Surgery Restores Movement to Kids With Polio-Like Illness
Kale Hyder was an active teenager and basketball player when a mysterious polio-like illness struck.
The 6-foot-2 youth from Davenport, Iowa, woke up with a stiff neck in June 2015 at age 15. Within weeks he was paralyzed from the chest down. He was diagnosed with transverse myelitis, and was told he would never regain function of his hands.
But a nerve specialist in New York City, Dr. Scott Wolfe, performed nerve transfers to each arm, and tendon transfer surgery a year later to restore function. The surgeries helped Hyder regain his independence.
Now, Wolfe reports that the same nerve transfer surgery has restored movement in some children stricken with a more notorious disease, acute flaccid myelitis (AFM).
Outbreaks of AFM have grabbed headlines in recent years. The mysterious illness affects children's nervous systems and typically causes severe weakness in the arms and legs. AFM is a subtype of transverse myelitis, the disease that struck Hyder.
Nerve transfer surgery restored motor function in two young patients partially paralyzed by AFM, according to a case report published recently in the journal Pediatric Neurology.
In one case, a 12-year-old regained the ability to flex and move his right arm, which had been immobile.
In the other, a 14-year-old girl experienced improved movement in her left and right arms, and regained the ability to work the thumb and fingers of her left hand.
How the procedure works
The surgery involves splicing small sections of healthy nerve into areas where AFM has destroyed the link between nerves and the muscles they coordinate, said Wolfe. He's a senior researcher on the study and an orthopedic surgeon at the Hospital for Special Surgery.
"We've been able to take completely normal nerves and we can go into those nerves and find the individual cables within the nerves, and rather than taking the entire nerve, we'll just take a small splice and move them over," Wolfe said. "We will not lose function in the nerve we borrow from, and we will gain function in the nerve we connect the splice to."
AFM cases have cropped up in the United States in every-other-year cycles since 2014, according to the U.S. Centers for Disease Control and Prevention. In 2018, there were 201 confirmed cases in 40 states, the most extensive wave to date. Experts suspect that viral infections might prompt AFM, but that hasn't been confirmed.
Nerve transfer surgery changed Hyder's life. He had been experiencing some hand tingling and shoulder weakness, but shrugged it off.
Then one afternoon "the symptoms rapidly progressed," Hyder recalls. "Within a half hour, I was unable to stand up or walk around anymore."
Hyder eventually regained the ability to move his arms around a little, but couldn't lift his arms above his head. His hands didn't work at all.
Wolfe performed nerve transfers to each of Hyder's arms, about 10 months after the teen first became ill. The delicate and painstaking surgeries are performed under a microscope and can take five to seven hours, not to mention hours of muscle and nerve testing beforehand to help plan the surgery.
"Since the disease causes almost random patterns of muscle paralysis, there's no road map to follow and we have to come up with a creative solution for each patient," Wolfe said. "We take a full inventory of what's working and what's not working in each limb by checking each muscle."
From paralyzed patient to college student
Following the surgeries and intensive physical therapy, Hyder, now a freshman at Johns Hopkins University in Baltimore, regained much of the lost function in his arms.
"It's a world of difference," Hyder said. "I'm able to extend my fingers so much better and grip a lot better than I was able to before." He also can extend his arms over his head, allowing him to comb or wash his hair, or reach up into a cupboard.
His function and independence has improved to the point where Hyder felt comfortable enough to leave the nest and attend Hopkins.
"I don't think I would have been able to do that without the nerve transfer surgeries," Hyder said.
Even though Hyder did not have AFM, "surgeons can utilize nerve transfer procedures to restore function in patients who've experienced partial paralysis of a limb, whether caused by transverse myelitis or AFM," Wolfe said.
Although the case study only focused on two AFM patients, there are now as many as six who have been helped by nerve transfer surgery, Wolfe said.
"I think it has the capability of working in any AFM patient," Wolfe said. "We do not have enough patients studied or operated on to say we can do it with every patient, nor do we know enough about this disease to say whether it will provide the kind of function and strength patients need."
Dr. Michael Hausman is vice chair of orthopedics at Mount Sinai Health System in New York City. He said that "conceptually it's a good idea. I think it certainly merits a closer look."
But Hausman, who wasn't involved with the study, noted that most AFM patients spontaneously regain much of their motor function within a year after they are stricken. This clouds whether or not the nerve transfer surgery is actually helpful.
"I don't think we can say it works yet because it's hard to tease out the effect of the nerve transfer from any degree of spontaneous recovery that might occur," Hausman said.
The U.S. Centers for Disease Control and Prevention has more about acute flaccid myelitis.
SOURCES: Scott Wolfe, M.D., orthopedic surgeon, Hospital for Special Surgery, New York City; Kale Hyder, Davenport, Iowa; Michael Hausman, M.D., vice chair, orthopedics, Mount Sinai Health System, New York City; Pediatric Neurology, November 2018