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Surgeons implant nerves to activate prosthesis

Surgeons implant nerves to activate prosthesis
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Reconstructive surgeons have transplanted and rerouted nerves into the paralyzed shoulder of a motorcycle accident victim so that he will have a better opportunity to operate a myoelectric prosthesis for his missing right arm. The operation was conducted at Christ Hospital in Jersey City, N.J., by a team led by Emran Sheikh of the Institute for Nerve, Hand, and Reconstructive Surgery. Sheikh said his patient is already showing some shoulder function. “If he gets back three or four muscle groups, then that will potentially translate to three or four prostheses actions,” Sheikh said. The Hudson Reporter (N.J.) (8/11)

For 18-year-old Hussein Agiz, a resident of Edison, the night of July 12, 2012 began like many others. The recent high school graduate left his job at BJ’s Wholesale Club and rode his motorcycle over to a local industrial park to watch fellow cyclists perform wheelies and other death-defying tricks on their bikes. Hanging out with his friends on that summer night, Agiz planned to enjoy the second half of his summer before entering college to study engineering.

At around 11 p.m., the teen left the industrial park for what should have been a routine ride home.

Agiz instead encountered two drivers who were allegedly engaged in their own death-defying motorsport: drag racing on the public streets.

Traveling at excessive speeds, the drivers clipped Agiz, who was thrown from his motorcycle. In a split second, Agiz was flung to the ground with a lacerated liver, multiple internal injuries, an injury to his brain, a crushed right leg, and a right arm that was severed from his body.

The arm was never reattached, and his leg was amputated as doctors at Robert Wood Johnson University Hospital worked to stabilize Agiz and save his life.

“He was in the hospital for about four months,” said Hussein’s father, Medhat Agiz. “First he was at Robert Wood Johnson, then he was transferred to JFK [Medical Center] before he was able to come home in November.”   _____________  ‘Fifty percent of something is better than 100 percent of nothing.’ – Hussein Agiz ____________

Miraculously, the younger Agiz recovered. He was outfitted with a prosthetic leg and after months of grueling physical rehabilitation he learned to walk unassisted. But the prospect of a similar miracle for his right arm dimmed even as his overall health grew brighter. In addition to losing the right arm above the elbow, Agiz also experienced some partial paralysis in his shoulder and neck, which narrowed his chances of being fitted with a prosthetic arm that might enable him to do ordinary daily tasks like carry a bag or open a bottle.

“We looked all over for a doctor who could do something to help him and that our insurance would take,” said the elder Agiz. “We went to Johns Hopkins in Baltimore. We went to a doctor in New York. We went to doctors in South Jersey.”

It wasn’t until the Agiz family met Dr. Emran Sheikh (pronounced “shake”) that there began to be some light at the end of tunnel.

A plan of action

A nerve reconstruction specialist with the Institute for Nerve, Hand, and Reconstructive Surgery, Sheikh believed from the outset that Agiz was a good candidate for a rare nerve regeneration surgery that few doctors around the country have ever heard of.

When Agiz first visited Dr. Sheikh, several doctors had tried to determine whether the teen could be fitted with a myoelectric prosthesis, but the paralysis in his shoulder posed a big problem.

“If you try to fit a prosthesis on a shoulder that doesn’t function, then that limits what you’re going to get out of your prosthesis, if anything at all,” Sheikh explained. “And because the shoulder doesn’t have any tone in the muscles, [due to the paralysis], the prosthesis can start to dislocate from the body.”

A myoelectric prosthesisis is the latest, most advanced type of prosthesis available, Sheikh said, because “it picks up muscle impulses from the patient and translates muscle twitches into some type of function in the prosthesis.”

So, for Agiz to be fitted for a myoelectric prosthesis, it became imperative for him to regain some movement in the paralyzed shoulder.

“We made a plan for Hussein where we took nerves from his chest and rerouted them into another nerve for his shoulder and we took another [nerve] from his neck, spliced it, and rerouted part of that nerve into his shoulder.”

Sheikh led a team of surgeons, which included Dr. Renata Weber, who also decompressed a nerve in Agiz’s spinal cord.

The surgery, which took place at Christ Hospital in Jersey City, was the first of its kind for the hospital, according to Christ spokesman Paul Hebert.

It may be months before meaningful success can be measured. Sheikh explained that nerves grow about one inch per month, meaning it could take nine to 12 months for the rerouted nerves to begin to communicate with Agiz’s spinal cord and for him to regain some movement in his right shoulder. The hope is that the rerouted nerves will eventually activate the muscles in Agiz’s shoulder, thus making it more stable and able to maximize a myoelectric prosthesis.

Thus far, the early signs look promising. Sheikh and the Christ Hospital medical team operated on Agiz in May and he is able to move his neck better and he has seen improvement in what’s known as “phantom pain” where amputee patients can still feel pain in the missing limb.

“And he already has some early function in his shoulder, which is great news, because now you have something to base a prosthesis on,” Sheikh said. “If he gets back three or four muscle groups, then that will potentially translate to three or four prostheses actions [Agiz will be able to use]. These actions would include elbow motion, digit motion, and thumb motion.”

(Some myoelectric prostheses now differentiate finger, or digit, motion from thumb motion, Sheikh said.)

Technique not effective for everyone

Not every paralysis patient is eligible for this type of treatment, Dr. Sheikh explained. Stroke patients and those with significant spinal cord damage that affects the upper body, for example, might not be helped by the surgery that Agiz underwent.

Stroke patients often have “patchy paralysis” and don’t have “donor nerves” on the side of the body affected by paralysis that can be rerouted. Picking up donor nerves from the non-paralyzed side of the body requires too much time for them grow and communicate with the muscles and spinal cord.

Severe damage to the spinal cord, which is part of the central nervous system, Sheikh said, still can’t be repaired using nerve reconstruction techniques. However, there is some evidence that people with less severe damage that is limited to the lower body might be helped.

‘There may be options’

It still remains to be seen how sophisticated Agiz’s myoelectric prosthesis might be or what tasks it will enable him to do. But, as Agiz, now 19, Tweeted on June 26, 2013 – just weeks before the one-year anniversary of his accident – “Fifty percent of something is better than 100 percent of nothing.”

The accident and its aftermath have changed the trajectory of Agiz’s life. He has had to undergo multiple surgeries, and still has at least two more to go, according to his father. He has had to learn to learn how to walk again and delay his college plans. But some unexpected gifts may have come from this experience as well.

Agiz is now interested in going to school for biomechanical engineering and is considering a career in prosthesis design, according to his father and Sheikh. He and his family are also interested in helping Dr. Sheikh to educate others about the nerve regeneration treatment he is going through so more people are aware of what treatment options might be available to patients with similar injuries.

“Years ago doctors were taught in med school that if you have a nerve injury it’s permanent. There’s nothing you can do about it. But that isn’t necessarily the case anymore,” said Sheikh. “There may be options. They’re not perfect. But it’s a lot better that what you have after the injury.”

Hussein Agiz, who was not available for comment last week, seems to agree, if his comments on social media sites are anything to go by.

“The people who say it can’t be done,” Agiz Tweeted on Dec. 20, not long after he was discharged from the hospital after his accident, “shouldn’t interrupt the people doing it.”

Read more: Hudson Reporter – They ve got nerve Rare procedure performed at Christ Hospital gives new life to double amputee