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Thread: interesting article in Paraplegia News.

  1. #1

    interesting article in Paraplegia News.

    "Life is about how you
    respond to not only the
    challenges you're dealt but
    the challenges you seek...If
    you have no goals, no
    mountains to climb, your
    soul dies".~Liz Fordredweb page Go to Periphereal Nerve re-routing.

  2. #2

    Here's the article

    A Real-world Therapy
    by S. Laurance Johnston, Ph.D.

    Is peripheral-nerve rerouting an answer to restoring significant function after SCI?

    Audur Gudjonsdottir and her daughter Bido live in Iceland. After the rerouting surgery in 1996, Bido has better ambulation despite having the procedure years after injury.

    Peripheral-nerve rerouting is an exciting surgical procedure that has considerable potential for restoring significant function after spinal-cord injury (SCI). Basically, with this procedure, peripheral nerves (i.e., those outside the spinal cord and brain) emanating from the cord above the injury site are surgically rerouted and connected to those below the injury site. This reestablishes a functional neuronal connection from the brain to previously dormant muscle or sensory systems.

    A key force behind developing this procedure into a real-world SCI therapy has been Dr. Shaocheng Zhang, of Changhai Hospital, Shanghai, China. Because he has treated more than 100 people with SCI, he has made routine a seemingly challenging neurosurgical procedure. In addition to Zhang's work, Dr. Giorgio Brunelli, University of Brescia, Italy, has greatly contributed to developing the procedure.

    After I met Zhang at a World Health Organization (WHO) SCI conference ("A Matter of WHO," September 2001), he invited me to Shanghai last December to become the first American to observe firsthand his peripheral-nerve-rerouting surgery.

    Many possible rerouting arrangements exist. Zhang commonly reroutes one of the intercostal nerves that lead from the spinal cord around each rib to the sternum. If the intercostal nerve is not long enough to reach the target nerve site below the injury level, a segment of the sural nerve (isolated from the calf) is attached to the intercostal nerve.

    If the injury site is above the thoracic area where the intercostal nerves originate, other peripheral nerves can be selected. For example, in several cases, Zhang has rerouted the ulnar nerve, which leads down to the wrist originating from the C8-T1 spinal-cord region, a procedure Italy's Brunelli has also used.

    In addition to the intercostal and ulnar nerves, peripheral-nerve-rerouting options can restore function for virtually any injury level. For example, in high-level injuries, functional peripheral nerves above the injury site (e.g., cervical plexus nerve branches originating from the higher cervical regions) can be connected to nearby dysfunctional nerves below the injury site (e.g., brachial plexus nerves originating from the lower cervical regions), potentially restoring respiratory ability to a previously ventilator-dependent quadriplegic.

    Zhang's patients have lost little function in the original area served by the donor nerve because of nerve redundancy, the availability of multiple nerve branches, or the creation of alternative connections.

    Although improvement in some cases is quickly apparent, restored function will gradually accrue over 12-18 months, depending upon the specific surgical complexity.

    While the procedure isn't precluded for older patients, younger ones with greater inherent regenerative potential often benefit more from peripheral-nerve rerouting. In addition, as more time passes after injury, the surgery may become less feasible, especially for lower-level injuries.

    Dr. Zhang's peripheral-nerve-rerouting approaches appear extraordinarily promising for restoring significant function after SCI. In the spirit of cooperation, we must open-mindedly develop synergistic, mutually beneficial collaborations that can evaluate innovative procedures such as his and, more importantly, facilitate new understandings.

    A resident of the Denver area, S. Laurance Johnston is a Mountain States PVA associate member who contributes PN's Healing Options column. Contact:

  3. #3




    Laurance Johnston, Ph.D.

    Although much of my professional career has involved large, institutionally funded research programs, I have been consistently amazed by how often the individual can make a difference. For example, Audur Gudjonsdottir (with author in photo), an Icelandic nurse, had little experience with spinal cord injury (SCI) until her daughter got severely injured twelve years ago in a car accident. With a committed mother's relentless energy, Gudjonsdottir started searching the world for therapies that could help her daughter.

    One indirect outcome of her search was a recent conference held in Reykjavik, Iceland on June 1-2, 2001. The conference, "New and Emerging Approaches to SCI," was sponsored by the World Health Organization (WHO) and Iceland health officials.

    The Icelandic setting influenced the meeting in many subtle ways. First, as the Vikings bridged the new and old worlds a thousand years ago through Iceland, the country seemed to be an ideal location to integrate divergent world SCI perspectives. Due to the convergence of tectonic plates, part of Iceland geologically resides in North America and part in Europe. The fact that the conference reflected neither an American nor European dominated endeavor helped to create a more neutral setting that was unencumbered by any over-riding SCI ideology.

