Use of calcitonin in recalcitrant phantom limb pain complicated by heterotopic ossification

BACKGROUND Phantom limb pain (PLP) is a common complication after amputation, affecting up to 80% of the amputee population. However, only 5% to 10% of amputees have severe PLP impacting daily function. The present report details the management of severe, treatment-resistant PLP in a 72-year-old man with a traumatic left transradial amputation and a comorbid complication of heterotopic ossification (HO). OBJECTIVE To describe a case of PLP with HO and the possible role of calcitonin in the treatment of both conditions. METHODS A systematic review of the literature regarding the management of PLP. RESULTS Seventeen articles that directly addressed PLP were identified; 11 were randomized controlled trials. All involved small samples and follow-up ranged from 6 h to one year, with the majority limited to six weeks. DISCUSSION In the present case, medication management was limited by side effects, lack of response and the patient's desire to avoid long-term medication. Investigations revealed HO, which was suspected to envelop the median nerve in the proximal forearm. After several unsuccessful medication trials, the literature was reviewed in search of common variables between HO formation and persistent PLP. Ultimately, the biochemical effects associated with nerve injury were identified to be a possible factor in both HO and PLP development. Calcitonin's proposed mechanisms of action may help to manage HO and PLP at multiple stages of disease development and maintenance. In the present case, a four-week trial of intranasal calcitonin was successful, with pain control lasting at least 18 months. CONCLUSION The present case report provided a review of the current literature in PLP pharmacological management and the current understanding of the etiology of PLP and HO, as well as how the two may coexist. It also provided an opportunity to discuss the proposed mechanisms of action of calcitonin in the management of PLP and HO.