Dr. Durmanian and colleagues (2019) used Targeted Muscle Reinnervation (TMR) to address phantom limb pain (PLP) and neuroma-related residual pain in a surgical clinical trial at Northwestern and Walter Reed National Military Medical Center. Dr. Durmanian and his team found that patients that received TMR treatment reported a notable decrease in their PLP or neuroma-related pain compared to patients who received the standard pain treatment. More specifically, at the 1.5-year follow-up, TMR patients reported an average of a 3.6 (out of 10) point decrease in pain compared to the 0.5 point increase in pain with the standard neuroma treatment (Durmanian 2019). Thus, on average, TMR patients experienced a sustained decrease in pain many months after treatment while the standard treatment patients experienced a slight increase in pain level, on average (Durmanian 2019). When considering the quality of life of patients with chronic pain, an improvement in pain levels by 1 or 2 points may be the difference between being able to work or enjoy recreational activities and having to live on disability or refrain from activities they enjoy. Moreover, TMR can also allow amputees to have more control over their prostheses, which has the potential to increase their level of independence. With permission from one of his patients, Josh Sundquist, Dr. Durmanian shares Mr. Sundquist’s experience with TMR surgery during his presentation to show us an example of how these treatments can change how people function in their daily lives. Josh Sundquist is both a comedian and social media influencer who has shared his experience of battling cancer and losing his leg to Osteosarcoma in his adolescence. Mr. Sundquist has used his social media presence to raise awareness and help other people who have had similar experiences by posting tips, assistive device reviews, among other types of helpful content.
Sarah Zizina, author of the article, “Surgical technique drastically reduces pain for amputee cancer patients” and Department Publications Coordinator in the Orthopedic Oncology Department at the University of Texas MD Anderson Cancer Center writes about how TMR can improve the quality of life for amputee cancer patients. Like Dr. Durmanian, Sarah Zizina also shares the experience of a cancer survivor, Annette Rios, who lost her right leg to Chondrosarcoma in an amputation just below the knee. Like many other amputees, Ms. Rios also experienced phantom limb pain for years following her amputation. In her article, Sarah Zizina interviews plastic surgeon, Dr. Margaret Roubaud who explains how difficult and time-consuming the process of relearning how to perform tasks with a prosthesis is, especially because the constant pain from severed nerves is an obstacle in the relearning process. TMR can help combat this obstacle since it has been shown to reduce this pain and give patients more control over their prostheses.
The article explains that surgeries before TMR used a technique that mainly “buried” the nerves that were cut during amputation which left these nerves with nothing to “do” other than send the brain pain signals which perpetuates the chronic pain cycle. Instead, TMR gives these nerves something to “do” by connecting these severed nerves to nearby nerve branches that innervate muscle tissue. This helps break the pain cycle which decreases pain levels for these patients. Dr. Roubaud explains that TMR is especially helpful for cancer patients since many of them experience pain from the cancer itself or from their cancer treatments and that people who go into amputation with pain are more likely to leave the surgery with worsened pain. She also emphasizes that TMR does not have many disadvantages since it has never been shown to make pain worse, which makes this an even more appealing technique for amputees who have already undergone many procedures during their cancer journey.
Ms. Rios worked in the medical field as a medical assistant and had a young daughter to keep up with at the time of her amputation. Her work and home life was made more difficult because of her debilitating PLP following the amputation which led her to opt for TMR. She explained that after surgery, she no longer had pain and was able to get her prosthetic limb. This allowed her to return to nursing school only a few months after TMR surgery. Ms. Rios explains that choosing TMR was one of the best decisions of her life since it allowed her to continue doing the things she loved to do before cancer and allowed her to pursue a career that she was passionate about.
Dr. Roubaud and doctors like herself have been training more and more surgeons on how to perform TMR to ensure that it is widely available. In the near future, I think that it will be extremely important to make sure more hospitals are able to conduct this procedure effectively so that individuals who may not be able to afford the additional expenses associated with having surgery away from home, still have the opportunity to receive this treatment. One observation from Dr. Durmanian’s study is that the sample was almost entirely made up of caucasian patients. Therefore, making sure that this procedure is widely available to all people who may benefit from it and making sure that even hospitals in low-income areas are able to provide this procedure is essential in allowing more people like Josh Sundquist and Annette Rios, the ability to achieve their highest level of independence and maintain a high quality of life after their cancer treatment.
Citations
Zizinia, S. (2020, November 23). Targeted muscle reinnervation drastically reduces pain for amputee cancer patients. MD Anderson Cancer Center. https://www.mdanderson.org/cancerwise/targeted-muscle-reinnervation-drastically-reduces-pain-for-amputee-cancer-patients.h00-159386679.html
Dumanian, G. A., Potter, B. K., Mioton, L. M., Ko, J. H., Cheesborough, J. E., Souza, J. M., Ertl, W. J., Tintle, S. M., Nanos, G. P., Valerio, I. L., Kuiken, T. A., Apkarian, A. V., Porter, K., & Jordan, S. W. (2019). Targeted Muscle Reinnervation Treats Neuroma and Phantom Pain in Major Limb Amputees. Annals of Surgery, 270(2), 238–246. https://doi.org/10.1097/sla.0000000000003088
