Preemptive Treatment of Phantom and Residual Limb Pain with Targeted Muscle Reinnervation at the Time of Major Limb Amputation

Valerio, Ian L.; Dumanian, Gregory A.; Jordan, Sumanas W.; Mioton, Lauren M.; Bowen, Juan; West, Julie M.; Porter, Kyle; Ko, Jason H.; Souza, Jason M.; Potter, Benjamin K.

doi:10.1016/j.jamcollsurg.2018.12.015

Cited by 184 publications

(246 citation statements)

References 52 publications

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“…11,[15][16][17][18] Only one trial focused specifically on lower extremity. 18 Four of the articles were retrospective reviews, [15][16][17][18] and one was a randomized control trial. 11 A total of 149 patients were included, of whom 82 underwent lower extremity amputation.…”

Section: Resultsmentioning

confidence: 99%

“…Three articles addressed phantom pain after primary TMR. Valerio et al 17 showed that 50 to 72% were free of phantom pain compared with 19.5% in controls, Bowen et al 18 showed improvement over time from 72% expressing phantom pain to 13% at 6 months, and Pet et al 15 showed that 6/12 developed phantom pain. For secondary TMR, phantom pain was addressed in two articles, with one noting it to be essentially unchanged 15 and the other noting an improvement to 2.3 out of 10 versus 4.4 out of 10 in controls on the Likert pain scale.…”

Section: Resultsmentioning

confidence: 99%

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Targeted Muscle Reinnervation: Outcomes in Treating Chronic Pain Secondary to Extremity Amputation and Phantom Limb Syndrome

McNamara

Iorio

2019

J Reconstr Microsurg

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Background Secondary to vascular disease, oncological resection, or devastating trauma, lower extremity amputations are performed globally at a yearly rate exceeding 1 million patients. Three-quarters of these patients will develop chronic pain or phantom pain, which presents a functional limitation for prosthetic use and contributes to deconditioning and increased mortality. Targeted muscle reinnervation (TMR) presents a surgical solution to this problem as either a primary or secondary intervention. Methods A review of the existing literature was conducted using a combination of the terms “phantom pain” “chronic pain,” “neuroma,” and “targeted muscle reinnervation” in Medline and PubMed. Results Five articles were found which addressed TMR for pain syndromes, four of which involved lower extremity amputation. Four of the articles were retrospective reviews, and one was a randomized control trial. A total of 149 patients were included, of which 82 underwent lower extremity amputation. Ninety-two of the patients underwent prophylactic TMR, of which 57 were secondary procedures.In patients who underwent TMR at the time of amputation, all studies reported a minimal development of symptomatic neuromas (27%). For secondary TMR, near-complete resolution of previous pain was found (90%). Phantom pain was noted to be similar to other studies in the literature but noted to improve over time with both primary (average drop of 3.5 out of 10 points on the numerical rating scale) and secondary (diminishing from 72% of patients to 13% over 6 months) operations. Conclusion Although much of the current literature is limited to retrospective studies with few patients, these data point toward near-complete resolution of neuroma pain after treatment as well as complete prevention of chronic pain if TMR is used as a prophylactic measure during the index amputation. This study was a level of evidence IV.

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Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Targeted Muscle Reinnervation: Outcomes in Treating Chronic Pain Secondary to Extremity Amputation and Phantom Limb Syndrome

McNamara

Iorio

2019

J Reconstr Microsurg

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“…This nerve transfer technique aims to facilitate reinnervation as close as possible to resembling physiological innervation thus potentially inhibiting the pathological central reorganisation of neuropathic pain mechanisms. 24 The authors found that TMR provided greater pain relief for both residual limb pain and phantom pain on the NRS compared with traditional surgical excision of the neuroma. 23 The same research group also conducted a multicentre cohort study comparing 51 patients undergoing major limb amputation with immediate TMR with 438 unselected standard major limb amputation patients.…”

Section: Discussionmentioning

confidence: 98%

Ultrasound-Guided Continuous Radiofrequency Ablation of Painful Residual Limb Neuroma in Individuals With Limb Amputation- a Retrospective Case Series

Guo

Mansour

Slater

2019

Can. Prosthet. Orthot. J.

