Utah plastic surgeon hopes to make phantom pain a thing of the past for amputees

LEHI — Amputation is one of the oldest known medical procedures and has a long history in many parts of the world as a punishment for crimes.

Roman encyclopedist Aulus Celsus published the first written account of medical amputations in his work De Medicina, in A.D. 47. Fictional written accounts date back to at least 1800 B.C., in India.

Anthropologists and archeologists, via human remains and cave paintings, believe amputations may have been performed to appease the gods as far back as 36,000 years ago.

Dr. Paul Deramo, a plastic surgeon at Utah Surgical Associates in Provo, credits the American Civil War with advancements in the procedure that were intended — for possibly the first time in history — to minimize the suffering and address the comfort of post-surgery amputees. Anesthetics, he said, were finally a standard part of surgical practice at that time, as well, which afforded surgeons more time to hone their techniques during surgery.

Despite many advancements in technique since, phantom pain — the pain associated with a limb no longer there — is still something common among amputees. It can either come and go or be continuous, Deramo said, adding that doctors have long debated to what degree the pain is physical or psychological.

"We know that 50% of patients will have chronic neurologic issues to deal with; either neuroma, phantom pain or both following an amputation," he said.

Compounding phantom pain are painful neuromas — abnormal growth and scarring at the end of severed nerves — which are also common following amputations. Deramo said neuromas make it painful for amputees to actually wear their prosthetic limbs.

Getting patients to use a prosthetic when working through that pain is sometimes difficult, the doctor said.

During his first residency as a general surgeon at Methodist Dallas Medical Center in Texas, Deramo performed amputations with traditional techniques that he believes contributed to phantom pain.

During his plastic surgery residency at Memorial Hermann Medical Center in Houston, consistently the nation's busiest Level I trauma center, Deramo took an interest in the more advanced techniques of well-known and often published plastic surgeon Dr. Ian Valerio — specifically a procedure he pioneered, called targeted muscle reinnervation, or TMR.

In a traditional amputation, the stretchy nerves are pulled tight, severed and then allowed to retract up into the remaining section of the limb or digit. Deramo believes those nerves are left without a purpose and that phantom pain may be caused by the nerve continually trying to act in ways it did previously. The brain, he said, interprets those now useless signals as pain.

In addition to scar tissue, neuromas are made worse by the severed nerve endings still trying to build out the tiny highways that allow for communication between nerves.

By contrast, when performing a TMR procedure, a surgeon locates the retracted nerve, removes the neuroma, and connects the nerve to another working motor nerve in the limb. It is a microscopic procedure and the sutures used are thinner than a human hair.

Following his residency, Deramo set about refining the techniques he learned from Valerio and worked to become more efficient so he could apply them to almost any patient.

Sondra Powell, a patient of Deramo's, had an infection set into her foot following a crush injury and her left leg was amputated below the knee. Debilitating phantom pain set in soon after, and the development of neuromas made wearing her prosthetic feel like electricity was shooting up her leg.

Following TMR surgery last year, Powell awoke from the procedure knowing almost immediately that her life would be improved by an absence of pain.

"I'm sleeping again, I'm no longer constantly irritable, and my grandchildren love me again," Powell said.

She had rarely been able to sleep more than one to two hours at a time prior to surgery, most any movement of her partial limb caused the neuromas to flare, and she credits getting regular sleep now with a marked improvement in her outlook and her quality of life.

Deramo, who is one of just two Utah physicians who do says that TMR surgery has a 95% post-amputation success rate, and he believes it could be even higher when performed as part of the initial amputation surgery.

Dr. John Rhinehart, a retired anesthesiologist, lost his right leg below the knee in 1966. He attended high school in Japan, his father was in the military, and while riding his motorcycle, a hit-and-run drunk driver struck him. He spent 10 months at the hospital for a variety of injuries, his leg being the most severe.

While his amputation didn't prevent Rhinehart from attending medical school and living a full life, including obtaining his pilot's license, phantom pain was his constant companion and wearing a prosthetic leg brought added stress from the anticipation of additional pain caused by neuromas.

"I won't lie, I wanted to jump off a bridge at times. The pain you feel, it's like your leg is burning from the inside out," Rhinehart recalled.

Rhinehart knew the moment he awoke from TMR surgery that the post-surgical pain he was feeling wasn't the burning pain he had felt for decades. He immediately felt relieved.

Deramo hopes that within 10 years, TMR will become the expected practice for amputations and that the physical and financial costs associated with pain management, reduced activity and complications for amputees will be alleviated. Those costs are shared by the entire health care system.

"In the first year of performing this procedure in Utah, about 70% of my patients were those who had prior amputations," Deramo said. "With only word-of-mouth among surgeons the second year, the majority of my patients were those having medical amputations that I could assist with."

Many don't realize that plastic surgeons are experts in all soft tissue and training isn't limited to any one part of the body. The delicate nature of surgeries involving arteries and nerves is right in their wheelhouse.

Most amputations in the U.S., unfortunately, are medical in nature rather than traumatic. Medical research shows diabetes, obesity and heart disease are the leading causes.

On the plus side, those surgeries are scheduled in advance, which provides the opportunity for trained TMR surgeons to take part, Deramo said. He hopes that as TMR becomes more widely known, phantom pain and neuromas could become a dwindling side effect that fewer future amputees experience.

Braxton Jones was 20 years old last July when a boating accident resulted in the amputation of his lower right leg. By a stroke of luck, Deramo was available to assist the surgeon, having only started his practice in Utah weeks earlier.

The TMR procedure spared Braxton the pain and complications he has seen a co-worker, and fellow amputee, experience.

"It's been everything. I go hunting or fishing every weekend," Jones said, adding appreciation that his active lifestyle hasn't been compromised at all. I did my best on crutches, out in the marshes, duck hunting, at first, but now with my prosthetic, and no pain, I'm fully mobile and won't be stopped."

The initial published works of Valerio and others centered on making very expensive robotic prosthetic hands work by attaching a patient's nerves via a surgically attached interface. It became clear during testing and trials that the patients weren't experiencing the anticipated phantom pain.

The nerves, typically left useless following an amputation, had a job to do in powering the prosthetic — a purpose, as Deramo described it.

"Like a lot of things we do in medicine, we discover the benefit of something serendipitously," he said. "We're trying to do something else, and we discover this cool positive side effect, and that's what happened with (TMR) surgery."

Deramo hopes to continue to build relationships with orthopedic, general and trauma surgeons in Utah so they can work together to improve the experience of amputees throughout the state.

A life without pain and with greater mobility is a life more fully lived, he said.

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