystem evaluation of the upper extremity amputee with phantom pain having atypical features. Based upon a literature review of the past four decades,[1-4] this is the first case, to our knowledge, of angina pectoris masquerading as phantom limb pain.

The syndrome of phantom limb pain includes burning dysesthesia, austere cramping, lancinating pain, or other abnormal sensations like as crushing, squeezing, or freezing.[4] Exacerbating factors include emotional stress[3] pre-amputation pain in the affected limb,[4] prosthetic wear,[5] and residual limb edema. The use of a prosthesis may exacerbate yet rarely initiates phantom limb symptoms. Symptoms usually are instant in the immediate postoperative period and decline in severity throughout the next 6 months.[6] When symptoms persist beyond this interval, phantom pain becomes chronic[7] and is usually refractory to therapy.[3] Phantom limb pain with an attack beyond 6 months of amputation is rare. Although more than 40 treatment modalities for painful phantoms have been described in the medical literature with varying stages of short-term success,[3,4] evidence of long-term benefit is lacking.

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