In the current healthcare landscape, many patients continue to suffer from pain without many good options available to them – particularly neuroma pain and phantom pain, post amputation. During this discussion, Dr. Rafael Diaz-Garcia provides a history of pain management for this demographic, and overview of novel solutions, focusing on TMR and RPNIs.
Rafael Diaz-Garcia, M.D.
Orthopedic Hand and Upper Extremity Surgeon
Baptist Health Orthopedic Institute
Good afternoon and welcome to our orthopedic and sports medicine lecture series. I am Doctor Galan Hakim, Assistant Vice President of International Health Care Partnerships and Insurance Development at Baptist Health International. It is my pleasure to welcome all of you to this informative presentation. I would like to extend more ingredients to our friends across Latin America, the Caribbean and everyone joining us today. During this interactive presentation, you have the ability to ask questions via the Q and A feature located in the bottom of our screen. I will be your moderator in today's lecture this afternoon. I have the pleasure of introducing Doctor Rafael Diaz Garcia. His presentation is titled TMR and RPN I, the alphabet soup in the management of neuromas and neuropathic pain. Doctor Rafael Diaz Garcia is a board certified orthopedic hand and upper extremity surgeon with Baptist Health orthopedic care. He specializes in peripheral nerve surgery to treat neuropath and neuropathic pain, nerve compression, nerve laceration and injuries as well as brachioplexus pathologies including neurogenic thoracic outlet syndrome. Uh In his clinic, interest includes the care of high level athletes orthopedic and Orthoplast uh of the hand and wrist arthritis, uh spasticity treatment of rheumatoid diseases and neuro uh and microsurgery in the upper extremity among other types of conditions. Doctor Diaz Garcia earned his medical degree at the University of Pennsylvania School of Medicine and a master's degree in health care management at John Hopkins University carry Business School. He completed a general surgery internship in a plastic and reconstructive surgery residency at the University of Michigan Health System. His post, his postdoctoral training also included an orthopedic hand and upper extremity surgery fellowship at the University of Pittsburgh Medical Center. Prior to joining Baptist Health, Doctor Diaz Garcia was the Director of Medical Operations and the chief of plastic Surgery at Alling Honey uh Health Network in Pittsburgh, Pennsylvania. He also served as a clinical associate professor of plastic surgery at the University of Pittsburgh School of Medicine. Doctor Diaz Garcia was one of the pioneers in using targeted muscle reinnervation for the management of neuromas and phantom pain in patients with limb loss. He has more than 10 years of experience using this procedure and finds it extremely gratifying to provide pain relief to patients who have had or have been told there are no options. Castle Connolly has recognized Dr Diaz Garcia on its list of top doctors. He serves as a reviewer for the hand journal and re and regional editor for the journal of hand surgery Global online. His work in orthopedic and hand surgery is widely published in peer review magazines uh throughout the world. He frequently lectures on the management of nerve injuries in the upper and lower extremities and limb salvage after trauma or cancer. Doctor Diaz Garcia is a fellow of the American College of Surgeons and a member of several professional organizations including the American Association of Hand Surgeons and the American Society of Plastic Surgeons. It is my pleasure to welcome you, Doctor Rafael Diaz Garcia to this presentation. Thank you so much for making the time to share with us your knowledge. The floor is yours. You may begin your presentation. Thank you so much. I appreciate that uh introduction. Hopefully you guys can see my slides. Um uh The reason I kind of chose this as a topic of discussion is I think that there's uh a lot of need for management of pain. Um I think that as we look at the landscape of medicine, um pain is kind of one of the last frontiers where a lot of people are suffering without necessarily good options. Um And I think having the discussion here was uh is of use. Um Hopefully we can kind of brainstorm together with, with new options for all of us. So yeah, um please try again. It hasn't projected. Oh, I'm sorry, it's OK. A uh no, and presenters view. OK, perfect. So, um you know, as I was trying to say, uh you know, the title of this is just because there's a lot of different people discussing TMR and RPN. I um for those of you taking care of neuropathic pain. Um And I kinda wanna just kind of give you my view of it and my landscape and answer any questions about, you know, what patients may benefit from this. But in general for neuromas, um I wanted to discuss what we've been doing for the