Revision targeted muscle reinnervation for management of neuropathic pain in lower extremity amputees

Introduction Targeted muscle reinnervation (TMR) surgery is effective for managing neuropathic pain in amputees. However, some patients experience persistent or recurrent pain, for which revision surgery can be considered. We analyzed outcomes and patient characteristics associated with revision TMR performed for pain in the same nerve distribution as the initial procedure. Methods Amputees who underwent revision TMR for pain in the same nerve distribution as a prior TMR were prospectively enrolled from a peripheral nerve clinic (2017–2025). Demographics, comorbidities, surgical details, medications, device use, and pain trajectories (numerical rating scale (NRS, 0–10 index)) were analyzed. Centralized pain criteria were retrospectively assessed before revision TMR. Of 319 amputees, 4.4% (n=14) required revision TMR in the same nerve distribution. We included 12 lower extremity amputees with ≥6 months of follow-up. Results Median age at amputation was 45.0 years (IQR:38.8–50.7 years) and 25% underwent initial TMR during amputation. Median interval between TMR procedures was 2.4 years (IQR:1.1–3.6 years), with a post-revision TMR follow-up of 1.6 years (IQR:0.9–2.4 years). Centralized pain was present in 50% (n=6) and psychiatric comorbidities were present in 75% (n=9). Mean pain scores improved from 8.2±0.8 pre-initial TMR to 4.4±2.4 at the final follow-up. Patients with centralized pain reported worse outcomes (NRS 5.4±1.9 vs. 3.3±2.3). Opioid use declined from 83% to 58%. Conclusions Revision TMR may be feasible for selected patients with recurrent neuropathic pain. Although overall pain improvement was observed in this small cohort, outcomes appeared less favorable in patients with centralized pain, suggesting the potential value of centralized pain screening and multidisciplinary care.