Wilson Z. Ray, MD, Professor of Neurosurgery, Vice Chair and Chief of Spine Surgery at Washington University talks about a breakthrough procedure to improve the lives of paraplegics.
So just a question, is a paraplegic and a quadriplegic the same? I mean because you say neck down and you can’t move.
RAY: Yeah. So, the quadriplegic would be the same as a tetraplegic patient or affecting all four limbs, whereas paraplegic is usually from we think about the waist down or something below the level of the neck or cervical spine.
So how often is it that someone has a spinal cord injury, and they regain any movement? And how long does it take?
RAY: It’s usually pretty rare for somebody when they have a traumatic spinal cord injury to have spontaneous recovery, particularly in those patients that have a complete spinal cord injury. People that have an incomplete injury. And those patients that have an incomplete spinal cord injury, far more common, are a much greater likelihood that they will have some return of function over time. Usually, we think about that plateau period anywhere from about six to twelve months, and that’s oftentimes why the aggressive rehab is after the immediate injury.
And so, of all your patients that you see, is there one thing that they really would like to have more control of?
RAY: Yeah. I think, you know, interestingly enough, and this has been fairly well studied that improved upper extremity’s function, specifically hand function, is always consistently rated as the No. 1 priority. And that’s surprising because that’s above bowel, bladder function, sexual function, standing need and pain control. So, it really is an important thing. And with somebody that has, you know, lost everything, any sort of subtle or minor improvement can be substantial.
And the use of your hands, I mean, that’s giving you freedom almost, you know?
RAY: Right. You know, the independence and ability to perform their activities of daily living is almost exclusively dependent on hand function.
And so, there’s very little that you can do before now to get that function back after…
RAY: Right. Right. And that’s what’s so exciting about this is most of the clinical trials, I would say, even those today is aimed at acute spinal cord injury before there’s the scarring and some of the challenges with addressing a complete spinal cord injury at the level of the spinal cord. And this is directed very much toward those patients living with a chronic and complete spinal cord injury year or even more after their injury.
What is a nerve transfer?
RAY: A nerve transfer is rerouting a less critical function to an area of more critical function. So, for example taking from Paul and giving to Peter to improve function in this case distally in the hands.
You would think, ‘oh, you’re going to take a nerve out of someplace and put it someplace else’. You’re going to damage Peter for Paul. But that’s not necessarily the case?
RAY: Yeah. In certain areas, we have more redundancy, and you imagine the larger muscles, the biceps or flexors of your elbow or the triceps where it extends your arm, some of these larger muscles, you have a number of fascicles or a number of nerves that are part of the same nerve. You can reroute a part of that nerve without downgrading function to the one that is the donor or supplying that donor nerve.
And does that usually come from the bicep?
RAY: Yeah. That’s a very common one that we might utilize. There are two elbow flexors. The more common one that everyone thinks of is the biceps, but there’s also another muscle, the brachialis, that we can take that entire nerve or the entire nerve that’s integrating that muscle to reanimate more distal function. Oftentimes, that would be the hand. The other one that’s a common one that we might do is taking a part of the back of the shoulder muscle or the deltoid nerve, the axillary nerve, and rerouting that to the triceps to reanimate the ability of self-transfer or extend the arm.
Now, let’s backtrack a little bit. You said almost all of these spinal cord injuries that you’re working with, their hands are how?
RAY: Yes. So oftentimes, patients learn this passive finger flexion to facilitate grip and then passive release or what’s called a tenodesis effect of the hand. So, if we eliminate that wrist function or they don’t have control of the wrist, they really don’t have any capacity to open or close their hand. And so oftentimes, we’re focusing on both that restoration of grasp and release.
When you do the nerve transplant, is there any risk to the other nerves or anything that you’re taking from?
RAY: Sure. We do worry about that downgrade of function. Again, I think we’ve had enough of an experience now. And then a lot of the pioneering work done by our plastic surgery colleagues, Susan Mackinnon, really set the stage for us having a good understanding of what we could do. And we’ve transferred that over to doing it for patients with spinal cord injury.
How long does it take after this transfer?
RAY: The nerves regenerate at a set rate. They regenerate at a millimeter a day. It’s frustrating because there’s no way to speed that up. So, you imagine the longer that nerve has to travel, the longer those patients have to wait in terms of return of function. For one where we were trying to restore triceps function or release, that might show signs of reinnervation as early as four to six months afterwards, whereas a longer nerve, where it has to regenerate length of the arm, that may take a whole year before we start to see signs of recovery.
