A Consensus Approach for Targeted Muscle Reinnervation in Amputees

Abstract

Amputations have been performed with few modifications since the dawn of surgery. Blood vessels are ligated, bones are shortened, and nerves are cut. In a percentage of people, this can result in severe neuropathic, residual limb, and phantom limb pain. Targeted muscle reinnervation is a surgical procedure initially conceived to optimize function for myoelectric prostheses in amputees. Recently, it has been adopted more widely by surgeons for the prevention and treatment of neuropathic pain. Perhaps as a function of its relatively recent development, many authors perform this operation differently, and there has been no overall agreement regarding the principles, indications, technical specifics, and postoperative management guidelines. This article is written as a consensus statement by surgeons focused on the treatment of neuropathic pain and those with extensive experience performing targeted muscle reinnervation. It is designed to serve as a roadmap and template for extremity surgeons to consider when performing targeted muscle reinnervation.

Technical Trick: Cryoneurolysis for Subacute Pain Mitigation in Patients with Limb Loss

“…Identification of nerves and potential nerve targets form TMR is performed based on published consensus guidelines. 9…”

Three Useful Tips and Tricks for Intraoperative Nerve Stimulation

“…3 There are three critical steps in TMR surgery: (1) recognizing the donor major sensory or mixed motor/sensory nerve, (2) identifying the recipient motor nerve branches to the target muscle, and (3) securing a functional nerve coaptation. 4…”

“…3 There are three critical steps in TMR surgery: (1) recognizing the donor major sensory or mixed motor/sensory nerve, (2) identifying the recipient motor nerve branches to the target muscle, and (3) securing a functional nerve coaptation. 4 During our experience with handheld peripheral nerve stimulators, the authors have developed several strategies that improve speed and accuracy during peripheral nerve surgery and may assist in a wide range of procedures performed by peripheral nerve surgeons. In this article, three useful tips and tricks are demonstrated in handheld intraoperative nerve stimulation to perform TMR and peripheral nerve surgery efficiently and successfully.…”

Social Deprivation is Associated with Increased Pain in Patients Presenting with Neuropathic Pain

“…[2][3][4] As a relatively novel modality, TMR has gained popularity for the treatment of these sequela and its utilization as a prophylactic modality is being more widely adopted across the United States. 5 However, it has been identified that access to this technique at time of amputation (primary TMR) is not always available for many geographical locations. 6 Differences in location and socioeconomic factors, expressed as Area Deprivation Index (ADI) score, 7 have been linked to worse pain coping and social support.…”