We report the case of a 30-year-old female patient with phantom limb pain and right lower limb stump pain intrathecal (DIP) level of 1/3 middle thigh pain refractory to analgesic treatment.
The patient had a history of obesity, depressive-anxiety syndrome, left atrial fibrillation in April 2007 and allergy to ciprofloxacin, chestnut, kiwi and latex.
Regarding her traumatological disease, the patient suffered a fracture of the distal third of the tibia and right peroneal malleolus in May 2000 after an occupational accident and was treated with neutralization of the plate.
After a postoperative course without complications, the patient was discharged.
The patient begins to present spontaneous pain, a sharp pain in the ankle and anterior face of the deformity that increases with the limping of the limb and when the diagnostic is sought, adding severe edema of the cold hypercondylosis
It is treated by means of regional techniques associated with failed medical treatment, so finally, after suffering several interventions (lumbar sympathectomy, abscess, ̄itis), an infracondylar amputation was decided.
Subsequently, an unfavorable evolution was observed, and a new amputation was performed on the middle third of the thigh IDS in March 2004.
Then the patient continues with intense continuous pain at the level of amputated ankle, foot and knee, so it was decided to implant an epidural catheter with ambulatory treatment using patient-controlled epidural analgesia (PCEA) on April 13, 2004, associated with significant doses.
The evolution was favorable until 2005 she suffered a traffic accident involving epidural catheter placement, muscle cervical contracture and vertigo with worsening of her depressive and painful condition.
The patient tried to adapt a prosthesis due to lack of success due to a sequel of chronic pain consisting of hip flexion of the IDS, which prevented him from adapting the prosthesis normally and as a consequence of a prosthesis.
In January 2008, the patient came to our Pain Unit, where the implantation of a continuous infusion pump from Zicono to intrathecal level was proposed. After being informed about the procedure, she accepted possible outcomes, complications and adverse effects.
Informed consent was given and an appointment for placing a pump was made on 2/20/2008.
1.
Placement of intrathecal ziconotium pump and subsequent evolution
With the patient in lateral decubitus, an incision is made at the abdomen level to place the subcutaneous infusion pump.
Subsequently, the intradural space was located at L4-L5 level where a continuous infusion catheter was introduced.
This catheter is tunneled subcutaneously until the connection with the infusion pump.
Close incisions.
Schedule of ziconotide pump.
The initial dose was 1.2 microg/day of ziconotide, which increased over 13 months to 7.8 microg/day.
The patient's condition when he first came to the unit was very unfavorable: VAS 8/10, impossibility of restorative sleep due to frequent awakenings due to pain, moderate constipation due to opiods, lack of appetite,
Analgesic requirements were high with very high doses of opioids and frequent rescue requirements (every 2 hours).
During the upheaval of the zico pump without increasing pain with 6 hours, progressive appetite decreased and markedly improved pain from 8/10 to 4/10 awakening on the VAS scale, in addition to a longer nighttime constipation (AU)
At this time of dose/effect adaptation, the patient had limited periods of dizziness, sensation of head numbness, tinnitus and headache that resolved with symptomatic treatment and over time.
He is currently being followed up in our unit without pain relapse.
