Peled Migraine Surgery Blog

Information and knowledge about migraine relief surgery.

New Paper Published - Anatomic and Compression Topography of the Lesser Occipital Nerve.

My newest paper, Anatomic and Compression Topography of the Lesser Occipital Nerve co-authored with Giorgio Pietramaggiori MD and Saja Scherer MD has been published by PRS Global Open, the International Open Access Journal of the American Society of Plastic Surgeons!  The paper, discussing how the knowledge of LON (Lesser Occipital Nerve) anatomy can aid in nerve dissection and preservation, thereby leading to successful outcomes without requiring neurectomy.  The article can be found here and is printed in entirety below.

 


 

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FREEZING THE NERVE

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There have been a number of interesting posts this week about a new device that has recently been introduced to the US market and I thought it might be an interesting subject for a brief synopsis.  I have used this device on a number of patients for a number of indications over the past six or seven months and the results are quite promising.  The name of the device is Iovera and while the concept is not new, the delivery mechanism is quite unique and efficient.  Iovera is different from past, similar treatments because although cold has been used for many years to treat several clinical conditions, the ability to precisely regulate the temperature and area treated have been problems which this device manages quite well.

Basically, the device delivers a stream of liquid nitrous oxide (which is very cold, about -56ºC) through a closed mechanism to the tips of the probe used.  In other words, nothing is actually injected into the patient - the liquid nitrous oxide simply flows through the device and the tip(s) becomes very cold thus causing the natural bodily fluids around it to freeze and essentially creating a tic-tac-sized ice ball near the target nerve.  What actually happens to the nerve is akin to what is known as a Sunderland II axonotmesis.  Say that three times fast.  In layman’s terms, there is some degeneration of the (axons of the) neurons downstream from the treatment site, but the overall structure (i.e. scaffold) of the nerve remains the same.  This type of “insult” allows the neurons to eventually re-grow in their typical configuration, back down through the treatment site over a period of a few weeks or months, thus ultimately restoring nerve function.  One thing to point out here is that the nerve is theoretically not “destroyed” as some have suggested.  Therefore, the term cryoablation is not really appropriate in my opinion because to ablate something as I have mentioned elsewhere (https://www.facebook.com/Peled-Migraine-Surgery-326501717396487/?fref=nf) means to excise or destroy.  I prefer to use the term cryo-neuromodulation because it is more precise what you are actually doing which is modulating the actions of the nerve on a temporary basis. These phenomena and concepts pose some really interesting questions about the role of such a device in any number of clinical scenarios, but since we’re particularly focused on chronic headaches such as ON…..here goes.

The fact that the nerve is not completely “destroyed” may be bad or good depending on your perspective.  In the case of painful conditions like ON or TN, one might argue that since the nerve will work again, this is a temporary fix.  In fact, at this point, Iovera is being used as a management tool.  Even if the results last 2-3 months at a time, you will still need to come in several times per year for treatment.  However, I personally believe that combined with other treatment modalities, there is real promise for this device.  As a lot of you know, many patients have a hard time for several months following surgical decompression or transection because the nerves are inflamed secondary to surgical manipulation and the baseline injury/pathology.  Now just imagine if one were able to modulate those nerves by essentially shutting them down for three months by precisely targeting them intra-operatively. It’s tempting to think of how potentially comfortable (albeit numb) a patient might feel in those first 90 days while at the same time taking comfort in knowing that the numbness should eventually fade away.  Even though decompressing a nerve improves the nerve physiologically following recovery, it is also tempting to think about the possibility that the cold stimulus may actually improve or simply speed up the regeneration and recovery process as another inducement to do so.  Moreover, there is the really tempting idea of also using the Iovera device on the nerve(s) to the surgical incision itself or the surgically dissected areas to minimize the typical post-operative pain.  In fact, a very early study in total knee replacement patients suggested that post-operative opioid requirements were decreased in patients treated this way.  Finally, if a nerve or patient are not candidates for surgical intervention, this device could represent a big arrow in the quiver of non-surgical treatment options.  My short post just scratches the surface of the many questions and possibilities raised by this device.  While the available data and the overall experience with cryo-neuromodulation using Iovera is limited at this point, I do believe it device has a substantive role in treating ON, perhaps TN and potentially many other disorders….time will tell. 

