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Thread: interesting article in Paraplegia News.

  1. #11

    Perhaps of some interest........

    This is a portion of an email dated July 20, 2001 that I received from Dr. Johnston regarding Kao, Goldsmith, as well as others involved in peripheral nerve procedures he wrote this:

    "Peripheral Nerve excerpts:

    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 zig-zag 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."

  2. #12
    Thanks BirdeR for posting this information.

  3. #13
    Senior Member rdf's Avatar
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    Wise, what do you think about Dr. Zhang's procedure? I'd like to hear your comments. Thanks
    -Bob

  4. #14
    Senior Member giambjj's Avatar
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    nerve transfer

    Shriners hospital in Philly is doing nerve to nerve transplantation to restore muscle function in kids with high spinal cord lesions with good success.

    JJG

  5. #15
    Super Moderator Sue Pendleton's Avatar
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    ""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."""

    First off, where does Dr Johnston work? And this is something I have been hearing about that is near to human trial (no don't write and ask where, I can't tell you). With the tiny amount of damage that I have and, that, mainly of myelin sheathing sural nerve autografts after going through a "food processor" of sorts makes a bit of sense to me. And now especially that the scar factor is gone. Is it possible to remove by micro surgery or laser to remove the current small area that was effected by the ischemia? Or is that even desirable before a gooey growth paste is slapped on?

    And if you didn't have too many grappas while talking to Dr Brunelli, Wise, is the sural or other removed transplant nerves going to cause future problems or will those nerves, peripheral, really regenerate on their own? I was hoping for M-1 but since my 10 year "I've had it date" is getting closer I have been looking more and more into the sural grafts and these just make sense to me. I doubt they'll fix things completely because even a small amount of gray matter that is damaged will remain but I can live with some of that if the main muscles get enough juice to get me around my own home.

  6. #16
    Sorry, I started to answer the questions here but realize that there is so much that needed to be said that I decided to write an article on peripheral nerve rerouting instead. Much of the procedures that are being tried and reported are not that new. They have been used in animals for a long time and the topic must be discussed with a clear picture of the neuroanatomy, to figure out what is going on and what may happen with such rerouting. I will post as soon as I finish the article. It is taking longer than I thought because I am trying to illustrate the reconnections that various surgeons are doing.

    I am also trying to get a clear handle on what Zhang has been doing. Several things in the description below bother me. The concept that a patient immediately recovers function in a biceps after a transplantation suggests that either the patient had a placebo response or the observation is not particularly objective. It certainly cannot result from regeneration or reconnection. It may also be a result of untethering or removal of scar tissues. I don't think that it is related to the sural nerve.

    Larry Johnston, by the way, is a old hand in the spinal cord injury field. I first met him in the 1980's. He worked at NIH for a number of years and then was the executive director of the SCRF of the PVA, managing the grant review process. About five or six years ago, he moved to Colorado where he has been focussing on alternative medicines and the potential role of such treatments on conditions such as spinal cord injury.

    The WHO conference in Reyjavik was an important one because it gathered together many of the principles of alternative medical approaches to spinal cord injury. I wish that I had the time to go that meeting. One of the outcomes of that meeting is that WHO has agreed to set aside budget to establish a new spinal cord injury research center in Iceland, one that is presumably focusing on both mainstream and alternative medicine. I have heard that if this Center is set up, Larry may be asked to head this Center. Larry has a web site and is a frequent visitor to these forums. I asked him if he would be interested in helping us moderate a forum on alternative medicines for spinal cord injury. He said that he would think about it. I think that it would be very interesting to have such a forum because a majority of the people who come to this forum are and have used alternative medicines.

    Wise.

    [This message was edited by Wise Young on Mar 31, 2002 at 08:05 AM.]

  7. #17
    Sue, the sural nerve is really several nerves. You can get pictures and a description of the anatomy of the sural nerves from http://www.medmedia.com/05/52.htm and the following quote is their outline.

    Medial sural cuteus nerve:

    - tibial nerve just below knee joint gives rise to medial sural cutaneous nerve, which runs downward across union of heads of gastronemius;
    - it is joined by peroneal communicating branch from common peroneal nerve (which may arise w/ lateral sural cutaneuos), thus forming sural nerve;


    - Lateral sural cutaneous nerve:

    - arises from common peroneal nerve above knee joint & joins w/ medial sural cutaneous; to form sural nerve;
    - it runs down posterolateral aspect of calf, innervating lateral side of leg;
    - supplies: lateral and adjacent parts of the posterior and anterior surfaces of the upper part of the leg;


    - Sural Nerve Anatomy:

    - sural nerve passes down posterolateral side of leg & onto dorsal aspect of lateral side of foot, giving rise to lateral calcaneal branches (medial branch supplied by tibial Nerve)

    - its terminal branches consist of lateral dorsal cutaneous nerve and the lateral calcaneal braches;
    - sural nerve, which lies superficial to deep fascia below knee, is used as guide to tibial nerve;
    - follow sural nerve upwards to pierce deep fascia and lead to tibial nerve which is its parent trunk;
    - except for unmyelinated autonomic fibers, sural is entirely sensory;
    - it innervates lateral & posterior third of leg and lateral aspect of foot & heel, & lateral portion of the ankle;


    - Grafts:

    - sural nerve grafts are frequently used as cable grafts:
    - blood supply to the sural nerve graft usually comes thru the muscular perforating branches of the posterior tibial artery or cutaneous branches of the peroneal artery;

    - upto 25 cm of nerve graft may be harvested;


    - Sural nerve block:

    - needle is introduced just lateral to the Achilles tendon approx 1-2 cm proximal to the level of the distal tip of lateral malleolus;
    - needle is directed to the posteromedial aspect of the fibula and 5 ml of anesthetic is injected after aspiration of the syringe;

  8. #18
    I just wrote and posted an article (with illustration) of the nerve bridging methods that are currently employed:

    http://carecure.rutgers.edu/spinewir...Rerouting.html

  9. #19
    Quote Originally Posted by antiquity View Post
    A Real-world Therapy
    by S. Laurance Johnston, Ph.D.



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



    pnapr_world.jpg
    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: laurancejohnsto@aol.com.
    I think Laurance Johston's considerable praise on Dr Zhang's treatment is widespread on web. I think the words 'Extraordinarily promising for restoring significant function after SCI' has influenced and convinced a lot of people. Those are the same articles from Laurance widespread on web. But actually some of the papers/articles were co-written by both Laurance and Dr Zhang. Maybe Laurance said good about Dr Zhang because they are friends. Better we look for articles talking about Dr Zhang's treatment not from Laurance to get more biased judgment.
    I saw Dr Young stating somewhere that he had not looked at the data. Sorry, Dr Young, if i don't use exact words

  10. #20
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    Thanks for the post BirdeR. The fourth point is so crucial. ...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.
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