Research Update: Restoring Movement

Washington University physician Michael Bavlsik, MD, right, shows surgeon Ida Fox, MD, how he can now grip an otoscope after having nerve-transfer surgery. Photo E. Holland Durando
Reprinted from PN/Paraplegia News December 2015

A pioneering surgical technique has restored some hand and arm movement to patients with spinal-cord injuries (SCI) in the neck, reports a new study at Washington University School of Medicine in St. Louis

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Like railroad switchmen, the focus is on rerouting passageways; however, instead of trains on a track, the surgeons redirect peripheral nerves in a quadriplegic’s arms and hands by connecting healthy nerves to the injured nerves.
Essentially, the new nerve network reintroduces conversation between the brain and the muscles that allows patients to accomplish tasks such as feeding themselves 
or writing with a pen.
The researchers assessed outcomes of nerve-transfer surgery in nine quadriplegic patients with a SCI in the neck. Every patient in the study reported improved hand and arm function.
The study is published in the October issue of the journal Plastic and Reconstructive Surgery.
“Physically, nerve-transfer surgery provides incremental improvements in hand and arm function. However, psychologically, these small steps are huge for a patient’s quality of life,” says the study’s lead author, Ida K. Fox, MD, assistant professor of plastic and reconstructive surgery. “One of my patients told me he was able to pick up a noodle off his chest when he dropped it. Before the surgery, he couldn’t move his fingers.”

Feeding Himself

More than half of SCI injuries involve the neck. However, until a cure is found, progress in regaining basic independence in routine tasks is important.
“Patients often can’t insert a catheter to empty their bladders or insert a suppository for bowel movement and have to rely on help from a caregiver,” Fox says. “But after this surgery, one of my patients was able to independently catheterize himself, which he hadn’t been able to do since his accident over a decade ago.”
The procedure allowed a St. Louis primary care physician and a father of eight to feed himself with a fork, write with a pen, look into patients’ ears with an otoscope and drive his kids to activities.
In 2012, Michael D. Bavlsik, MD, lost the ability to use his left hand and extend his left elbow. On a trip with his son and other Boy Scouts in Minnesota, his van collided with a boat and a trailer. None of the boys were severely injured, but the accident left Bavlsik a quadriplegic.
“Nerve-transfer surgery has been very successful in helping me because it restored triceps function and improvement in my grip,” says Bavlsik, an assistant professor of clinical medicine at Washington’s School of Medicine. “I am extremely grateful for this surgery.”

Rerouting Nerves

Developed about 25 years ago by the study’s senior author, Susan E. Mackinnon, MD, director of the Division 
of Plastic and Reconstructive Surgery at Washington’s School of Medicine, nerve-transfer surgery initially was performed to restore movement in the extremities of patients who had injured peripheral nerves.
But in the past five years, the same technique has been used to restore limited movement to patients with SCI. The operation can be performed even years after a SCI. It usually takes four hours and most patients go home the next morning.
Since surgeons connect working nerves in the upper arms to a patient’s damaged nerves in their arms and hands, the technique targets patients with injuries at the C-6 or C-7 vertebra, the lowest bones in the neck. It typically doesn’t help patients who’ve lost all arm function because of higher injuries in vertebrae C-1 through C-5.
Bypassing the spinal cord, surgeons reroute healthy nerves sitting above the injury site, usually in the shoulders or elbows, to paralyzed nerves in the hand or arm. Once a connection is established, patients undergo extensive physical therapy to train the brain to recognize the new nerve signals, a process that takes about 6-18 months.
“The gains after nerve-transfer surgery are not instantaneous,” says Mackinnon, director of the School of Medicine’s Center for Nerve Injury and Paralysis. “But once established, the surgery’s benefits provide a way to let individuals with spinal cord injuries improve their daily lives.”

Building Expertise

Another patient benefiting from the nerve-transfer technique is a 72-year-old right-handed man who had the surgery two years after he sustained a cervical SCI.
The doctors took healthy tissue from the patient’s upper arm, connected it to a paralyzed nerve that controlled his ability to pinch, then plugged it into a working nerve that restored the man’s ability to flex his thumb and index finger.
This allowed him to feed himself and to hold a water bottle, which reduced his risk of developing urinary tract infections and has bolstered his overall health.
“Our innovations to address spinal-cord injuries came directly from a quarter century of nerve-transfer work in nerve injury,” Mackinnon says. “We want to continue building our expertise in this area very carefully. While the surgery itself can be relatively straightforward, the decision-making is complicated. We want to encourage people with spinal-cord injury to consider this option when so little is often offered or made available.”

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Kristina Sauerwein is a member of the Washington University School of Medicine Public Affairs staff. 


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