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POSTURE AND OCCIPITAL NEURALGIA

I was recently asked an interesting question: “If you have bad posture and have a decompression procedure, won’t the results eventually diminish as the bad posture would re-injure the nerves?” There was actually a recent, non-scientific article in a different publication (http://gizmodo.com/my-smartphone-gave-me-a-painful-neurological-condition-1711422212) which suggested that posture secondary to cell phone use was a factor in the development of ON in some people.  As you might suspect, I don’t know of anyone who would argue with the concept that good posture is important for any number of reasons.  However, can it cause ON to recur after an adequate decompression procedure?  Not likely.

As the article above suggests, even a little flexion or extension in the neck can lead to significant increases in pressure on the nuchal structures.  The reason is that many of these structures, such as the nerves, pass through very small spaces on their way to the scalp.  When those spaces which are tight to begin with are narrowed even just a little bit, the increase in pressure on the nerve can be dramatic.  However, it is not the bending or as to the point here, the bad posture that causes the neuralgia, it is the tight space becoming tighter.  When these narrow spaces are opened up, the reverse is also true - the pressure on the nerves can dramatically decrease.  The two pictures of the greater occipital nerve below illustrate the concept (warning- not for the easily grossed out).


                           BEFORE                                                                     AFTER

Before-After

In the picture on the left, you can see the greater occipital nerve (long arrow) bulging out of the semispinalis muscle (short arrow) - a well-described compression point for this nerve. After removal of a small amount of said muscle (the upper and lower edges of which are denoted by the limbs of the “V”) you can see the GON more clearly.  What is also dramatic is that the nerve appears much smaller even though the picture on the right is at slightly higher magnification.  This all happens within a few minutes in the OR.  Anyone who has ever tied a rubber band tightly around the base of their finger for a minute and had a nice purple digit knows exactly what happens when the rubber band is released. The key here is balance.  As a surgeon I want to make enough space so that the nerve can now move freely with almost any position or posture, but not so much space that I remove too much muscle and cause some imbalance or weakness.  Moreover, when patients move their heads post-operatively, which I insist my patients do gently right away, the gliding prevents significant scar formation and re-narrowing of these spaces. Hence, if done correctly, persistent poor posture following decompression should not cause the ON to return. Hope that helps.

For more information, or to make an appointment, call Peled Migraine Surgery at 415-751-0583 and visit www.peledmigrainesurgery.com to learn more about migraine relief through surgery.  

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THE DOCTOR TOLD ME HE CUT THE NERVE, BUT I STILL FEEL THAT AREA - HOW IS THAT POSSIBLE?

Over the years, I seem to have had this question come up on a fairly consistent basis and the answer is actually relatively straightforward.  Let’s assume that we have an arbitrary portion of the scalp which is innervated by 3 different nerves.  When someone touches that area, sensation is mediated to some degree by each of those nerves, all of which likely branch to some degree within that particular area of skin. In other words, the areas of sensation mediated by each of those nerves likely overlap, much like a Venn diagram (see below).  Now let’s assume that one of those nerve is injured.  It is likely that the person in question now has some degree of discomfort in that area.  If a procedure is performed in which that injured nerve is transected and implanted deep within the local muscle, hopefully with time, the painful sensations mediated by that nerve also diminish.  However, s/he still has two nerves which innervate that portion of skin.  When that same person touches that area of skin, s/he will feel it almost the same as before the operation.  This person has no idea which nerve is mediating that perception of feeling, but for all practical purposes it doesn’t matter.  Hopefully, this explanation clears up some confusion.  This phenomenon of overlapping nerve territories also explains why patients tolerate the transection/burial of some nerves better than others.  It is not the only reason to consider when deciding whether or not a nerve can be transected and buried in the local muscle, but it is an important one.

Venn

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Dr. Ziv Peled Invited To Speak At Plastic Surgery 2015

Ziv Peled, MD has been invited to be a Panelist at ‘Plastic Surgery 2015’ in Boston, Massachusetts on October 17 – 20, 2015 held by the American Society of Plastic Surgeons (ASPS).  This meeting is the largest and most prominent plastic surgical meeting internationally.  This panel is sponsored by ASPS and held in cooperation with the Plastic Surgery Foundation (PSF) and the American Society of Maxillofacial Surgeons (ASMS).  Dr. Peled will speak on his established experience with surgical intervention for chronic headaches. A specific emphasis of the program will be on incorporating the latest in plastic surgical techniques in order to understand what the future holds for plastic surgery as a profession and medicine in general. 

