Expanding patients' abilities through nerve surgery [Music playing] [Text on screen: WexMed <Talks> Amy Moore, MD Chair, Department of Plastic and Reconstructive Surgery Time and Change, The Ohio State Campaign The Ohio State University Wexner Medical Center] Amy M. Moore, MD, FACS: Good evening. I am Amy Moore. [Music stops] Dr. Moore: And I'm the Chair of the Department of Plastic and Reconstructive Surgery at The Ohio State University. I'm excited to share my research and clinical work with you today. When I tell someone I'm a plastic surgeon, I often get a look of surprise followed by a touch of the face and a, "Can you help me?" My response is, "Well, I'm not a cosmetic surgeon, but I have great partners who are." Interestingly, cosmetic surgery comprises only a small subset of our specialty. [Screen shows photos from popular TV shows. Text on screen: Extreme Makeover Nip Tuck The Swan Dr. 90210] Dr. Moore: But due to the televised shows such as Nip/Tuck and Dr. 90210, most of us believe plastic surgery is only cosmetic surgery. Well, plastic surgery is cosmetic surgery, but it is also reconstructive surgery. We can treat patients with congenital differences and wounds from cancer resection, wounds from trauma and burns. We are specialized micro-surgeons. Some of us are hand surgeons and others are surgeons that move tissue from all over the body to restore form and function. I am a very sub-specialized plastic surgeon. I completed a plastic surgery residency and orthopedic hand fellowship, and I spent two years in a basic science laboratory studying how and why nerves grow. Thus, today I stand before you as a peripheral nerve surgeon. I am a plastic surgeon, but I am one who restores motion to limbs, sensation to hands and I alleviate pain with surgical procedures on nerves. [Text on screen: Brain Spinal cord Nerves] Dr. Moore: The peripheral nervous system involves all of the nerves that extend out of the spinal cord and they enter into the muscle and skin to allow us to move and feel. Unlike the brain and spinal cord, peripheral nerves can regrow after injury. [Text on screen: ~1mm Growth/Day 3cm Growth/Month 36cm Growth/Year] Dr. Moore: This regrowth is powerful, but slow and inefficient, such as a millimeter a day, an inch a month and a foot and a half a year. So if you have an injury of the nerves of the brachial plexus at the neck, it would take almost two years before the nerves can grow down the arm and reach the muscles of the hand. [Text on screen: Normal Time of Injury Atrophy 0-12 Months "Irreversible" Atrophy 12+ Months] Dr. Moore: Unfortunately, muscle has an expiration date of about 12 to 18 months. So as a nerve surgeon, my goal is to get that nerve and the electrical signals it carries to the muscle before it's too late, and thus, it prevents irreversible atrophy of the muscle. We seek to understand many things in nerve surgery, such as can we improve the speed and efficiency of nerve regrowth? Or is it possible that we can rewire nerves to prevent muscle atrophy, to avoid pain or restore motion? My research is focused on these questions and it is driven by the patients I see every day in my clinic who suffer from nerve injuries. Nerve surgery, the plastic surgery that I perform, restores quality of life, and that is often life-changing. Let me tell you about George. George is a professional guitar player. He was in a motor vehicle collision and suffered numerous injuries including broken bones and injuries to the muscles and nerves of his left arm. This was devastating because George was unable to play the guitar and that was his livelihood. I was the hand surgeon on call when he arrived into the emergency room and I took George to the operating room to assess the damage. Unfortunately, he lost many muscles of his arm and he cut the ulnar nerve, which left him with a large nerve gap between the two ends. This is a problem because the ulnar nerve supplies the electrical energy to all of the small muscles of the hand, which are essential for playing the guitar. That night, I rearranged tissue and skin of his arm to cover the exposed blood vessels and bone, and I also reconstructed his nerve using a spare nerve of his leg just like an extension cord. I also performed a special nerve transfer, a rewiring of the nerves, to save the delicate muscles of his hand. It was in our research laboratory that we studied the ability to move nerves and reconnect them to improve function. [Text on screen: From Bench-top to Clinic Innovations of Peripheral Nerve Surgery Nerve Grafting PLUS Nerve Transfers] Dr. Moore: