- December 20, 2019
So who all in the audience has heard of this. TMR. Or who sees patients with amputations with neuroma pain maybe in the acute setting or chronic setting? Maybe you don’t but if you haven’t, this is something that is relatively new over the last 10 years or so.
So for neuroma management when someone has an injury to a nerve or an amputation, the nerve is cut and a neuroma forms. So the treatment for a neuroma say in a non-amputee patient it would be to repair or reconstruct the nerve. If you can’t do that then taking the nerve and allowing it to do something by transferring it to another muscle target which is another finding another nerve in that muscle and transfer it.
So that’s the idea. So the background on amputations again, this is back in the civil war. Not much has really changed, other than using you’re doing it in the hospital instead of outside of this tent here.
So two main issues with amputations pain and function. That’s what we’re trying to restore or limit as you see here this Disney character.
That’s what he got. Now there’s better myoelectric prosthetics that allow better function for upper extremity.
So with the advent of that we’ve found new ways to treat neuroma type pain in patients with amputations. So the question comes well people have an amputation for a trauma or an infection or sarcoma. Well do they all do fine? Not necessarily. There’s going to be some patients that do find. Some patients that have good days and bad days, and others that have severe problems. And as you see, amputees are common and only going to increase with time.
So as shown here most orthopedic surgeons’ kind of fear change. They don’t like to consider new ideas. So many years go on and no change. We keep doing the same thing over and over again. Send them somewhere else. Send them with more therapy. Send them with a different process. Some new pain management. But with the wars we’ve had some ability to research amputees and their function and pain. So there’s always something that comes good out of something bad. This is a patient. Back in 2001 he’s the first TMR patient. This out of Northwestern with Dr. Dumanion, and he has a bilateral upper extremity injury. They’re doing this to increase the myoelectric variables to allow him better function with his myoelectric prosthetic so he can do elbow and hand functions at the same time. That’s why this was done. So the idea is you’re taking nerves and you’re transferring it into nerves within muscle. Again, this is for a better function. This is not for pain. Here’s the technique. It’s fairly simple. You’re not really burying muscle but you’re finding, you’re stimulating a nerve within the muscle and then transferring it. What traditionally was done for amputations were just traction neurectomies. We’d pull the nerve and cut it. Okay. The nerve disappears.
So in doing this they improved his function. I think his prosthetics are like two-million-dollar prosthetics if you add him up because he’s the only person to get this one back when they got it, and they noticed well what happened to his pain.
He wasn’t having as much pain as he did beforehand.
So they studied it in the lab. This is a rabbit study looking at well what happens. What does this nerve actually repair itself into the other nerve? How does it look compared to another neuron? So they checked it in an animal model and said yes it looks fairly similar to a normal nerve. So then they took it and said OK what happens to neuromas with TMR. These are patients that had neuroma pain and then had TMR afterwards.
So this is a multi-Center study. There are various charts in all these papers you can tease through but basically the idea is that you’re giving the nerve something to do and their pain was better. So they tried to survey amputee patients in this study looking at well, do people really have a problem or not. Or maybe it’s the type of injury. Maybe it’s the age of the patient. And in looking at this, 16 percent of amputees are pain free. So if they’re pain free and functioning then considering something like this is not a value.
However, the other people, again like I said, they’re in the middle have good days, bad days. And there’s some people that have horrible phantom pain or horrible neuroma type pain that they can’t do anything. So they did a randomized control study which took a while to do. It’s kind of challenging obviously and they did standard treatment which is traction neurectomies versus TMR.
So what they found out was if you look at these charts red is bad. Basically, it takes away the outliers and for TMR took away the outliers more. It’s not a magic treatment. It doesn’t make people normal. But for people that had both Phantom and neuroma pain it took away the outliers more for doing TMR over traction neurectomies for people of chronic pain.
And these diagrams show similar things.
