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Understanding Phantom Limb Pain and Its Causes
Interviewer: Phantom limb pain is a complex and often debilitating condition that affects many amputees. While various therapies do exist, surgical interventions have emerged as a promising option for those who have not found relief through these conventional treatments.
We're joined today with Dr. Shaun Mendenhall, who is an assistant professor of surgery with the at 亚洲自慰视频 of Utah 亚洲自慰视频.
Dr. Mendenhall, let's kind of start with the basics. What is phantom limb pain, and what does it feel like? What is a patient experiencing? And what's causing it?
Dr. Mendenhall: So when people have lost a limb, they're often plagued by two types of pain. There's what we call residual limb pain, and that's pain in the part of their leg or their arm that they still have intact. And that's often due to scarred nerve endings called neuromas.
The other major type of limb pain after an amputation is called phantom limb pain, as you mentioned, and that is where they actually experience pain in the part that is missing. And so this is a very complex type of pain that is really the patient's brain just trying to sort out the lost part of their body, and still conveys pain coming from that area even though it no longer exists.
How Common Is Phantom Limb Pain?
Interviewer: Wow. And how prevalent is this type of phantom limb pain among amputees?
Dr. Mendenhall: It's very common, actually, in major limb amputees. My experience and most of the literature have this being quite severe, somewhere upwards of 30% to 40% of patients.
Traditional Management of Phantom Limb Pain
Interviewer: And for these patients that are experiencing some of this pain, what are some of the more traditional management approaches that might be tried first before we look at surgery?
Dr. Mendenhall: Oftentimes, the patients are managed by their primary care doctors or sometimes by rehabilitation physicians, and often are treated with medications, such as gabapentin or Lyrica, which are nerve pain medicines that can help some.
And then many, many other things have been tried as well, including just adjustments to their prosthetics, to radiofrequency ablation of the nerves, and things of that nature.
Cognitive Behavioral Therapy
Interviewer: Yeah. I've also heard about mirror therapy, cognitive behavioral therapy. Those types of things are all part of a complex treatment?
Dr. Mendenhall: Yeah, that's exactly right. So those are some of the therapy modalities that, again, all do have a role, and they can improve the pain, but patients are often left with significant and often debilitating pain.
When to Consider Surgery for Phantom Limb Pain
Interviewer: So, when those particular methods kind of fall a little short, when is it time for both a healthcare provider and a patient to start to maybe consider surgical intervention?
Dr. Mendenhall: Really, as soon as possible, as soon as it's recognized that this is a pathologic type of pain that is affecting the patient's quality of life.
In fact, more and more the literature is showing that if we can do these procedures at the same time as the amputation, the outcomes are actually much better, and the incidence of phantom limb pain and residual limb pain is significantly decreased.
And so many of these patients, unfortunately, don't know that and suffer this pain for many, many years, 10, 20, 30 years before they get referred to see us as surgeons. And by that time, the downside is that the longer they've had that pain, the more it has become centralized, and it becomes very difficult to then treat. So, really, the sooner the better.
Targeted Muscle Reinnervation (TMR)
Interviewer: All right. Well, let's talk a little bit about the procedure itself. What are the options available to patients today when it comes to surgical treatment of phantom limb pain?
Dr. Mendenhall: So the two most cutting-edge options nowadays are called Targeted Muscle Reinnervation, and then another one is called the Regenerative Peripheral Nerve Interface.
And so I can tell you a little bit about TMR first, which has been around for a little over 20 years now and was first described by Todd Kuiken and Greg Dumanian at Northwestern 亚洲自慰视频. They sort of stumbled onto this procedure as a helpful adjunct to pain in the sense that they designed the procedure not for pain but actually just to give better inputs for myoelectric prosthetics in patients who have high limb type of amputations.
What the procedure of Targeted Muscle Reinnervation is, is it's taking that dead-ended nerve that has been amputated that used to go into the limb that's now gone, and instead of just leaving this dead-ended nerve, it's taking that and rerouting it into another nerve nearby that's going into a remaining muscle.
And so what it does is it gives that nerve somewhere to go and something to do instead of just going into nothing and creating a painful nerve ending. Again, this was done originally just to get a better signal for a prosthetic into a remaining muscle.
But the side effect that they noticed after their first 20 or 30 patients was that none of these patients were developing these painful neuromas, and almost none of them had phantom limb pains. And so, because of that, it's now sort of become one of the standard approaches to dealing with phantom limb pain.
Regenerative Peripheral Nerve Interface (RPNI)
Interviewer: All right. And so what about the other one, the RPNI?
Dr. Mendenhall: Yeah. So RPNI is, again, a newer procedure. We don't have as much data on it, but it was developed at the 亚洲自慰视频 of Michigan by Paul Cederna, again, with the idea of trying to improve the control of myoelectric prosthetics.
But instead of rerouting the nerve like TMR into a nearby motor nerve, instead what Dr. Cederna developed was you just take a little shave of healthy muscle and you shave it off of a nearby muscle into a little free muscle graft, and then you take the dead-ended nerve, trim it up back to healthy nerve, and then you wrap this little piece of muscle graft around the end of the nerve.
And what that does is that allows this nerve now to grow into that little bit of muscle, some of which stays alive just like a skin graft or just a free tissue graft, and it reinnervates that little piece of muscle. And again, it gives that nerve somewhere to go and something to do.