Dr. Peled’s panel will teach the participants to:

  1. Identify current and emerging issues and advances affecting the diagnosis and delivery of treatment for plastic surgical problems and assess their potential practice applications.
  2. Compare and contrast therapeutic options to determine appropriate recommendations for patient treatment.
  3. Incorporate into practice, new technical knowledge, state-of-the-art procedures, advanced therapeutic agents and medical device uses.
  4. Communicate current practice management and regulatory issues necessary for the efficient and safe delivery of patient care.
  5. Translate expanded knowledge into practice for the improvement of patient outcomes and satisfaction

Ziv M. Peled, MD is a Board-Certified plastic surgeon trained to perform the full spectrum of aesthetic and reconstructive plastic surgical procedures. He completed his medical school training at the University of Connecticut, School of Medicine where he earned honors in multiple surgical disciplines. He subsequently completed four years of rigorous general surgical training at the University of Connecticut during which he also completed an additional two-year, post-doctoral Basic Science Research Fellowship at Stanford University under the tutelage of Dr. Michael T. Longaker, a pioneer in the field of scarless wound healing. During that time, Dr. Peled not only helped establish Dr. Longaker’s laboratory at Stanford, but was also awarded a 5-year NIH grant for his work in keloid biology and scarless wound repair. Ziv then completed a prestigious and highly sought-after plastic surgical residency at Harvard University. While there, he was awarded an “Excellence in Teaching” award from the Harvard medical students. Dr. Peled continued to hone his specialty skills with an additional year of training in peripheral nerve surgery at the Dellon Institute for Peripheral Nerve and Plastic Surgery. He is Board-Certified by the American Board of Plastic Surgery, which means that he graduated from an accredited medical school, completed numerous years of residency training, and successfully passed a series of comprehensive written and oral examinations. The American Board of 
Plastic Surgery is one of only a select few specialty boards recognized by the American Board of Medical Specialties (ABMS) and is the only ABMS board which certifies candidates in the specialty of plastic surgery of the entire body. Dr. Peled is also a member of the California Society of Plastic Surgeons.

In addition to his cosmetic and reconstructive work, Dr. Peled helped to found a peripheral nerve surgery institute here in San Francisco. In that institute, he served as Director and Chief Plastic & Peripheral Nerve Surgeon. His specific training enables him to perform a unique set of surgical procedures designed specifically to restore sensation and minimize/eliminate pain in patients suffering from chronic headaches as well as neuropathy due to diabetes, chemotherapy and thyroid disorders.  He has also treated many patients with various forms of nerve trauma as well as many other types of nerve disorders. Dr. Peled has authored and co-authored over 40 manuscripts and book chapters on all aspects of plastic surgery and has presented his work at numerous national and international meetings. He has performed several hundred peripheral nerve procedures of various kinds.  Ziv is an Active Member of the American Society of Plastic Surgeons and a member of the American Society for Peripheral Nerve. This honor recognizes and highlights Dr. Peled's breadth of work with peripheral nerve patients suffering from migraines and diabetes as well as his published work on peripheral nerve surgery.  He continues to volunteer for the American Diabetes Association and has recently traveled to South America to provide reconstructive surgery to underprivileged children. In his spare time, he actively competes in both Half-Ironman and Ironman-distance triathlons.

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WHICH CAME FIRST THE MUSCLE OR THE NERVE?

