Does targeted nerve implantation reduce neuroma pain in amputees?

Abstract

Background: Symptomatic neuroma occurs in 13% to 32% of amputees, causing pain and limiting or preventing the use of prosthetic devices. Targeted nerve implantation (TNI) is a procedure that seeks to prevent or treat neuroma-related pain in amputees by implanting the proximal amputated nerve stump onto a surgically denervated portion of a nearby muscle at a secondary motor point so that regenerating axons might arborize into the intramuscular motor nerve branches rather than form a neuroma. However, the efficacy of this approach has not been demonstrated.

Questions/purposes: We asked: Does TNI (1) prevent primary neuroma-related pain in the setting of acute traumatic amputation and (2) reduce established neuroma pain in upper- and lower-extremity amputees?

Methods: We retrospectively reviewed two groups of patients treated by one surgeon: (1) 12 patients who underwent primary TNI for neuroma prevention at the time of acute amputation and (2) 23 patients with established neuromas who underwent neuroma excision with secondary TNI. The primary outcome was the presence or absence of palpation-induced neuroma pain at last followup, based on a review of medical records. The patients presented here represent 71% of those who underwent primary TNI (12 of 17) and 79% of those who underwent neuroma excision with secondary TNI (23 of 29 patients) during the period in question; the others were lost to followup. Minimum followup was 8 months (mean, 22 months; range, 8-60 months) for the primary TNI group and 4 months (mean, 22 months; range, 4-72 months) for the secondary TNI group.

Results: At last followup, 11 of 12 patients (92%) after primary TNI and 20 of 23 patients (87%) after secondary TNI were free of palpation-induced neuroma pain.

Conclusions: TNI performed either primarily at the time of acute amputation or secondarily for the treatment of established symptomatic neuroma is associated with a low frequency of neuroma-related pain. By providing a distal target for regenerating axons, TNI may offer an effective strategy for the prevention and treatment of neuroma pain in amputees.

Fig. 1A–B

Diagrams illustrate an example of secondary TNI. (A) A median neuroma in the setting of previous elbow disarticulation is shown. (B) The median neuroma has been resected and the median nerve stump has been implanted into a secondary motor point of the biceps brachii muscle. Primary TNI would be illustrated similarly, except without the component of neuroma resection.