NERVE AND A LOT OF SKILL
It’s been years since he’s been able to hold a toothbrush or feed himself a grape. Groundbreaking surgery could change that, and for quadriplegics like Tim Raglin, even a little bit of extra mobility is huge. Andrew Duffy reports.
Ottawa Hospital surgeon Dr. Kirsty Boyd helps prepare Tim Raglin for nerve transfer surgery, the first time it has been performed in Canada. This delicate procedure is designed to restore function to a hand that’s been frozen since a diving accident left Raglin a quadriplegic.
On a bitterly cold morning in late February, a medical team gathers at 7 a.m. on the third floor of The Ottawa Hospital’s Civic Campus to launch what will be an unprecedented day of surgery.
The team’s goal is audacious: to restore movement to the right hand of Tim Raglin, a 44-year-old quadriplegic whose fingers have been frozen in place since August 2007.
During that year’s Civic Holiday long weekend, Raglin, a project manager at an Ottawa high tech firm, dove from the dock of his family’s Round Lake cottage, near Pembroke. The cottage had been in his family for generations; he had made the same plunge hundreds upon hundreds of times.
This time, however, a heat wave and a deep dive combined to produce disaster. Water levels were unusually low in Round Lake that year and Raglin smashed hard into the sandy bottom.
He floated to the surface with a vertebra in his cervical spine shattered to pieces.
Now, more than seven years later, surgeons will try to reanimate Raglin’s paralyzed right index finger and thumb.
Dr. Kirsty Boyd, an Ottawa Hospital plastic surgeon, will be performing the nerve transfer surgery — the first operation of its kind in Canada — under the mentorship of the woman who pioneered the technique at the Washington University School of Medicine in St. Louis, Dr. Susan Mackinnon.
Mackinnon is one of the most acclaimed reconstructive surgeons of her generation. Canadian-born and educated, Mackinnon is recognized both as an innovator in the use of nerve transfers and a powerful evangelist for the technique. In fact, she and a colleague, Dr. Ida Fox, are in Ottawa at their own expense to share their expertise.
“We’re here to make sure it’s just perfect,” says Mackinnon, who first performed nerve transfer surgery on a quadriplegic five years ago.
The surgical team meets Raglin just before he’s wheeled into Operating Room 10, where he’s to be anaesthetized and draped for surgery. He demonstrates for the assembled crowd the existing function in his right arm. Raglin can move his shoulder and bend his elbow. He has some ability to turn his wrist, but his hands cannot move on their own. The fingers remain motionless, folded over his palm.
That Raglin has movement in his upper extremities makes him eligible for today’s surgery since it means there are nerves in his arms that still communicate with his brain. The nerves below his spinal cord injury, including those that move his hands, do not.
The goal of the surgery is to create a new route that will allow messages from Raglin’s brain to reach his thumb and finger. To do it, surgeons will connect a functioning nerve in his upper arm to another, nearby nerve that has been useless since the day of his accident.
Unthinkable only a decade ago, the operation will see surgeons cut the end of Raglin’s working brachialis nerve — a nerve that bends the elbow — and connect it to the anterior interosseous nerve that once controlled his thumb and index finger. The new connection effectively bypasses Raglin’s spinal cord injury.
Yet it is not as simple as joining two electrical wires. Although nerves carry electrochemical signals, they are made up of living tissue. And the tissue inside the anterior interosseous nerve will die back once it’s cut to connect it to the brachialis. That process, however, provides an empty nerve tube to guide the rerouted brachialis nerve as it slowly grows down to Raglin’s hand muslces.
The brachialis can be redeployed to operate Raglin’s hand because it is one of the nervous system’s builtin redundancies: the arm has three nerves that help flex the elbow.
Mackinnon explains the concept behind her breakthrough: “There are 3,500 motor fibres in the brachialis nerve, and in this patient, he doesn’t need them. And they connect to the brain. He doesn’t need them and they connect to the brain. That’s the key. Because there are nerves below that don’t connect to the brain but go into muscles that are perfectly healthy — and are just wishing they could talk to the brain.”
