Surgeon-talking-with-amputee-patient Targeted muscle reinnervation (TMR) is an advanced surgical procedure to eliminate or significantly reduce pain after an amputation or serious injury by reconnecting injured nerves.

Quality of life after limb loss can be significantly impacted by pain in the residual limb or phantom limb. Plastic and reconstructive surgeons at The Ohio State University Wexner Medical Center in Columbus, Ohio, are at the forefront of advances of managing pain after amputation. They’re specialists in restoring and reconstructing injured limbs and fixing the issues that may arise from an amputation.

If you or a loved one has problems with an existing amputation or are facing an amputation, our nerve repair experts have pioneered techniques, such as TMR, to relieve pain for those with amputations.

What is targeted muscle reinnervation?

Targeted muscle reinnervation is a highly specialized procedure that reroutes the nerves in the body for people experiencing phantom limb pain, residual limb pain or pain from an injured nerve that cannot be repaired or reconstructed.

Roughly 55% of people with amputations experience phantom pain. This occurs when the nerves don’t recognize the limb is gone, and the sprouts of regenerated nerves are disorganized, continuing to send signals when the signals have nowhere to go.

TMR reroutes the damaged nerves or nerves cut during amputation into motor nerves in nearby muscle, re-establishing neural circuitry and giving the nerves somewhere to go and something to do. This decreases painful neuroma formation (the "pinched nerve" sensation) and phantom limb pain.

This procedure was originally developed to allow those with upper-limb amputations to have better control of their limb prosthetic devices, with more individual muscle function, more refined movements and a wider range of motion. The Ohio State Wexner Medical Center researchers found that TMR is a reliable way to treat and prevent those painful, disorganized nerves or symptomatic neuromas.

Even when performed years after an amputation or injury, TMR can be an effective method for reducing pain and improving patients’ quality of life. The procedure poses minimal health risks, and recovery is similar to that of traditional amputation surgery.

Helping wounded veterans experience life with less nerve pain

Ohio State’s Military Medicine program is innovating treatment for limb damage and chronic nerve pain for veterans like Shane Jernigan, whose life has been transformed after years with debilitating pain through treatments such as TMR.

Who is a candidate for targeted muscle reinnervation surgery?

Candidates for TMR surgery include people who:

Are having an amputation
Have had an amputation in the past (even if years ago) and experience pain
Have damaged nerves or nerve pain

Primary or acute targeted muscle reinnervation

Primary TMR (or acute TMR) is performed at the time of initial amputation. It’s used to prevent phantom limb pain or other amputation complications from ever occurring.

Secondary or delayed targeted muscle reinnervation

In secondary TMR, or delayed TMR, a person with a previous amputation is seen and evaluated in the Ohio State Wexner Medical Center’s Department of Plastic Surgery clinic. Surgery is elective and subject to preoperative medical clearance. Candidates for this surgery include those with amputations who suffer from:

Painful neuromas
Phantom limb pain
Residual limb pain that causes issues with wearing prosthetic devices or affects activities of daily living

TMR for damaged nerves or painful nerves

Our surgeons can treat peripheral nerve issues and neuromas unrelated to amputation with procedures similar to TMR that reroute nerves to reduce pain.

What to expect during targeted muscle reinnervation surgery

Preparing for your procedure

Before scheduling your TMR procedure, you’ll meet with a surgeon for a consultation to discuss your individual situation and how TMR may benefit you. At this appointment, you’ll need to bring with you your medical records, including any imaging and operative reports. You may also send these records to our office ahead of time.

The night before your procedure, you’ll be instructed to take a dosage of gabapentin (a sedating anticonvulsant), unless you’re allergic to the medication or have certain conditions that prevent you from taking it. You’ll also have to stop eating and drinking at a certain time.

The morning of the procedure, you’ll again take gabapentin, if instructed to do so. Sometimes an injectable nerve block is given prior to surgery to numb the area and help control pain after the surgery.

During your procedure

TMR surgery typically takes between one and three hours and often requires a one- to five-day hospital stay, depending on the extent of your operation and the postsurgery pain management you need.