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BACKGROUND: Residual limb neuromas are a significant cause of post-amputation pain. There is little knowledge concerning ultrasound-guided (US) radiofrequency ablation (RFA) as treatment. OBJECTIVE: To investigate US-guided RFA for neuroma associated pain in individuals with limb amputation. METHODOLOGY: The notes of nine consecutive patients were retrospectively reviewed. Information obtained included neuroma size and nerve, RFA duration/temperature, pain scores, analgesic requirements and ease/comfort of prosthetic use. Eight patients had lower-limb amputations and one had a trans-radial amputation. All except one, underwent diagnostic US-guided steroid injection to confirm the neuroma as the source of pain, prior to RFA. RESULTS: Six patients reported significant reduction in pain scores (defined as at least 50% reduction) and an improvement in comfort/ease of wearing their prosthetic limb, with no adverse effects. Three of these six patients also reported a reduction in analgesic requirements. Of the three remaining patients – one had a large sciatic nerve neuroma that was eventually surgically excised, another had confounding pain from an adjacent bony spur, whilst the third patient did not receive a routine diagnostic steroid injection prior to RFA. CONCLUSIONS: Our findings suggest that US-guided RFA is safe and effective for small to medium-sized residual limb neuroma associated pain in individuals with limb amputation. It can reduce pain and analgesic requirements, improve comfort/ease of wearing the prosthesis and potentially avoid surgical excision. We recommend patients should undergo a diagnostic steroid injection prior to RFA to confirm that the neuroma is the source of pain. LAYMAN’S ABSTRACTAfter amputation, many patients can get a neuroma which can cause significant pain leading to discomfort wearing the prosthetic limb. Ultrasound-guided radiofrequency ablation can successfully treat painful residual limb neuromas in individuals with limb amputation which in turn can reduce the patient’s pain medications and improve the comfort of wearing the prosthetic limb. Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/33061/25509 How to Cite: Guo S, Mansour R, Henderson Slater D. Ultrasound-guided continuous radiofrequency ablation of painful residual limb neuroma in individuals with limb amputation- A retrospective case series. Canadian Prosthetics & Orthotics Journal. 2019; volume2, Issue1, No.4. https://doi.org/10.33137/cpoj.v2i1.33061 CORRESPONDING AUTHOR:Shigong Guo,LLM MSc(Orth Eng) MRCS, Specialty Registrar in Rehabilitation MedicineOxford Centre for Enablement, Nuffield Orthopaedic Centre, Oxford, UK.Email: shigong@doctors.org.uk

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“…These results are also echoed by other studies, with phantom limb pain scores (0-10) of 1 in patients who underwent TMR and 5 in patients who did not undergo TMR. 53 Furthermore, TMR may also reduce postoperative opioid use by roughly 50%. 54 To date, there is only retrospective data on RPNI from a single center which has shown significant reduction in phantom limb pain compared with a variety of conventional techniques.…”

Section: Discussionmentioning

confidence: 99%

Risk Factors for Neuropathic Pain Following Major Upper Extremity Amputation

Lans

Hoftiezer

Lozano-Calderón

et al. 2020

J Reconstr Microsurg

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Background Active treatment (targeted muscle reinnervation [TMR] or regenerative peripheral nerve interfaces [RPNIs]) of the amputated nerve ends has gained momentum to mitigate neuropathic pain following amputation. Therefore, the aim of this study is to determine the predictors for the development of neuropathic pain after major upper extremity amputation. Methods Retrospectively, 142 adult patients who underwent 148 amputations of the upper extremity between 2000 and 2019 were identified through medical chart review. All upper extremity amputations proximal to the metacarpophalangeal joints were included. Patients with a follow-up of less than 6 months and those who underwent TMR or RPNI at the time of amputation were excluded. Neuropathic pain was defined as phantom limb pain or a symptomatic neuroma reported in the medical charts at 6 months postoperatively. Most common indications for amputation were oncology (n = 53, 37%) and trauma (n = 45, 32%), with transhumeral amputations (n = 44, 30%) and shoulder amputations (n = 37, 25%) being the most prevalent. Results Neuropathic pain occurred in 42% of patients, of which 48 (32%) had phantom limb pain, 8 (5.4%) had a symptomatic neuroma, and 6 (4.1%) had a combination of both. In multivariable analysis, traumatic amputations (odds ratio [OR]: 4.1, p = 0.015), transhumeral amputations (OR: 3.9, p = 0.024), and forequarter amputations (OR: 8.4, p = 0.003) were independently associated with the development of neuropathic pain. Conclusion In patients with an upper extremity amputation proximal to the elbow or for trauma, there is an increased risk of developing neuropathic pain. In these patients, primary TMR/RPNI should be considered and this warrants a multidisciplinary approach involving general trauma surgeons, orthopaedic surgeons, plastic surgeons, and vascular surgeons.

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Preemptive Treatment of Phantom and Residual Limb Pain with Targeted Muscle Reinnervation at the Time of Major Limb Amputation

Cited by 184 publications

References 52 publications

Targeted Muscle Reinnervation: Outcomes in Treating Chronic Pain Secondary to Extremity Amputation and Phantom Limb Syndrome

Targeted Muscle Reinnervation: Outcomes in Treating Chronic Pain Secondary to Extremity Amputation and Phantom Limb Syndrome

Ultrasound-Guided Continuous Radiofrequency Ablation of Painful Residual Limb Neuroma in Individuals With Limb Amputation- a Retrospective Case Series

Risk Factors for Neuropathic Pain Following Major Upper Extremity Amputation

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