Post-amputation and phantom pain is a phenomenon that occurs in individuals after they have a limb surgically removed. John R. Barbour, MD, FACS, is a triple board-certified plastic and reconstructive surgeon who treats post amputation and phantom pain symptoms. His experience as a fellowship trained hand and peripheral nerve specialist has made him a respected post amputation and phantom pain surgeon amongst the residents of the Washington, DC, area, including Fairfax, Arlington, Alexandria and surrounding communities in Virginia.
After limb amputation, patients frequently experience pain, either residual or phantom, that is related to nerve trauma during or after amputation. Residual pain is in the remaining limb and can result from damaged or cut nerves that form scarring known as neuromas. Additionally, pain can result from changed anatomy of the limb, including bone spurs, which can cause pain with prosthetic use. Phantom pain is pain that is perceived to be in the limb which is no longer present on the body, and can present as burning or shocking pain, tingling or itching, pressure or feeling as though the limb is “frozen.” Phantom limb pain can be difficult to treat as it is related to neuroma formation as well as a cognitive reorganization of the central nervous system after trauma. Phantom pain is a complex, multi-layered issue and is often not as responsive to treatment with medication.
A number of treatments have been previously used to address residual or phantom pain stemming from nerve trauma including nerve ablation to destroy or remove symptomatic nerve tissue by radiofrequency or neurotoxin injection; excision of neuroma; or excision of neuroma and subsequent reattachment of nerve ending into nearby muscle. The most commonly used treatment has been excision of symptomatic neuromas and subsequent reattachment of nerve ending into nearby muscle. The goal of this technique is the removal of the problematic nerve tissue and placement into a healthy microenvironment that will allow the nerve to regrow without neuroma formation. Through clinical experience, it has been found that in a small percentage of patients this method may result in a newly formed neuroma that may be smaller than the previous neuroma, which can still be symptomatic.
The most cutting-edge and effective treatment for residual and phantom limb pain is Targeted Muscle Reinnervation. Dr. Barbour was integral in the development and application of this new technique. During this procedure, the terminal end of the neuroma is excised and a nearby healthy motor nerve is divided, then the proximal end of the new healthy nerve is coapted (fastened) together with the nearby divided motor nerve. This coaptation of the nerves allows the healthy nerve fascicles to grow, using the motor nerve as scaffolding, and then re-innervate the muscle and regenerate healthy nerve. This technique allows the damaged nerve to grow towards a specific nerve receptor target, which lessens the possibility of a neuroma forming due to non-directed growth of damaged nerve tissue.
Additionally, it has been clinically shown that dividing motor nerves during coaptation does not result in a new formation of symptomatic neuromas. In clinical trials, as well as Dr. Barbour’s clinical experience, Targeted Muscle Reinnervation was shown to be more successful in decreasing or resolving residual and phantom pain. Additionally, it has been shown that Targeted Muscle Reinnervation lessened recurrence of symptomatic neuromas and allowed patients to decrease medication usage, allowing increased prosthesis use and increased quality of life of amputees.