Describing it another way, Mackinnon says surgeons will reroute Raglin’s nerve traffic to avoid the blockage in his spinal column by engineering a detour in his arm to reach his hand. “Instead of going to Toronto via Highway 401,” she says, “we’re going to go to Toronto the back way: on Highway 7.”
The new route, however, will require considerable patience on Raglin’s part. It will be six to nine months before he knows whether the operation has worked its magic.
That’s how long it will take for the brachialis nerve to grow down its new nerve pathway to the muscles in the hand. If the surgery is a success, Raglin’s thumb and index finger should slowly twitch back to life late this year.
Some months after that, once he learns to control his hotwired hand, Raglin hopes to feed himself some grapes, maybe a potato chip or two.
“Even being able to pick up a Kleenex to blow my nose,” he says, “that would be an improvement over what I can do now.”
Tim Raglin calls himself the world’s luckiest unlucky man.
“I was unlucky to get in the accident originally, but lucky ever since,” he says.
His streak of good fortune began within moments of his life’s defining calamity. Raglin hit the bottom of Round Lake and blacked out. When he regained consciousness, he was face down in the water, staring at the bottom of the lake, unable to move.
“I knew right away what had happened. I knew exactly what it was and I thought, ‘Uh no, this is not good.’ I knew the clock was ticking. I only had so much air. I held my breath for as long as I could then I blacked out again.”
Raglin had jumped into the lake to cool off before dinner. Luckily, his friends and relatives reacted quickly: Raglin was pulled ashore unconscious, but his sister and brother-in-law — both OPP officers — were trained to handle such emergencies. An air ambulance was dispatched.
“I woke up on the beach, surrounded by people making sure I was OK and comfortable,” Raglin says.
He was lucky the break was at the base of his neck since injuries higher in the cervical spine result in more profound paralysis.
During nine months at The Ottawa Hospital Rehabilitation Centre, Raglin learned to take full advantage of the limited movement in his shoulders, arms and wrists.
His mother also fashioned him Velcro cuffs, with a pointer attached, that he strapped around each palm. The devices give him the ability to navigate his computer tablet, phone and remote control devices.
Now on long-term disability, Raglin says he has always been good at spending time alone — he reads, watches documentaries and follows the news —and is even luckier to have Nathalie Mainville in his life.
They met through friends and were married last year in Las Vegas. The couple and her two children now share a spacious home in Carp that backs onto a forest.
It was a friend of Nathalie’s who pointed Raglin to the surgical breakthrough authored by Dr. Susan Mackinnon in St. Louis, Missouri. An account of the operation was published in the Journal of Neurosurgery in May 2012.
About two years ago, Raglin asked his rehab centre physiatrist whether the surgery was available in Ottawa. His physiatrist referred him to Ottawa plastic surgeon Dr. Kirsty Boyd, who happened to know Mackinnon and her work. Boyd had completed a year-long surgical fellowship with Mackinnon in June 2011 — just six months before joining The Ottawa Hospital. The fellowship focused on nerve transfers.
“I haven’t done it in this patient population (quadriplegics), but I’m willing to try,” Boyd told Raglin.
At the time, it wasn’t clear whether Raglin would even be eligible for the surgery. But tests conducted by Dr. Gerald Wolff, co-founder of Ottawa’s Peripheral Nerve Trauma Clinic, established that he was an ideal candidate since his arm and hand muscles were well preserved.
Boyd and Wolff travelled to St. Louis last year to consult with Mackinnon. At some point, Boyd admitted that she was “a little nervous” about attempting the procedure.
“Well, we’ll come,” Mackinnon announced.
The hardest part of nerve surgery, other than maybe the decisionmaking, is the finding things. DR. KIRSTY BOYD
That fortuitous chain of events brought Raglin through the doors of Operating Room 10 in late February, trailed by some of the world’s leading peripheral nerve surgeons.
Half a dozen doctors and residents watch as Dr. Boyd cuts into Raglin’s upper right arm and unpacks its muscles, arteries, tendons and nerves. Boyd begins her search for the two nerves she needs to reroute signals from Raglin’s brain to his hand. Nerves are bigger than you might expect — they look like cooked spaghetti.
