D. Cunningham, H. Laycock, V. Ratnamma

Great Ormond Street Hospital, UK

Lower limb amputation is a common surgical intervention in both adults and children. Up to 80% of patients who undergo lower limb amputation will go on to develop residual stump pain or phantom limb pain. Control of pain in the peri-operative period is a priority for the anaesthetic team as evidence shows that uncontrolled acute pain can lead to worsening chronic pain. There is currently no agreed gold standard approach to managing the pain associated with lower limb amputation in children. Options include central neuraxial or peripheral nerve approaches, and intravenous and oral analgesia. We aimed to explore the approaches used for perioperative pain management in paediatric patients undergoing lower limb amputation at Great Ormond Street Hospital and to determine efficacy in managing post operative pain using post operative pain scores.


The SlicerDicer function on EPIC (search criteria “Through knee amputation” OR “Below knee amputation” OR “Above knee amputation”) was used to identify all patients who underwent a lower limb amputation between 20th September 2017 to 19th September 2023 (earliest recorded amputation was 10/05/2019). A data collection proforma (Microsoft Excel) was completed from reviewing patient notes. Data were extracted including patient characteristics, indication for amputation, analgesic techniques used in the perioperative period and postoperative pain scores.


Eighteen patients (Median age: 8.5 years, Range: 1- 17 years) underwent lower limb amputation. Twelve patients (66%) received preoperative gabapentinoids (pregabalin or gabapentin). A range of analgesic approaches were used intraoperatively including caudal (17%), epidural (22%), single shot nerve block (50%), and IV analgesia only (11%). An opiate only PCA/NCA was used postoperatively in 50%, a combined opiate/ketamine PCA/NCA in 39% and epidural only in 11% of patients. The median highest recorded pain score in recovery was 0 (Range 0-7). On day 0 median highest recorded pain score was 0 (Range 0-7) and day 1 median 1 (Range 0-6). High pain scores were not related to use of iv analgesia only.


There is currently no local or national standard approach to the management of pain in the perioperative period for children undergoing lower limb amputation. As a result, various techniques are utilised in the perioperative period by anaesthetists at Great Ormond Street Hospital. The number of patients undergoing this procedure makes it difficult to determine improved pain outcomes with particularly techniques. Future work is required to establish an evidence-based approach to rationalising perioperative pain management in children undergoing lower limb amputation.


1)               Major lower limb amputation audit – introduction and implementation of a multimodal perioperative pain management guideline. Aladin, Adrian Jennings, Max Hodges, and Alifia Tameem – British Journal of Pain 2018


2)               The Influence of pre-amputation pain on post-amputation stump and phantom pain. L.Nikolajsen, S.Ilkjaer, K.Kroner, J H Christensen, T S Jensen – Pain 1997

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