Surgical Advances Improve Nerve Prognosis for Patients

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New Treatments for Paralyzed Limbs

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Surgical Advances Improve Prognosis for Patients

With Certain Nerve Injuries

by Jane Spencer

Advances in surgical techniques are helping patients with a common type of limb

paralysis regain some movement and sensation.

The procedures employ grafting and splicing tactics to reroute healthy nerves to

paralyzed muscles. In rare cases, surgeons are trying nerve transplants, in

which nerves are taken from a live donor and implanted in an injured patient.

The new surgeries aren't useful in treating the devastating paralysis that can

result from spinal-cord injuries or stroke. But they are showing promise in

so-called peripheral-nerve injuries, which often lead to paralysis in localized

areas of the body, such as an arm, shoulder or hand.

Such injuries, which involve the nerves that travel from the brain and spinal

cord to the extremities, affect more than 500,000 new patients each year in the

U.S. They can result from a wide range of causes, including car accidents,

combat wounds or tumor-removal surgery.

The nerve-repair treatments may also help some of the more than eight thousand

American infants born each year with a type of nerve damage in the shoulder and

arm that can result from birth trauma. And they are being used to restore

erectile function in men whose nerves are severed during prostate surgery -- a

consequence of about 10% to 20% of prostatectomy operations.

Dozens of recent articles in medical journals, including the Journal of

Reconstructive Microsurgery and the Journal of Neurosurgery, suggest that

peripheral-nerve surgeries can restore a considerable amount of function to

injured areas in most patients. But despite their promise, access to the

treatments is extremely limited. Only a handful of surgeons around the country,

at medical centers including s Hopkins Hospital in Baltimore, the Mayo

Clinic in Rochester, Minn. and Memorial Sloan-Kettering Cancer Center in New

York City, are performing the most-sophisticated procedures.

" The vast majority of patients with these injuries are getting inadequate

treatment, or no treatment at all, " says E. Mackinnon, a leading nerve

surgeon who has pioneered some of the new techniques and performs around 500

procedures a year with her team at -Jewish Hospital in St. Louis, Mo. Dr.

Mackinnon, a professor of plastic surgery at the Washington University School of

Medicine, says about 80% of her patients regain a significant amount of function

in their limbs.

The surgery works best if it is done within six months of the original injury.

But many patients are never referred to a nerve specialist, so they don't find

out about the treatments until it is too late for them to be useful.

Primary-care physicians often take a wait-and-see approach to nerve injuries,

since about 70% heal on their own. While nerve specialists typically wait for

six months before doing surgery to see if the nerves recover, they say patients

should be carefully monitored during this period.

Even patients who get access to the treatments aren't guaranteed a recovery.

Between 20% and 30% of patients don't experience any significant improvement

after the surgery. Serious injuries require hours-long procedures under general

anesthesia. And it can take years for the results to be complete because the

nerves have to regenerate after the operations.

Serious nerve repair procedures -- which cost anywhere from $15,000 to $60,000,

including anesthesia and hospital stay -- are usually covered by insurance.

Successful nerve surgeries typically restore between 50% and 80% of function to

an injured limb. But even when the procedures restore only partial function, the

result can be life changing for a patient. " If you can give someone back

movement in their elbow, all of a sudden they can use their forearm to hold a

book, or carry their shopping bag. It even helps them get their coat on, " says

Spinner, a neurosurgeon and orthopedist at the Mayo Clinic who

specializes in nerve procedures on the shoulder and arm. Dr. Spinner performs

about 270 arm and shoulder surgeries a year with a team, and says between 70%

and 90% of patients regain a significant amount of function.

In September 2003, Adam Albee of Rochester, Minn., crushed his right shoulder in

a motorcycle crash, leaving most of his right arm paralyzed. He could no longer

get his clothes on by himself, carry his six-year-old son or do any of his

hobbies like weightlifting.