And it’s a decrease in pain. It’s not elimination of pain but it’s a decrease even if you look at narcotic use and in Northwestern, they develop the promise score. We talk about these outcomes scores but evidently, they developed it at Northwestern so they use it in this study.
And here again. So TMR at the time of amputation they found this again reduces the outliers. So the idea here is well instead of waiting until they have pain five years later, four years later, ten years later, doing it at the time of amputation and they found, Yes some people still have pain. But those outliers are reduced.
So phantom pain. Well what is phantom pain. Phantom pain we have a general understanding of. It’s multifactorial. It’s centrally mediated. It’s at the level of the nerve injury or amputation. So the idea here maybe in doing acute nerve transfers or acute TMR, maybe we’re going to minimize or eliminate some of the phantom pain that can occur. So if we can prevent it it’s easier than treating it.
So here’s a case example by Ian Valerio who’s my inspiration for doing TMR, another former military person. So this is a patient with a high amputation. You see how the nerves are left long. Why. Because at the time of soft tissue reconstruction he had nerve transfers or TMR. And then here he is afterwards at a year has no pain. It doesn’t show as myoelectric. He has it myoelectric. So above elbow and amputee is a is the classic candidate for a myoelectric whereas below elbow it’s less beneficial. And that’s originally what was TMR indicated for, for above elbow.
So again, here is upper extremity population again pre TMR pain versus post TMR neuroma pain. It’s less frequent again you can’t say you know zero pain but it’s definitely a lot less.
Here’s a patient of mine who had I think twenty-five surgeries and all this other craziness going on in her life she was unable to wear her prosthetic she used a motorized scooter.
Here we are. We do a TMR. We find this sciatic neuroma. This is a above knee amputation so its posterior on the thigh. We tease the two nerve branches out. We stimulate we stimulate the branches within the muscle transfer them and afterwards she’s able to walk again with her prosthetic. Here she’s back in rehab trying to get fit again because she has an above knee that she hasn’t really used in so long. Here is a patient of mine who had a sarcoma for her thumb and you see her thumbs amputated but if you look at the shaded areas on her thumb, she had horrible sensitivity. Can’t really do anything they fit her just for a static thumb prosthetic and she can’t wear it. She can’t function.
So the way to determine if someone would benefit or if they have a neuroma you can just do a lidocaine injection, and their eyes light up and they feel great afterwards. So here we are we’re dissecting out the new aromas which we know there’s digital nerves to the thumb. We find them they’re fairly easy to find because they’re look like a big neuroma.
You just have a tease amount of scar. Then we transform into the muscles. We take the radial sensory nerve and transfer it into there’s a nerve with that lies deep in the forearm that goes to a small muscle and we did that. So for her Phantom Pain resolved almost within a week or two and then she’s I think she’s fit it again for her prosthetic now. She’s again and she had sarcoma she just happened to be here.
So these are other studies that look at just different techniques for TMR. You know for upper extremity lower extremity.
Just looking at different targets that you kind of have in here again you can do it for chronic. You could do it for acute. These are just all the different targets there’s different information online if anybody’s has more interest in this.
So in summary there’s people with amputees. A lot of them do well. However, if you really break down and see how they’re doing some of them do have problems with this.
And I think this is a fairly simple treatment with all the surgery we do in orthopedics This is not that complicated. It doesn’t require anything crazy. It’s fairly straightforward and simple. I think the awareness of this is the most important for patients, in primary care doctors, for therapists reprocess, for hand surgeons, other orthopedic surgeons. I think maybe doing primary tomorrow we’ll find out well in five or ten years or people are going to have some other problem I don’t think so.
There’s other new research coming out for primary amputation out of Boston. That’s pretty cool looking at different ways to add proper reception at the time of amputation. If you look online something called a viewing amputation it’s pretty cool the way they do it but there is a lot of research going into the improvement in our amputee community.
I think due to the wars these are the people again in charge of the TMR group and I give them credit. Thanks guys.