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Just this week, several patients have asked about the tight muscles in their necks and upper backs. They have all wondered at some point whether it’s the tight muscles that are irritating the nerves or the nerves that are irritating the muscles and causing them to spasm. In most cases, this question ends up being like the one about the chicken or the egg - in other words difficult if not impossible to answer with certainty.  I do, however have several thoughts on the matter that I figured I would share as I believe them to be relevant to peoples’ understanding of their condition. First of all, spastic muscles irritating or compressing occipital nerves can certainly cause ON and an irritated nerve can certainly cause pain in the nuchal region, leading to both voluntary and involuntary guarding and spasm of neck muscles.  These factors feed on one another and as the pain increases, the muscles often contract more, causing more irritation/compression and hence more pain which leads to greater contraction and so on.  Second, in most patients, these processes have been happening for years and it is often difficult to remember which factor precipitated the other. None of this is to say that since we can’t always figure out “what started the ON”, that we therefore can’t do anything about it. For example, many of my patients have tried muscle relaxants as part of their medical regimens, often without success. In addition, my typical patient has not only tried and failed many different pharmacologic agents, but also many different non-operative treatment modalities.  PT, massage, Active Release Techniques (ART) are just some examples of therapies that focus on the muscles and which are common components of patients’ past medical histories.  The point is that if you’ve unsuccessfully tried to release, lengthen or relax your neck muscles in a number of different ways and still suffer from occipital neuralgia, then perhaps attempting to address another component of the ON symptom complex is also reasonable. In these same people, I often find that a well-placed nerve block or blocks not only seems to relieve their pain, but several minutes after the block has really set in, they are able to move in ways they have not been able to in years.  I use long-acting blocks and then have those same patients leave the office and engage in several provocative maneuvers to try and exacerbate their ON.  Many of them find that those typical “triggers” now don’t bother them and they remain relaxed until the blocks wear off.  What do these results tell you?  Among other things, they suggest that if the nerve, which has been chemically and temporarily “calmed”, can be treated permanently, perhaps the muscles that have relaxed will also benefit secondarily.  Moreover, they suggest that other distant muscles in other parts of the body may also benefit as they no longer have to compensate for spastic and ineffective muscles in the neck.  The take home message is that just because you can’t figure out which came first, the chicken or the egg, doesn’t mean that you can’t still treat the problem of occipital neuralgia effectively.

To learn more, visit www.peledmigrainesurgery.com today, or call 415-751-0583 to schedule an appointment.

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Dr. Peled Co-author On New Paper

The paper, 'Supraorbital Neuroma: A Rare and Unreported Complication Following Blepharoplasty' co-authored by Giorgio Pietramaggiori, MD, PhD, Sandra Saja Scherer, MD, Ziv M. Peled MD and Raffoul Wassim, MD has been accepted for publication by the Journal of Reconstructive Microsurgery (Theime Medical Publishers, Inc). This manuscript describes a novel approach for managing a supraorbital branch neuroma following blepharoplasty - a very popular aesthetic procedure. A short excerpt from this article is shown below with the full text to be published soon.

Supraorbital 1

 

Supraorbital 2

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Why Is the Recovery So Long, Sometimes?

migraine4This post is a modification of one I did about one year ago, but is a question I still hear a lot. It relates to any nerve procedure, not just those for headaches. The answer to this question has many components: the technical aspects of the surgical procedure, the physiology of peripheral nerves, the wound healing process itself and the overall physiology of the patient. To begin, as you can imagine, a compressed nerve is usually compressed on all sides because it is a three dimensional structure. Therefore when decompressing a nerve, it has to be manipulated such that the superficial, deep, medial, lateral, cranial and caudal aspects of the nerve can be examined and released if necessary. In addition, there are often multiple compression points (the GON has up to 6 that have been described and often others that are noted intra-operatively). Moreover, there are times when there is intra-neural scarring (scarring within the nerve, not just around it) which also requires removal. Hence, there can be a fair bit of manipulation required (albeit with microneurosurgical techniques) during any decompression procedure. You may realize that as part of the normal wound healing process, there is swelling. With the above factors in mind, the more neural manipulation required during the operation, the more swelling of the nerve you’re likely to have post-operatively. I tell my patients to think of nerves as electrical wires, pure and simple. All they do is conduct electrical signals back and forth, but it is the brain the interprets these signals as ‘hot’, ‘cold’, ‘painful’, ‘ticklish’ etc. Therefore, if you think about pouring water into the drywall in your house near the electrical wires, it is likely that the lights will start to flicker on and off until the water dries up because the fluid is interfering with the electrical signals. In the same way, swelling of the nerve can result in all sorts of “unusual firing” of the nerve and is one reason many patients may experience weird, sometimes painful sensations post-op. However, if the nerves are going to recover, when the swelling has subsided, this “unusual firing” abates and the nerves “calm down”, but the final result may not be realized until 12 month following the operation as changes to the nerve continue to occur. Just like with cutaneous scars (which also swell as part of the healing process) the time for swelling to decrease is usually longer than a few days or weeks.

