Surgical Procedures offered by Professor Giorgio Brunelli in Italy

[Wise Young]

Many news articles have covered the operation of Professor Brunelli. The following is an example of one that appeared in The Times

August 15, 2000 British TV report (http://www.google.com/search?q=cache:QQ8fGyeobhw:www.channel4news.co.uk/home/20000815/Story03.htm+brunelli+spinal+surgery&hl=en)


CHANNEL 4 NEWS
SPECIAL REPORTS

The will to walk

Broadcast: August 15, 2000

Reporter: Andrew Slorance


It's an irresistible dream: for a person paralysed after an accident to walk again.

But what happens if hope becomes an unrealistic obsession?

One Italian surgeon is pioneering radical new treatment which he claims will one day help his patients walk.

Critics say that rather than a miraculous breakthrough, the controversial operation is just raising false hopes.

In the first of two special reports on the victims of spinal cord injuries, Andrew Slorance went to meet Professor Giorgio Brunelli at his clinic near Bologna - to find out for himself:

Many hundreds of people in the UK will suffer a spinal injury this year. Most will walk away, but one in ten will have severed the spinal cord, and will not walk again.

One in 20 of those will commit suicide within five years, making suicide second only to respiratory failure as the highest cause of death among spinal cord injury victims.

The only therapy available for victims is rehabilitation to help them to learn to live life in a wheelchair. Patients spend an average of nine months in a rehabilitation unit, learning everything from scratch; even the smallest of tasks will have become a struggle of incomprehensible frustration.

Most victims of spinal cord injury do not believe they will walk again and the therapy received during rehabilitation does not encourage them to consider it probable. But for some, the only way to keep going is to hold on to a tiny ray of hope.

Much has changed in the treatment of spinal cord injuries since I was a patient in 1983. At the age of 14, I fell 50ft from a tree, breaking my back and severing the spinal cord. The rehabilitation I experienced took the hardline approach and the unit was run like a military camp. I was told that I would need to use a wheelchair for the rest of my life and that the sooner I dispelled any thoughts of walking again, the better. In spite of this, 17 years on, I still carry hopes of walking.

Research into spinal cord injury has made encouraging progress in recent years, although most doctors say that a treatment that would return functional walking (a level of walking that would be considered natural) is still years away.

Until recently, progress has been confined to the lab, but now an Italian surgeon, Professor Giorgio Brunelli, has taken his controversial research into the operating theatre.

As part of a team for Channel 4 News, I went to meet Brunelli at the Montecatone Rehabilitation Centre near Bologna, where he was to perform a new experimental operation during our visit.

Angelo Colombo, his most recent patient, had been paralysed five years ago after falling from scaffolding. He had severed his spinal cord at lumbar level, leaving his hand and arm function unaffected. Brunelli offered him experimental surgery in an attempt to restore some motor function to his legs, using a procedure called an ulnar nerve transfer.

This is based on the principle that while all the nerves above a spinal injury, and all the muscles below an injury, remain intact, the communication between them has been cut off. Professor Brunelli planned to reroute a nerve from above the injury to a muscle below it. The ulnar nerve, one of the main motor nerves running from the spinal cord down the arm to the hand, is ideal for the procedure because of its length.

Brunelli disconnected the nerve from Angelo's hand, leaving the other end connected to the spinal cord. He then removed it from the arm and rerouted it down the chest wall connecting it to the quadriceps muscle in the leg. This is open surgery, which results in significant scarring on both right and left sides. Reconstructive surgery was carried out to try to restore the lost motor function to both hands.

In time, Angelo's brain adapted to the new nerve mapping so he could move his legs on command. Until then, his brain had treated his quadriceps as though they were his hands and when he thought about moving his hands, his legs would move. Brunelli told us that the procedure had been successful but that Angelo had not been doing enough exercise recently, so his walking was not as good as it could be.

Angelo, wearing supportive splints around his ankles, was ready and waiting to demonstrate his newly restored ability to walk. I did not believe that I was about to witness functional walking, but I was hoping I would be proved wrong. Under instruction from Brunelli, Angelo pulled himself from his wheelchair to his feet and, using a walking frame, began to make his way across the gym.

