Thirteen young adults who were paralysed in sporting or traffic accidents have had movement in their hands restored through pioneering nerve transfer surgery, enabling them to feed themselves, hold a drink, write and in some cases return to work.
The team at Austin Health in Melbourne, Australia, have been using combinations of tendon transfers, which result in greater strength for the muscle, and nerve transfers, which improve dexterity. Their findings from their work on 13 patients are reported reported in the Lancet medical journal. Van Zyl says she hopes they will encourage the thousands of people who become tetraplegic (also known as quadriplegic) by losing the function of all four limbs to seek surgery which could help them live more normal lives.
Natasha van Zyl, the surgeon who leads a research programme that has given some people their lives back, said the patients were able to use their hands and extend their arms from the elbow. “Extending your elbow allows you to push a wheelchair better, helps you to transfer in and out of a car, reach out and do something in space in front of you, shake someone’s hand.
“It allows you to reach above your head, which you need to be able to do because the world is designed for standing-up people. So you can switch a light off, you can get something off a shelf. Hand function is everything you use your hand for. You would just need to tape your hands up for five minutes to experience how frustrating life would be without your hands, without your fingers.”
Nerve transfers are not new, but had not been successful in spinal cord injuries. Van Zyl had been using nerve transplants in brachial plexus injuries, where neck and shoulder nerves have been pulled out of the spinal cord, and wondered why they did not try them to restore function in patients who had been paralysed. In 2014, she and her team designed a triple nerve transplant.
The first patient had “really fabulous results from the surgery.” “Word got out and we were fairly inundated with people wanting nerve transfers,” she said
They set up a structured project to track everything they did and all the outcomes, which has resulted in the Lancet paper. They recruited 16 young adult patients who had become tetraplegic after motor accidents, falls, sports or diving. Two of them did not continue with the programme and one died, unconnected to the surgery.
Nerves were taken from shoulders and transplanted into paralysed muscles in the arm so that they bypassed the injury and connected back up to the spinal cord. Ten of the patients had nerve transfers to one arm and tendon transplants in the other. Four nerve transplants in three patients failed, but the team say tendon transplant is then available as a backup.
Two years on from surgery, the patients have significant improvements in their hand function, particularly enough pinch and grasp strength to carry out most tasks of daily living.
Van Zyl says she gets strength and inspiration from her patients. She tells of one who had been “a very high-functioning individual. He was in a boating accident – he was thrown out of a boat. He was the CEO of three different companies he’d set up and he was working seven days a week and he went from that to a head on a stick, as he described himself.
“He told me, after he’d had his surgery and had enough of a result from it, that he had decided that he would try this surgery but if it didn’t work he was going to exit. He didn’t want to live any more. His was a very high level of injury but he got enough out of what we did for him, which was a combination of tendon and nerve transfers, for him to start to work again at home, to be able to take a young family member out to the movies independently and handle the money, get the tickets, get the popcorn.”
She and her team have now done about 160 nerve transfers. Between 250,000 and 500,000 people every year have a spinal injury, more than half of whom become tetraplegic. There are surgeons who could help at least some of them, says Van Zyl. “We are all dedicated to this cause and absolutely love this work. All around the world there are surgeons – we all know each other – some of them waiting for patients, frustrated that they don’t get enough.”
They cannot do anything for someone as badly paralysed as Christopher Reeve was, but they can help the most common spinal injuries that cause tetraplegia, called C5 and C6 – damage to the fifth and sixth cervical (neck) vertebrae. She hopes the published paper will encourage rehabilitation teams to suggest surgery and patients to seek it out.