last, uh you know, 100 years of management and why that doesn't make any sense. Um What are the current treatment options that have really been adapted over the last uh 10 to 15 years? And you know, what are some options that we may know in the future? So, limb loss uh is something that people suffer with uh around the world in the United States. We have about uh 1.7 million to 2 million people who suffer uh from upper and lower extremity amputations. Although the lion's share uh are seen in the lower and they may be from traumas or a vascular disease, diabetes, melodic and cancer. Um And obviously is that this is not only a devastating um event for the patients in terms of function. Um but ultimately, uh you know, for their quality of life across the globe, it's a much bigger problem. You see, um particularly in China and Southeast Asia where there's a much bigger motorcycle and the moped culture um that, you know, we're talking about uh tens of millions of people that are suffering with uh limb loss. And the biggest thing that people don't talk about whether they be on the orthopedic surgery side, uh, in trauma, um, or in the physiatry side, uh, after placing the prosthetics is that even if they're doing pretty well, um, you know, a lot of them have pain and they kind of learn to live with pain. Uh, I break up these, these pain into two different things. One is residual limb pain. So this is pain with direct palpation of a specific portion of their uh residual limb or extremity versus phantom pain, the pain of uh the limb that's no longer there. And the reality is that only about a quarter of patients who've had an amputation. Um And I say major amputation more than a digit or a toe uh have a pain free life and ultimately, the majority of them are living with moderate to severe pain. We were taking a step back to looking at just the the progression of prosthetics. Um Nothing's really changed very much. So, this is a photo back from uh around the civil war. Uh You have leather, some steel. Um They haven't really got any good joints yet, but overall, um you know, it's biscapular uh motion that's driving the motion of the, these prostheses, you move fast forward to 1960. So 100 years go by and a little better fit a little better products. Now, we have cables and elastic bands that can help uh with a little bit more prehensile function. Uh And now you have some articulating joints um at the elbow that can be turned on and off. Um but still really just leather and cables and you know, looking now uh nothing has changed for the average patient. Um but we have robotics, right? This is the 2024 and, and we have these amazing robotics that exist um and can have uh 21 or 23 degrees of freedom, almost mirroring the function of the hand. Um But it's uh similar to having an Apache helicopter and trying to drive it with an RC uh controller that just isn't enough uh fidelity of signal and enough control to be able to do it safely and functionally. Um I won't go into the, all the different discussions of uh where to control prosthetics. But people have talked about, you know, you control prosthetic with the brain directly and, and put electrodes there. Can you do it in the spine um or can you do it peripherally? Um And they each have their, their proponents, people who make an argument for it. Um But ultimately, um I think most people feel that the peripheral prosthetic control makes the most sense for a lot of biologic reasons because the signal is right um is right where you want it to be uh it's amplified um and can control um you know, a prosthesis through signaling um when a nerve is cut, uh whether it be a laceration, um or an amputation, uh The downstream nerve begins to de to degenerate and disappear through some a process called learning degeneration. Then a growth cone develops uh in an attempt to recreate those nerve fibers. And as it's growing, um you know, that uh that signaling distally uh kind of directs the nerve to go back to where it was before. If the two ends are close to each other, the nerve will find its way. Um However, um you know, as you continue to see more and more nerve fibers, if there's nowhere for them to go because there is no nerve end because it wasn't repaired or if it was a large injury, um or there was an amputation. Um you get a nerve tumor and this nerve tumor is essentially uh a benign mass that every nerve injury has. Uh if it's not repaired and we call it a neuroma, but it's functionally just a fibrotic nerve tumor. And why do we care? Well, they cause pain and they make it difficult for people to use their prostheses. So, these are two patients. Uh one on the left is uh you know, swollen tibial nerve, uh which is an aroma and continuity after gunshot wound. This is after an amputation. You have this big nerve tumor uh involved in scar um as a result of um the amputation, the history of neuroma surgery never really made that much