Another reason why nerves may take a while to recover has to do with the severity and duration of compression. I’m sure everyone has fallen asleep on their arm(s) at some point in their lives. Sometimes, when you wake up, your hand is just a little numb and it takes about 10 seconds of shaking your hand to restore normal sensation. Other times, however, when you wake up the entire arm seems paralyzed, weak and numb! In these cases, aside from some transient agita, it takes up to 1-2 minutes of shaking the arm out for function and sensation to return fully. Phew! The difference between these two situations is that in the latter, the compression of the nerves to the arm has been present for longer and may have been more severe as compared with the former. Therefore, it takes longer for sensation (and function) to return. Now take that phenomenon and stretch the timeline out months and often years - that is how long many peoples’ nerves have been compressed. Therefore, in some cases it can take many weeks or months for function to return to “normal”. Also, since the blood flow to the nerves in the latter scenario has been compromised for a longer period of time, they become more engorged with blood after flow is restored and then that extra blood takes time to return to its baseline levels. It is for this reason that you often experience that sensation of tingling and pain after you remove pressure from the arm and as blood flow resumes. The same thing happens when blood flow is restored after decompression - (more intra-neural blood flow usually combined with more surgical manipulation). In addition, since we don’t immobilize our heads after surgery (doing so would just stiffen all the joints), the nerves will glide right away after we do all of these things to them and also likely contributes to the recovery process.

Finally there are the patients themselves. Everyone’s physiology is different. Some people are older, others younger, some otherwise quite healthy, others with multiple other medical problems. We heal slower as we age and other medical problems (e.g. diabetes or multiple sclerosis) can have effects not only on the nerves, but on healing following surgery. Moreover, since we are really talking about a chronic pain condition, there is the issue of medication use both pre and post-operatively. Some patients are taking relatively little medication before their procedures while others are taking a lot more. These medicines do have systemic effects and while some can be stopped “cold-turkey”, others often need to be weaned very gradually and carefully post-operatively. It is therefore reasonable to conclude that they can impact how people feel following their operations. The take home message is that as patients and physicians, we have to be patient in assessing whether or not decompression has been successful as the final results may not be apparent for many months (as noted by many) and the same would true of a facelift or breast augmentation. You are unique so be patient with yourself and do what you need to give your body time to heal. After all, many years of nerve pathology may not be undone after a three-hour procedure. 

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To Decompress Or Transect: That Is The Question

Axon -mediumThere continue to be questions raised both in my office as well as online about the difference between neurectomy/implantation (transection of the nerve and implanting it in the local muscle) and decompression. Along with these questions come many misconceptions about the advantages and disadvantages to each. This post hopes to address some of those issues.

To decompress a nerve means simply to remove some form of external compression that is putting excess pressure on the structure. As has been mentioned previously, compression can be a result of scar tissue, tight muscles, abnormal blood vessel anatomy, connective tissue, etc. Decompression also means that the nerve is left intact and that hopefully, once the effects of the operation (e.g. swelling) and the effects of the compression wear off, the nerve will function well again. There are advantages to decompression. The most obvious advantage is that the nerve is preserved so hopefully sensation to that area will also be preserved. Secondly, since the nerve is not cut, the chances of a post-operative neuroma are theoretically low. There also disadvantages to this approach. First, the surgeon and/or patient make a judgement call that the nerve will recover if simply decompressed, but this doesn’t always occur. I believe that this is the primary reason some people who have decompression ultimately require neurectomy and implantation Second, just because the chances of a neuroma are low it doesn’t mean that they are zero - you can still get a neuroma-in-continuity, especially if there is a lot of manipulation required to adequately decompress a nerve. Third, if the compression has been severe and long-standing, the nerve may take many months to fully recover. Fourth, if recovery does occur, there is no guarantee that sensation to the relevant area will be “normal”. It may always feel a little bit off.

