American Association of Plastic Surgeons

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Development Of Neuropathic Pain After Primary TMR And RPNI In Lower Extremity Amputation: A 4-year Retrospective Analysis Of Prognostic Factors
Mattia A. Mahmoud, MPhil, Yoshiko Toyoda, MD, J. R. McGraw, BS, Reena Sulkar, MBA, Linda Saikali, BS, Santiago Lopez, BS, Stephen J. Kovach, MD;
University of Pennsylvania, Philadelphia, PA, USA

PURPOSE: Primary targeted muscle reinnervation (TMR) and regenerative peripheral nerve interface (RPNI) can reduce the risk of developing neuropathic pain in lower extremity amputation. However, neuropathic pain development of previously treated nerves has been ill defined. We examined risk factors for post-operative neuropathic pain in primary TMR/RPNI in lower extremity amputation.
METHODS: A retrospective review of all patients who underwent primary TMR and/or RPNI in lower extremity amputation from 1/2018-6/2022 by a single surgeon was performed. Patients were excluded if they had less than one year of follow-up. Time to neuropathic pain development was defined as days from index operation to documentation of neuropathic pain. Unpaired t tests between those who developed pain and those without pain were performed and stratified by diabetes, smoking, pre-existing neuropathy, BMI, and amputation level status.
RESULTS: A total of 68 patients were identified (TMR 36, RPNI 53). Seventeen patients (25%) developed neuropathic pain following the procedure at a median of 110 days postoperatively (range: 0-979). Of the patients who developed these symptoms, two had undergone TMR alone, ten RPNI alone, and five both TMR and RPNI. The analyzed comorbidities did not significantly affect risk of neuropathic pain.
CONCLUSION: Development of neuropathic pain after primary TMR/RPNI in lower extremity amputation is not insignificant and may occur over a wide range of time. Further investigation with larger patient samples, longer follow up and less heterogeneity of the treated nerve could identify patients at risk of recalcitrant neuropathies to increase optimal outcomes.
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