sense. So this is a Morton's neuroma uh this is a nontraumatic um kind of repetitive neuroma develops uh in the feet of patients. Um And, you know, the treatment was exciting, just cut out the neuroma. The idea though that you can do have a neuroma, a cut nerve develops this nerve tumor and then you're gonna shorten the nerve and then expect something different to happen. You're just getting another neuroma now at a different level, at a shorter level. And Albert Einstein was famous for being told that, uh, you know, insanity is doing the same thing over and over again, expecting different results. And that's really what the 1st 100 years of neuroma surgery uh had been. If you don't change the biology, you're gonna end up with failure because you're gonna get the same results over and over again. So, uh you know, some mentors of mine Greg Dumani on the left and pulsed on the right, uh these independent thinkers and really kind of on their own path, uh found a similar solution, um kind of accidentally. So, uh, Doctor um Ken and Dumani were looking for prostheses, control using um bigger nerves. Uh Doctor Cerno was looking at small nerves and putting um grafts of nerve of muscles onto nerves to see if they could control prostheses. But ultimately, what they found was that while they were trying to get prostheses to work that their pain got better, it was completely incidental. They were not trying to do this or trying to do a functional operation. You know what is TMR, the target muscle innervation is where you, you take nerves that have nowhere to go reroute them to muscles uh that are still present. And what that does is it gives them nerves something to do that down regulates all the um growth factors that create the neuroma and down regulates the central nervous system from developing um or continuing to have phantom limb pain. Um These are kind of some patients of what you see. So this is a, a trans uh femoral amputation uh in a delayed fashion. And so we find these nerves that are long and have nowhere to go and have these nerve tumors. We find motor branches that are going into muscle and we essentially cut the nerves and reroute them. So now, instead of being a nerve to nowhere, it's a nerve that's been um coop and repaired to grow into and, and heal into a muscle. Um the effects are actually pretty amazing. So this is a video, I don't know if the audio will play but um uh I kind of just want to, to describe it. Um but this is a patient who had a high uh you know, uh four corner amputation who just after TMR after this is healed, several months can um control a my electric prosthesis with almost no training because it's just um intuitive. You think I wanna open my hand and a muscle contracts. You think I wanna close my hand, a muscle contracts. You don't have to move your shoulder blades apart in kind of an unnatural way to be trained to do the functions. All we're doing is creating new amplification points for those nerves have nowhere to go. Um So as I was mentioning before, benefit of TMR is that now you don't get a terminal neuroma because the nerve has somewhere to go and something to do, you get down regulation of pain um in the central nervous system because uh of the feedback that that nerve is not searching for some type of signaling. Um It helps in my electric controls of prosthetics, which was the ultimate goal. But again, I think that the the use of pain, particularly in lower extremity amputations where you're not trying to get higher level prostheses um is super helpful and I think has really become the, the the main reason we do this operation, it doesn't even work. Uh I won't go through all the papers but paper after paper has shown that it improves task efficiency for patients who undergo nerve transfers and end up with a prosthesis. Uh They, their neuromas don't come back if they have TMR. Um and that their phantom limb pain significantly improves if um it hasn't been present for a long time. My experience has been that patients who have the surgery within six months or a year of their amputation do a lot better than people who have kind of established phantom limb pain of 567 years. Um, it doesn't mean that those patients with longer term symptoms don't have, um, options but they're just less predictable. Um, you know, this is just looking at the general population on the right versus patients who had TMR. And so the, uh, general patients, their worst pains of five, and their, uh, current pains of one, the worst that their pain ATM R patient is one. So they're not pain free, but they're significantly improved. Uh The neuroma pain, that residual limb pain, the worst that the TMR patients have won. Those that have traditional neurosurgery are fours an RPN I is essentially just a microscopic version or mini version of TMR. Um We're taking small muscle grafts, we're incorporating them. And um you know, I don't wanna get into the weeds of why