Management of nerves during leg amputation - a neglected area in our understanding of the pathogenesis of phantom limb pain

Background: Chronic neuropathic pain after leg amputation is a significant problem, with a reported incidence during the first year as high as 70%. Intra-operative handling of the nerves during amputation has not been discussed in the literature on post-amputation pain and, in major textbooks, it is recommended that the ischial nerve be ligated, despite the fact that the experimental literature uses nerve ligations to produce neuropathic pain. The purpose of this study was to investigate the clinical practice of nerve handling during leg amputation. Methods: Trainees with at least 2 years of practice received a questionnaire regarding handling of the nerves during leg amputation; 128 of 149 questionnaires sent (86%) were returned. Results: Ligation of the nerves was used by 31% of surgeons. Conclusion: There is no consistency in the management of the large nerves during lower leg amputation. The recommendations in major textbooks may not be appropriate when compared with the experimental literature on nerve ligature models to produce neuropathic pain. Future studies on post-amputation pain should consider intra-operative nerve management.