Risk Factors for Neuropathic Pain Following Major Upper Extremity Amputation

Abstract

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.

Beyond the Knife—Reviewing the Interplay of Psychosocial Factors and Peripheral Nerve Lesions

“…Neuroma excision alone and neuroma excision with nerve stump implantation as well as higher PROMIS Depression scores were all independently associated with higher, e.g., more severe PROMIS Pain Interference scores. Higher numeric rating scale pain scores showed a significant correlation with neuroma excision alone and neuroma excision and implantation whereas neuroma excision with consecutive nerve repair or reconstruction was associated with lower numeric rating scale pain scores [61].…”

Regenerative Peripheral Nerve Interfaces Effectively Prevent Neuroma Formation After Sciatic Nerve Transection in Rats

“…At present, the effectiveness of RPNI in preventing the formation of neuromas is generally recognized (Loewenstein et al, 2022 ), and its utilization rate is increasing gradually. The research on the postoperative safety of RPNI (Lans et al, 2021 ) and more innovative surgical methods [c-RPNI (Svientek et al, 2020 ), TMRpni (Svientek et al, 2022 ), MC-RPNI (Kurlander et al, 2020 ), etc.] are also underway.…”

Long‐term patient‐reported outcome measures following limb salvage with complex reconstruction or amputation in the treatment of upper extremity sarcoma

“…Accordingly, the PROMIS Pain Interference scores were higher in these patients (53.4 vs. 34.9 points). Prior studies have shown neuropathic stump pain to be highly debilitating and to be more common in amputations proximal to the elbow 36‐38 . Recent innovations in the treatment or prevention of neuropathic pain provide opportunities to improve outcomes in patients opting for amputation or in cases where an LS procedure is impossible.…”