Steps to the procedure include:

You’ll be put under general anesthesia, so you’ll remain asleep the entire procedure.
Your surgeon will make an incision in the limb and identify the sensory and motor nerves, using a nerve stimulator device.
The sensory nerves that gave sensation to the limb no longer there will be cut and reattached to motor nerves.
The incision will be closed, and you’ll wake up in a recovery room.

After your procedure

Immediately following your surgery, there are some steps to follow to ease your recovery and lessen the risk of complications. Those steps include:

Starting your normal diet after surgery.
Doing gentle range-of-motion movements with your limb as you are able, unless your surgeon has instructed you not to.
Not placing weight on your limb until your surgeon says that you can, which is usually four to six weeks after surgery.
Wearing your shrinker sock every day to help lessen swelling and stop fluid from building up.
Additionally, the wound dressing can be removed after 24 hours. Use sterile gauze or a similar dressing after showering and before putting on the compression dressing.
You can get your stitches wet after 24 hours. You may shower, and soap and water can be used on the incisions. Do not bathe or submerge the incisions.
You may have more than one drain after surgery. Keep the drain dressing in place. Record how much fluid comes from the drains daily. Drains can usually be removed when less than 30cc of fluid is coming out per day.

Recovery from TMR

What to expect during your recovery from TMR depends on what type of surgery you have.

Primary TMR

Those who have a new amputation and receive primary TMR should expect surgery follow-up appointments scheduled at the two-week, four-week, three-month, six-month and 12-month marks, with annual follow-ups. If needed, discussions about your prosthetic typically begin between two and four weeks after amputation surgery. About four to six weeks after surgery, the prosthetic-fitting process may begin, along with stump-molding and fabrication of a trial prosthesis. Commonly, you’ll receive a prosthesis between six and eight weeks after surgery.

Recovery time from amputation and primary TMR varies from person to person, as some amputations present dramatic life changes.

Secondary TMR

Those who typically use a prosthetic should expect to abstain from using it for four to six weeks while healing after surgery. Follow-up appointments commonly are scheduled at the two-week, four-week, three-month, six-month and 12-month marks after surgery, with annual follow-ups. People who have secondary TMR surgery typically can expect to be able to work again as soon as two weeks after surgery, depending on the type of work.

TMR procedures to treat painful nerve issues

Follow-up appointments will be scheduled based on your individual needs. Depending on their work, people with these procedures typically can expect to be able to work again as soon as two weeks after surgery.

Risks or possible complications of targeted muscle reinnervation

While TMR poses minimal health risks, it’s important to remember that complications can arise. Contact your doctor if you experience any of the following after TMR surgery:

Fever of 101 F degrees (38 degrees C) or higher
Severe or worsening pain that medicine does not relieve
Increasing swelling or spreading redness
Nausea or vomiting that continues
Loose stool of three days or more
Bleeding, an increase in bloody drainage or yellow, foul-smelling drainage at the surgical site

It’s also important to remember that healing and pain relief can take time. Pain is sensed by the brain. Often, the longer the brain has been exposed to a pain signal and the more severe your pain, the longer it takes for your pain to improve after surgery.

Phantom pain may get worse for four to six weeks after surgery before it begins to improve. The benefits of TMR are often seen within three months after having the TMR surgery. Keep in mind that it may take longer, or it may keep improving beyond three months.

Why choose Ohio State for targeted muscle reinnervation?

The Ohio State Wexner Medical Center nerve repair experts are leading the way when it comes to advanced techniques for nerve reconstruction, such as TMR.

Differentiators in our nerve repair care include:

Our treatment of your nerve damage is truly multidisciplinary. The TMR team includes plastic and reconstructive surgeons, orthopedic surgeons, physical therapists, physician assistants and nurses who specialize in the procedure and are part of a unique network of care providers developing individualized treatment plans.
TMR is the standard of care at Ohio State. Most people who need a traumatic or oncologic amputation are offered primary TMR at the time of amputation to prevent amputation complications and nerve pain from ever occurring.
We’re constantly evolving our nerve repair care. Our TMR experts not only lead the way in performing the procedure, but they’re heavily involved in the research surrounding its use and how to improve it.