ABC News recently reported on 5 common medical tests that the American Board of Internal Medicine Foundation deem unnecessary. A team of researchers with the UC San Diego School of Medicine and the Urinary Incontinence Treatment Network have one more the add to the list: unnecessary invasive bladder tests before incontinence surgery.
Charles Nager, MD, director of Urogynecology and Reconstructive Pelvic Surgery at UC San Diego Health System and researchers found that post surgical outcomes for stress urinary incontinence (SUI) were just as successful for women who had an office check-up alone. More here
From Shattered Elbow to Ground Breaking Mountain Climbs
Mountaineer, Ben Horne, has accomplished athletic endeavors that most people never even attempt in a lifetime – he’s finished marathons, climbed Mt. Whitney, ran the Grand Canyon from rim to rim, and most recently, made the first winter ascent of the Evolution Traverse – an eight mile route that links nine peaks in the Sierra.
“Our team climbed 36 hours over four days, enduring temperatures as low as negative seven degrees Fahrenheit,” said Horne, an economics graduate student at UC San Diego.
But three years ago, Horne never thought he would step foot on a mountain again after shattering his elbow during a long distance bike ride.
“I thought this was it – my lifestyle is over,” said Horne.
His elbow was crushed in five pieces upon impact.
“Because he is young, and an athlete, the team wanted to preserve his natural bone. We also wanted to avoid a prosthetic replacement, which is commonly used but unpredictable in terms of longevity. As a cyclist, I understood the flexibility and stability that Ben would require for cycling, climbing and swimming well into the future,” said Reid Abrams, MD, chief of hand and microvascular surgery at UC San Diego Health System.
During a delicate two-hour surgery, Abrams’ team re-built Horne’s elbow with a series of strategically placed plates, screws and pins woven with wire. After four months of healing, a second surgery was performed to remove hardware and to reduce bone adhesions to improve range of motion.
Now, due to surgery, physical therapy and Ben’s tenacity, he can fully flex his elbow.
“For mountain climbing, you have to be able to pull yourself up under rigorous conditions,” said Horne. “Since my surgery with Dr. Abrams, I’ve been able to climb at even higher levels. I’m a stronger athlete now because I had to learn different sports from cross training during the recovery process.”
“As a surgeon, and someone who has recovered from his own hand injury after a biking mishap, I understand the need to get back to doing what you love,” said Abrams. “I encourage every athlete to continue to pursue their passion after an accident. With the right surgery and follow-up care, the results can be amazing. Ben proves it every day.”
Since the surgery, Horne has completed an ironman and climbed Mt. McKinley in Alaska, referred to as “Denali,” which stands 20,320 feet tall and is the highest mountain in the United States.
“These latest accomplishments are a big deal for me personally. As my rock climbing group says, ‘go big and don’t cut corners,’ and Dr. Abrams made it possible to do so – I am forever grateful.”
Bridging the Gap: three questions about nerve grafts
On February 14, a team of UC San Diego Health System surgeons performed a complicated cancer surgery on Hall of Fame outfielder, Tony Gwynn. The process involved utilizing a nerve graft from Gwynn’s neck to reconstruct the facial nerve.
We asked Justin Brown, MD, director of the Neurosurgery Peripheral Nerve Program and co-director of the Center for Neurophysiology and Restorative Neurology three questions about this type of nerve grafting.
Question: Where are nerves for graft typically harvested? Can nerves be donated?
Answer: Usually a nerve is harvested from a part of the patient that is not critical. We often use a sensory nerve from the side of the foot or inside of the arm, often a region that is close to the nerve being reconstructed as in this case. The removal of this nerve from its normal location causes an area of numbness, but usually it is small and not a problem. It does not cause any weakness to take these nerves because they are purely sensory nerve. The nerve is a graft – that is, a bridge to replace the piece of nerve that is missing.
An actual nerve transplant from another person is possible, but requires taking immunosuppression drugs. In the case of a nerve transplant, however, a patient wouldn’t have to take these drugs forever as they would with an organ transplant. Nerve transplants are therefore only used in severe nerve injuries when the patient’s own nerve grafts do not appear to be enough.
Q: How long does it take for nerves, once grafted, to work?
A: In this diagram, the part of the nerve that still is in contact with the spinal cord (A) has the “wires” or axons that need to grow through the graft (C) to the paralyzed muscle in order to recover it. Those wires grow through the graft and into the distal nerve (B) and finally to the muscle. They typically grow at 1 mm per day-a little less than the thickness of a dime. So measure the distance from the proximal stump (A) to the muscle (not pictured) and you have a rough idea of how long it will take. Typically it is three months for a short distance and even more than a year for long distances.
Q: Do nerves have memory? How does a transplanted nerve know how to behave once it has been moved?
A: It’s all about the “wires” or axons within the nerve. With a nerve graft we are trying to help the original wires re-grow to the original target so often there’s nothing to learn. In complex nerves sometimes the correct wires do not go to the correct target. When this happens in the face it can cause the whole side of the face to contract instead of just the mouth when a patient tries to smile. This is called “synkinesis.”
