Scott W. Wolfe, MD, is the Director of the Center for Brachial Plexus and Traumatic Nerve Injury at the Hospital for Special Surgery in 
New York. Steve K. Lee, MD, is the Research Director at the Center for Brachial Plexus and Traumatic Nerve Injury. Together Dr. Wolf and Dr. Lee answer questions about the latest in nerve reconstruction surgery and where the field is headed.
Q: How has nerve reconstruction surgery advanced in the past few years?
Dr. Scott Wolfe and Steve Lee: The major advances in nerve reconstruction have been in the development and use of an array of nerve "transfers," instead of nerve repair or nerve graft. A nerve transfer uses a portion of a fully functional nerve to splice to a nearby injured nerve. Because the donor nerve is closer to the paralyzed muscle, the technique greatly shortens the distance that the nerve must regenerate. This has led to much more predictable and quicker results from nerve reconstruction surgery.
For instance, if a patient cannot bend the elbow but has hand function, the gold standard nerve transfer set can allow the patient to bend the elbow in greater than 95 percent of cases.
Q: What injuries does nerve reconstruction surgery often address?
SW and SL: One of the most common scenarios for nerve reconstruction is in the area of brachial plexus injury. The brachial plexus is a complex web of nerves that extends from the spinal cord in the neck, under the collarbone and down the arm. Patients may injure the brachial plexus in a variety of ways, usually as a result of car and motorcycle accidents, falls from heights and sports injuries. Other reasons for nerve reconstruction include penetrating injuries from gun or knife wounds, shoulder fractures and dislocations, spine trauma or disease and tumors.
Q: What are the greatest challenges of performing this type of procedure?
SW and SL: The greatest challenge to nerve regeneration is the amount of time that has elapsed since injury. The results of nerve reconstruction diminish the longer the injury has been present; ideally nerve repair, graft or transfer should be done in the first six months. After approximately 12 to 18 months, nerve surgery is no longer an option.
Other techniques, such as tendon transfer, joint fusion and even the transfer of an entire muscle from the leg to the arm may then be needed. Technical challenges during nerve reconstruction surgery include the degree of scarring, associated injury to the vascular supply of the limb and associated deformities from fracture, radiation or prior surgery.
Q: What can orthopedic surgeons do to raise physician and patient awareness of nerve reconstruction surgery?
SW and SL: The amount of new information in the nerve regeneration field is staggering. It is difficult for all physicians and surgeons to be aware of the types of treatments available to patients with brachial plexus and complex nerve injuries. Increasing awareness through education via live lectures, enduring content on the internet, publications, patient blogs and word of mouth will hopefully raise awareness and accelerate referrals to centers of excellence for brachial plexus and nerve care.
Q: What future advances do you think will change how these procedures are performed?
SW and SL: The next wave of truly revolutionary advances will come in the form of biological manipulation of the processes of nerve regeneration and the preservation of the target organs such as the nonfunctioning nerve, the atrophied muscle and the skin surface receptors. Replicating the formative and efficient growth potential of the young into an older patient may be one of the methods of augmenting the nerve healing process. Applying cells and molecules to the end targets may allow them to reside longer in waiting and not degenerate into permanent paralysis.
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