The biggest misconception with a neurectomy is that it is like pulling the plug out of a wall outlet. However, the injured nerve is not ripped out of the spinal cord. A better analogy is that the injured portion of the nerve is identified and the area just upstream where the nerve appears healthier is where the nerve is transected. This maneuver is just like cutting the central portion of a power cord to a lamp where the wires have frayed. The downstream part of the nerve (e.g. that which goes to the skin) is now irrelevant just like the part of the cord that is still attached to the lamp. There is no longer any electricity going though that part so the bulb will not turn on. However, that upstream cut end is still a live wire as it is still connected to the wall outlet and therefore must be capped. In the human being the same goal is achieved by implanting the upstream (proximal) nerve end (which is still getting nerve impulses from the spinal cord) into the local muscle. There are advantages and disadvantages to this approach. One advantage is that you may see immediate improvement in symptoms although not always. Sometimes, people continue to experience pain in that nerve even though when they touch their skin they are numb. This situation exists because the nerve that used to go to that area of skin is getting impulses from the spinal cord and brain albeit ending within the muscle and so your brain thinks that part of the skin hurts even though when you touch it is numb. Eventually in most cases, the nerve end in the muscle calms down and the pain improves. Another potential advantage is less dissection because the downstream area of the nerve doesn’t need to be dissected once transected as it is now irrelevant. There are potential disadvantages as well such as persistent nerve pain if the implanted nerve doesn’t calm down, a neuroma if the nerve comes out of the muscle and the obvious numbness in that nerve distribution. Another misconception is that neurectomy is a guaranteed, home-run result which is not true for those reasons mentioned above. There are clearly other nuances that exist which is why discussing these issues with your peripheral nerve surgeon is so important. Just as each patient is unique, each person will have different tolerances for different post-operative outcomes so a good discussion is useful both for the patient and the surgeon.

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The Bionic Arm

I recently read with interest the work of Dr. Oskar Aszmann and colleagues in Vienna, Austria regarding bionic reconstruction of the hand (The Lancet , February 2015). I have been listening to Oskar speak about this work for the past several years at our annual meetings and it is great to finally see it in publication. My hope is that this research will raise awareness of the possibilities for nerve reconstruction in the near future as well as what we are capable of doing today.

 

For those that haven’t seen or heard about this paper, it describes three patients who had severe brachial plexus injuries. The brachial plexus is the network of nerves in the neck and shoulder regions that mediate all of our upper extremity function and sensation. All three patients had failed traditional reconstruction methods and the patients were left with minimally functioning upper extremities. Something else had to be done. To simplify it, the wiring of the remaining upper extremity was reconfigured using a combination of nerve transfers and bringing in muscles from other parts of the body along with their nerves so that the remaining, functional nerves could intuitively and predictably innervate the upper extremity muscles. Then, by following a specific rehabilitation protocol, the patients re-learned how to use this re-wired musculature. This protocol included the use of a hybrid myoelectric (i.e. robotic) prosthetic which was attached to the native, non-functional hand so that the patients could appreciate how much additional function they had with the robotic hand as compared with their native hand which was often minimally functional and insensate. After adequately learning how to control this myoelectric (i.e. robotic) hand, each patient underwent elective amputation of the native hand and permanent fitting of the same myoelectric prosthetic which they had been learning to use. Post-operatively all three patients demonstrated significantly improved upper extremity function, decreased pain as well as improvements in quality of life according to well established measures.

 

Oskar’s work is exciting for a number of reasons. First of all, it wonderfully demonstrates the degree to which we are able to restore function in the upper extremity for those with previously devastating injuries that were once thought to be irreparable. Secondly, while these surgical procedures are not for everyone and can be complex, the technical challenges that we face in the operating room are being greatly aided by improvements in electronic prosthetic development. Already in the works are myoelectric prosthetics with vastly more degrees of freedom (i.e. independently moveable joints) and signal processing capabilities which will ultimately allow a very precise level of function at the wrist, hand and finger levels beyond those which are available today. Third, I believe that in the not too distant future, we will see prosthetics that can actually be surgically implanted and will not need to be taken on and off as we have today, thereby removing a psychological downside to prostheses in general. Fourth, such procedures and prosthetics may ultimately provide us with a level of functionality that even a “normal person” doesn’t have. While there are certainly moral and ethical implications to consider with these possibilities, the concepts and potential are exciting indeed.

 

In many ways, this type of work represents the ultimate melding of computer science/engineering and modern medicine/surgery. Dr. Darrell Brooks and I have performed several similar procedures, so far with very encouraging results. We sincerely hope that the publication of this paper and hopefully soon others like it will encourage peripheral nerve surgeons to pursue even greater achievements. I believe that in time and in collaboration with our engineering/biomedical colleagues, devastating injuries suffered by those returning from war or after accidents will no longer mean a lifetime of dysfunction.

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