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In musculus, veritas? Nerve “in muscle” versus targeted muscle reinnervation versus regenerative peripheral nerve interface: Historical review

Today, the microsurgeon is given new choices about this relationship, choices that make use of microsurgical skills such as nerve connection and muscle grafting. What is the evidence that an older, now “classic” technique, the technique of implanting a proximal nerve end into an innervated, intact muscle, should be abandoned to be replaced by these newer techniques? These new choices are targeted muscle reinnervation (TMR), which involves suturing the proximal end of a nerve, after resection of the painful neuroma, to the motor nerve of an intact, vascularized muscle, and creating a regenerative peripheral nerve interface (RPNI), which involves implanting the proximal end of a nerve into a devascularized, denervated muscle graft. The hypothesis of those microsurgeons advocating for TMR and RNPI is that, to prevent painful peripheral nerve impulses from arising from the regenerating proximal end of the nerve, from which the neuroma has been resected, the regenerating axon sprouts must have an appropriate distal target. But what are those targets purported to be? Do they actually become innervated? Are there inherent drawbacks in using these approaches? What is the cost of using these new approaches in terms of increased operating room time and additional current procedural terminology (CPT) codes to the healthcare provider? Would an economic cost–benefit analysis favor either of these new approaches over the more simple “implant nerve into muscle” approach? Finally, to date, there is no controlled clinical or basic science study directly comparing the classic nerve implanted (transposed) into muscle with either TMR or RPNI.