What Happens When the Limb Is Gone, but the Pain Remains?

Losing a limb can deliver a one-two punch. First there’s the physical and mental trauma of an amputation. Then, for more than 80 percent of amputees, comes the chronic pain that can be nearly as debilitating as their original injury.

For some, the painful feelings radiate from the limb that has been removed. Others experience the sensation that the missing limb is still attached. And still others feel the pain focused in what remains of the original limb.

In each case, the limb is gone, but the pain persists. For the vast majority of the estimated 2 million Americans living with limb loss, chronic pain following amputation is a constant companion.

This is frustrating for a patient not only because of the painful sensation, but from the psychological aspect of still suffering after a part of their body is lost. Besides affecting quality of life, this pain can interfere with wearing a prosthesis, further slowing a patient’s recovery and return to normal life.

When Michelle Sorbella, an Orlando CPA and new mother, was facing the possibility of an amputation after cancer treatment, she was concerned that chronic pain afterward would interfere with the active lifestyle she wanted to live. Sorbella researched her options and decided to move forward with a ground-breaking treatment developed to limit the pain of limb loss.

Who Is At-Risk?

More than 28 million Americans are at-risk of suffering amputation based on common factors such as:

• Vascular disease: Complications from vascular disease cause about 54 percent of all surgical amputations. This includes other conditions affecting blood flow, like diabetes and peripheral arterial disease (PAD).
• Trauma: 45 percent of amputations are due to accidents and trauma events.
• Cancer: Accounts for less than 2 percent of all amputations.
• Race: Black Americans are up to four times more likely to have an amputation than white Americans.

The Pain of Loss

Three types of pain commonly affect amputees.

• Phantom limb pain (PLP): Feelings of continuous pain seem to come from the limb that has been removed. This pain can feel like burning, twisting, itching or pressure.  
• Phantom limb sensation: A sense that the amputated limb is still attached.
• Stump pain: Pain confined to the remaining body part post-amputation.

What Causes PLP?

During amputation, nerves are severed. Whenever a nerve is cut, it attempts to regenerate. If the nerve does not have a clear target for regrowth, it will create a disorganized mass of nerve tissue called a neuroma. These neuromas can result in PLP, which is caused by disorganized signals sent to the brain from the limb, often interpreted by the brain as uncomfortable or painful

PLP can develop soon after surgery. Certain activities or conditions also can trigger PLP in some amputees, including:

• Touch
• Exposure to cold
• Changes in barometric pressure
• Tobacco use

For some, PLP may slowly disappear over time. For many, however, the pain persists, creating a constant, severe pain that greatly interferes with their quality of life and resuming their desired activities. 

Treating PLP

Limited treatments have been available to decrease PLP. Traditionally, surgeons have done a traction neurectomy during amputation, severing the nerve as far from the limb stump as possible and relocating it into muscle and soft tissue, where any neuroma formed might be less irritated. This is thought to decrease PLP in some amputates.

Follow-up pain management may include medications and therapies such as:

• Acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs)
• Narcotic pain medications, neuroleptics, antidepressants, beta blockers and muscle relaxants
• Acupuncture and massage
• Mirror box therapy, virtual reality therapy and biofeedback

What Is Targeted Muscle Reinnervation?

A surgical procedure called targeted muscle reinnervation (TMR) is proving effective in treating and preventing PLP. It was originally pioneered to help amputees better work with their myoelectric prosthetic limbs.

TMR uses microsurgery to reroute the severed nerves that once controlled the amputated limb, reconnecting them to new target nerves in the remaining muscles. By giving the cut nerve “somewhere to go, and something to do,” the cut nerve is able to regenerate in a more organized fashion, lowering the chance of a neuroma forming and PLP developing.

Once experimental, this advanced technique is now available for both upper- and lower-extremity limb loss. TMR can be done either at the time of amputation or several years after amputation to prevent painful neuromas from forming or returning. By restoring continuity to the nerve, TMR reduces the chances of developing PLP and makes it easier for amputees to return to the activities they enjoy.

When foot reconstruction failed after cancer treatments, Sorbella of Orlando asked her doctors about the possibility of amputation with TMR. In October 2019, she had TMR microsurgery in conjunction with a lower limb amputation. Today, she is back to running 5K races with her prosthetic blade and enjoying an active, pain-free lifestyle with her family. TMR combined with her amputation gave her the ability to move again, free from PLP.

With more than 185,000 amputations performed annually in the U.S. to treat injury, disease or infection, Sorbella is on the leading edge of PLP treatment. In the future, TMR nerve transfers like hers are expected to become the standard of care, with the surgery occurring at the same time as the initial amputation.