Practice News

The Institute for Advanced Reconstruction’s New Jersey plastic surgeons, Doctors Matthew Kaufman, Andrew Elkwood, Tushar Patel and Russell Ashinoff have had their collective work published in Clinical Neurology and Neurosurgery. The full article, entitled “Diaphragm paralysis caused by transverse cervical artery compression of the phrenic nerve: The Red Cross syndrome” can be found by clicking the front page image above.

(Beachwood, NJ- April, 12, 2012) – When Fran Wisnewski fell in her own kitchen, she had no idea what her future would hold. After landing on her knees, two months later she had foot drop. “I could feel everything to the touch, but I couldn’t move my foot,” she reports.

Foot drop describes the inability to raise the front part of the foot due to weakness or paralysis of the muscles that lift the foot. As a result, individuals with foot drop drag their toes along the ground or bend their knees to lift their foot higher than usual to avoid the scuffing, which causes what is called a “steppage” gait. Foot drop can be unilateral (affecting one foot) or bilateral (affecting both feet).

Although foot drop has a variety of causes, it can be the result of nerve damage alone, such as in Wisnewski’s case.

Wisnewski, a 45-year-old Beachwood, New Jersey resident, who works as a manager of a group home for the mentally disabled, started off at her primary care physician, who then sent her to an orthopedist. The orthopedist sent her to a neurologist, who gave her a brain scan to rule out any neurological problem. “It’s very frustrating when they can’t tell you what’s wrong,” she says. Finally, the neurologist referred her to Dr. Michael Rose of The Institute for Advanced Reconstruction located in Shrewsbury, New Jersey.

Fortunately for Wisnewski, Dr. Rose is among a handful of plastic surgeons trained in nerve decompression surgery for those suffering from all forms of neuropathy. He felt Wisnewski had suffered nerve damage in the knee caused by her fall. It could either be rectified by a nerve graft, or by the removal of scar tissue around the nerve. The latter, more conservative approach, worked for her.

Wisnewski is one of nearly 20 million Americans who suffer from neuropathy, a chronic condition that results from damage to or compression of the nerves outside the spinal cord and brain, and also referred to as peripheral neuropathy. According to Dr. Rose, traumatic neuropathy is common –and he sees a good deal of in his practice.

Within a week after surgery, Wisnewski had some movement in her foot. “Today,” she reports, “I feel like nothing happened.”

Says Dr. Rose, “I think the best advice is not to automatically accept it when you are told there is nothing that can be done. It took Fran Wisnewski three doctors until she was sent to the proper person. It’s just fortunate that her neurologist was aware of the work I do, and so she was sent to me. Many doctors would simply say: Learn to live with it; there is nothing we can do. It’s hard to believe, but often even very good doctors don’t know what cutting-edge procedures that other specialists are doing. There is simply so much to know, and so much new being discovered all the time.

“In an ideal world, Fran would somehow know to call me directly, but the reality is, most people go to their general practitioner first for some direction. It wasn’t a straight line, but she did, in fact, end up at the right place in the end.”

Wisnewski appreciated Dr. Rose’s demeanor and knowledge. “You can tell he knows what he’s talking about. I had immediate confidence in him. He told me the surgery was not 100 percent guarantee, but he still gave me hope.”

Dr. Michael Rose gave Fran Wisnewski more than hope; he gave her a “rescue after a fall.”

Imagine your body—bones, muscles and skin—collapsing like a building. Now, imagine an actual building doing the deed. That’s what happened to construction worker Paul Nese, when, in October of 2011, he went into a building to oversee a job—a simple task that would be over in 15 minutes from when disaster struck. From 22 feet above him, 60 trusses, weighing 300-500 pounds each, came down, some of them landing directly on top of him.

The results were tibia and fibula (major bones) broken in his right leg, which also tore through his skin, a broken femur, fractured ribs, bone chips in his spine and severe herniated disks in his lower back. The 39-year-old Plainsboro, New Jersey, resident was rushed to the hospital, where he underwent several surgeries, lasting a total of approximately 15 hours.

Among those surgeons treating Nese, at this point at Jersey Shore Medical Center, was Dr. Michael Rose, who repaired the leg in which the bones had torn through muscle and skin. Dr. Rose salvaged what he could of the damaged muscle and did a skin graft from Nese’s thigh to his lower leg.

After undergoing some months of rehab, and additional surgery for what became the need for a full titanium hip replacement, Nese realized he had yet further damage. “When bones tore through my leg, they also tore tendons and caused nerve damage.” This caused Nese to experience foot drop as a result of the traumatic nerve damage, and also a severe case of traumatic neuropathy. “It was so painful from the calf to the tip of my toes. You know that painful tingling you experience when coming in from the cold? That’s what I had, only 24 hours a day.”

“This type of neuropathy is often overlooked in the aftermath of a life-changing injury when there are more pressing issues to which to attend. That being said, Paul (and others like him, who come into contact with me and our practice) was fortunate that I am familiar with and skilled at treating traumatic nerve injuries,” said Dr. Rose.

In all of Paul Nese’s misfortune, he had a stroke of good luck: a connection to Dr. Rose, who is among a handful of plastic surgeons trained in nerve decompression surgery for those suffering from all forms of neuropathy.

