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Targeted Reinnervation for the Upper Extremity Amputee; Clinical Outcome of Phantom Limb Pain and Painful Neuroma
John Byers Bowen, MD, MS; Kanu Goyal, MD; Sonu A. Jain, MD, FACS; Ian L. Valerio, MD, MS, MBA
The Ohio State University, Wexner Medical Center, Columbus, OH
Introduction: The negative effects of painful neuroma (PN) and phantom limb pain (PLP) in upper extremity amputees greatly limit prosthetic use. This pilot study examines targeted reinnervation (TR) in the upper extremity amputee to understand the success of TR in preventing PLP and PN when performed at the time of amputation (i.e. primary TR) and in specifically treating PLP and PN (i.e. secondary TR).
Methods: A retrospective review of all patients that underwent upper extremity TR at our institution was completed. Each patient had his or her major amputated mixed motor-sensory and sensory peripheral nerves identified. Neuroma was excised in patients undergoing secondary TR. A nerve stimulator was utilized to identify proximal motor nerves entering specific muscle units. These target motor nerves were divided near their associated muscle and the prior amputated nerves were coapted to the target motor nerve. Subjects were followed at one, three, six, and twelve-month intervals to evaluate symptoms of PN, PLP, phantom limb sensation, patient satisfaction, and functionality.
Results: Five patients have undergone upper extremity TR. Operative details and follow-up reports of PN and PLP are shown (Table 1). Thus far, all patients have denied PN post TR. PLP was reported by 100% of patients at one month, but resolved by three months in all patients except for one secondary TR patient.
Conclusion: PLP and PN are noted as early as three months post-amputation at 9% and 2%, respectively. This pilot study suggests that primary TR can decrease the incidence of PLP and PN. Additionally, secondary TR has thus far been a successful treatment of PN. Our primary TR patients demonstrate early muscle fasciculation that suggests better muscle motor end plate function and less disuse/atrophy due to earlier nerve to muscle interface. We have also noted majority of patients to wean from narcotic use more quickly. This pilot study provides a basis for future studies regarding the specific use of TR to prevent and treat PLP and PN.
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