    Second, because Iceland is a sparsely populated country with relatively few SCI cases, it must reach out to other countries to supplement its expertise. As a result, Gudjonsdottir could not merely rely on the local experts but had to search abroad for SCI therapeutic options. The more expansive, international perspective she acquired clearly molded the conference by open-mindedly ensuring that diverse SCI approaches were included, ranging, for example, from mainstream to alternative medicine, from the status quo to the controversial, from the large academic medical center to the small independent clinic, and from Western to Eastern medicine. The goal was to be inclusive not exclusive.

    Third, many of Iceland's leaders united behind Gudjonsdottir's efforts. For example, the country's popular, Ex-President Vigdis Finnbogadottir (front row center in thumbnail photo) became an additional force behind the conference. In another example, Lara Margaret Ragnarsdottir (sitting to the left of President Vigdis), Iceland parliament member, participated in the conference's strategic discussions with the goal of developing an SCI focus at the Council of Europe. In a third example, the Mayor of Reykjavik hosted a reception attended by the ambassadors of participating countries. The reception was held in one of Iceland's most famous buildings, the Hofdi, the site of the 1986 Reagan-Gorbachev summit.

    Fourth, augmented by the energy of continuous, Arctic Circle summer daylight, Icelandic hospitality generated an incredible esprit de corps, enthusiasm, and commitment to move the field forward.

    Finally, although many men contributed to this conference on a predominately male disorder, Icelandic women were the strategic energy behind all levels of the meeting, ranging from Gudjonsdottir's injured daughter to Iceland's former president. Perhaps, this unique conference, which brought in an infusion of fresh ideas, reflected a more feminine viewpoint on cooperation and, in turn, problem solving.

    Finnbogadottir opened the meeting with a discussion of SCI as a human rights issue. She emphasized that medical research is one mechanism by which people with SCI can be meaningfully integrated into society and enjoy mankind's most fundamental freedom of self-determination. Finnbogadottir noted that the overall goal of today's exciting SCI research "should not be viewed as making one whole again because the spirit is always whole. The goal is empowerment, freedom of self-determination, and the ability to manifest the spirit within."

    About 30 scientists attended the conference, including representatives from Brazil, China, England, France, Iceland, Israel, Mexico, Russia, Sweden, and the United States.


    Precursor Cell Transplantation: Paul Reier summarized his recently completed clinical trial in which human embryonic spinal cord tissue was transplanted into humans with post-traumatic progressive syringomyelia. The study showed that the procedure is safe, feasible and obliterates the cyst. Reier now believes that fetal tissue research is essentially stem cell research.

    Reier has also evaluated whether cellular grafting can augment spontaneous repair processes by investigating the plasticity of respiratory function following cervical injuries in rats. He has found that a unilateral lesion can induce changes in respiratory function at both segmental and suprasegmental levels, including upstream effects in a brainstem respiratory generator. In animals with C2 hemisection, fetal grafts favorably influenced several of these compensatory changes.

    Reier is exploring alternatives to fetal-derived CNS stem or precursor cells, including the potential of certain cancer cells to transform themselves into neuronal like cells. Specifically, he has shown that grafts of purified and retinoic acid-treated human Ntera2 neurons into chronic C4-5 contusion lesions (i.e., six-month delayed grafts) can differentiate into neuronal subtypes and survive for a year post-transplantation without tumor formation.

    Second, Evan Snyder discussed how neural stem-cell biology might play a therapeutic role in SCI. His research, primarily using a rat model of a contused cord focused on motor neurons, shows that stem cells can not only differentiate into neurons that integrate into circuitry, but also give rise to the cells necessary to support them. He believes that there is much communication amongst stem cells and between stem cells and the damaged host. For example, stem-cell differentiation is triggered by repair signals issued by the damaged spinal cord host. His overall goal is to try to understand the various molecular signals and then to try to harness and exploit them to enhance more effective recovery after SCI.

    Third, Semion Rochkind discussed the use of low-power laser treatment to enhance the regeneration and repair of a reconstructed injured spinal cord. Specifically, the spinal cords of 31 adult rats were transected. Rat embryonic spinal cord cells were cultured, adhering to microcarriers (MCs) and forming cell-MCs aggregates. After these aggregates reached intensive sprouting, they were implanted into the transected spinal cord of 24 rats. The implants served as regenerative and repair sources for reconstructing neuronal tissue. During 14 post-operative days, 780-nm laser treatment was applied transcutaneously 30 minutes to the implanted spinal cord area of 15 of the 24 rats. The remaining rats underwent spinal cord transection with no implantation or laser treatment. Somatosensory evoked potential, histological, and immunohistochemical analyses were carried out. The results indicated that the most effective re-establishment of limb function and gait performance, transport of electrophysiological signals and histological parameters (indicating growth of the implanted tissue in the injured area) occurred after nerve cell implantation and laser irradiation, compared to nerve cell implantation without laser treatment.

