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Targeted Reinnervation as a Strategy for Neuroma Treatment: A Multi-Center Study
Jason M. Souza, MD; Jason H. Ko, MD; Mickey S. Cho, MD; Aaron E. Barrow, MD; Todd A. Kuiken, MD, PhD; Gregory A. Dumanian
Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
Introduction: Targeted reinnervation (TR) is a decade-old surgical procedure designed to provide intuitive control of upper limb prostheses through transfers of residual nerves to denervated target muscle. Early in the clinical series of TR procedures, we observed that most patients reported resolution of their preoperative neuropathic pain symptoms following surgery. This early observation prompted pre-clinical animal studies that have shown TR to facilitate coordinated nerve regeneration and prevent the disorganized progression to end-neuroma. In response to this clinical observation and supportive pre-clinical data, we performed a multicenter retrospective review of neuropathic pain outcomes for all TR cases performed at 2 different medical centers, one civilian and one military.
Materials and Methods: A retrospective review was conducted of all elective TR cases performed at the participating institutions between February 2002 and February 2012. The presence or absence of neuroma pain was garnered from electronic and paper medical records, which included documentation of clinical examination by the operating surgeon, prosthetist, therapist, and physiatrist.
Results: Data from all 28 patients who underwent TR at the participating centers were reviewed and included in the final analysis. The procedure was performed on 18 patients with a transhumeral amputation level, as well as 10 patients who had previously undergone a shoulder disarticulation. The average duration between amputation and TR surgery was 17 months. Each of these patients had between 2 and 5 end-neuromas excised as part of the procedure, with a total of 80 nerves transferred. Of the 28 patients who underwent TR, 15 (54%) complained of preoperative neuroma pain, whereas only 1 (3.5%) exhibited post-TR neuroma pain involving a transferred nerve (Table). Two additional patients reported post-TR neuroma pain; however, the painful sites were localized to nerves not transferred as part of the conventional TR procedure. The average follow-up period was 25 months.
Conclusions: Targeted reinnervation may represent a novel technique for the treatment of end-neuromas and their painful sequelae. By transferring transected nerves to denervated muscles, TR gives the nerves somewhere to go and something to do—elements lacking in current neuroma treatments.
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