Nerve regeneration gives hope to 10-year-old

By Maureen Gilmer, IU Health senior journalist, mgilmer1@iuhealth.org

In her gray jumper and sneakers, with her hair pulled back in braids, Khloe Hairell looks like a typical 10-year-old. But she has endured more than her share of pain in her short life.

Perhaps that’s why it’s endearing to hear her yell “Nobody home” each time there is a knock on the door of the small exam room at Riley Hospital for Children, where she waits with her mother, Maegen Bramblett.

Her sass is a relatively new feature of her personality, Bramblett says. It might be due to injuries suffered in a motorcycle accident nearly a year ago, but there’s a bit of pre-teen sarcasm bubbling up as well.

Khloe spent her 10^th birthday last September in the hospital. She and her mom, who live in Marion, Indiana, want to be sure this year she can have a proper birthday at home, so they are relieved when Riley plastic surgeon Dr. Joshua Adkinson says now is not the time for another surgery to help regain the use of her left arm.

After rehabbing at Riley last year and learning to walk again, Khloe wasn’t finished healing yet. She points to her nose and says, “Everything on my face got ruined but this nose.”

Her face appears perfect now, but her left arm is a different story. She suffered an injury to her brachial plexus, which is a network of nerves in the shoulder that carry movement and sensory signals from the spinal cord to the arms and hands. Brachial plexus injuries typically stem from trauma to the neck, and can cause pain, weakness and numbness in the arm and hand.

NERVE TRANSFER

In January, Khloe underwent a relatively novel surgery performed by Dr. Gregory Borschel, chief of plastic surgery at Riley, and Dr. Adkinson. The surgeons transferred nerves, borrowing “power” from her strong right arm to restore power to her left arm.

Called a “Cross C7” nerve transfer, Dr. Borschel said, the idea is to regenerate the nerve to promote healing and restore some function.

“We think it’s the first time this has been used in a child in Indiana,” he said. “Our team is a leader in this field.”

That kind of advanced surgery is Dr. Borschel’s passion. When he joined Riley, he made a point to talk about its collaborative culture.

“I like to be part of a team, and I love bringing people together to form teams. The other thing I really like doing is developing new approaches to treating certain conditions.”

His clinical work focuses on nerve injuries, like Khloe’s, as well as pediatric facial paralysis, hand surgery and other plastic and reconstructive surgery. In addition, he has pioneered corneal neurotization to treat blindness in patients with neurotrophic keratopathy.

“I’ve been fortunate to collaborate with lots of specialties in the operating room, and we’ve come up with some novel solutions to difficult problems through teamwork,” he said in an earlier interview. “The goal is to develop the best strategies in the world for these patients with traumatic injuries.”

CUTTING EDGE

As Dr. Adkinson examined Khloe during a follow-up appointment last week at the Riley Outpatient Center, he explained the surgery in layman’s terms.

“We stole some power from her unaffected right side, and we have it extended over to the left side through an extension cord of sorts,” he said.

Grafts taken from Khloe’s legs served as the “extension cords,” connecting the normal nerve root to the injured area. The surgery took about eight hours.

It’s too early to say how successful the procedure will be for Khloe, though she has some tingling and sensation in her upper arm and can shrug her shoulders.

“The surgery went really well,” Dr. Adkinson said. “Nerves regenerate slowly, but I think she’s progressing nicely.”

It can take a year to 18 months to see results, he added. Khloe, who is seven months out from surgery, still carries her left arm in a sling, something doctors and her mom would like to see her less dependent on, especially at night.

“I’m supposed to sleep with it off, but I can’t,” she said. “Cause I have to sleep with my arm on my side and it falls forward and backward and gets pain in my shoulder. I still get pain.”

Asked how she deals with the pain, she says, “I just make a face.”

THERAPY CONTINUES

Khloe sees an occupational therapist close to home twice a week, but during her Riley appointment, she is evaluated by OT Amy Bercovitz, who is patient, encouraging and enthusiastic as Khloe attempts to show her how she can raise her left arm off the exam table.

For whatever reason, the motion is a lot harder today, and Khloe struggles to lift her arm, using all the muscles in her core.

“I can’t do it,” she says.

“I see you arching your back, I want you to try to keep it straight,” Bercovitz tells her, before moving on to another exercise.

She asks Khloe to close her eyes and tell her where Bercovitz is touching her on her arm. The fifth-grader easily points to spots on her upper arm when Bercovitz touches them, but she is unable to identify proximity with her eyes closed when the therapist lightly touches her lower arm. Nor can she feel touch on her left hand, despite occasional tingling in that hand.

That’s to be expected at this point, Dr. Adkinson said.

“Really the goal of today is just to keep coaching you through the therapy process,” he said, reiterating the need for her to rely less on the sling.

“The sling is her crutch,” her mom said. “When I take it from her, she’ll hold her arm and go pout.”

“We’ll have to work on that,” the doctor said, explaining that it could inhibit motion and slow the healing process.

TRAMPOLINE IS A NO-GO

One big question on Khloe’s mind at her Riley appointment is whether she could be cleared to jump on the trampoline that sits in her front yard. Her occupational therapists aren’t fans of that idea, but it is Dr. Francisco Angulo-Parker, pediatric rehabilitation specialist at Riley, who puts the kibosh on it – for now.

Dr. Angulo-Parker, who has been part of Khloe’s care team since she first arrived at Riley last September, said even though she may try to protect her left arm when jumping, it’s not safe.

“There is not enough protective positioning of that shoulder to prevent a serious injury,” he told Khloe and her mom. “I would be scared about her shoulder stability if she fell the wrong way. It’s too soon.”

It’s not the answer Khloe is hoping for – her body language makes that clear.

And so the road to recovery continues. Khloe will return to Riley for a follow-up exam in three months.

Photos by Mike Dickbernd, IU Health visual journalist, mdickbernd@iuhealth.org