    Fourth, Fernando Ramirez discussed his use of xenotransplants to treat 47 patients with SCI over the past decade. The program targets those who have sustained a compression injury in which some neurons remain structurally intact across the injury site. Initially, his surgical team removes bone fragments and scarring tissue from the injury site. Any cysts that have developed are drained, and a shunt is inserted to keep fluid from accumulating. The spinal column is then reconstructed and strengthened. Following this surgery, blue shark embryonic neuronal cell cultures are injected within the dura mater. This procedure is based on xenotransplantation therapies developed by Swiss physician Dr. Paul Niehans beginning in the 1930's and, in turn, by German scientist Dr. Wolfram Kuhnau. Ramirez stated that the transplanted cells would eventually form an infrastructure matrix that will accommodate neural transmissions, and, in turn, restore some function over time.

    Peripheral Nerves: Tarcisio Barros has grafted peripheral nerve tissue into the spinal cord gap caused by gunshot wounds in seven male adults with thoracic level injuries. The gap is repaired using a peripheral nerve bridge obtained from the sural nerve plus fibroblast growth factor and fibrin glue. The patients were evaluated according to the ASIA/IMSOP standards, and with magnetic resonance imaging and somatosensory evoked potential. After 30 months, the grafts remain viable. Although no change has been observed in motor or sensory recovery, less spasticity was observed in the operated group.

    Second, Giorgio Brunelli has rerouted the ulnar nerve to leg muscles. The nerve is cut at the Guyon canal and elevated through a zigzag approach. Motor branches for adductor pollicis and first interosseous, for interossei, and for flexor carpi ulnaris and flexor digitorum profundis of the little and ring finger are respectively sutured to the motor branches for gluteus medius and maximus and for quadriceps (the latter by means of an intercalated sural nerve graft). Temporarily, the patient has to think to move the hand to obtain hip movement. Rudimentary walking is regained with the help of a light walker. EMG shows interference of the muscle is under volitional contraction. Proprioceptive sensation is also regained over time.

    ******Third, Zhang Shaocheng has rerouted the intercostal nerve to spinal cord nerve roots below the injury. Specifically, after microsurgically releasing and decompressing the cord, intercostal nerves were transferred and bridged to the root that controlled the function to be restored (e.g., muscle function, bladder control, or sensation). Over 30 patients followed an average of 2.5 years regained lower extremity muscular control and could stand up and walk a short distance with crutches and braces. Many had improved bowel and bladder control and proprioception recovery.

    Avulsed Nerve Roots: Thomas Carlstedt's has replanted avulsed ventral roots, frequently caused from motor vehicle accidents, into the cord. These implanted roots serve as a conduit for outgrowing motor axons. The procedure restores some useful function about 30% of the time and also reduces the pain associated with this type of injury. The first signs of recovery are often not observed until 9-12 months after surgery.

    New Supporting Circulatory and Physiological Connections: Harry Goldsmith discussed the transposition to the injured cord of omentum, a highly physiologically active, stem-cell-containing tissue that hangs like an apron over the intestines and lower abdomen area. The omentum is surgically tailored to create a pedicle of sufficient length with intact blood and lymphatic circulation to reach the injury site. The omental pedicle is tunneled underneath the skin, placed over the exposed cord, and sutured to the dural membrane edges. The procedure was used to treat a woman with a nearly totally transected cord. In this case, the scar tissue that filled the 1.6-inch gap in her cord was replaced with an omental-collagen bridge. Prior research with animal models, discussed by another speaker. Jack de la Torre, has shown that this procedure promotes regeneration and adrenoreceptor contact distal to the transection. The patient has gradually gained strength and control of muscles below the injury, including leg movement. Her MRI now shows the continued development of structure connecting the spinal cord segments.

    Second, Hernando Rafael reviewed his experience with grafting an unattached piece of omental tissue over the injured cord and connected it to a surrounding vascular source. Over 13 years, he has treated 232 patients with traumatic SCI with the procedure. About 43 percent have neurologically improved, including 43 who are walking with or without the use of orthopedic devices.

    Third, Georgie Stepanov has used reconstructive microsurgical vascular operations to revascularize the injured cord by displacing the intercostal neurovascular fascicle into the cerebrospinal channel and also by microsurgical omentomyelopexy. The method of suture of the vessels with small diameter allowed them to perform microsurgical anastomosis of the Adamkevich's artery. The procedure has been applied to several patients with encouraging results.

