Phantom limb syndrome associated with herniated nucleus pulposus.

A review of the literature revealed three contributions dealing with the problem of lumbosacral radiculitis and/or herniated lumbar discs in patients with amputations of the leg. Ricard and Girard 3 described a patient in whom sciatic and causalgic pain developed in a phantom limb 4 years after the amputation. Although a preoperative diagnosis of herniated disc had been made, an extradural cyst of the 5th lumbar nerve root was found instead. This finding seemed to offer a satisfactory explanation for the symptoms present in this case. On the basis of their observation the authors further submitted the hypothesis that the "phantom" may be caused by intraspinal changes (resulting from excessive lumbar motility caused by ambulation with a prosthetic device) involving the nerve roots and causing vasomotor paresthesias and pains. Perazzini 2 reported $ cases of herniated nucleus pulposus in leg amputees. In both instances, however, the disc protrusions were verified at operation on the side opposite to the amputation. The author concluded that increased strain on the lumbar spine produced by ambulating with a prosthesis may hasten the onset of symptoms in individuals predisposed to discogcnic disease. Since both cases presented a protruded disc opposite to the amputation, the author speculated on the clinical picture in ipsilateral lesions. Bonica 1 presented an interesting case of a 54-year-old woman who experienced what were apparently symptoms of a herniated nucleus pulposus in 1936. These were described as shooting pains in the back of the thigh radiating to the foot, with aggravation by coughing, sneezing and straining. Her physician injected the sciatic nerve with procaine and later with alcohol. The temporary relief afforded by this procedure was followed by increased pain; in addition to the shooting pain there was now a burning discomfort apparently associated with an alcoholic neuritis. The pain became so severe that an amputation of the lower end of the thigh was performed at the patient's request. She continued to suffer increasingly, and in addition to her previous symptoms there developed a moderately painful phantom limb. During the next 8 years the stump was revised twice, and a rhizotomy and two unilateral cordotomies were performed without effect. Following a detailed neurological examination including myelography, two herniated discs at the 8rd and 4th lumbar interspaces were removed. The severe shooting pain disappeared, yet the phantom sensation associated with mild pain persisted.