there are some benefits for this in certain um studies. But the reality is that again, if you give the nerve something to do, you don't even need a full muscle if you give a little bit of muscle there, um it'll grow into that, it'll renerve it and uh they won't form an aroma. Uh This is a notation model. So, you know, again, previously, a nerve would get cut, it would be placed into muscle blindly and say, oh, that'll get better because it's away from the edge of the skin. Um It just forms a neuro in a deeper location. But if you give it um denervated muscle, so the muscle no longer has a signal. Uh that muscle will send out signals asking for that nerve to create new uh neuromuscular junctions. And those neuro muscular junctions are what then create the environment that prevents neuroma formation. Um This is kind of what it looks like inter operatively. So uh you have a, a nerve on one side, you have a graft of muscle that gets wrapped around almost like a, like a burrito or an a banana. Um You know what happens over time. So, uh this is in a rat model, but you could see that a year after these implantations that comparing the muscle that was grafted onto the nerve versus the control muscle, that there is a reduction in bulk about 20%. Um There's also a reduction in contraction about 40% but they don't develop these neuroma. So their pain is improved and you can see that they still contract. So this is a control um uh on the left, you have a patient, uh not patient but a rat with um perineal ante nerve emg during their ambulation. And the contralateral side, you have the nerves were cut, muscle grafts were wrapped around them. And then you see that they'll contract along an ambulation phase, very similar to the contralateral side. So even though they're not normal, they don't contract normally, they will promote the same signal and this is a patient of mine. So this is a um he was about two years out from a traumatic amputation of a fingertip. You can see here uh he had these painful neuromas at the tips of his fingers which were causing difficulty um to, for him to use that hand. So he was bypassing that finger and not using it. And so I do is we cut out these neuroma, take a small two by one CRE graft from his form. We cut it into small uh ribbons and we wrapped them around the nerves allow the nerve to um innervate that and down regulate that signal. So they don't uh develop syma neuromas again. So should everyone get ATM R and RPN? I, uh to be honest, we don't know, I think we, we favor doing it on more patients than not because uh the the uh downstream effects are so helpful. The reality is that certain patients, the neural pain and phantom pain is so much better. Um upper extremity patients who have uh amputations at high levels for sure, traumatic patients who are younger that don't have diabetes don't have vascular disease or some people who should consider it. And same with oncologic patients who don't have diabetes who don't have vascular disease. Um People with poorly controlled diabetics, they often have some element of neuropathy, which kind of confounds the picture where they may have some pain. Um That's more from the neuropathy, not necessarily from a neuroma and it's difficult to kind of p um to split that out. But ultimately, 25% of patients um are gonna have chronic localized pain uh in the residual limbs if we don't treat their neuromas and they do better if we get to those patients earlier rather than later. Um So hopefully, you know, I tried to kind of get through a lot of information in a short period of time. Um But I hope that you guys walk away from this understanding that pain from nerves really affects a lot of people, um particularly those who suffer some type of amputation. Um It affects your quality of life but also uh affects their ability to use prostheses and affects their ability to interact with the community. And that TMR and rpnis are these novel solutions to these difficult problems that for a long time, we just ignored, but ultimately, it can do better if we address them early. And I hope that you think about this as an option with acute patients who have amputations or patients who have failed to reach goals within a reasonable time and six months, eight months out, you think maybe they ha they're a candidate for something else. And I really thank you for your time, Doctor Diaz Garcia. Thank you so very much for this uh brief synopsis of all the incredible things that you do uh for our patients, especially those uh individuals that are seeking some kind of a relief from pain. Uh as you described it, uh It is mind boggling what you guys have accomplished in the past uh 20 years in regards to these uh functions of these limbs uh that are created um uh in laboratories practically to aid on the patient. Uh You did mention incredible things here and I wanna make sure that I recapitulate this accordingly because uh we do get a lot