I felt for Angelo as he struggled to move one leg in front of the other. I had seen more effective walking by patients using full-length callipers. The sweat was pouring from Angelo's brow as he came to the end of the demonstration

six metres and two minutes later. I asked how he felt about the operation, given that he had sacrificed some hand dexterity and sensation for a very limited ability to walk. I suggested that he could have achieved the same results using callipers and avoided the dreadful scarring.

His response was that the operation had been a tremendous boost to his mental state. He rolled up his trouser leg to above his quadriceps muscle and demonstrated the restored movement. As he flexed his hand, his quadriceps clenched in unison; being able to move his leg at all was fantastic, he said, and over time his brain had learnt the new nerve mapping. Now if he thought about moving his leg, he could do so.

Gigilola Centurelli, another of Brunelli's patients, was having a variation of the ulnar nerve transfer the next morning. She had been in a traffic accident only four months earlier and was still in rehab. I was concerned that she had not had enough time to adjust to her circumstances, and therefore was not in a position to make an informed decision whether to undergo experimental surgery.

Gigilola was bound to try anything offered to her, no matter how well-advised she was that the operation was experimental and the outcome uncertain. It would be impossible for her not to have huge hopes that the operation would restore her ability to walk.

Gigilola told me that she wanted the operation and felt that, no matter what the outcome, she could not be worse off than she was now - and if it was God's will, then she would walk again. I asked her about her family and what they thought about the operation, and as she began to tell me, she broke down in tears.

It was evident to me that Gigilola was pinning her future on the operation by Brunelli.

This was also to be a nerve transfer, but the nerve used this time would be the sciatic nerve, which would mean that non-paralysed muscles would not be affected. The sciatic nerve has many more motor fibres than the ulnar nerve so, when rerouted, could supply more muscles, therefore potentially achieving more movement and an improved ability to walk. The outcome of Gigilola's operation will not be clear for several months.

Brunelli admitted: "This is the first time I have performed this operation on a human being. Gigilola is a volunteer patient and has been warned that though we get beautiful results when operating on monkeys, the result with her may not be as good. We cannot perform miracles."

At the moment Brunelli assesses the suitability of patients himself, though he says he may seek an examination by psychologists in the future.

Professor Martin Ferguson-Pell, ASPIRE chair in disability and technology at University College London, shared my concerns that the operation on Gigilola might have been premature.

"What Brunelli is doing is controversial. It is very important to look at the whole picture and make sure the patient understands exactly what to expect. At the moment procedures such as these provide a very limited degree of movement, and they don't, for example, restore bladder or bowel function. It is important to look at thewhole picture. As far as I can tell, it is unlikely that this technique will result in people coming close to recovering from spinal injury and being able to do the things they would do in normal life. But then for some people, just being able to stand up is very important."

Between the rehabilitation unit we visited in Italy and those in the UK there is an enormous difference in the attitudes towards walking. In the Italian rehabilitation unit, paraplegics could be seen walking using splints and frames. All the patients I spoke to said they were certain that they would walk again and are actively encouraged to think this way. Every patient was optimistic about his future.

[Wise Young]

Here is his web site, called the Foundation for Research Spinal Cord Lesions
http://www.dracmanet.it/fondazione/home1.htm#eng

Giorgio Brunelli has an MD and PhD, is a professor at the University of Brescia in Italy. He is a well-known surgeon who has several hand procedures named after him, who has written several surgery textbooks, and who has presented a numerous international symposia.

[This message was edited by Wise Young on August 20, 2001 at 08:29 PM.]

[Wise Young]

Reeve anger at nerve transplant operation

The long wait: Centurelli will not know for years if the spinal operation has helped

John Follain, MontecatonePhotograph: Nick Cornish Mending broken bodies

THE wheelchair-bound Superman actor, Christopher Reeve, has criticised an experimental nerve transplant carried out in an attempt to help an Italian woman walk again after she was paralysed in a car crash.

The revolutionary surgery was performed on Gigliola Centurelli, 27, who was married only last year and has been in hospital since her accident five months ago.

A length of sciatic nerve - the largest in the body, running from the pelvis to the thigh - was removed. It was then re-

attached to Centurelli's spinal cord above the point where it had been severed, and joined to three hip muscles that normally control movement of the legs.

The operation was carried out by Professor Giorgio Brunelli, of Brescia University, after 20 years of tests on animals, including monkeys. However, Reeve, who was paralysed from the neck down after falling from a horse five years ago, warned against experimental surgery for the sake of research.

