Targeted Muscle Reinnervation in Non-Amputees: Using Expendable Motor Nerve Targets for the Treatment of Refractory Neuroma
Patrick W Harbour, MD1, Brian L Chang, MD1, Christopher M Fleury, MD1, Nicole C Episalla, BA2 and Grant M Kleiber, MD1, (1)Georgetown University, Washington, DC, (2)Georgetown University School of Medicine, Washington, DC
Introduction
Targeted muscle reinnervation (TMR) has been shown to be an effective technique for treating and preventing neuropathic pain and phantom limb pain in otherwise unreconstructable nerves. This technique has been increasing in popularity, particularly performed prophylactically at the time of amputation. In patients with a symptomatic neuroma, the neuroma is excised and the nerve is typically reconstructed when possible using an interpositional nerve allograft or conduit. Unreconstructable nerves have been traditionally managed with neurectomy and implantation into muscle. The results from this approach is often marginal and recurrence is not uncommon. We present our series of superficial sensory neuromas that were successfully treated with TMR to an expendable local motor nerve.
Materials and Methods
This series presents a single surgeon's consecutive cases of non-amputee patients with recurrent symptomatic neuromas treated with TMR during a one year period. All patients had failed previous interpositional nerve reconstruction. Pre- and postoperative pain outcomes were compared.
Results
Between March and July of 2019, a total of 6 cases of TMR were performed in non-amputees with recurrent neuromas. These cases were performed for symptomatic neuromas in the saphenous, sural, dorsal cutaneous ulnar, and radial sensory nerves that had failed interpositional reconstruction. The motor target nerves in these cases were all from muscles that were expendable due to redundant function, joint fusion, or previous harvest for soft tissue coverage. Motor targets included sartorius in one case, medial gastrocnemius muscle flaps in two cases, redundant ECRB nerves in two cases, and redundant FCU nerve in one case. All patients endorsed significant improvement in their perception of pain in the affected nerves. Average preoperative VAS pain score was 8.7 (range 8-10). Postoperative pain scores averaged 3.0 (range 2-5). The average decrease in pain was 66%. (50%-78%). No patients experienced postoperative weakness or decrease in function. No patients reported postoperative phantom pain.
Conclusion
TMR is an effective technique for the prevention or treatment of symptomatic neuroma. The approach to TMR must be patient-specific and follow conceptual guidelines, including an expendable motor target nerve, and favorable anatomic proximity, ideally located within the same anatomic compartment with reasonable size match. While TMR has typically been reserved for unreconstructable nerves during or after an amputation procedure, we demonstrate that it is a viable alternative to traditional methods of surgical neuroma treatment when interpositional reconstruction is not an option.
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