    SCI in the Developing World: Based on his Red Cross experience treating the Afghan war wounded in Pakistan and the Romanian poor, Anba Soopramanien discussed SCI rehabilitation in the developing world. Most of the world's SCI patients do not have access to the sophisticated, costly, rehabilitative technology that those in developed nations take for granted. For example, Somalia's $11 per capita health-care expenditure (compared to about $1,800 in Iceland and $4,700 in the U.S.) can do little to promote SCI rehabilitation. Given such economics, Soopramanien felt, among other things, that Western-trained SCI professionals should supplement their expertise with the wisdom offered by more affordable and accessible traditional or indigenous medicine. Overall, there is little appreciation of the concept of integrated SCI health care in developing countries. To truly alleviate the world's SCI-related suffering and mortality, we must work with the third world as a partner to develop new SCI-care approaches, strategies, and paradigms suitable to unique cultural conditions.

    Alternative & Eastern Medicine: Laurance Johnston provided an overview of various alternative, complementary, energy-based, or non-mainstream therapies that have the potential to benefit individuals with SCI. He believes that these therapies can not only can help a variety of secondary conditions but have the ability in some people, for certain injuries to restore function. Alternative therapies highlighted included Traditional Chinese Medicine approaches (e.g., acupuncture and qigong), Ayurvedic medicine, surgical interventions, craniosacral therapy, chronologically controlled developmental therapy, homeopathy, and electromagnetic approaches.

    Johnston summarized the results of a self-report, pilot study he carried out in 13 paralyzed veterans using a commercially available Ayurvedic multi-herbal product (ReGenTM Maharishi Ayurveda Products). The anecdotal results suggested that the product exerted a variety of subtle effects in many subjects, e.g., reduced spasticity. Others have shown that extract of mimosa pudica, a key herbal component of the product, can promote regeneration in rat peripheral nerve injuries.

    Second, Margaret Naeser summarized several Chinese studies that she had reviewed for a 1997 NIH Consensus Conference on acupuncture. Although none had a control group, 94% of the 360 treated patients regained some function, including reduction in muscle spasms, increase sensation, and improved bowel and bladder function. The authors recommended electroacupuncture along the bladder meridian (paravertabral) area and beginning acupuncture as soon as possible after injury. Additional studies published since 1997 supported these findings.

    From her own work, Naeser noted that stimulating acupuncture points with low-level lasers (5-500 mW, red beam or near infrared, 600-1000 nm wavelength) reduces muscle spasticity in the hand and foot and promotes decubitous ulcer healing. Evidence indicates that the effects may be mediated through the increased production of cellular adenosine tri-phosphate (ATP).

    Third, Albert Bohbot discussed laserpuncture, a therapy based on Traditional Chinese Medicine and a quantic explanation of the energetic physiology of the acupunctural network. Laserpuncture focuses on a new matrix of 300 acupuncture points located on the abdomen and back. With the treatment, an infrared laser triggers a dialog with the body under the lesion in the form of tingling, hot, cold sensations. The propagated sensation along the meridians is qi expression. The choice of acupuncture points is patient specific. Laserpuncture has promoted motor, sensation, and visceral recovery. Bohbot believes that with laser therapy, the brain is able to convert the electrochemical nervous impulse conduction into an electromagnetic post-lesion conduction, through the conversion of wavelength of the potential of normal depolarization, allowing it to cross the lesion.

    Acute Injury: Jack de la Torre discussed the use of fructose 1,6-diphosphate combined with dimethyl sulfoxide to treat acute spinal cord trauma. Extensive research shows the benefit of dimethyl sulfoxide in stabilizing spinal cord trauma and fructose diphosphate as a high-energy substrate to the injured tissue. This cocktail therapy addresses some of the immediate physiological, biochemical, and metabolic problems associated with acute SCI, such as reduced spinal cord blood flow, free radical formation, sodium channel activation, inflammatory reaction and energy substrate depletion.

    Second, Anders Holtz reviewed various neurosurgical considerations following acute SCI. For example, before surgery, there is a need to be aware of the secondary injury damage stemming from residual compression; to establish the extent of neurological damage using ASIA/IMSOP criteria; and to radiologically characterize the injury. Initially, it is also important to focus on the respiratory system, to help the cardiovascular system, and to initiate methylprednisolone treatment within the drug's therapeutic window. Overall, the aim of surgery is to minimize neurological deterioration, to restore alignment and stabilization, to facilitate early mobilization, to reduce pain, to minimize hospital stay, and to prevent secondary complications. Holtz summarized some of the factors that are often used to choose surgical over conservative treatment. Specifically, surgery is often preferred if there is concern with secondary injury, the fractures are unstable, there is a contusion to the cord, there is canal compromise, there is ongoing neurological deterioration, the lesion is incomplete, it is a lower injury, and the patient is younger.