Nese is one of nearly 20 million Americans who suffer from neuropathy, a chronic condition that results from damage to or compression of the nerves outside the spinal cord and brain, and also referred to as peripheral neuropathy.

However, cases like Nese’s are more complicated because medical experts have to deal with the other injuries and make timing decisions for surgery for neuropathy. That being said, Dr. Rose points out that although one has to wait for other injuries to improve before working on the nerves, for the best surgical result for neuropathy, “the sooner the better in most cases.”

On Februrary 17, 2012, Nese underwent surgery with Dr. Rose, who did a tendon transfer on his toes, allowing his right big toe–that was completely hanging limp–to be connected and work with the rest of his toes. Dr. Rose also repaired the nerve in his ankle and on top of his foot.

Relief was immediate. “I experienced a huge result. It is so much better than it was,” says Nese. Of his overall recovery, Nese reports, “I’m able to sleep more comfortably, and not on constant pain killers. I’m looking forward to more future progress.”

In his 22 years working construction, Paul Nese had never had an accident prior to an event that so radically altered his life. But for those like Nese, who experience such life-altering events, medical experts such as Dr. Michael Rose can return part of the normalcy that was taken away.

This article was originally posted on the Philadelphia Inquirer.

By Melissa Dribben, Inquirer Staff Writer

The equipment that could add years to Kevin Neary’s life came in a flat gray box the size of a frozen taco dinner.

His father, Joe, pulled the device out of a backpack and placed it on the desk in a nondescript medical office park in Egg Harbor Township, N.J.

“Let’s do this,” said Neary’s surgeon, Matthew Kaufman.

“I’m ready,” said Neary.

The 29-year-old graduate of the University of Pennsylvania had been on a ventilator since Nov. 15, when he was shot during an attempted robbery in Northern Liberties and left quadriplegic. Doctors thought that the damage from the bullet, which was still lodged in his neck, had impaired the phrenic nerve, which triggers the diaphragm and allows the lungs to draw in air.

Three weeks ago, Kaufman operated on Neary in a South Jersey hospital, expecting to perform a delicate and rare procedure with about a 50-50 chance of success. He was going to salvage one of Neary’s healthy nerves, the one that allows him to shrug his shoulders, and transplant it to replace the phrenic nerve. If that worked, it would have taken six to 10 months before Neary could try using a pacemaker to fire up his diaphragm and breathe without the ventilator for minutes, perhaps hours, maybe even 24/7, if they were very, very lucky.

But once the surgery was under way, Kaufman discovered that Neary didn’t need a transplant after all. His phrenic nerve was intact and functioning. It had been merely caught in a clutch of scar tissue and shoved out of place. Kaufman cleaned out the biological muck, both freeing the nerve and giving Neary more mobility in his neck, then sent him home to heal.

Kaufman also was able to extract the bullet from Neary’s neck and gave it to him to take home. (The bullet, about 3/4 of an inch long and weighing less than an ounce, will be handed over to the Philadelphia District Attorney’s Office this week.)

As soon as the scars healed to pink and brown dashes above his collarbone and along his rib cage, Neary was anxious to try out his new equipment.

He, his father, and one of his nurses had been up before dawn Wednesday, preparing for the 90-minute drive from Upper Chichester.

“Not many health-care professionals are comfortable with this pacemaker,” said Kaufman, an elegant man in a dove-gray suit. He is 39, tall and thin, with the poise and posture of a ballet dancer.

“The only thing we want to do is turn it on and see if he’s getting responses. We don’t expect miracles today. This is like Week One of a four-week training for a marathon.”

Neary laughed. “I do a lot of walking and running in my spare time!”

Neary’s father reached into the backpack for a 9-volt battery to plug into the gray box, which would emit signals to the internal transmitters. Then he tore off strips of athletic tape to attach the antennae – two rubbery-looking circles – to his son’s chest.

Then Kaufman’s assistant called Kenneth Aron, the vice president of sales and marketing for Avery Biomedical Devices, the company that manufacturers the phrenic nerve stimulator.

The device was first approved by the FDA in 1986, Aron said. In 2003, actor Christopher Reeve, who had been paralyzed in a horse-riding accident, was part of a trial testing a system similar to the one Neary received.

A few dozen patients have been breathing with these pacemakers for 20 years, Aron said. Fewer than 100 a year are implanted.

From his office in Long Island, Aron would be guiding Kaufman through the test run. He had planned to monitor, by telephone, how well the device was working, but the connection was not clear enough. Kaufman, instead, would report Neary’s oxygen levels and heart rate and adjust the power of the electrical impulse accordingly.

“You’re going to have to walk me through this,” said Kaufman. Normally, the test run is handled by a pulmonologist or respiratory therapist, but there had been scheduling difficulties and Neary was impatient, so Kaufman agreed to get him started. There was no risk, he said, because if the device didn’t work, he would immediately put Neary back on the ventilator.

“How do we want the settings?” Kaufman asked Aron.

“My starting point would be 1.8 to 2.4 . . . look for maximum diaphragm contraction.”

