Managing Neuroma and Phantom Limb Pain in Ontario: The Status of Targeted Muscle Reinnervation

Abstract

Painful neuromas (PN) and phantom limb pain (PLP) are common following amputation and are unreliably treated, which impacts quality of life. Targeted muscle reinnervation (TMR) is a microsurgical technique that repairs the severed proximal nerve end to a redundant motor nerve in the amputated stump. Evidence supports TMR as effective in treating PN and PLP; however, its adoption has been slow. This study aimed to characterize: (1) the populations experiencing post-amputation PN/PLP; (2) current trends in managing PN/PLP; and (3) attitudes toward routine use of TMR to manage PN/PLP.

Methods: A cross-sectional survey was distributed to all orthopedic surgeons, plastic surgeons, and physiatrists practicing in Ontario, via publicly available emails and specialty associations. Data were collected on demographics, experience with amputation, managing post-amputation pain, and attitudes toward routine use of TMR.

Results: Sixty-six of 698 eligible participants submitted complete surveys (9.5% response rate). Respondents had a greater experience with surgical management of PN (71% PN versus 10% PLP). However, surgery was considered a 3rd-line option for PN and not an option for PLP in 57% and 59% of respondents, respectively. Thirty participants (45%) were unaware of TMR as an option, and only 8 respondents have currently incorporated TMR into their practice. Many (76%) would be willing to incorporate TMR into their practice as either an immediate or delayed surgical technique.

Conclusions: Despite its promise in managing post-amputation pain, awareness of TMR as a surgical option is generally poor. Several barriers to the widespread adoption of this technique are defined.

Fig. 1.

Overview of clinical background of respondents. A, Plastic Surgery (n = 18); B, Orthopedic Surgery (n = 25); C, Physiatry (n = 20). Nearly all subspecialties were represented in the cohort of respondents among the 3 target physician groups. The only subspecialties that did not contribute to the dataset were orthopedic oncology, orthopedic spine, and cancer rehabilitation physiatrists. Respondents were permitted to identify with more than 1 subspecialty in this component of the questionnaire. Rehab, rehabilitation; CV, cardiovascular; MSK, musculoskeletal; CP, chronic pain.

Fig. 2.

Clinician experience with managing or performing amputations among respondents. A, Histogram depicting the volume of amputations carried out or managed within each specialty. Participants indicated how many they performed annually on average, and these responses were categorized into the intervals presented (n = 63). B, Among surgeons who stated that they performed amputation (n = 40), frequency of surgical indication is presented for each diagnosis.

Fig. 3.

Participants’ perceived incidence of PN and PLP among amputees in their practice. A, Estimates of the proportion of patients developing painful neuroma (PN) after amputation organized in a box plot. B, Estimates of the proportion of patients developing phantom limb pain (PLP) after amputation organized in a box plot. The “˚” indicates an outlier (1.5 x IQR), while the “*” indicates an extreme outlier (3 x IQR). The “†” indicates a statistically significant difference (Kruskal-Wallis test, P < 0.05).

Fig. 4.

Extent to which quality of life is impacted by PN and PLP. Respondents were asked to rate the degree to which each domain impacted quality of life. The list of quality-of-life domains was developed based on a combination of items included in the 36-Item Short Form Survey Instrument and the Prosthesis Evaluation Questionnaire as well as expert input.

Fig. 5.

Comprehensive overview of strategies to manage PN and PLP among PRS, OS, and physiatrists. A, Strategies most commonly used to treat painful neuroma (PN). B, Strategies most commonly used to treat phantom limb pain (PLP). Topical treatments trended toward being more commonly used in managing PN, whereas managing PLP involved putting relatively more emphasis on behavioral and rehabilitative techniques. Medical treatments were commonly used to manage both PN and PLP across all specialty groups. NMDA, N-methyl-D-aspartate receptor antagonists; CBT, cognitive behavioral therapy. *Topical compounds refer to agents such as lidocaine, TCAs, and NSAIDs. **Guided imagery, visual-kinetic feedback therapy, or mirror therapy.

Fig. 6.

Overview of current surgical practices in managing PN and PLP among respondents. A, Comprehensive list of known surgical techniques that depicts the degree of familiarity and use of each technique (PRS: n = 18; OS: n = 25; PMR: n = 20). B. Perceived priority of surgical management in treating PN and PLP.

Fig. 7.

Assessment of clinician willingness to incorporate TMR into their practice and under what conditions they would do so. A, Participants’ responses to whether they would consider performing TMR (surgeons) or referring for TMR (physiatrists) in their practice (n = 54). B, Among surgeons who answered “Yes”(as indicated in panel A) (n = 28), a follow-up question explored under what time and supportive conditions they would consider performing TMR.

Fig. 8.

Perceived barriers to incorporating TMR into practice, among OS, PRS, and physiatrists. A, Perceived barriers among surgeons willing to adopt TMR (n = 29); B, Perceived barriers among surgeons not willing to adopt TMR (n = 11); C, Barriers perceived by physiatrists (n = 15).