When the proximal nerve stump (A) is not available for a graft reconstruction, sometimes we use a nerve that originally went to a different target muscle to bring axons to the distal nerve stump (B). This is called a nerve transfer. For the face, part of the nerve to the chewing muscle (masseter) can be used to recover a smile. When this is done the smile usually occurs whenever the patient bites down (the movement that made this nerve work when it was involved in chewing). With time the brain can learn which axons are going to the face and which are still involved in chewing and the patient may learn to smile more naturally, without biting down.
Dr. Alan Hemming discussing how the patient’s liver was removed from the body, cooled, treated and returned tumor free.
Radical Surgery Saves Life of Young Mom, California First
Liver Removed, Reconstructed, Re-Implanted
A team led by Alan Hemming, MD, transplant surgeon at UC San Diego Health System, has successfully performed the west coast’s first ex-vivo liver resection, a radical procedure to completely remove and reconstruct a diseased liver and re-implant it without any tumors. The procedure saved the life of a 27-year old mother whose liver had been invaded by a painful tumor that crushed the organ and entangled its blood supply.
“During a 9-hour surgery the team was able to remove the basketball-sized tumor,” said Hemming, professor and surgical director of the Center for Hepatobiliary Disease and Abdominal Transplantation (CHAT) at UC San Diego Health System. “This is a surgery that carries a 15 to 20 percent risk of mortality. In this case, the patient would not have survived if she did not have surgery. This was the only way we could save her liver and her life.”
Celebrating the opening of the Center for The Future of Surgery (CFoS) at the UC San Diego School of Medicine. The CFoS is the largest state-of-the art facility in the nation dedicated to catalyzing novel surgical technologies, techniques and teaching methods.
*Photos illustrating the phantom limb phenomenon and how a mirror can create the illusion of two limbs again. Photo credits: Department of Defense (left); The New Yorker (right).
Phantom Limb Syndrome. The very name conjures spooky nights spent around the camp fire. But this is no ghost story: Phantom Limb Syndrome is a condition that affects people who’ve suffered the loss of a limb and yet can still “feel” the missing body part.
We asked Anna Kulidjian, MD, assistant clinical professor at the UC San Diego School of Medicine’s Department of Orthopaedic Surgery and chief of Orthopaedic Oncology at UC San Diego Health System about this strange phenomenon.
Question: What is Phantom Limb Syndrome?
Answer: Phantom Limb Syndrome occurs after a limb is removed due to surgery or trauma but the patient feels as if the missing limb is still there. They feel as if they can move it and control it. Sometimes, if the limb was lost after experiencing painful or traumatic circumstances, they can still feel pain in the limb although it’s gone. It’s often reported in veterans. 70 percent of patients with an amputation experience the sensation, though at around two years, the feeling disappears or greatly diminishes in most. Interestingly, phantom sensations occur not only with limbs but even with a loss of an eye or even organs.
Q: What type of injuries/patients do you see this happening to?
A: I deal with patients who have threatened limbs due to tumors of the bone or soft tissue and occasionally due to a major trauma or infection which has set in and become chronic. In the last decade, we have learned new techniques to salvage limbs while removing tumors around the vital structures. Occasionally, we still need to amputate if the tumor involves the blood vessels and nerves, which cannot be bypassed. If the limb was painful before the surgery, I warn patients that pain may remain after, and we try to aggressively treat the pain even prior to surgery in the hopes that sensation of discomfort will be diminished. I spend a great deal of time with my patients who are at risk to help them develop coping strategies when the sensation “hits.” Typically, the pain or feeling is intermittent. One strategy we use to help patients overcome pain is to retrain or “trick” the brain into associating the feeling with something else. Patients know the pain may come but when it does they immediately engage in an activity that will distract them and refocus the sensation. Some patients go for walks; one of my patients calls her daughters and they go shopping. Through humor and support, most patients can beat the problems associated with the sensation.
Q: Does this syndrome stay with them forever or just a short time period after the limb is removed?
A: Most patients with appropriate interventions improve and essentially stop feeling the limb. Occasionally, stress or illness can bring the sensation back. Overall, with early intervention, most patients will improve.
*Editor’s Note: Vilayanur S. Ramachandran, PhD, professor of psychology and director of the Center for Brain and Cognition at UC San Diego, is broadly credited for developing the mirror box treatment for phantom limb syndrome and for deepening understanding of its underlying neurological and physiological bases. In 2009, the New Yorker published an excellent profile of Ramachandran and his work. You can read a synopsis here: http://www.newyorker.com/reporting/2009/05/11/090511fa_fact_colapinto.
Stephen Bickler, MD, a surgeon at Rady Children’s Hospital and clinical professor of surgery and pediatrics at UC San Diego School of Medicine, discusses the lack of surgical care plaguing 2 billion people worldwide. Lack of surgical care costs 5 million people their lives every year. The Global Initiative for Emergency and Essential Surgical Care: Building Sustainable Surgical Systems will be held Nov. 9 to Nov. 11 to address this problem. Surgeons, anesthesiologists and public health specialists will try to create ways to influence public policy at a global level. For more information call 619-543-7602.