Case Study · 04
Residual limb and phantom pain after below-knee amputation
A patient in their sixties with residual limb and phantom limb pain eleven months after a below-knee amputation. Treated with a temporary sixty-day peripheral nerve stimulation system targeting the sciatic and femoral nerves, removed entirely at the end of therapy.
At a glance
- Patient
- Early 60s
- Region
- Left residual limb, phantom foot
- Procedure
- 60-day temporary PNS
- Outcome
- Benefit retained at 12 months
Is there an option that does not require a permanent implant — and can sixty days of stimulation help after the device is gone?
Patient names are omitted from this account. The clinical course and reported outcome describe an actual treated case and do not predict another person's response.
Clinical Summary
What the patient came in with
Presentation
Sharp, electric residual limb pain with intermittent phantom sensations described as the absent foot being clenched. Baseline pain 7/10 in the residual limb and 8/10 phantom, worse in the evening and disruptive to sleep.
Prosthesis tolerance limited to two hours before pain forced removal, which was limiting rehabilitation more than strength or balance were.
Prior treatment
Below-knee amputation for a non-healing diabetic foot ulcer with osteomyelitis. Wound healed uneventfully; no neuroma identified on ultrasound.
Gabapentin at maximum tolerated dose, nortriptyline, mirror therapy, desensitisation, and a peripheral nerve block with good but temporary relief.
Why temporary PNS
The response to a diagnostic nerve block indicated the peripheral target was correct. The patient was firmly reluctant to accept a permanent implant, and had diabetes with a history of a serious skin infection — a reasonable consideration in any implant discussion.
A sixty-day temporary system requires no permanent hardware. The lead is placed percutaneously, the patient wears an external stimulator, and at the end of therapy the lead is withdrawn in the office and nothing remains.
Setting expectations
The published data on lasting benefit after the device is removed is genuinely encouraging in post-amputation pain, but several of the most striking long-term results come from small cohorts. The patient was told plainly that the therapy might provide sixty days of relief and no more.
The proposed mechanism — peripherally induced reconditioning of central pain processing — is a hypothesis, and it was described as one.
Procedure
Two leads, sixty days, then nothing
The entire therapy is delivered in a single office-based procedure. There is no trial phase, because the therapy itself is temporary.
01
Ultrasound
Ultrasound targeting
The sciatic nerve identified in the posterior thigh, proximal to the level of injury. A location roughly a hand's breadth from the nerve is chosen deliberately — the lead sits remote from the nerve, not against it.
02
Ultrasound
Lead placement
A fine coiled MicroLead introduced through a needle and deployed under direct ultrasound visualisation. Test stimulation confirmed comfortable sensation across the residual limb without motor recruitment.
03
Ultrasound
Second target
The sequence repeated for the femoral nerve to cover the anterior residual limb, a territory the sciatic lead did not reach.
04
Bedside
External system
Leads secured with adhesive dressings and connected to a small wearable stimulator. The patient was taught to manage the device and the dressing before leaving.
05
Office visit
Withdrawal at day 60
Both leads withdrawn intact in the office with steady traction. No anaesthesia, no incision, nothing left behind.
Follow-Up
What happened afterwards
Weeks one to four
Residual limb pain fell to 3/10 within the first ten days. Phantom clenching became intermittent rather than constant by week three.
Prosthesis wear extended from two hours to most of a day by week four, which changed the trajectory of rehabilitation.
Weeks five to eight
Sustained relief. A minor dressing-site skin reaction at week five managed with a change of adhesive.
Gabapentin reduced by half. Sleep no longer interrupted by phantom pain.
After removal
Some return of symptoms in the fortnight after withdrawal, followed by stabilisation at a level well below baseline.
At twelve months: residual limb pain 2–3/10, phantom pain infrequent, full-day prosthesis wear maintained. No implant required.
Outcome
Relief that outlasted the hardware
60 days
Of therapy, with benefit retained at 12 months
- Residual limb pain
- 7/10 → 2–3/10
- Prosthesis wear
- 2 hours → full day
- Permanent implant
- Not required
- Retained hardware
- None
Clinical pearl
Not every neuromodulation answer is an implant. When the peripheral target is clear and the patient is reluctant, sixty days of temporary stimulation costs very little to try and occasionally settles the question permanently.
Individual results vary. This case is presented for education and does not predict the outcome of any therapy in any other patient.
Put this case in context
Individual outcomes cannot predict yours. Learn how candidacy is assessed, or explore U.S. physician listings as an unverified starting point for finding care. This site does not book appointments.