COPYRIGHT 2004 BY THE JOURNAL OF BONE AND JOINT SURGERY, INCORPORATED

Phantom-Limb Pain Due to

Cervical Spinal Tuberculosis
A CASE REPORT
BY YOGESH K. PITHWA, MS(ORTH), DNB(ORTH), D(ORTH),
AND S. RAJASEKARAN, PHD, FRCS(ED), MCH(ORTH), MS(ORTH), DNB(ORTH), D(ORTH)

Investigation performed at Ganga Medical Centre and Hospitals, Coimbatore, India

P
hantom-limb sensations refer to the phenomenon of good general condition. Examination of the stump revealed no
feeling the presence of an amputated limb. Phantom- evidence of infection, undue osseous prominences, scar tender-
limb pain refers to the sensation of pain in this limb. ness, or neuroma formation. The range of motion of the elbow
This is a form of deafferentation pain, which refers to pain and shoulder was normal. Examination of the cervical spine re-
originating from neural injury. In a survey study by Sherman vealed slight tenderness overlying the posterior aspects of the
et al. of 2694 patients who had had an amputation, phantom C5 and C6 vertebrae, without any notable paraspinal muscle
sensations were reported by 2101 patients (78%) postopera- spasm. The range of movement of the cervical spine was normal
tively1; 1282 (61%) of those patients reported a decrease of
this phenomenon over an average period of twenty-six years.
In a retrospective study of 176 patients who had undergone
amputation of a lower limb, Houghton et al. reported that
phantom sensations were experienced by 141 patients (80%)
and phantom pain, by 134 (76%)2. However, only thirty-eight
patients (22%) reported severe phantom pain.
Phantom-limb pain and sensations can be primary or
secondary. Primary phantom pain and sensations start in the
immediate postoperative period after the amputation. Sec-
ondary phantom-limb problems start after an asymptomatic
interval following the amputation and are usually indicative of
the onset of a new disease unrelated to the primary cause of
the amputation3-14. We report the case of a young man who
underwent amputation of an upper limb after trauma. Sec-
ondary phantom-limb pain developed two and one-half years
later, as a result of an epidural tubercular abscess that affected
the cervical spine. Our patient was informed that data con-
cerning the case would be submitted for publication.

Case Report
thirty-two-year-old man sustained a crush injury of the left
A forearm and hand and the medial four digits of the right
hand in a motor-vehicle accident. A guillotine-type below-the-
elbow amputation was performed on the left side and was fol-
lowed by secondary closure at a later date. The patient had no
stump-related problems and received adequate rehabilitation.
He then returned to his job as a lottery-ticket salesman. Two
and one-half years later, phantom-limb sensations developed in
the left upper limb. This uncomfortable sensation progressed to
pain within a few days. The pain was distributed along the lat-
eral border of the forearm up to the tip of the phantom thumb. Fig. 1
The patient returned to the hospital after failure of symptom- A lateral cervical radiograph showing loss of the disc space at the C5-
atic therapy prescribed by his general practitioner. C6 level (arrow) and mild retrospondylolisthesis of the C5 vertebra over
The physical examination revealed that the patient was in the C6 vertebra.

THE JOUR NAL OF BONE & JOINT SURGER Y JBJS.ORG
VO L U M E 86-A N U M B E R 6 J U N E 2004
in all directions, and the patient reported slight pain at the pos-
terior aspect of the neck on terminal extension. There was no
objective evidence of a motor or sensory deficit. The general ex-
amination revealed enlarged, matted cervical lymph nodes on
the left side.
Hematological investigations showed a moderate lym-
phocytosis and an elevated erythrocyte sedimentation rate of
48 mm/hr (normal range, 0 to 30 mm/hr). The Mantoux test
was positive, with induration extending up to 16 mm. The
results of the sputum examination were negative for the
presence of acid-fast bacilli. A radiograph of the chest
showed that the lungs were clear. Radiographs of the cervical
spine showed loss of the disc space between the C5 and C6
vertebrae. There was mild retrospondylolisthesis of the C5
vertebra in relation to the C6 vertebra (Fig. 1). Magnetic res-
onance imaging revealed an epidural abscess in the interver-
tebral foramen between C6 and C7 (Fig. 2) but no notable
compression of the spinal cord. A 24-gauge hypodermic nee-
dle was used to perform a fine-needle aspiration of fluid
from the matted cervical lymph nodes, and the diagnosis of
tuberculosis was confirmed on cytologic examination of the
aspirate.
Because the patient had only slight local symptoms and
because no major cord compression was evident, we treated the
patient nonoperatively with antituberculous therapy, which in-
cluded four drugs (isoniazid, rifampicin, pyrazinamide, and
ethambutol) for two months and two drugs (isoniazid and
rifampicin) for another four months. The phantom pain de-
creased within three weeks after initiation of the antitubercu-
lous drugs, and the patient reported good relief of symptoms by
the end of six weeks. He continued to have intermittent phan-
tom sensations for about three months. At the one-year follow-
P H A N T O M -L I M B P A I N D U E T O
C E R V I C A L S P I N A L TU B E R C U L O S I S
up evaluation, he was completely free of all symptoms, includ-
ing phantom-limb sensations.
Discussion
he management of phantom-limb pain depends on
T whether the problem is primary or secondary. Primary
phantom-limb pain is often refractory to treatment. Medica-
tions such as antidepressants, transcutaneous electrical nerve
stimulation15, thermocoagulation of the dorsal-root entry
zone16, or epidural spinal cord stimulation17 may be used, but
no one therapy is uniformly successful1. Unlike primary phan-
tom-limb pain, secondary phantom-limb pain can be treated
more successfully by the appropriate management of the incit-
ing abnormality. A herniated intervertebral disc has been
reported to trigger phantom-limb pain4. Phantom pain sec-
ondary to spinal cord injury and spinal anesthesia has also
been reported5-8. Phantom pain has also developed in patients
who had lesions of the contralateral cerebral hemisphere and
sensory loss9. Angina referred to a phantom limb has also been
described13,14. In addition, diabetic neuropathy has been re-
ported as a cause for this entity12. Chang et al. reported the
worsening of phantom-limb pain as a result of neoplasia af-
fecting the L4 vertebra10. The onset of phantom-limb pain
years after resection of a limb also has been shown to be one of
the first symptoms of recurrent disease in the pelvis11.
To our knowledge, this is the first report of a patient
with phantom-limb problems caused by tuberculosis of the
cervical spine and an epidural abscess. Protracted presenta-
tions of spinal tuberculosis are known to occur in patients
who have good immunity. This would explain the fact that the
presenting symptom in our patient was phantom-limb pain
rather than any notable local symptoms. Because of the lack of
Fig. 2
An axial T1 weighted magnetic resonance imag-
ing section showing an epidural abscess (ar-
rows) in the intervertebral foramen at the C6-
C7 vertebral level.

