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figure 2. Computed tomographic scan with contrast illustrating complex tubo-ovarian abscess (white arrow). While our patient had left-sided OVT, a right-sided predominance has been reported, probably attributable to the immediate postpartum retrograde flow of venous blood down the left ovarian vein, through the pelvis, and up the right ovarian vein. 6,7 With thrombosis, the clotted vein can be imaged along the psoas muscle to the vena cava on the right or left renal vein, as in our case. The clot may extend into the vena cava, and pulmonary embolus may ensue. Imaging studies reveal sensitivities of 100%, 92%, and 50% for CT scans, magnetic resonance imaging scans, and ultrasonograms, respectively. 8 Blood cultures usually remain negative for pathogens, with positive cultures seen in only about 3% of patients.1 The bacteria most commonly associated with OVT reflect the vaginal origin of these infections: enteric gram-negative rods, including Escherichia coli, Enterobacter and Klebsiella species, along with microaerophilic streptococci, and anaerobic bacteria such as Peptostreptococcus, Bacteroides, and Prevotella species. 1,3 Antimicrobial treatment of OVT should be directed against these gastrointestinal/genitourinary facultative and anaerobic flora. A genetic hypercoaguable state in has been found in 50% of women with OVT. 9 Our patient had no family history of thromboembolic disease, thus genetic causes for a hypercoagulable state were not evaluated. Literature approximately 40 years ago indicated that anticoagulation had replaced the surgical ligation of the vena cava or ovarian veins to prevent pulmonary emboli. 3 More recent literature has shown that resolution of fever and length of hospitalization were not significantly different in women treated with antibiotics alone versus those treated with antibiotics and anticoagulation, probably due to a spectrum bias of earlier detection and, therefore, milder cases. 10 poSt–CeSAreAn deLiVery SeptiC oVAriAn Vein throMboSiS Despite these recent reports, a short course of anticoagulation is often given due to concerns of vena cava thrombosis or pulmonary emboli seen in approximately 13% of OVT, 6 although the type and duration of anticoagulation for OVT remains controversial. 7,11,12 Until better evidence is available, the authors believe anticoagulation should be considered until the patient is ambulating and asymptomatic, and for 3 to 6 months in cases complicated by pulmonary emboli. If warfarin is given to a woman who breast feeds, Vitamin K supplement and coagulation testing of her infant is considered prudent. referenCeS 1. Brown TK, Munsick RA. Puerperal ovarian vein thrombophlebitis: a syndrome. Am J Obstet Gynecol. 1971;109(2):263-273. 2. Dunnihoo DR, Gallaspy JW, Wise RB, Otterson WN. Postpartum ovarian vein thrombophlebitis: a review. Obstet Gynecol Surv. 1991;46(7):415-427. 3. Josey WE, Staggers SR,Jr. Heparin therapy in septic pelvic thrombophlebitis: a study of 46 cases. Am J Obstet Gynecol. 1974;120(2):228-233. 4. Garcia J, Aboujaoude R, Apuzzio J, Alvarez JR. Septic pelvic thrombophlebitis: diagnosis and management. Infect Dis Obstet Gynecol. doi:10.1155/ IDOG/2006/15614. 5. Witlin AG, Mercer BM, Sibai BM. Septic pelvic thrombophlebitis or refractory postpartum fever of undetermined etiology. J Matern Fetal Med. 1996;5(6): 355-358. 6. Munsick RA, Gillanders LA. A review of the syndrome of puerperal ovarian vein thrombophlebitis. Obstet Gynecol Surv. 1981;36(2):57-66. 7. Kominiarek MA, Hibbard JU. Postpartum ovarian vein thrombosis: an update. Obstet Gynecol Surv. 2006;61(5):337-342. 8. Twickler DM, Setiawan AT, Evans RS, et al. Imaging of puerperal septic thrombophlebitis: prospective comparison of MR imaging, CT, and sonography. AJR Am J Roentgenol. 1997;169(4):1039-1043. 9. Salomon O, Apter S, Shaham D, et al. Risk factors associated with postpartum ovarian vein thrombosis. Thromb Haemost. 1999;82(3):1015-1019. 10. Brown CE, Stettler RW, Twickler D, Cunningham FG. Puerperal septic pelvic thrombophlebitis: incidence and response to heparin therapy. Am J Obstet Gynecol. 1999;181(1):143-148. 11. Beigi RH, Wiensenfeld HC. Enoxaparin for postpartum ovarian vein thrombosis. A case report. J Reprod Med. 2004;49(1):55-57. 12. Ortin X, Ugarriza A, Espax RM, et al. Postpartum ovarian vein thrombosis. Thromb Haemost. 2005;93(5):1004-1005. Gundersen Lutheran Medical Journal • Volume 6, Number 1, June 2009 25