of uh uh uh requests and I am so happy that you are uh already in our center of excellence in orthopedics. Uh because I think you're going to get a, a huge international following eventually. Uh But uh one of the most important components is here. Obviously, it is the pain. Uh these individuals that have suffered already amputations, they're constantly complaining of pain and they do not know what to do about it. And of course, uh they referred from one specialist to another. Uh And that might not necessarily get the relief. So, uh this uh thing about uh reducing pain by uh allowing the neuroma to disappear and using the uh targeted muscle, um muscular renovation, I believe it will be a game changer in the future. Now, uh doctor uh on these particular uh amputees that you treat, are they freshly amputated or can anybody with a chronic amputation come to you and say I need to be considered for a limb? Yeah. So anyone can be considered, um, the, uh, the work out of uh Northwestern, uh, showed that I know how to state that people who have them within six months, uh, tend to do better than people who have waited longer. But I had a patient, uh, when I was still in Pittsburgh, uh who had had this, you know, she was a young mother, had, had a complication, ended up having um, uh aortic balloon pump complication from that end up losing her leg and she was on methadone, you know, really high level narcotics for years. She was seven years out and about six months after I had done her TMR, she was all of a narcotics. She still had some pain. Um but, you know, it had been life changing for her. I've also had patients who are four or five years out who don't get a ton of relief. So it, it, the longer you wait, the harder it is to know what kind of um benefit you'll see. It's rare that you'd get worse. Um You usually see some relief but whether or not it's gonna be worth it to you. It's tough to say, but ideally getting patients who are under a year um is ideal. Now, uh one thing that is always mind boggling, it's uh how patients that receive this type of limbs, um can actually start using them as you demonstrated in the video almost without coaching because it is intuitive. Uh can you recapitulate and actually briefly mention how does this work in essence, uh because obviously you're thinking it is an automatic process to lift a cup or to do something with you new arm. Uh but does, how does that in essence work? Sure. So right now when you move your hand, you're not thinking about specifically moving your hand, you just do it right. So you go to move your thumb, a signal from your brain goes to your spinal cord comes down your nerve and your muscle contracts when you cut the nerve and the nerve is no longer connected to the muscle, that signal is still there. When you think about, when amputation, patient thinks about moving their thumb, even though their thumbs, not there. They're saying that signal, but it's not going anywhere. It's the middle of, you know, essentially going into space by rerouting that signal. Now to a muscle that's been denervated, that signal will then be sent down. It'll cause that muscle to contract and we send them to specific um prosthetist that will map out their chest or their arm, whatever residual limb they have to pick up the signals where now these new muscles are contracting. They map it out on a computer program, essentially put that program into the, the, the software of the limb. So that now when you say I'm gonna move my thumb, that little piece of muscle contracts, if the emg off of the device picks it up and then moves the robotic arm. Wow, that uh that's simply uh amazing. Uh And then uh you did mention that uh depending on the schools of thoughts or, or, or how you would uh uh determine which kind of prosthesis you're going to use on, on the prosthetic you're gonna be using on the individual? Uh Do we still think of actually using any of the brain channels to do this or is it more on the shoulder side? Yeah. So the problem with using like e cog or some type of um you know, intracranial signaling is that it works really well for a while. Um But then you get a lot of scarring and you lose the fidelity. It's been kind of the issue that's happened whenever they've tried to put signals uh to type of um conduction signals, whether it be in the nerve around the nerve in the spinal cord in the brain uh is that it works for a while, looks kind of favorable. But over 34 or five months, you lose that signal, you lose the resolution and doesn't work. Um The benefit is that uh the nerve grows into the muscle and that's a natural relationship. It's a, you know, it's a symbiotic relationship between the two. And so you don't lose that signal over time. It maintains fidelity over years. Wow. And, and then uh uh one final question doctor, and it has to do with the fact that obviously, now we uh the patient has gone through the entire process of uh