    Functional Electrical Stimulation (FES) and Orthotic Devices: Jack Edwards reviewed his upright mobility programs, which have cumulatively treated 470 people with SCI. With training, most users of reciprocal gait orthoses (RGO) can walk distances of over 300 meters at speeds from 0.2 to 0.5 m/s. Furthermore, after standing rest, they can continue up to distances of 0.6 Km without sitting down. The most common complaint was upper limb pain and discomfort, especially the hands. To reduce these effects, Edwards used a number of advanced orthotic designs, including hybrid RGO-FES systems and microprocessor controlled orthotic knee joints, which allow the RGO knee to bend during the swing phase of walking. The devices reduced the force on the hands by 15% and energy expenditure by up to 30%. Overall, the incidence of urinary tract and lower respiratory tract infections, spasms, and pain were less in individuals that were part of their upright mobility program compared to general wheelchair users.

    Second, Maurizio Ferrarin discussed how biomechanics allows the optimal design of mechanical orthoses for restored walking in paraplegics and provides information for the development of musculoskeletal system models useful for the design and test of strategies for the control of FES systems. Multi-factorial movement analysis techniques allows the quantification of the functional advantages of a single treatment, the comparison of different solutions, and the adaptation of a device to the characteristics of a specific individual. The following examples were presented: the development of a new hip joint for the RGO that provides a more physiologic pelvic rotation; the analysis of the improvements provided to patient hemodynamics by the combination of FES to the RGO; and the development of a control strategy for FES-induced standing up, based on the EMG signal of supralesional muscles.

    Third, Anatoly Vitzenson has used FES muscle stimulation to artificially correct movements in 900 patients with SCI. In his study, which focused on lumbar-sacral injuries, the hip and knee joints muscle extensors were stimulated in 20 sessions. The program resulted in improved anthropomorphous walking properties; enhanced walking velocity, cadence, and step length; decreased fatigue; growth in muscle force and electrical activity during maximal effort; and partial normalization of innervative gait structure. Also, the therapy has restored some pelvic organ function. Vitzenson believes that excellent, good, and satisfactory results have been obtained in 6%, 83%, and 11% of his patients, respectively.

    Fourth, Michael Keith summarized the results of implanting the FreehandTM neuroprosthesis to recreate gripping hand motion in quadriplegics. To date, over 200 neuroprostheses have been implanted using 50 surgical and 55 rehabilitation centers. Typically, the implanted muscles are those that represent key movements, such as the thumb abductors, flexors, extensors, and finger flexors and extensors. The chosen muscles are strong and have good innervation. The muscles after having been instrumented by the implantable device are then programmed by an external computer. The patient carries a portable device, which has information regarding the quality of muscles and the patterns of motion that the patient is to have. Up to eight muscles can be controlled by a variety of control sources. Patient independence was improved by average of 85% over their pre-operative state. Adverse effect incidence has been low.

    Fifth, Nick Donaldson discussed possible locations for and issues surrounding the placement of implanted stimulators. Overall, he believes that implanted stimulators are more convenient to use, give more repeatable responses, and more muscles may be stimulated. However, there is no consensus about where the electrodes should be sited. Possible sites include nerve twigs, nerve branches, nerve trunks, nerve roots, or the spinal cord. The most promising methods seem to be stimulation of the nerve roots in the cauda equina and spinal cord microstimulation.

    Finally, Antony Tromans summarized a variety of potential FES applications beyond limb movement, including respiration; bladder, bowel, and sexual function; and skin problems.

    Aggressive Physical Rehabilitation: As the likelihood of real-world SCI therapies increases over time, Arnie Fonesca emphasized that it will be important to have follow-up aggressive physical rehabilitation to maximize function in long dormant muscles. Professional athletes rehabilitate more efficiently because they have access to the best care and equipment and are surrounded by highly motivated people to complement their own skill and motivation. Fonesca believes that if we similarly treated SCI, functional recovery would be much greater. At minimum, the individual would be in better physical shape, better able to endure SCI secondary conditions, and have a self-confidence boost. As an example, Fonesca discussed how aggressive physical rehabilitation enhanced function following omental transposition therapy.


    In conclusion, the conference's whole-is-greater-than-the-sum-of-the-parts philosophy believed that the big breakthroughs will happen only if we open-mindedly bring together divergent yet often synergistic treatment and research perspectives. Recognizing that today's cutting-edge, scientific insights are often tomorrow's anachronisms, this conference attempted to set aside the illusion of knowledge that so frequently inhibits discovery.

