Justin Brown, MD: Peripheral Nerve Surgery

Slide show is called Building Bridges to Restore Function

When you cut a peripheral nerve, Schwann cells go to work, attracting axons like a magnet.  How do you repair nerves that are too damaged?  You can do grafting by building an effective bridge, usually with nerve cells swiped from a place on the body where you don’t care much about sensation (side of the foot, e.g.)  it works pretty well.

Obstacles are distance, time, complexity, and age.  Closer is better.

The traditional way is to try to recreate what it used to look like . . . results are often mediocre. And sometimes you pop the nerve right out of the spinal cord (this is called avulsion).

A new idea was to do nerve transfer, which is a way of redistributing nerves that doesn’t try to reproduce what used to be there but rather invents a new system.  The peripheral nerve system is just as plastic as the CNS . . . showing a guy who survived a bad motorcycle crash and ended up with a fully paralyzed arm.  They did a graft . . . video from 3 months later, and he’s got some function back, 2 years later he’s got a normal arm with full range of motion, and you can’t tell which of those arms was injured.

You can take nerves that used to have a whole other destination and put them where you want them . . . and make them work.  And it doesn’t always take high end rehab.

Another example — guy got shot in the arm and lost use of his hand.  After the graft, video of his hand working normally while running off completely new nerve set.

So what about SCI?  You have a similar situation to a peripheral nerve loss.  Even years after injury, you should be able to take nerves still connected to the brain and use them in exactly the same way.  You’re transferring axons.

New video of a hand that was rewired.  Can you redistribute axons and restore grip?  Worked with a typical c5 patient, regrafted some nerves that were connected to the brain to replace those that had lost that connection . . . (Arghhhh, showing the surgery itself.  Okay.  Very bloody.)

Ha ha, Jerry Silver says from the audience, “You know, 2 shots of ChABC would really help!”

Justin says, “Let’s do it!”

They find the target with electronics, and — the guy can extend his fingers.  He has brain connection to fingers– connection that didn’t exist before this surgery.  “You can’t come into this game passive.  You have to work to get what you get.  It’s really dependent on how hard you work.”

What about incomplete injuries . . . There are classifications of EMG activity that show level of spasticity.  Turns out you can do peripheral neurotomies to deal with that.  Showing a video of man who had this treatment and went from needing a walker to being able to free-walk, and that was 15 years post.

The thing is, once these stem cell and other strategies get up and running, there’s going to be a tuneup phase.  Things won’t go back to the way they were; there will probably be a need for these kinds of targets.

We’re also working now on restoring the bladder.  With dogs, we’ve already been able to get that working.

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