THE JOUR NAL OF BONE & JOINT SURGER Y JBJS.ORG
VO L U M E 86-A N U M B E R 6 J U N E 2004
severe local symptoms and the absence of spinal cord com-
pression, there was no absolute indication for surgery. Hence,
we adopted a nonoperative approach, which was successful.
Because of the direct association between the cervical tubercu-
losis and the onset of phantom-limb problems, treatment of
the tuberculosis was successful in addressing the secondary
phantom-limb problems as well.
In conclusion, the development of progressive phantom-
limb symptoms in an amputation stump after an asymptom-
atic period may indicate an abnormality proximal to the limb.
Appropriate management of the underlying abnormality may
be a successful way of treating the secondary phantom-limb
symptoms as well.

References
1. Sherman RA, Sherman CJ, Parker L. Chronic phantom and stump pain
among American veterans: results of a survey. Pain. 1984;18:83-95.
2. Houghton AD, Nicholls G, Houghton AL, Saadah E, McColl I. Phantom pain:
natural history and association with rehabilitation. Ann Coll Surg Engl. 1994;
76:22-5.
3. Melzack R. Phantom limbs. Scientific American. 1992;266:90-6.
4. Finneson BE, Haft H, Krueger EG. Phantom limb syndrome associated with
herniated nucleus pulposus. J Neurosurg. 1957;14:344-6.
5. Bors E. Phantom limbs of patients with spinal cord injury. AMA Arch Neurol
Psychiatry. 1951;66:610-31.
6. Sweet WH. Phantom sensations following intraspinal injury. Neurochiru-
rgia. 1975;18:139-54.
7. Mackenzie N. Phantom limb pain during spinal anaesthesia. Recurrence in
amputees. Anaesthesia. 1983;38:886-7.
8. Sellick BC. Phantom limb pain and spinal anesthesia. Anesthesiology.
1985;62:801-2.
9. Appenzeller O, Bicknell JM. Effects of nervous system lesions on phantom
experience in amputees. Neurology. 1969;19:141-6.
P H A N T O M -L I M B P A I N D U E T O
C E R V I C A L S P I N A L TU B E R C U L O S I S
Yogesh K. Pithwa, MS(Orth), DNB(Orth), D(Orth)
S. Rajasekaran, PhD, FRCS(Ed), MCh(Orth), MS(Orth),
DNB(Orth), D(Orth)
Department of Orthopaedic Surgery, Spine Unit, Ganga Medical Centre
and Hospitals, Swarnambika Layout, Ramnagar, Coimbatore 641 009,
India. E-mail address for S. Rajasekaran: rajaorth@eth.net
The authors did not receive grants or outside funding in support
of their research or preparation of this manuscript. They did not
receive payments or other benefits or a commitment or agreement
to provide such benefits from a commercial entity. No commercial
entity paid or directed, or agreed to pay or direct, any benefits to
any research fund, foundation, educational institution, or other char-
itable or nonprofit organization with which the authors are affiliated
or associated.
10. Chang VT, Tunkel RS, Pattillo BA, Lachmann EA. Increased phantom limb
pain as an initial symptom of spinal-neoplasia. J Pain Symptom Manage.
1997;13:362-4. Erratum in: J Pain Symptom Manage. 1997;14:135.
11. Roth YF, Sugarbaker PH. Pain sensations after amputations: character and
clinical significance. Arch Phys Med Rehabil. 1980;61:490.
12. Rajbhandari SM, Jarratt JA, Griffiths PD, Ward JD. Diabetic neuropathic pain
in a leg amputated 44 years previously. Pain. 1999;83:627-9.
13. Deenadayalan CV. Anginal pain in a phantom limb. Br Med J. 1976;2:228.
14. Mester SW, Cintron GB, Long C. Phantom angina. Am Heart J. 1988;116:
1627-8.
15. Morrison JD. Amputations and prostheses. In: Bulstrode CJK, Buckwalter
J, Carr A, Fairbank J, Marsh L, editors. Oxford textbook of orthopedics and
trauma. Oxford: Oxford University Press; 2002. p 1496-511.
16. Samii M, Moringlane JR. Thermocoagulation of the dorsal root entry zone for
the treatment of intractable pain. Neurosurgery. 1984;15:953-5.
17. Kumar K, Toth C, Nath RK, Laing P. Epidural spinal cord stimulation for treat-
ment of chronic painsome predictors of success. A 15-year experience.
Surg Neurol. 1998;50:110-21.