Article
Targeted Muscle Reinnervation at the Time of Amputation Reduces Pain Severity and Behavior in Upper Extremity Amputations
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Authors
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Andrew O'Brien
- Ohio State University Medical Center, Dept. of Plastic and Reconstructive Surgery, Columbus, United States
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Sumanas Jordan
- Northwestern University, Div. of Plastic Surgery, Chicago, United States
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Julie West
- Ohio State University Medical Center, Dept. of Plastic and Reconstructive Surgery, Columbus, United States
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Geoffroy Sisk
- Ohio State University Medical Center, Dept. of Plastic and Reconstructive Surgery, Columbus, United States
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Steven Schulz
- Ohio State University Medical Center, Dept. of Plastic and Reconstructive Surgery, Columbus, United States
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Joel Mayerson
- Ohio State University Medical Center, Dept. of Orthopedic Surgery, Columbus, United States
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Thomas Scharschmidt
- Ohio State University Medical Center, Dept. of Orthopedic Surgery, Columbus, United States
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Gregory Dumanian
- Northwestern University, Div. of Plastic Surgery, Chicago, United States
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Ian Valerio
- Ohio State University Medical Center, Dept. of Plastic and Reconstructive Surgery, Columbus, United States
| Published: | February 6, 2020 |
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Outline
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Objectives/Interrogation: Targeted muscle reinnervation (TMR) is a technique for the management of peripheral nerves in amputees. Regarding pain management, TMR aims to address symptomatic neuromas, which are disorganized ends of severed nerve fibers encased in scar. Neuromas are often responsible for much of the residual limb pain (RLP) experienced by those with limb loss, limiting function and making the use of prostheses uncomfortable, or even impossible. Moreover, neuromas may be a driver of phantom limb pain (PLP), or the feeling of discomfort in the non-existent limb. We have employed TMR as a means to prevent such pain when performed at the time of amputation.
Methods: A retrospective review of patients who underwent upper extremity amputation with concurrent TMR was performed. Pain was assessed using the NIH-funded Patient-Reported Outcome Measurement Information System (PROMIS) Pain Intensity Short Form 3a, and Pain Behavior Short Form 7a, which assess the intensity and outward manifestations of pain over a 7-day recall period, respectively. Our TMR cohort was compared to benchmarked data from an unselected population of upper extremity amputees.
Results and Conclusions: Sixteen patients who underwent upper extremity TMR at the time of amputation were identified and were compared to 55 patients who underwent upper extremity amputation without TMR. Among TMR patients, 25% underwent transradial amputation, 31.2% transhumeral amputation, and 43.8% underwent shoulder disarticulation. Median follow-up time was 13.7 mos, ranging from 3.1 mos to 5.3 yrs. Nine patients (56%) were using a prosthetic at most recent follow-up, and avg time to prosthetic was 4.7 mos. The mean PROMIS PLP intensity t-score for the general amputee population was 47.02 vs 36.6 in the acute TMR population (p=0.001), representing a statistically significant reduction in the TMR cohort. PROMIS pain intensity for RLP trended towards benefit with TMR (44.68 versus 39.8, p=0.133). Additionally, the PLP behavior t-score among general amputees was 52.2 vs 46.7 in the TMR population (p-0.046), demonstrating a reduction in pain behavior among TMR amputees.
In addition to the benefit of TMR for myoelectric prosthetic control, our study demonstrates that TMR performed at the time of amputation is a promising strategy for improving PLP and RLP severity and behaviors in the upper extremity. TMR performed at time of amputation is cost-effective, technically easier, and permits the patient early prosthetic rehabilitation without need for delayed procedures.