“OK,” Kaufman said, talking over static on the phone line. “Are we on Mars yet? On the transmitter, the lever is switched to B. . . . Is that correct?”

Neary listened carefully, trying to follow.

“Hello?” Kaufman asked. The telephone connection was lost.

While the assistant redialed, Neary complimented Kaufman. “I like your shirt and tie,” he said, offering to send him something from his own collection. Before the shooting, he had started his own business, recruiting health-care staff, and had been an impeccable dresser. Now his injuries made sweatpants and hoodies more practical.

With Aron back on the line, Kaufman flipped a few switches.

“OK. Take the vent off,” he told the nurse.

“Nice!” said Neary. “I hate the vent.”

The room fell silent. Everyone stared at Neary’s chest. The machine beeped. His rib cage jerked suddenly. Then again. “He’s getting some movement,” Kaufman said.

For the first time since he was shot, Neary was breathing independently.

His dad began to cry and left the room to regain composure.

“Apollo has landed!” said Kaufman. “He’s cranking.”

“It feels weird,” Neary said, mouthing the words. It will take months for him to learn how to speak with the reversed flow of air. And over time, as his breathing muscles regain strength, the contractions will grow smoother.

After 14 minutes, Neary’s oxygen levels were still at 98 percent, but Kaufman didn’t want to push him too fast, too far. “Why don’t we switch him back to the vent?”

Neary shook his head, “No!”

“All right. We’ll go to 15.”

Reattached to the ventilator a minute later, Neary thanked Kaufman. “Good job, doc.”

“You’re on your way, my friend.”

According to The National Stroke Association, public knowledge of stroke is low. That’s why The Institute for Advanced Reconstruction in Shrewsbury, New Jersey, is joining the effort during Stroke Awareness Month in May and throughout the year. The Institute is a leader in stroke treatment, performing life-altering procedures for select patients who have suffered from some devastating effects of stroke.

Definition

A stroke is the sudden death of brain cells in a localized area due to inadequate blood flow.

Description

A stroke occurs when blood flow is interrupted to part of the brain. Without blood to supply oxygen and nutrients and to remove waste products, brain cells quickly begin to die. Depending on the region of the brain affected, a stroke may cause paralysis, speech impairment, loss of memory and reasoning ability, coma, or death. A stroke also is sometimes called a brain attack or a cerebrovascular accident (CVA).

Some important stroke statistics include:

• More than one-half million people in the United States experience a new or recurrent stroke each year
• Stroke is the third leading cause of death in the United States and the leading cause of disability
• Stroke kills about 160,000 Americans each year, or almost one out of three stroke victims
• Three million Americans are currently permanently disabled from stroke
• In the United States, stroke costs about $30 billion per year in direct costs and loss of productivity
• Two-thirds of strokes occur in people over age 65 but they can occur at any age
• Strokes affect men more often than women, although women are more likely to die from a stroke
• Strokes affect blacks more often than whites, and are more likely to be fatal among blacks

Paralysis

Paralysis is one of the most common disabilities resulting from stroke. The paralysis is usually on the side of the body opposite the side of the brain damaged by stroke, and may affect the face, an arm, a leg, or the entire side of the body. This one-sided paralysis is called hemiplegia if it involves complete inability to move or hemiparesis if it is less than total weakness. Stroke patients with hemiparesis or hemiplegia may have difficulty with everyday activities such as walking or grasping objects. Some stroke patients have problems with swallowing, called dysphagia, due to damage to the part of the brain that controls the muscles for swallowing. Damage to a lower part of the brain, the cerebellum, can affect the body’s ability to coordinate movement, a disability called ataxia, leading to problems with body posture, walking, and balance.

The specialists of The Institute for Advanced Reconstruction deal with some of the results of stroke. According to Dr. Andrew Elkwood, “Whereas we cannot cure stroke, we can sometimes help treat some of the results. We can sometimes mitigate the paralysis and help patients with increased function. It is possible to lessen some of the spasticity caused by stroke. Ultimately, the goal is to cure and prevent strokes; nonetheless, surgeons at The Institute for Advanced Reconstruction can help limit its devastating effects.”

Relevant procedures deal the results of most major types of stroke. These include:

Right-Hemisphere Stroke

A stroke in the right hemisphere often causes paralysis in the left side of the body. This is known as left hemiplegia.

Left-Hemisphere Stroke

The left hemisphere of the brain controls the movement of the right side of the body. It also controls speech and language abilities for most people. A left-hemisphere stroke often causes paralysis of the right side of the body. This is known as right hemiplegia.

Brain Stem Stroke

Strokes that occur in the brain stem are especially devastating. The brain stem also controls abilities such as eye movements, hearing, speech and swallowing.

Innovative Stroke Treatments at the Institute for Advanced Reconstruction

At the Institute for Advanced Reconstruction, the world famous surgeons have pioneered treatments to help reverse arm paralysis in some stroke patients. In fact, the Institute was the first and only center in the nation and probably in the world to successfully perform nerve reconstructive surgery in a stroke patient.

For more on this procedure, and on The Institute for Advanced Reconstruction, log on to www.advancedreconstruction.com