With Dr. Mackinnon at her side, offering instructions and encouragement, Boyd carefully isolates the noodle-like nerves from the meatier muscle using red and yellow loops that look like coloured strings.
In explaining nerves to her patients, Boyd likes to draw on the spaghetti analogy. A peripheral nerve, she says, is basically like a plastic bag of spaghetti: It has a plastic wrapper and bunch of noodles inside. It is a challenge to sort it all out. “The hardest part of nerve surgery, other than maybe the decision-making, is the finding things,” says Boyd.
Once she isolates the one she wants, Boyd delicately cuts opens the outer covering to expose the smaller nerves bundled inside. She must now identify which one connects to the muscles of the index finger and thumb.
Using a handheld nerve stimulator, the size of an electric toothbrush, Boyd delivers a tiny electric charge to one of the exposed noodles. Raglin’s wrist rotates in response.
Assisted by Mackinnon, Boyd continues to explore the exposed nerves until hitting upon the one that makes Raglin’s finger and thumb close in a spasmodic jump.
The surgeons have found the “recipient” nerve, the anterior interosseous (AIN), which looks like any other healthy nerve.
Although its electrical signals can’t get through to the brain, the nerve still receives blood and nutrients from its connection to the spinal cord.
Once that connection is cut by the surgeons, however, the nerve will start to die and melt away. But its outer covering will remain in place as a “conduit” for the working brachialis nerve to follow to the finger and thumb.
About 90 minutes into the operation, as she peers through what look like small binoculars — surgical loupes — Boyd cuts the two nerves and folds them over one another.
Then, while using a microscope that further magnifies her exacting surgical handiwork, she sutures them together .
Three hours after the operation began, Boyd closes the initial incision. In the afternoon, the surgical team conducts a second nerve transfer in Raglin’s right forearm in an attempt to further improve his pinching ability.
Later, in the hospital cafeteria, Boyd declares herself thrilled with the day’s surgery. “It went really smoothly,” she says.
For Boyd, however, the worst part of the procedure is about to begin: the wait. It will be six to nine months before her patient’s hand shows any sign of life.
The long wait for results in nerve transfer surgery is dictated by the rate of a severed nerve’s regrowth. The brachialis nerve, cut in Raglin’s biceps, will grow down its new pathway, like the stem of a pruned grape vine, until it reaches the muscles of his thumb and finger.
The nerve must stretch about 30 centimetres to the finger and thumb, but it regrows only one millimetre each day.
“This is going to be extremely difficult,” Boyd says of the waiting process.
“Even with my other nerve transfers that take three months, I’m impatient. We see them in clinic and I’m hovering to see if there are any signs of recovery yet.”
The daughter of two physicians in London, Ont., Boyd decided early in her medical career that she wanted to be a surgeon because she liked its instant rewards. “I liked that you could get right in there, see and address a problem, and fix it,” says Boyd, who splits her time between breast reconstruction surgery and peripheral nerve surgery.
Raglin will begin intensive physical therapy to learn how to use his hotwired hand as soon as there are signs of nerve growth. If everything unfolds according to the medical script, the nerve signal that used to bend Raglin’s elbow will later this year trigger a pinch of his right thumb and forefinger.
Mackinnon has no doubt the procedure will work: it is, to her, a strict law of anatomical engineering: “You found the right nerves and you plugged them together.”
But Boyd is anxious to prove that she can duplicate Mackinnon’s results.
“I will be very happy when I see these transfers work, yes,” she says.
One week after the surgery, Tim Raglin sits in the light-filled living room of his Carp home, waiting on his miracle.
“The arm is pretty angry at me right now: there are a lot of muscle spasms,” he says. “But I can still move my elbow: It’s not as strong as it was before but I can still do it.”
Waiting for his nerves to regrow will be the easiest part of the nerve transfer procedure for Raglin. He’s good at waiting.
“In my condition, you learn to be patient,” he says. “Besides, my expectations are pretty modest: I want to gain a little more independence and look after myself a bit better.
“I might not be able to feed myself chicken wings, but if I could pick up some chips or some grapes, maybe hold a toothbrush, that would be great.”