    Adapted from article appearing in Paraplegia News, September, 2001 (For subscriptions, contact

    Icelandic Officials:

    Audur Gudjonsdottir, R.N.O.R., University Hospital, Iceland (meeting organizer)
    David Gunnarson, Secretary General, Ministry of Health
    Vigdis Finnbogadottir, ex-President & UN Goodwill Ambassador
    Lara Margaret Ragnarsdottir, Member, Parliament & Representative, Council of Europe
    Elias Olafsson, M.D., University of Iceland
    World Health Organization:

    Enrico Pupulin, M.D., Chief Medical Officer for Disability & Rehabilitation, Geneva
    National Institutes of Health:

    Ralph Nitkin, Ph.D., Nat. Center Medical Rehabilitation Research, Bethesda, Maryland

    Tarcisio Barros, M.D., Ph.D., University of Sao Paulo, Brazil
    Albert Bohbot, Sens-Beaujeu, France
    Giorgio Brunelli M.D., Ph.D., University of Brescia, Italy
    Thomas Carlstedt M.D., Ph.D., Royal National Ortthopaedic Hospital, Stanmore, U.K.
    Nick Donaldson, Ph.D., University College, London, U.K.
    Jack Edwards, Ph.D., University of Salford, U.K.
    Maurizio Ferrarin, Ph.D., Don Carlo Gnocchi Foundation Polytechnic of Milan, Italy
    Arnie Fonseca, M.S., Neurostrength Physical Therapy & Conditioning, Arizona, U.S.
    Harry Goldsmith, M.D. University of Nevada, Reno, U.S.
    Anders Holtz, M.D., Ph.D., University of Uppsala, Sweden
    Laurance Johnston, Ph.D., Mountain States Paralyzed Veterans of America, Colorado
    Michael W. Keith, M.D., Case Western Reserve University, Cleveland, Ohio, U.S.
    Margaret Naeser, Ph.D., Boston University School of Medicine, Massachusetts, U.S.
    Hernando Rafael, M.D., Universidad Nacional Autonoma de Mexico, Mexico City
    Fernando Ramirez, M.D., Int. Spinal Cord Regeneration Center, Tijuana, Mexico
    Paul Reier, Ph.D., University of Florida, Gainesville, Florida, U.S.
    Semion Rochkind, M.D., Ph.D., Tel Aviv University, Israel
    Evan Snyder, M.D., Ph.D., Harvard University Medical School, Boston, Massachusetts
    Anba Soopramanien, M.D, Ph.D, Duke Cornwall Spinal Treatment Centre,, UK
    Georgie Stepanov, M.D., Ph.D., Central Inst. of Traumatology & Orthopaedics, Moscow
    Jack de la Torre, M.D., Ph.D., University of California, San Diego, U.S.
    Antony Tromans, M.D, Ph..D, Duke Cornwall Spinal Treatment Centre, Salisbury, U.K.
    Anatoly Vitsen, M.D., Ph.D., Central Research, Institute, Moscow, Russia
    Shaocheng Zhang M.D., Ph.D., Military University of Shanghai, China

  4. #4
    Senior Member mk99's Avatar
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    Jul 2001
    toronto, canada

    peripheral-nerve rerouting

    Peripheral-nerve rerouting sounds pretty interesting. I'd love to hear more on this... Dr. Young or anyone else?

    Could you do enough grafts to restore some motor function to hip flexors, hamstrings & quads? That would be good enough to walk wouldn't it? (you'd still need brace for knee, foot drop, etc)

    of course this doesn't restore any sensation at all. Very interesting though.

  5. #5

    At the Brescia meeting, I had the opportunity to spend some time with Professor Giorgio Brunelli who has been doing the peripheral to peripheral nerve grafting. As you may remember, he had earlier taken taken part of the ulnar nerve in several patients, rerouted and bridged the ulnar nerve so that it can be connected to the peroneal nerve (a branch of the sciatic nerve). He was also to show that these patients recovered some ability to activate the quadriceps and gluteus muscles. This approach unfortunately does not restore sensation or feedback. Several people before and at the meeting had met the patients and described the recovery as being real but not particularly useful yet for walking.

    Two years ago, Professor Brunelli did a different procedure in a young woman (she is now 25 years old). He rerouted a peripheral nerve and inserted the nerve into the spinal cord above the injury site. The patient apparently is able to stand and take some steps. Dr. Brunelli claims that the corticospinal tract is sending axons into the nerve and is reinnervating the muscle. Most of the people in the audience, including myself, were very skeptical that this was indeed the case. He has not yet done much o the electrophysiological studies that are needed to demonstrate this. According to Dr. Brunelli, the patient had a virtually transected spinal cord at about T8 (I think) and so he believes that all the recovery is stemming from the peripheral nerve transplants. A person in the audience asked if he tested the reflexes of the patient's legs... if there was a reflex , then it must be partly mediated by segments below the injury site. In any case, he had not tested this and therefore could not say. However, Dr. Brunelli did say that the patient was recovering bladder function which makes me think that the patient is recovering function across the injury site and not from the nerve transplant.

    There is a great deal of controversy about this procedure. Much still needs to be done to figure out whether the observed recovery is due to the transplants and what is really happening with the peripheral-peripheral bridging, and the peripheral-cord bridging.


  6. #6
    By the way, I spent some time renewing old friendships with Larry Johnston at the Brescia meeting. He is very active and doing well. He told me that comes to our site here often. Wise.

