Two Surgical Options to Lessen Phantom Pain
My last post listed non-surgical options for dealing with phantom pain. I hope they were helpful to you all for finding relief. Unfortunately, sometimes a surgical solution must be used; the two most common procedures are TMI and RPMIs.
TMR – Targeted Muscle Reinnervation
TMR has been used in upper extremity cases for quite some time, and relatively recently, for lower limb extremity cases. For nerves to be affective, they need a place to go, a place to grow, and a “job” to do. If an amputation is done without TMR, the ortho surgeon bundles the nerves and sews up the incision. The nerves are loose and have no direction, which researchers believe activates phantom pain. TMR is performed by a neurosurgeon who takes the nerves and reinserts them back into the remaining muscle of the residual limb, thereby giving the nerves a place to go, a place to grow, and a “job” to do. TMR is not 100% effective, and for some amputees, does not work at all. On the other foot, for many it has been an incredible relief from phantom pain.
I can’t compare what it’s like not to have phantom pain due to TMR because I was one of the first amputees at Mass General Brigham to have TMR done with my amputation. Do I have phantom pain? Yes, but it doesn’t happen often. When it does, like many others, it is just as painful.
TMR revision surgery is gaining traction in the field as the percentage of folks who find relief from TMR increases. Also, having an amputation with TMR is becoming more mainstream as the research continues to show its benefits (more so with elective amputation). My hope is that it becomes standard practice in the future. One must have a knowledgeable surgeon who works in tandem with the orthopedic surgeon for success.
There is one caveat to having TMR surgery, though, and I am thinking far ahead into the future. A few months ago, I was invited to the M.I.T. Media lab as a test subject for their ongoing work with neurologically interfacing the residual limb with a prosthesis, thereby creating proprioception. This was the second time they had asked me to participate; I was pumped. As the researcher began putting electrodes on my residual limb, I mentioned that I had TMR with my amputation (which I assume he knew, as he had months to review my records, and it was my second time there.) Everything quickly came to a FULL STOP. Because my nerves were reinnervated and not on the surface of my residual limb, they could not get any readings. I was bummed because the second phase of the research that day was trying out a prosthetic prototype that would allow me to perceive proprioception. Of course, that never happened. If research progresses to where proprioception is available to the mainstream, will amputees forgo TMR in exchange for proprioception? Can TMR be performed in a way that the nerves can still be used for a neural interface between the limb and the prosthesis? More research, please.
If you have tried non-surgical remedies (see my June 1, 2023 post) to reduce phantom pain without success, then perhaps it is time to talk to your doctor about revision TMR surgery.
RPMIs – Regenerative Peripheral Nerve Interfaces
RMPIs is a technique where each nerve ending is embedded in a small piece of grafted muscle. Think of a mini meatball on the end of a toothpick.
RPMIs is mainly used with neuromas, but the technique has also enjoyed success with phantom pain, as many amputees who have RPMIs to alleviate neuromas have also reported a reduction in phantom pain. Again, a skilled surgeon is in order. RPMIs can also be performed for amputees who do not have enough muscle to make TMR successful.
Whether to have TMR or RPMIs depends on your personal medical history and your amputation. There are too many individual factors to say which one is best. Your surgeon is your go-to if you are to the point where surgery is your only option.
I would love to have a post from someone who has had revision TMR or RPMIs, as I have no experience with either of these medical interventions.
We have all had more than our fair share of pain, and we shouldn’t have to go through the rest of our lives just “dealing with it.”
And remember: You never know how much strength you have until you are called upon to use it.
Respectfully submitted,
Beth Hudson, LBKA