"I think it's pretty immoral because you have to follow a sequence," said the actor, who has vowed to stand again by his 50th birthday in 2002, and has raised huge sums for spinal research. "You've got to go from rats, a lot of rats. Then you have to go to bigger animals, pigs hopefully, not monkeys. You've got to demonstrate safety and efficacy."

Reeve's concern was rejected by Centurelli, who said she had nothing to lose. Confined to her bed in the hilltop Montecatone Rehabilitation Institute near Bologna for a month since the operation, she will be taken to its gymnasium for massages and electro-stimulation this week, at the start of a long process to determine whether the surgery has been a success.

"I want to be a bit more independent," she said. "Just taking a few steps is my greatest dream."

Centurelli was a barmaid with "no children, thank God", who remembers little about the Saturday last March when she left her home in the northern city of Bergamo to go to the dentist. On the return journey, her Lancia ploughed into a field, rolling over. She was not wearing her seat belt, her spinal cord was severed, and she spent three weeks in a coma.

"What I miss most of all is my work," she said. "Bad luck - it was fate."

Her husband, Alfredo, sought out Brunelli, who had already operated on another patient paralysed in a fall from scaffolding, taking a nerve running from the spinal cord through one of his arms, and attaching it to a leg muscle. The man is now able to walk short distances.

"But I took the decision alone," Centurelli said. "I thought it's my life, I must try."

Brunelli says a rerouted nerve should regenerate at the rate of 1mm a day. Centurelli's surgery may re-establish communication between the nerves above her injury and the muscles below it 18 months from now, he believes.

He warns patients not to delude themselves. "The gains are marginal. We are still in the Stone Age as far as spinal cord injuries are concerned. I am not peddling illusions - I am experimenting on volunteers."

Brunelli plans only another half-dozen operations before pausing for up to two years to judge the results.

Reeve doubts whether the time is right to experiment on people. "You've really got to test everything, and then do it on a limited number of humans who are at a low-level risk in case of failure," he told Channel 4 News.

Brunelli's methods have aroused further scepticism in London. "What he is doing is controversial," said Martin Ferguson-Pell, professor of disability and technology at University College London. "At the moment procedures such as these provide a very limited degree of movement."

Centurelli now faces two years of physiotherapy. "What will happen when I try to stand on my two feet I just don't know," she said.

[Wise Young]

A few comments on the procedure of bridging a peripheral nerve to a root above the injury site.

• When the peripheral nerve is cut, many axons in the peripheral nerve will regrow out. This includes both motor and sensory fibers. What Professor Brunelli did was to cut a peripheral nerve in the arm, leaving the peripheral nerve still attached to the spinal cord, tunneled the nerve downward underneath the skin, cut a peripheral nerve going to the leg, and reconnected the arm nerve to the leg nerve. Amazingly, the peripheral nerves from the cut arm nerve (ulnar) regrew into the leg nerve and reinnervated muscle, allowing the patients to activate their leg muscles by moving their pinky. Presumably, some of the sensory fibers also regrew but I don't know how much sensory recovery the patients received.

I heard Professor Brunelli talk about this subject about a year ago when he gave a talk right after I did in London. He actually spent nearly a decade doing experiments on monkeys before applying this procedure to humans. He is a serious and well-regarded surgeon in Italy, a man who has published many papers on spinal surgery. Some doctors have been quite critical of his operation, particularly in the case where he operated on a young woman who was just 4 months after injury. It was a bold and, in some ways, a courageous move on his part.

The procedure has several advantages and drawbacks. Let me deal with the advantages first. The concept that peripheral nerves will regrow and re-innervate the muscles is well known. The demonstration that they can grow to the leg muscles and re-innervate is perhaps not surprising. This approach clearly produces some function in the legs.

The drawbacks are as follows. First, the procedure requires the sacrifice of a peripheral nerve, in the arm. He used the ulnar nerve that controls the movements of the ring finger and pinky and receives sensations from that lateral aspects of the arm. Second, the cutting of the sciatic nerve in the leg is a bit more worrisome because if the procedure failed to achieve regeneration, the muscles innervated by the sciatic nerve would undergo atrophy. Third, the procedure would be largely irreversible. It would be difficult, for example, to imagine going back and reconnecting the leg nerve back to its nerve roots in the spinal cord.

Wise.

[Max]

Any news about it? or it was hoaxx