  7. #7
    Senior Member mk99's Avatar
    Join Date
    Jul 2001
    toronto, canada
    Thanks very much Dr. Young. I appreciate your response.

    hey perhaps with this method & some fancy FES, walking (although like a robot) is not far off at all. I'd still MUCH prefer real meaningful regeneration.

    Somedays I feel quite positive & hopeful about the not too distant future... somedays not.

  8. #8
    Senior Member
    Join Date
    Mar 2002

    Peripheral Nerve Rerouting; updated 03/30/02

    I am interested in PNR (or?) to help with a complete SCI injury at T12. If the procedure is capable of restoring any function, than why not try it? My family will consider a "grant" to anyone who can provide documented results to our attorneys. Many terms and conditions apply. I or our attorney can be reached through the following email address.

    [This message was edited by Bob/TN on Mar 30, 2002 at 04:24 PM.]

  9. #9

    I am not sure that you are aware of the mechanisms or the implications of the peripheral nerve reconnection approach. Can you describe what you think that procedure is doing and why you are so interested in it before we delve into who is doing it and why in the Western hemisphere? There are actually many neurosurgeons and plastic surgeons that are doing peripheral-to-peripheral nerve grafting in the United States, although not for spinal cord injury. I need to know what your understanding is of the procedure so that we can fill in some of the gaps. This kind of grafting requires an understanding of the neuroanatomy of the spinal cord and peripheral nerves.


  10. #10

    I also posted this at the Kao site........

    First you all need to know that the article written by Dr. Johnston that was posted was really only a partial portion of the actual article.....if you purchase the magazine (April 2002) you will find the entire article complete with pictures describing everything much better.

    Here is a part of that article that better explains what it is that Dr. Zhang is doing-explained by Dr. Johnston-:

    "In spite of intimidating neuroanatomical terminology, peripheral-nerve rerouting is conceptually relatively easy to understand. For example, visualize a house in which power to the back bedroom is lost (i.e., area below the injury) due to a burned-out master electrical cable (i.e., SCI). Instead of fixing the master cable, you disconnect the wire that powers the living-room TV (i.e., a nerve to the rib or wrist region), tunnel it through the walls (i.e., the body), and splice it directly to the bedroom wiring, circumventing the damaged section of the master cable. If the redirected wire (i.e., the the nerve) isn't long enough to reach the bedroom (i.e., area below the injury), you splice an intervening piece of wire (i.e., sural nerve) cut out from a part of the basement that you rarely use (i.e., the leg region). In order not to lose TV function (i.e., rib or wrist function), you simply insert the TV plug (i.e., rib our wrist nerve) into another living-room outlet (i.e., an area-nerve- close to the wrist or rib) (i.e., establishing alternate connections). Although this procedure may not be as desirable as replacing the master cable, you now have power in the back bedroom (i.e., function below injury)."

    The article in the magazine goes on to explain "As expected, the body attempts to heal itself with scar tissue, which is a Band-Aid. When the Band-Aid is removed (i.e., the scar tissue is removed), and the pressure alliviated from the spinal cord or the nerve root, things begin to work again". The article tells about 3 people that had the peripheral-nerve-rerouting operations by Dr. Zhang (and that Dr. Johnston observed these operations)........I won't re-write all 3 cases BUT here is case #3-

    "Although involving a peripheral-nerve SCI treatment, the 3rd surgery represented a fundamentally different procedure, which Dr. Zhang has performed in more than 12 patients, and is included because of it's radical nature. This case involved a 36-year-old Chu, who had recently become a C4 quadriplegic due to a construction accident. In Chu's operation, detached sural-nerve segments were inserted directly into his injured spinal cord. These segements were initally scraped to expose nerve fibers and, after scar tissue was removed from and incisions made in the remaining cord, inserted lengthwise without suturing. The next day Chu, who had previously had only residual bicep function, was able to move his hands."


    I contacted Dr. Johnston via email after I read this article that he wrote. I first explained to him everything that Dr. Kao did for Jim. Next I asked him what the differences (if any) were with what Kao did in Jim's operation verses Zhangs procedures-GIVEN THAT CASE #3 SOUNDS LIKE WHAT KAO DOES BASICALY. I also asked if this might be something that we may want to at least look into (Zhangs procedure). The reason I asked that was because the article also said: "One surgical rerouting designed to restore a specific function (i.e., the bladder), DOES NOT PRECLUDE a future rerouting to restore a different fuction (i.e., walking)."

    OK, OK, OK, so what if any was Dr. Johnstons reply you are on.....he did answer me via email and here is his answers:

    "Dear Robin:

    Thank you for sharing your husband's surgical procedures with me, as well as
    the results he has obtained. Perhaps you should consider writing a letter to
    "Paraplegia News" so you you could share this information with other readers.

