By Jane Spencer of The Wall Street Journal, February 21, 2006

Advances in surgical techniques are helping patients with a common type of limb paralysis regain some movement and sensation.

The procedures employ grafting and splicing tactics to reroute healthy nerves to paralyzed muscles. In rare cases, surgeons are trying nerve transplants, in which nerves are taken from a live donor and implanted in an injured patient.

The new surgeries aren''t useful in treating the devastating paralysis that can result from spinal-cord injuries or stroke. But they are showing promise in so-called peripheral-nerve injuries, which often lead to paralysis in localized areas of the body, such as an arm, shoulder or hand.

Such injuries, which involve the nerves that travel from the brain and spinal cord to the extremities, affect more than 500,000 new patients each year in the U.S. They can result from a wide range of causes, including car accidents, combat wounds or tumor-removal surgery.

The nerve-repair treatments may also help some of the more than eight thousand American infants born each year with a type of nerve damage in the shoulder and arm that can result from birth trauma. And they are being used to restore erectile function in men whose nerves are severed during prostate surgery a consequence of about 10 percent to 20 percent of prostatectomy operations.

Dozens of recent articles in medical journals, including the Journal of Reconstructive Microsurgery and the Journal of Neurosurgery, suggest that peripheral-nerve surgeries can restore a considerable amount of function to injured areas in most patients. But despite their promise, access to the treatments is extremely limited. Only a handful of surgeons around the country, at medical centers including Johns Hopkins Hospital in Baltimore, the Mayo Clinic in Rochester, Minn. and Memorial Sloan-Kettering Cancer Center in New York City, are performing the most-sophisticated procedures.

"The vast majority of patients with these injuries are getting inadequate treatment, or no treatment at all," says Susan E. Mackinnon, a leading nerve surgeon who has pioneered some of the new techniques and performs around 500 procedures a year with her team at Barnes-Jewish Hospital in St. Louis, Mo. Dr. Mackinnon, a professor of plastic surgery at the Washington University School of Medicine, says about 80 percent of her patients regain a significant amount of function in their limbs.

The surgery works best if it is done within six months of the original injury. But many patients are never referred to a nerve specialist, so they don''t find out about the treatments until it is too late for them to be useful. Primary-care physicians often take a wait-and-see approach to nerve injuries, since about 70 percent heal on their own. While nerve specialists typically wait for six months before doing surgery to see if the nerves recover, they say patients should be carefully monitored during this period.

Even patients who get access to the treatments aren''t guaranteed a recovery. Between 20 percent and 30 percent of patients don''t experience any significant improvement after the surgery. Serious injuries require hours-long procedures under general anesthesia. And it can take years for the results to be complete because the nerves have to regenerate after the operations.

Serious nerve repair procedures which cost anywhere from $15,000 to $60,000, including anesthesia and hospital stay are usually covered by insurance.

Successful nerve surgeries typically restore between 50 percent and 80 percent of function to an injured limb. But even when the procedures restore only partial function, the result can be life changing for a patient. "If you can give someone back movement in their elbow, all of a sudden they can use their forearm to hold a book, or carry their shopping bag. It even helps them get their coat on," says Robert Spinner, a neurosurgeon and orthopedist at the Mayo Clinic who specializes in nerve procedures on the shoulder and arm. Dr. Spinner performs about 270 arm and shoulder surgeries a year with a team, and says between 70 percent and 90 percent of patients regain a significant amount of function.

In September 2003, Adam Albee of Rochester, Minn., crushed his right shoulder in a motorcycle crash, leaving most of his right arm paralyzed. He could no longer get his clothes on by himself, carry his six-year-old son or do any of his hobbies like weightlifting.

When the arm failed to improve, Mr. Albee, was referred to Dr. Spinner at the Mayo Clinic. (At the time, Mr. Albee worked as a hospital-supply manager at the Mayo Clinic, and got his health care there.) During a three-hour operation in 2004, a team of doctors conducted a nerve-transfer procedure, which involved rerouting a branch of a nerve from his triceps, and attaching it to his paralyzed deltoid muscle to restore function to his shoulder.

It took nearly a year before Mr. Albee began to see improvement in the arm, and the healing process was painful: He occastionally felt burning and needle-prick sensations in his shoulder that brought him to tears. He also spent several hours a day doing arm exercises. But two years later, Mr. Albee, now age 34, says he has recovered about 95 percent of function in his arm. He can lift weights, dress himself and he is back at work. He does 100 push-ups a day and says he''s working toward one-arm push-ups with the injured arm.

Surgeons say nerve transfers, the procedure Mr. Albee had, are the most promising new technique for treating nerve injuries. They are currently being done at hospitals including Montefiore Medical Center in New York, the Mayo Clinic, and Barnes-Jewish Hospital. A nerve transfer only works if at least one nerve near the injury has been spared. In such cases, doctors can reroute a small branch or piece of the healthy nerve to a paralyzed muscle that has lost connection with the spinal cord. The nerve branch can transmit signals to the paralyzed muscle, restoring function to the injured area. The procedure has a high success rate, with most patients recovering at least 80 percent of function.

In more experimental settings, some doctors are trying nerve transplants, where nerves are taken from a live donor or a cadaver and implanted in a patient. When a live donor is used, doctors remove a non-essential nerve, such as the sural nerve, responsible for sensation on the outside of the ankle.

However, the transplants are a last resort since they require patients to take immunosuppressant drugs for at least a year. And they pose a slight risk to the donor: For instance, donating a sural nerve would leave a numb area a little larger than a tennis ball on the ankle, and it involves surgery under general anesthesia. Only a few dozen such procedures have been conducted in the U.S. over the past decade, at hospitals including Johns Hopkins, Memorial Hermann Children''s Hospital in Houston, and Monmouth Medical Center in New Jersey.

Most peripheral-nerve experts say simpler, less-invasive tactics are usually more effective and pose fewer risks. Transplants are used only in situations where an injury is so severe that a huge number of extra nerves is needed to repair the gaps.

New technologies are also helping to improve treatment for nerve patients. In the past several years, medical-device companies, including Integra LifeSciences Corp. and Synovis Micro Companies Alliance, have started selling tiny devices called nerve tubes that can be used to bridge small gaps in severed nerves. The tubes, which cost roughly $700 to $1,000, serve as a conduit through which the nerve can grow and regenerate.

So far, the longest tubes available are around three centimeters, which means they are useful in bridging only short gaps in broken nerves. But companies are exploring the possibility of creating much longer synthetic nerves that could one day replace nerve grafts or transplants.

Some of the techniques doctors are finding success with such as nerve grafting have been around for centuries: Doctors began experimenting with nerve grafts in the 1700s, and they were commonly attempted on wounds during World War II. But recent advances in microsurgery techniques have improved the success rate, and doctors have found new uses for the procedure. Nerve grafts to restore erectile function after prostate surgery are being done at Memorial Sloan-Kettering and University of Washington Medical Center in Seattle, for instance.

Nerve grafts involve taking a non-essential nerve from somewhere else in the body and using a piece of it to bridge a gap in a broken nerve. The graft serves as a scaffold along which the patient''s own nerve can grow and regenerate.

One reason there is so little awareness about the treatments in the broader medical community is that peripheral-nerve injuries don''t fit tidily into any particular medical discipline. Doctors devoted to peripheral-nerve work come from a range of backgrounds, including plastic surgery, neurosurgery and orthopedics.

"We''re still trying to get the word out," says Allan Belzberg a neurosurgeon at the Johns Hopkins Hospital, who performed the hospital''s first nerve transplant last November. "Please don''t sit on these injuries, and give us a chance."