Authors: Ines H. Berger, MD, PhD Department of Pain Medicine Gundersen Lutheran Health System Douglas R. Bacon, MD, MA Department of Anesthesiology Mayo Clinic Foundation Rochester, Minnesota Address for correspondence: Ines H. Berger, MD, PhD Mail Stop EB3-001 Gundersen Lutheran Health System 1900 South Avenue La Crosse, WI 54601 Telephone: (608) 775-9000 Facsimile: (608) 775-1018 email: ihberger@gundluth.org A Historical Notes on Amputation and Phantom Limb Pain: “All Quiet on the Western Front?” AbStrACt mputations have been performed since antiquity for punitive, therapeutic, and ritualistic purposes. 1 Hippocrates practiced amputation of gangrenous limbs, preferring transection through the gangrenous portion because it was less painful. Celsus, in contrast, stressed the necessity to sever between the healthy and the diseased body part. Since the 16th century, especially in France and in Germany, barber surgeons have attempted to perfect the techniques of amputation. Until the advent of adequate general and regional anesthesia techniques, an amputation was probably the most challenging operation a surgeon could perform. Although opium had been known for a long time, it did not find its use in amputations. With the lack of perioperative analgesia, the operation had to be short. It took an experienced barber surgeon 3 to 4 minutes to amputate a leg and was performed as a circular cut—a single cut for skin, muscles, bone and tendon (Figure 1). A limb amputation was associated with an extremely high morbidity and mortality (50%-80%) prior to the introduction of antisepsis in the late 19th century. The invention of cannon balls and gunpowder worsened the injuries sustained in battle. Many famous surgeons, such as Ambroise Paré (Figure 2) and Baron Larrey, who reportedly amputated 200 limbs in a day, 2 have been associated with battle surgery. Important progress was made with the introduction of vessel ligature. Previously, hemostasis had to be achieved by immersing the stump in substances such as hot oil or vitriol, or cauterizing with a hot iron. Ambroise Paré described an arterial forceps for the use of vessel ligation in 1590, thereby significantly reducing blood loss. 3 Amputations in the 16th and 17th centuries were primarily accomplished in a single cut through the soft tissue, thereby necessitating an assistant holding the limb. This was consequently modified into 2- and 3-stage circular cuts to reduce the tension on sutures. Lowdham (1679), Verduyn (1696), and Langenbeck (1810) changed the operative technique with the creation of a soft tissue flap to cover the stump without tension. Despite these advances, mortality was high and amputation remained the best option possible. William Keen, an American Civil War surgeon, The first detailed description of phantom limb pain is credited to the French barber surgeon Ambroise Paré (ad 1552) in his tract on “harquebusses and other guns.” He differentiated phantom limb pain from stump pain and phantom sensations. Paré speculated on peripheral and central nervous system involvement, as well as psychological factors in the algogenesis of this pain. Although classically described as occurring after limb amputation, the sensation can occur after a spinal cord injury, nerve avulsion, mastectomy, or removal or deafferentation of many other organs or body parts. Almost 450 years later, the incidence of phantom limb pain has remained high (up to 80% in some studies). Paré’s observation and theories are still the basis of our current treatment strategies, including aggressive postoperative analgesia, nerve blocks, centrally acting medications, physiotherapy and behavioral/psychological interventions. figure 1. Plate illustrating amputation at the thigh. Courtesy of the National Library of Medicine. wrote: “The popular opinion that the surgeons did a large amount of unnecessary amputating may have been justified in a few cases, but, taking the army as a whole, I have no hesitation in saying that far more lives were lost from refusal to amputate than by 26 Gundersen Lutheran Medical Journal • Volume 6, Number 1, June 2009
Page 1 and 2: Th e Gundersen Lu T h e r a n M e d
Page 3 and 4: editor David E. Hartman, PhD, BC-AN
Page 5 and 6: through our online Scholarly Activi
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Page 9 and 10: effect. These data suggest that the
Page 11 and 12: Authors: David E. Hartman, PhD, BC-
Page 13 and 14: discharge. Twelve patients (2%) dev
Page 15 and 16: pneumonia rates of 2.4%, versus 5.4
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Page 35 and 36: figure 2. Longtime LEHP member Don
Page 37 and 38: Summer Splendor Kelly Hodgson Kline

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