being a candidate selected to be uh the recipient of this device. And uh how long do you typically expect for uh these individuals to feel, to feel fully proficient in actually managing their new limb? And how long is it good for? So, in terms of how long it takes, it, it really depends a lot on the level of amputation. So the higher the level um the more nerve transfers that we have to do, uh the more they have to map um and, and nothing is going to recreate a normal limb for them, right? So, uh if you have a four quarter irritation through the shoulder, um there isn't a lot of muscle left to power the signals. So it's a lot harder for us to be able to kind of um get the degrees of freedom with different contractions um versus a trans radial or through the form. Um You have a lot more options and a lot more signals you can kind of control. Um So the training part uh is done by the physiatrist. They do an amazing job here. Um And that can take, you know, it's easier than it is with a, with a mechanical prosthesis because there you have to kind of do uh you know, abnormal shoulder motions to try to get the prosthetic to work. Versus this is much more intuitive, but you do have to kind of learn where and how much to, to contract to, to be able to, because you don't have sensation there, you're trying to get that signal, you have to kind of get used to how much you can or can't do with that hand. Um And then even when you're not doing prosthetic control, which is really for upper extremity, you know, amputations, um for lower extremity, amputations, just the neuroma pain, um you know, management of uh you know, the discomfort and the ability to use prosthesis. Um irrespective of their reconstructive options for the prosthetic, uh I think are valuable. Absolutely. Uh Doctor Downs has uh a comment. Actually, a question. It says, is it practical to perform this on elderly, for instance, 80 or 90 year olds. Yeah, I mean, I think it's uh it's an interesting question and I think it depends on what they need an amputation for. So, if you gave me an 80 year old who has vascular disease, um you know, there's evidence out of Michigan that uh those patients do worse if you try and do it because the planes you have to create increase your likelihood of wound infections that increase your likelihood of complications. Um If it's uh somebody who, you know, is a poorly controlled diabetic, uh my experience is that those patients don't usually sym get symptomatic neuromas even though they may have neuromas uh there. Um but, you know, if you had an 80 year old who was running marathons and was otherwise healthy and had an injury. Um I think you have to treat this person. Um, not chronologically as 80 but physiologically. So if they're, you know, otherwise like a 50 or 60 year old, um but just happened to be 80 I think that's someone to have a conversation with. Um And again, it doesn't mean that they, you have to do it at the time of amputation, which I think, you know, can be helpful if you have that team together. Um But you give them 3 to 4 months and let them rehab and see if they're injured of the prosthesis. And if they're doing 90% of what they, they wanna do, then maybe they don't need anything else. But if they feel like, you know what, I can only wear my prosthesis a couple of hours a day, I find myself being at home more and more. I feel more, you know, ostracized or secluded from my community. Um There are options for them and, and the opposite spectrum I will say in pediatrics. Uh do you guys consider pediatric patients uh for this type of procedures that eventually will need to be changed? Yeah, so they do. Um I don't personally do them. Um but uh I work with surgeons at Nicholas here in Miami um that do offer those operations for oncologic patients and traumatic patients. Wow. Well, uh this is absolutely phenomenal that we have you in our team. Doctor. Welcome. Once again uh to the orthopedic and Sports Medicine uh institute. We are honestly uh very honored to have you. Um Thank you so much for your presentation and I wanna thank everybody that participated today uh for your attendance. If you do have additional questions or you're curious about other types of procedures uh that uh Doctor Garcia Diaz Garcia has uh in his uh tools and our momenta uh please uh feel free to send them to us at BH I webinars at Baptist health.net, BH I webinars at Baptist health.net. We'll make sure to pass along uh your questions in order for him to elaborate. And if you do want uh to see him directly, please contact us directly at uh our international Services department for us to be able to assist you. We look forward to seeing you all uh during our next orthopedic and sports medicine lecture series. Uh This time is scheduled for Wednesday, November 13th 2024. Thank you once again and have a great afternoon. Thank you so much, Doctor Diaz Garcia. Thank you for your time. I appreciate it.
