Regenerative Peripheral Nerve Interface (RPNI) surgery is becoming a widely adopted useful surgical technique for the treatment of both residual limb pain and phantom limb pain. Following amputation, multiple molecular changes and central nervous system adaptations take place. Experts in the field state that both maladaptive neuronal remodeling in the spinal cord and cerebral cortex and central sensitization contribute to the development of neuropathic and phantom limb pain¹. RPNI surgery and targeted muscle reinnervation are currently the two main techniques studied in the field of the reconstructive microsurgical treatment of pain in amputees.  The rationale for RPNI is to provide neuromuscular targets for regenerating axons of transected nerves². It involves the placement of free nerve ends into free, devascularized muscle or dermal grafts. The technique description as well as surgical considerations depending on the etiology has been published by the pioneers and the most experienced surgeons and researchers in regenerative peripheral nerve interfaces². While the indication for a limb amputation in children varies significantly worldwide, the most common causes are tumors (for example osteosarcoma, Ewing sarcoma, rhabdomyosarcoma) and trauma.  The pediatric population represents an exceptional set of patients in the setting of amputation surgery, not only because of the mental health implications and the emotional impact of losing a limb (which can be devastating in any age group indeed), but also because among all, children hold the best opportunity for a successful recovery in terms of wound healing, pain relief, rehabilitation, and familiar and social reintegration. Neuroplasticity along with other central and peripheral molecular events will undoubtedly play an important role in the development of residual limb pain, however, the most important factor may be related to the optimization of care during the amputation, a moment when ideally an interdisciplinary team-based approach has the possibility to improve the overall effective management of an amputee patient.  A recent study demonstrated that prophylactic RPNI surgery in major limb amputees resulted in a lower incidence of symptomatic neuromas and phantom limb pain, compared with control patients undergoing amputation (without RPNI). This suggests that prevention of peripheral neuromas could potentially diminish the central nervous system pain mechanisms involved in phantom limb pain³. This also strongly advocates for performing RPNI surgery during the amputation as it permits to isolate and identify the nerves in a simplified manner and potentially avoids the development of a neuroma and the cascade of events related to residual limb pain and phantom limb pain. The creation of a coordinated multidisciplinary team can be quite a challenge, specially in the emergency setting⁴. However, we should constantly strive to cooperate between orthopedic surgeons or oncologic surgeons (or the primary surgeon who performs the amputation), and the reconstructive surgeon, who is capable of performing RPNI surgery safely and effectively both at the time of primary amputation or as an elective separate procedure. RPNI surgery could be then considered as part of the myriad of microsurgical procedures available to help pediatric patients⁵.  Funding This article has not received any specific grants from public, commercial, or for-profit agencies. Conflicts of interest The author declare no conflicts of interest.

References

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