    Please note because I am not a medical professional but a scientist, I am not
    the most appropriate person to comment on Dr. Kao's surgical procedures. Dr.
    Kao's surgery seems much more involved than any of the surgeries I observed
    in China. Kao combines peripheral nerve implants, which sounds like case
    three in my article, with a variety of other surgical procedures, including
    an omental graft.

    Although I cannot assess the whether Jim would be a could candidate for the
    procedure, the peripheral nerve rerouting that I mostly emphasized in my
    article is a fundamentally different procedure in which the injury site is

    For your reference, there is a physical therapist, Arnie Fonseca in Phoenix, who has gotton some excellent results maximizing
    function in individuals with SCI, who have had function-restoring surgical

    All the best


    Now, I have not spoken with Arnie Fonseca since before we went to Ecuador. Yes, I know him or should I say I know OF him, and have spoken via phone and emails with him several times. Very NICE man!!! I did not speak to him regarding Dr. Kao or Kao's procedures.....I spoke with him in regards to Dr. Harry Goldsmith and his procedures with the omentum and so Mr. Fonseca (Arnie) is not aware, I am sure, that we did go to Ecuador and had Dr. Kao's procedure, to be honest, I forgot all about Arnie until Dr. Johnston brought him up again. So, I will be contacting him again. I do seem to remember Arnie saying that basicaly we would have to "re-locate" to Arizona for at least 3 months if not 6 months for this therapy to be worth while, and that he would help us find a place to stay. Three to six months seemed very "hard" for us given we have 2 kids in school and that would either require leaving them with a relative, or me staying and Jim going, or up-rooting the kids from school here, and going to Arizona and putting them in a new school for a while......HARD!!! is a portion of that email from July 2001:

    "Jim we would love to work with you. We understand that you have to also live your life also. In general our program would cost you about $4,000 per month. This would be private pay but each persons situation is a little different. This would allow for a minimum 3 hours of intense therapy six days per week. If you have access to insurance we would have to negotiate the price with them. We also would be able to help with relocation information. This would require a great sacrifice. We also would want a 6 month commitment. Any less would be less than beneficial. And this is a minimum. We don't have any goals besides enabling you to reach the highest potential you may have. Let me know your mailing address and I'll send you a brochure."

    SO, until I hear from Dr. Zhang(I was asked by a few people at the Kao site what the differences are Kao vs. zhang, or if Kao's patients would bennefit in any way with Zhangs procedures)......I know little more then you. As soon as I do hear something, I will share with you what he said. I can tell you, I think I said it before, Dr. Harry Goldsmith told me in late June-early July of 2001 (just before we went to Ecuador) to look into Dr. Shaocheng Zhang and his procedures.......I did and we decided to "stick" with Kao.....alot had to do with his experiance.....Kaos hundreds verses Zhangs 12 (handful).......

    I also found Dr. Johnston's comments and thoughts at the end of the article to be "QUITE INTERESTING" - YOU BE THE JUDGE-

    1.) "Increasingly, it seems the most exciting SCI therapeutic breakthroughs are originating in numerous places other than America..."

    2.) "I believe the cows will come home a long, long time before the pigs tell us anything".....this comment was made by Dr. Johnston about "Christopher Reeve's opinion which reflects the prevailing conservative approach of the American SCI research community, which believes serving its needs for scientific rigor is the best way to meet the needs of people w/ SCI for new therapeutic options."

    3.) "Dr. Zhang's peripheral-nerve-rerouting approaches appear extraordinarily promising for restoring significant function after SCI"

    4.) "...we must open-mindedly develop synergistic, mutually beneficial collaborations that can evaluate innovative procedures such as Zhangs and, more importantly, facilitate new understandings." Johnston goes on to say that if the world can share culinary technology, such as the BIG MAC, around the world....that it would be "an absurd sense of priorities not to be able to somehow share SCI therapeutic knowledge that would benefit so many. If we bring together all the exciting SCI developments throughout the world, restoration of function would no longer be some pie-in-the-sky dream but a real-world expectation."

    Can you or anyone argue with that?

    Until later.

    FYI- in case anyone wants to contact Dr. Shaocheng Zhang- here is his contact info:

    MAIL: 32-43-301, ZHONGYUAN RD.
    SHANGHAI 200433, CHINA

    FAX: 0086-21-65346003

    *for anyone interested in this peripheral-nerve-rerouting surgery, Dr. Zhang is willing to consider foreign patients who would stay in a modern foreign-guest clinic, or he is willing to visit America to carry out the surgery if an appropriate collaborative relationship can be established w/ a U.S. hospital.

    To contact Dr. S. Laurance Johnston (author of the article) email him at:

    To contact the physical therapist, Arnie Fonseca, of Phoenix, Arizona email him at:

    [This message was edited by BirdeR on Mar 30, 2002 at 02:11 PM.]

    [This message was edited by BirdeR on Mar 30, 2002 at 03:11 PM.]

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