When the arm failed to improve, Mr. Albee, was referred to Dr. Spinner at the

Mayo Clinic. (At the time, Mr. Albee worked as a hospital-supply manager at the

Mayo Clinic, and got his health care there.) During a three-hour operation in

2004, a team of doctors conducted a nerve-transfer procedure, which involved

rerouting a branch of a nerve from his triceps, and attaching it to his

paralyzed deltoid muscle to restore function to his shoulder.

It took nearly a year before Mr. Albee began to see improvement in the arm, and

the healing process was painful: He occasionally felt burning and needle-prick

sensations in his shoulder that brought him to tears. He also spent several

hours a day doing arm exercises. But two years later, Mr. Albee, now age 34,

says he has recovered about 95% of function in his arm. He can lift weights,

dress himself and he is back at work. He does 100 push-ups a day -- and says

he's working toward one-arm push-ups with the injured arm.

Surgeons say nerve transfers, the procedure Mr. Albee had, are the most

promising new technique for treating nerve injuries. They are currently being

done at hospitals including Montefiore Medical Center in New York, the Mayo

Clinic, and -Jewish Hospital. A nerve transfer only works if at least one

nerve near the injury has been spared. In such cases, doctors can reroute a

small branch or piece of the healthy nerve to a paralyzed muscle that has lost

connection with the spinal cord. The nerve branch can transmit signals to the

paralyzed muscle, restoring function to the injured area. The procedure has a

high success rate, with most patients recovering at least 80% of function.

In more experimental settings, some doctors are trying nerve transplants, where

nerves are taken from a live donor or a cadaver and implanted in a patient. When

a live donor is used, doctors remove a non-essential nerve, such as the sural

nerve, responsible for sensation on the outside of the ankle.

However, the transplants are a last resort since they require patients to take

immunosuppressant drugs for at least a year. And they pose a slight risk to the

donor: For instance, donating a sural nerve would leave a numb area a little

larger than a tennis ball on the ankle, and it involves surgery under general

anesthesia. Only a few dozen such procedures have been conducted in the U.S.

over the past decade, at hospitals including s Hopkins, Memorial Hermann

Children's Hospital in Houston, and Monmouth Medical Center in New Jersey.

Most peripheral-nerve experts say simpler, less-invasive tactics are usually

more effective and pose fewer risks. Transplants are used only in situations

where an injury is so severe that a huge number of extra nerves is needed to

repair the gaps.

New technologies are also helping to improve treatment for nerve patients. In

the past several years, medical-device companies, including Integra LifeSciences

Corp. and Synovis Micro Companies Alliance, have started selling tiny devices

called nerve tubes that can be used to bridge small gaps in severed nerves. The

tubes, which cost roughly $700 to $1,000, serve as a conduit through which the

nerve can grow and regenerate.

So far, the longest tubes available are around three centimeters, which means

they are useful in bridging only short gaps in broken nerves. But companies are

exploring the possibility of creating much longer synthetic nerves that could

one day replace nerve grafts or transplants.

Some of the techniques doctors are finding success with -- such as nerve

grafting -- have been around for centuries: Doctors began experimenting with

nerve grafts in the 1700s, and they were commonly attempted on wounds during

World War II. But recent advances in microsurgery techniques have improved the

success rate, and doctors have found new uses for the procedure. Nerve grafts to

restore erectile function after prostate surgery are being done at Memorial

Sloan-Kettering and University of Washington Medical Center in Seattle, for

instance.

Nerve grafts involve taking a non-essential nerve from somewhere else in the

body and using a piece of it to bridge a gap in a broken nerve. The graft serves

as a scaffold along which the patient's own nerve can grow and regenerate.

One reason there is so little awareness about the treatments in the broader

medical community is that peripheral-nerve injuries don't fit tidily into any

particular medical discipline. Doctors devoted to peripheral-nerve work come

from a range of backgrounds, including plastic surgery, neurosurgery and

orthopedics.

" We're still trying to get the word out, " says Allan Belzberg a neurosurgeon at

the s Hopkins Hospital, who performed the hospital's first nerve transplant

last November. " Please don't sit on these injuries, and give us a chance. "