We showed that in the scenario of the extension cord or nerve grafting, if we added this nerve transfer or the rewiring, we could increase the amount of axons into the muscle and ultimately increase the power of that muscle. Because of the many laboratory animals that received nerve transfers and the multiple positive outcome metrics that demonstrated improvement, we have translated this procedure into the clinical realm. George is one of the many patients who have received this type of nerve reconstruction, and as you can see from his video, two years later, his function and more importantly, his quality of life have been restored. [Video: Patient playing "Sweet Child of Mine" on the guitar] Dr. Moore: But now let's talk about Zach. Zach has a different nerve problem. He was a 15-year-old boy who fell off a motorcycle and suffered a spinal cord injury affecting his left leg. This means that the nerves powering the muscles below the knee were unable to work. From my experience with nerve injuries in the upper extremity, my research studying nerve transfers and my knowledge of the anatomy of the lower extremity, I created two nerve transfers to restore movement to his gastrocnemius muscle. This muscle is the one that allows us to point our toes and to push off the ground when running. I used the redundant nerves of his thigh and rewired them to the gastroc nerve. Thankfully, the novel procedure worked and at one year after surgery, he was back playing on his varsity basketball team, a feat not previously thought possible. Most recently we've been exploring this question, how can we use nerve transfers to help children walk again? This is Brandon. Brandon was a healthy seven-year-old child when he caught the common cold. In addition to fevers and a cough, this virus also attacked his spinal cord, causing flaccid paralysis of his arms and legs. It left him wheelchair-bound. He was diagnosed with a rare disease called acute flaccid myelitis. [Text on screen: Acute Flaccid Myelitis Polio-like illness] Dr. Moore: Many refer to this as the polio-like illness because it has the same clinical features of polio and predominantly affects children under the age of 10. Due to the success of using nerve transfers in the lower extremity, like Zach, my colleagues at a children's hospital in Philadelphia asked if I could help. After hearing their stories, I was compelled to apply nerve transfers to these children. I heard many of the children could wiggle their toes, and I saw this on my exam. Unfortunately, they couldn't stand. Thus, after planning and practice, I performed a novel nerve transfer that rewired those nerves that moved the toes to the nerves that could stabilize the hip and thighs. Here is a video of Brandon now. Thankfully, he is only in his wheelchair to play basketball, and I have had the opportunity to help many more patients with acute flaccid myelitis walk. You may have noticed that nerve transfers haven't restored my patients to quote, unquote "normal". However, Brandon and Zach still wear braces and George still has trouble extending his fingers. Sterling Bunnell, a famous hand surgeon once said, "For those who have nothing, a little is a lot." My patients inspire me to innovate, they push me to explore surgical options in my laboratory. They motivate me to understand. In the world of nerve surgery, restoring a little bit of motion changes lives, but there's more for us to do. While I've shared with you stories of where we have been and those I have helped, we are ready to do more with the great resources and collaborators at Ohio State. [Text on screen: Congressionally Directed Medical Research Programs CDMRP Department of Defense] Dr. Moore: I'm excited to partner with the Department of Defense to help treat our nation's war fighters who have also suffered devastating nerve injuries. As part of a larger military program, we are launching a clinical trial that explores the use of electrical stimulation to increase the speed and that efficiency of nerve growth. It is through the combination of basic science research and translational clinical trials that we will be able to truly restore the quality of life in our patients with nerve injury. So let me take you back to the beginning. I am a plastic surgeon. I am a scientist who studies nerves. I move nerves. I rewire them to restore function, and together with your support, we will change lives. [Music playing] Dr. Moore: Thank you. [Text on screen: WexMed <Live> Time and Change, The Ohio State Campaign The Ohio State University Wexner Medical Center]