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.
Natasha van Zyl, the Melbourne-based 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.”
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 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.
Nerve transfers are not new, she says, 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”, she said. “Word got out and we were fairly inundated with people wanting nerve transfers.”
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.”
One time Van Zyl video-called him and saw people milling about in the room. She asked if his carer could do something for her. “He said: ‘That’s not my carer – that’s my assistant. I’m working. These are people working for me.’
“In his case it was life-saving, not just life-changing.”
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.
In a commentary published with the paper, Dr Ida Fox from Washington University in the USA writes: “Stem cells and neuroprostheses could change the landscape of regenerative medicine in the future. For now, nerve transfers are a cost-effective way to harness the body’s innate capability to restore movement in a paralysed limb.”
Case study: ‘I wouldn’t hesitate to do it again’
Paul Robinson, 34, from Australia’s Gold Coast, said the surgery had been “life-changing”.
Robinson fractured his C6 vertebra in a dirt bike accident in early 2015, a month before his 30th birthday. It left him a tetraplegic. He lost function in his hands, and was only able to manage a slight grip. Picking up objects like a cup to drink required squeezing two hands together.
“Even something light like an empty can would really be a struggle for me to grab with one hand because all I had was slight tenodesis grip, which is when you pull your wrist back and your fingers automatically close,” Robinson said.
After a few months in the spinal unit at Brisbane’s Princess Alexandra hospital, one of his health workers mentioned the research being done by Dr Van Zyl into tendon and nerve transfers.
Patients have been able to regain some independence
In December 2015, he received a nerve and tendon transfer on his right side and nerve transfer on his left side. Recovering from the surgery was difficult, both physically and emotionally, because it erased progress he had made toward rehabilitation. But once he started rehab again, he forgot about the setback.
“You spend so much time in rehab learning to do things with what you have got … and then all of a sudden you go almost back to the start,” he said. “I think I was four weeks [post surgery], not being able to move my arms, so it was back to ‘Can someone give me a drink of water, can someone change the channel?’ I was more or less bedridden for a while.
“It was probably about six months and I started really noticing the results, and then after about eight months it was like: ‘Oh wow, I didn’t even notice I was doing that.’
“I was picking stuff up and I couldn’t have done that previously. It is a slow healing process but I wouldn’t hesitate to do it again if I was in the same position. The amount of difference it’s made to my daily life makes that recovery beyond comparison.”
Robinson can now lift up to 9kg with his right hand and 4kg with his left. The restored grip function means he is able to live independently and has recently moved out of his parents’ home.
“It means I am able to pull apart and put my wheelchair in and out of the car, pick things up off the ground, hold a drink with one hand,” he said.
Using his wheelchair is also easier now he can rely on his increased strength to manoeuvre on uneven ground. He travels to Brisbane several times a week to play wheelchair rugby and regularly meets other people who have received similar injuries who might benefit from the same surgery.
“There might be someone else out there who doesn’t see that this is an option,” he said. “It has made such a big change to my life; hopefully it can help someone else too. It’s really a life-changing thing.”