Melanie Cole (Host): Today we’re talking about nerve transfers in the pediatric population and my guest is Dr. Felicity Fishman. She’s and Orthopedic Hand and Upper Extremity Surgeon at Shriners Hospital for Children in Chicago. Dr. Fishman, it’s a pleasure to have you back on with us. Tell us what is nerve transfer surgery.
Felicity Fishman, M.D. (Guest): So, nerve transfer surgery is a very specialized way to try and treat specific deficits and for me, I’m targeting the upper extremity and in specific, we are looking at ways to use nerves that are functioning and hopefully we have nerves that are expendable and redundant, and we can use those to make something that isn’t working work in the future.
Host: Wow, isn’t that amazing what you can do? So, when would a child need this kind of surgical intervention?
Dr. Fishman: Nerve transfers can be used in a lot of different scenarios. One pathology that is helped by nerve transfers is brachial plexus birth palsy. We have started using that in addition to other types of surgery. Otherwise, it’s helpful in scenarios in which a child has had a trauma that resulted in changing of function in the upper extremity and more recently, we’ve started using it for acute placid myelitis.
Host: Well that’s interesting since that’s relatively new to the scene here. So, tell us a little bit about the benefits for nerve transfers over nerve repair. Are you providing closer to the targeted muscle? Tell us about recovery time and benefits to this.
Dr. Fishman: Well one of the great things about a nerve transfer is that you are hopefully shortening the amount of time that it takes to recover. And what we know about nerves is that they begin to regenerate about a millimeter a day which is about an inch a month. And really, it’s a numbers game in terms of repairing something and hoping that it gets to it’s target in time. For motor function, in terms of moving the hand or the arm; you have about a year to 18 months before the target is no longer able to be activated even if your repair recovers. So, if we think about the length of a child’s arm or where the injury occurs; it’s different if it is up near the axilla than if it’s down near the hand in terms of the length that it needs to regenerate.
So, a nerve transfer takes one nerve that’s working and puts it very close to it’s target and therefore the time is shortened in which it needs to recover.
Host: That’s so cool Dr. Fishman, so, can you explain for the listeners, for parents out there, a little bit about the procedure? Tell us a little bit about what it’s like for the child.
Dr. Fishman: Well it depends exactly which nerves we are transferring. Some of the procedures are much bigger than others. If we’re doing sensory nerves or even motor nerves in the forearm or hand; you would have an incision with a general anesthesia and probably a cast afterwards. If we’re doing bigger procedures which sometimes are targeted for the children who have less function in their arm and therefore, we have to be more creative with our donor nerves than sometimes that surgery does require an overnight hospital stay and potentially a prolonged recovery in that sense.
Host: and then what sort of testing do you do? Nerve function testing, physical exam and after the procedure, how do you know that it worked?
Dr. Fishman: Well most of our testing is just via a physical examination. Certainly, preoperatively, and especially in older children or children with acute flaccid myelitis, we usually obtain a nerve conduction study or an EMG and then postoperatively if we’re having trouble figuring out in terms of the physical exam, a second EMG may be helpful after six months to nine months. But really, we’re mostly following the clinical exam to see if there are signs of recovery.
Host: And then what is that recovery process like, the postoperative care? Tell us a little bit about after the procedure
Dr. Fishman: So, depending on what nerves were transferred, we may restrict certain motions. So, if we transfer a nerve from beneath the rib cage over to your arm, then we would restrict your ability to passively move the arm away from the body for a few weeks to allow those nerves to have time to heal to each other. But after that, usually we resume therapy as the child is doing prior to surgery and allow them to continue with therapy both actively and passively.
Host: Are there any disadvantages or challenges to the nerve transfer as you see it? What would you like us to know about some of the challenges that you may face when you’re telling parents about this procedure?
Dr. Fishman: Well when we’re doing a procedure such as a nerve exploration or a direct nerve repair; we aren’t borrowing function from anywhere else to try and improve a function that we’re missing. We’re simply trying to restore what was missing. When you are thinking about a nerve transfer, in the same way that I think about a tendon transfer, I have to borrow something that I hope is expendable or redundant in order to try and make something else work. So, a technical downside would be that you are borrowing something that is currently working to try and make something else work, but you do have to borrow something else. So, you are robbing from Peter to pay Paul.
Host: That is amazing how you can do that. And certainly, Dr. Fishman, this is a team approach both surgical and after; explain a little bit about the multidisciplinary care that a child receives when they are going through this procedure.
Dr. Fishman: Depending on what the diagnosis is, the child has often seen multiple physicians before they even end up having a surgical evaluation. And we rely upon all of the other team members in order to have a maximal outcome. For sure, we have the physiatry or physical medicine and rehabilitation doctors and they are very helpful from both the rehab side as well as the initial diagnosis and watching kids as they initially recover. The neurologists are helpful with some of our testing such as the EMG or other nerve studies and then therapy is the mainstay of the rehab for all of these patients.
Host: Now one thing I didn’t ask you Dr. Fishman, as nerves take a long time to recover when they’ve been traumatized in any way. Tell us a little bit about how long this recovery takes for the parents and a child so that they have hope that yes, it is going to work, it just, nerves take a while.
Dr. Fishman: You are correct. Nerves take and incredibly long time in which to see any sort of recovery and again, it’s mainly a math game in that they recover a millimeter a day or an inch a month and so for most nerve transfers, we don’t expect to see even a flicker of motor recovery for almost six months sometimes. And when we say motor recovery at that point it’s not watching a child lift his arm up against gravity, it’s often just a little bit of the muscle contracting. So, it can be even longer, nine months or so, before we are seeing functional recovery. And that waiting period can be very frustrating for the patient and doctor alike and so, we have to discuss this in depth ahead of time so that we all are on board for the six to nine months in which we are hoping for recovery.
Host: Well that’s really an important point and I’m so glad that you made it because that would be frustrating for as you say both the patient, the parents and the doctor because it’s kind of just a waiting game. But it really is amazing, technology that you are doing there at Shriners Hospitals for Children in Chicago. As we wrap up, please tell listeners what you’d like them to know about nerve transfers in the pediatric population. Why these are so amazing that you’re able to do this and really what you’d like them to know about your team at Shriners.
Dr. Fishman: So, I think the Shriners team is wonderful because we have all the components of the team, the physiatry side, the surgical side, the rehab side and a great inpatient and outpatient facility for all of our surgery and rehabilitation needs. And I think that having the ability to offer nerve transfers for a variety of different reasons whether it be traumatic or brachial plexus or acute flaccid myelitis is a great scientific and surgical advancement that I hope brings function to many kids that may not have had that opportunity 20 or 30 years ago.
Host: Thank you so much Dr. Fishman. That really is amazing. Such an interesting topic. Thank you again for sharing your expertise. This concludes another episode of Pediatric Specialty Care Spotlight with Shriners Hospitals for Children in Chicago. Please visit our website at www.shrinerschicago.org for more information and to get connected with one of our providers. Please remember to subscribe, rate and review this podcast and all the other Shriners Hospitals for Children in Chicago podcasts. For more health tips and updates on the latest medical advancements and breakthroughs please follow us on your social channels. I’m Melanie Cole.