And therapy is really important for this to work.
RAY: Yeah. I would, therapy is absolutely paramount. That is a critical aspect in that cortical reeducation or relearning a different function is a big part of it. So, the therapy is a key to this after surgery.
Is there a limit to how much they can regain?
RAY: Yeah. You know, we have been learning along the way, and I would say that this is a little different than the typical brachial plexus injury or nerve injury where you’re dealing with, you know, both a spinal cord injury and you’re dealing with that nerve recovery. And so, I think what we’re learning is that capacity for a full functional recovery, that bar might be a little higher with spinal cord injury.
And what have you seen? What is the most dramatic that you’ve seen happen?
RAY: It’s such a nice surgery to see patients back for because it is very dramatic, again, back to that point. Somebody that has nothing, a little is a lot. And so, as they start to regain function, it really is amazing watching their progression to be able to do things for themselves, feed themselves, use a joystick on their wheelchair or even use a phone. And so again, I’ve had the opportunity to observe that with a lot of patients, which is really nice.
Can you tell me a little bit about Andy?
RAY: Andy is one of the patients that I’ve treated. He was a part of the first Department of Defense clinical trial. Andy suffered an injury after a chiropractic manipulation, and unfortunately it was a C6 spinal cord injury so no hand function. And we did a nerve transfer to restore grip and release on Andy. It’s been several years now.
Can Andy continue, because I know his physical therapy got a little bit messed up because of COVID. So, can he come back and start in again and it will pick up right where he left off?
RAY: You know, I think there is probably some time dependence that you do want to have that early therapy, but unfortunately, COVID has created barriers for spinal cord injury patients just because they are at such a high risk if they were to become ill. I suspect Andy will do well if he resumes that therapy and we get him back in a more normal state.
Is there any thought of moving on with this nerve transfer to other parts of the body?
RAY: Yeah, and that’s a question that comes up a lot. And a lot of times, it has to do with the number of donors. And that’s why we can’t do these sorts of transfers to reanimate lower extremities is we just don’t have the donors to provide the nerve or motor function to power the distal lower extremities. So that is a question that comes up. It’s not one that we’ve been able to apply this sort of technique to as of yet.
Now, I guess the nerves all speak to the brain, but with a spinal cord injury, you’re always told that that discussion, that talk is interrupted. How does that work?
RAY: We’re taking advantage of that preserved architecture or that preserved connectivity below the spinal cord injury. With a spinal cord injury, effectively there’s a conduction block at that area of injury. The signals are no longer getting through there, but it doesn’t mean the muscles and nerves aren’t still connected to the spinal cord, and that’s what we’re taking advantage of is we’re taking advantage of that preserved connectivity below the zone of injury and taking advantage of what preserved function or volitional function they have above the zone of injury.
What’s next for this?
RAY: Just recently, and this is exciting, it started last year is we launched a new multicenter clinical trial. We’ll continue to be the lead site here, but we’ve also recruited Stanford, Michigan, Pennsylvania, Calgary, University of Texas and Utah.
That will just continue on with what you’re doing?
RAY: Right. So now, you know, the neurosurgeons that have some expertise in spinal cord injury and nerve transfers are going to be able to provide these procedures more locally. Now patients don’t need to travel here to Wash U, that this sort of treatment therapy would be available locally or closer to home.
Ideal candidate?
RAY: Somebody that’s had a stable spinal cord injury. Right now, we usually like to wait about a year. There are rare circumstances where we might offer surgery sooner, but somebody that has a chronic spinal cord injury in the neck or the cervical spine that is not making ongoing progress or ongoing recovery and interestingly enough, we just treated a woman who is 30 years out from her spinal cord injury and have a patient that is greater than 10 years out from a spinal cord injury.
And they’re seeing just as much progress as the first then one year out?
RAY: Yes. So, the person that was 10 years out, it was an interesting case that his brother-in-law just happened to be a spinal cord injury physiatrist before his injury. And so, he has done stimulation and exercise with him that entire 10 years. And so, it made it sort of an ideal candidate.
Perfect. And any risk that they would lose any function that they have?
RAY: Yeah. I think there’s always a risk, and, you know, I don’t want to downplay that because certainly when we’re taking, you know, some what we call redundant nerve or muscle function, there certainly is some chance that people could notice a downgrade. Fortunately, we haven’t had that occur to date, and that tends to be quite rare.
Interview conducted by Ivanhoe Broadcast News.
END OF INTERVIEW
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