Limb amputation represents a profound life alteration, often accompanied by many physical and emotional challenges. Plastic and reconstructive surgeon Dr. Brian Cripe explains the benefits of undergoing targeted muscle reinnervation or regenerative peripheral nerve interface procedures.

Nerve pain is a significant concern for amputation patients, with phantom limb pain and residual limb pain diminishing the quality of life for many amputees. However, recent advancements in surgical techniques have ushered in innovative approaches, such as Targeted Muscle Reinnervation (TMR) and Regenerative Peripheral Nerve Interface (RPNI) procedures. These interventions help patients tackle nerve pain and may heighten prosthetic control and sensory feedback. 

My amputee patients have experienced significant improvements in overall pain and phantom limb sensations after peripheral nerve surgery. In this article, I’ll cover the multifaceted benefits that I discuss with patients, explaining how TMR and RPNI microsurgeries have the potential to significantly enhance the overall well-being and quality of life of patients grappling with limb loss.

Why Are Amputation Sites Painful? 

Amputation sites can be painful for various reasons, both during the immediate and long-term post-amputation periods. Some key factors contributing to pain at amputation sites include:

• Nerve Damage and Neuroma Formation: Amputation involves cutting through nerves, which can result in neuropathic pain. Nerves might regenerate abnormally or send incorrect pain signals to the brain, leading to pain, burning, tingling, or even phantom limb pain. Scar tissue can also form near the end of the nerve following nerve severance or trauma. This scar tissue forms a painful lump of disorganized nerves, called a neuroma, that transmits intense pain signals to the brain when aggravated.
• Phantom Limb Pain: Phantom, or residual, limb pain is a complex phenomenon described when individuals experience pain or other sensations in a limb that is no longer there. The exact mechanisms behind phantom limb pain are not fully understood. Still, it is believed to involve a combination of nerve reorganization in the brain and the residual activity of severed nerves at the amputation site.
• Surgical Trauma and Healing: The amputation procedure causes tissue trauma, which triggers the body’s natural inflammatory response. This inflammation is expected to cause pain during the initial healing period post-amputation. Thickened or tethered scar tissue can also contribute to post-amputation pain.
• Infection and Complications: Infections or complications at the amputation site can cause ongoing pain and discomfort. Infections can delay the healing process and result in chronic pain if not properly treated.
• Prosthetic Use and Fit: Improper fitting or continuous friction between the residual limb and the prosthetic socket can cause irritation, pressure sores, and pain.
• Psychological Factors: Emotional distress, anxiety, and depression can influence pain perception. Coping with the loss of a limb can lead to heightened pain sensitivity and exacerbate the overall experience of pain.
• Central Sensitization: Chronic pain can lead to changes in the central nervous system, amplifying pain signals and making the brain more sensitive to pain. This phenomenon, known as central sensitization, can contribute to ongoing pain at amputation sites.

Managing pain at amputation sites involves a combination of treatments, rehabilitation, and medical support. These may include medications for pain management, physical therapy to improve mobility and strength, psychological counseling to address emotional distress, surgical interventions, and well-fitted prosthetics to reduce irritation and friction. It’s essential for individuals who have undergone amputations to work closely with a team of healthcare professionals to develop a comprehensive pain management plan tailored to their specific needs. 

In my experience as a plastic surgeon, I highly recommend targeted muscle reinnervation or regenerative peripheral nerve innervation surgeries to eligible patients.

Benefits of Peripheral Nerve Surgery Post-Amputation

Phantom Limb Pain Alleviation

Emerging clinical evidence attests to the remarkable success of peripheral nerve procedures in mitigating the torment of phantom limb pain. TMR and RPNI diminish pain sensations by providing a conduit for nerve signals and sensory input, offering respite to patients.

Enhanced Prosthetic Control

Peripheral nerve surgery’s benefits extend beyond pain alleviation by revolutionizing prosthetic control. In conjunction with myoelectric prosthetics, the rerouted neural pathways empower amputees to execute a broader spectrum of movements and undertake tasks more proficiently, making prosthetic usage a more seamless extension of their physiological capabilities. These procedures promote a more intuitive interaction between the patient’s nervous system and the prosthetic device.

Psychosocial Implications

Diminished pain and enhanced prosthetic control can foster a constructive influence on the psychological well-being of amputation patients. Renewing a sense of agency over prosthetics further correlates with improved self-esteem and a more positive body image.

Targeted Muscle Reinnervation (TMR): A Paradigm Shift in Limb Amputation Rehabilitation

Targeted muscle reinnervation constitutes a pioneering surgical approach. Targeted muscle reinnervation redirects severed nerves from the amputated limb into nearby muscles. This re-routing process fosters the establishment of novel neural-muscular connections, ultimately reducing phantom limb pain and augmenting prosthetic control.

