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Targeted Muscle Reinnervation Reduces Opioid Usage Compared to Neuroma Excision in Patients with Phantom or Residual Limb Pain
Rea Chroneos¹, Olivia Waldron^*1, John Roberts^2
1Pennsylvania State University College of Medicine, Hershey, PA; ²Department of Surgery, Milton S. Hershey Medical Center, Hershey, PA

BACKGROUND
Amputations of upper and lower extremities are common procedures but often lead to phantom limb pain and neuroma development. Neuroma excision (NE) is the historically standard treatment; however, targeted muscle reinnervation (TMR) has recently gained popularity. This retrospective study aims to elucidate the comparative pain outcomes in TMR versus NE, which is lacking in current research.

MATERIALS AND METHODS
Patient data was collected using TriNetX LLC National Health Research Database since its inception in 2013. Patients with upper or lower extremity amputation whom developed phantom limb pain/neuroma were identified. Opioid consumption was utilized to study pain levels. Patients were separated into two cohorts - NE or TMR - with opioid use evaluated at 3-months preoperatively versus 3-, 6- and 12-months postoperatively. Patient demographics were matched for gender, age, diabetes mellitus, and smoking. Statistical analyses included measures of association tests with 95% confidence intervals.

RESULTS
Preoperative opioid use at 3-months was significantly greater in TMR (n = 396) than NE (n=198) patients (p=0.0152). All TMR postoperative timepoint values had significantly higher risk ratios than NE (p<0.0001; p=0.0006; p=0.0042[1] ). However, the pre- to post-operative risk ratio change over time revealed only a 3.81% increase in TMR-related opioid use versus a 9.87% increase in NE patients (Table 1).

CONCLUSION
Based on opioid usage, TMR patients had significantly higher preoperative pain levels, yet their risk ratio percentage increased at a slower rate than NE patients. Therefore, TMR appears more effective than NE in managing phantom limb and neuroma pain levels in upper and lower extremity amputees. This data is another promising justification for TMR use in patients experiencing phantom and/or residual limb pain.
Table 1. Pre- and post-operative opioid usage in TMR vs. NE

		Targeted Muscle Reinnervation		Neuroma Excision
Pre-Op Time	Post-Op Time	Risk %	Outcome n-value	Risk %	Outcome n-value	p-value
3 months	--	96.79	211	91.28	199	0.0152
3 months	3 months	81.65	178	64.68	141	<0.0001
3 months	6 months	82.73	182	68.64	151	0.0006
3 months	12 months	85.46	188	74.55	164	0.0042

Risk ratios are included for opioid use in treatment of post-amputation pain in the form of either TMR or NE.

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