And so, again, that was originally thought of as just a way to get another signal for a prosthetic. So this would be kind of guided right up underneath the skin, and then they can read the myoelectric signal through the skin.
But similar to TMR, they realized that when they rerouted the nerves this way into little muscle grafts, the patients had much less pain and phantom limb pain.
The downside is, again, we don't have a lot of long-term data on RPNIs at this point, and we certainly don't have a randomized head-to-head trial of TMR to RPNI. But what we do know is that both of them tend to decrease phantom limb pain, both of them are quite feasible to do from a surgical standpoint, and so are being done more and more at specialized centers throughout the country.
Comparing Surgical Options and Patient Outcomes
Interviewer: Who are some of the, let's say, ideal candidates? Are there some people who are better suited for this than others? Is it just a time thing?
Dr. Mendenhall: Anybody who has had a major limb amputation and has pain would be a candidate for this, as long as they're safe and healthy enough to undergo an operation under general anesthetic.
So, again, typically, in my experience, the sooner we can get to this after an amputation, the better. And again, if we can even do it at the same time as the amputation, which is becoming more and more our goal, just to do it from the very beginning, we feel like the outcomes are much better.
Interviewer: Why don't we talk a little bit about the surgery itself? I mean, how complicated is this one? What kind of surgeons can perform it? And what can a patient expect when they go in to get a consult about this?
Dr. Mendenhall: Yeah, all great questions. So, typically, these are done by surgeons who have experience in peripheral nerve surgery. And the majority of peripheral nerve surgeons are surgeons who have done either a plastic surgery residency or an orthopedic surgery residency, and then go on to do specialized training in hand surgery. And then there are some neurosurgeons who also do peripheral nerve surgery.
As a plastic surgeon myself, I feel uniquely qualified to help these patients because oftentimes, at the same time as we're doing the nerve operations, we also do a lot of soft tissue revisions on these residual limbs. And what that entails is just optimizing the soft tissue envelope in order to optimize the use of prosthetics.
And so very, very commonly, when we go in to do a TMR or an RPNI procedure, we also tighten up the skin, we can excise some of the excess scar tissue, we can replace some of the tissue if it's deficient for padding. And again, this just helps patients utilize the prosthetics better.
What to Expect from Surgery and Recovery
Interviewer: As someone on the outside, that sounds like a pretty intensive surgery. I mean, how long is the recovery for something like this?
Dr. Mendenhall: It depends a little bit on whether it's an upper limb or a lower limb and at what level the amputation is.
For example, the most common targeted muscle procedures that we do are on below-knee amputees, just because we have many more of those than we have any other level.
And so this typically requires that the operation itself is going to take anywhere from two to four hours, give or take, depending on what else needs to be done. And then if the distal part of the limb that is weight-bearing is revised, I typically will keep the patient for about six weeks non-weight-bearing until the skin heals very well, and then we will have them get back up with their prosthetist on a new prosthetic and begin ambulating again.
If it's an upper limb, typically, they're back at their normal kind of day-to-day schedules within a couple of days. And depending on whether they're a bilateral or a unilateral amputee, they'll typically have the other hand to function while they're allowing their operative side to heal.
Interviewer: After they've gone through their healing, they've spent those couple of weeks, etc., what kind of outcomes can a patient who has been experiencing phantom limb pain expect?
Dr. Mendenhall: So, in my experience, the shorter the amount of time that they have experienced the phantom limb pain, the better outcome they're going to have. If somebody has had phantom limb pain for many, many years and it's become centralized, then they don't get quite as much of a pain relief from the operation as somebody who's had that for a shorter period of time.
But I've had patients even with 20 years of phantom limb pain that have significant pain improvement, upwards of, say, 50% or so. And again, the patients who we get to sooner and the ones that we do right away at the same time as their amputation, 90%-plus of them can expect not to have problems with long-term pain.
So it is quite effective, but is somewhat dependent on how long they have had the abnormal pain.
Finding Help for Phantom Limb Pain
Interviewer: I guess my final question is, maybe there is someone out there who is currently struggling with phantom limb pain, or maybe someone who cares for someone struggling with phantom limb pain. What message would you like to share with them?
Dr. Mendenhall: My response would be that there is a lot of hope. In this day and age, we have such great technology, and with these new procedures that have really been game-changers for amputee care, if you reach out to us, we'd be happy to see you in the office and go over all the options with you. And there really is hope that we can significantly improve, if not eliminate, most of the pain that comes with these major limb amputations.
Interviewer: If they're hearing this and they are curious about this type of treatment, where do they go first?
Dr. Mendenhall: They can call us at the . Our number is 801-581-7719. Get in contact with us that way. We'd be happy to set up an appointment. Can also reach out to us on social media. My Instagram handle is
Interviewer: What about for someone who maybe is not in the service area of the 亚洲自慰视频 of Utah 亚洲自慰视频 System?
Dr. Mendenhall: Yeah. So if you're not within a reasonable travel distance to the 亚洲自慰视频 of Utah Hospital, then I recommend going on . . . There is a website that's designed as a resource for patients called tmrnerve.com. And there's a little link there. You can click on Find a Physician, and it will show you, by location, physicians who do this procedure.