Based on the amputation location, we take different approaches. For lower extremity amputations, we reinnervate no longer essential muscles to create a pathway for sensory nerves to grow into. This channel gives the nerve a new function, which helps interrupt pain signals and relieve residual limb pain. Research has shown that when surgeons perform above-knee or below-knee amputations combined with targeted muscle reinnervation during the same procedure, we’re more efficient and able to preserve donor nerve length and stimulate targeted nerves. Ultimately, this means patients spend less time in surgery and may have improved results. For patients who have already had an amputation, TMR  or RPNI can also be performed post-amputation to alleviate pain.

In the hands and arms, we reinnervate motor and sensory nerves to relieve pain while creating new motor targets for myoelectric prosthetics. This gives patients additional control by fostering an intuitive and organic interface for controlling prosthetic devices. Your surgeon may use different surgical techniques depending on where the amputation occurs. For example, this trans-radial amputation TMR approach has been shown to help improve prosthetic control by amplifying the range of detectable signals that modern myoelectric prostheses can utilize. This expansion in signal availability leads to an increased repertoire of distinct movements that can be executed. 

Targeted Muscle Reinnervation Surgical Overview

Targeted muscle reinnervation provides multiple benefits, including reducing phantom limb pain, enhancing prosthetic control, and promoting a more intuitive interaction between the patient’s nervous system and their prosthetic device.

Depending on the patient’s anatomy and preferences, we can perform TMR during the amputation procedure or down the road. The procedure begins with a comprehensive evaluation of the patient’s severed nerves and the adjacent muscles. We carefully identify the nerves that formerly supplied the amputated limb and determine suitable target muscles for reinnervation. We make a small incision to access severed nerve endings before attaching them to targeted muscles. 

As the reinnervation progresses, the brain’s motor commands are rerouted to the newly connected muscles, leading to muscle contractions when the patient thinks about moving their missing limb. This innovative approach essentially “tricks” the brain into activating the reinnervated muscles, resulting in improved prosthetic control. Reinnervation also gives severed sensory nerves a new job, interrupting pain signals. Over time, the patient learns to associate specific mental commands with movements of the reinnervated muscles, creating a more intuitive and natural connection between thoughts and prosthetic actions. 

Targeted muscle reinnervation not only holds the potential to alleviate phantom limb pain but also empowers individuals with enhanced prosthetic functionality, ultimately contributing to a higher quality of life for those who have undergone limb amputations.

I’d recommend reading this 2015 article published in the Journal of Hand Surgery to learn more about specific surgical techniques.

Regenerative Peripheral Nerve Interfaces (RPNI): Pioneering Sensory Reintegration

When a nerve is cut or damaged, it naturally tries to heal itself through regeneration. However, if the nerve lacks a clear direction to regrow towards, it can form a chaotic cluster of nerve tissue known as a neuroma.

Regenerative peripheral nerve interface procedures attempt to accomplish the same result as targeted muscle reinnervation. Instead of redirecting nerve impulses, we wrap pieces of denervated muscle around the severed nerve endings. This approach offers the nerve a supply of muscle tissue to reconnect with, encouraging the nerves to regenerate organizationally. This organized regeneration helps prevent the development of disorderly neuromas, subsequently reducing pain for the patient.

RPNI is appropriate in patients who have undergone limb amputation or are experiencing painful neuromas due to nerve injuries.

Optimism for the Future of Biomedical and Surgical Advances

Limb amputation, once synonymous with loss and debilitation, now bears the promise of revitalization and restoration through innovative surgical procedures. Both targeted muscle reinnervation and regenerative peripheral nerve innervation procedures emerged within roughly the past 10 years. These surgeries offer tremendous value, offering respite from immense nerve pain, resuscitating functional capacity, and rekindling sensory experiences. As scientists and physicians continue to innovate in basic and translational biomedical research, we’ll continue to advance transformative surgical interventions that enhance the lives of amputees. 

Book a Consultation at the Hand Center of Northern Arizona

Our board-certified plastic and hand surgeons can help you relieve painful neuromas related to amputations through peripheral nerve procedures. 

Author Profile: Brian Cripe, M.D., is an award-winning, board-eligible plastic and reconstructive surgeon proudly working with the Plastic Surgeons of Northern Arizona practice. Dr. Cripe specializes in cosmetic surgery, limb salvage, peripheral nerve microsurgery, hand surgery, and oncologic reconstructive procedures. He has performed over 5,000 surgical cases during his nine-year tenure as a surgeon.