Targeted muscle reinnervation (TMR) is an advanced limb restoration procedure that significantly reduces pain by reconnecting injured nerves.
Quality of life after limb loss can be significantly impacted by pain in the residual limb or from phantom limb pain. Plastic and reconstructive surgeons at The Ohio State University Wexner Medical Center in Columbus, Ohio, are at the forefront of advances in managing pain after amputation, orthopedic trauma or nerve damage.
Our Limb Restoration Program team specializes in restoring and reconstructing limbs to maximize function and minimize pain. At Ohio State, we’ve pioneered many nerve repair techniques to allow you to live your life to the fullest following an accident, injury or disease that may impact your limbs.
What is targeted muscle reinnervation?
Targeted muscle reinnervation (TMR) is a procedure that can help relieve phantom limb pain, residual limb pain and nerve pain after amputation or serious injury.
About 55% of amputees have phantom pain, which is pain that feels like it is coming from the missing limb. This can happen when nerves keep sending mixed or disorganized signals.
TMR works by reconnecting damaged nerves to nearby muscles. This gives the nerves a new place to send signals, which can help reduce pain. TMR was first used to help improve control of upper-limb prosthetics. Now, it’s been proven to be a reliable way to treat and prevent pain from scarred nerve endings called neuromas.
TMR can be done during amputation surgery or later, even years after limb loss.
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 now 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 through our Limb Restoration Program. Surgery is elective, and you are subject to medical clearance before your operation. Candidates for this surgery include those with amputations who have:
- 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 limb restoration surgeons can treat peripheral nerve issues and neuromas unrelated to amputation with procedures that reroute nerves to reduce pain.
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.
What to expect during targeted muscle reinnervation surgery
Preparing for your procedure
First, you’ll meet with your surgeon to talk about your care and how TMR may help you. Bring your medical records, including imaging and past surgical reports, or send them to our office ahead of time.
The night before surgery, you may be asked to take gabapentin (an anti-seizure medication). You’ll also need to stop eating and drinking at the time your care team gives you.
On the morning of surgery, you may take gabapentin again if your care team tells you to. Some people also receive a nerve block before surgery to numb the area and help with pain afterward.
During your procedure
TMR surgery typically takes between one and three hours. You’ll remain in the hospital for one to five days, depending on the extent of your operation.
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 will identify the sensory and motor nerves using a nerve stimulator device.
- The sensory nerves that gave sensation to the amputated limb 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, 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, using soap and water 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 with 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.
Commonly, we’ll begin discussing prosthetic devices two to four weeks after surgery, and you’ll receive the prosthesis between six and eight weeks after.
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 device should expect to abstain from using it for four to six weeks while healing. Follow-up appointments commonly are scheduled for 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. People with these procedures typically can expect to be able to work again as soon as two weeks after surgery.
Risks 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:
- Fever of 101 degrees F (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.
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. 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 limb restoration, such as TMR.
Differentiators in our nerve repair care include:
- Our treatment of your nerve damage is truly multidisciplinary. The limb restoration team includes plastic and reconstructive surgeons, orthopedic surgeons, physical therapists, physician assistants and nurses who specialize in TMR 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 amputation or amputation for cancer 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.