It Takes Nerve

Brainwaves, Fall 2004,  Volume 16, Number 4

Belzberg's daring sciatic nerve repair saves soldier's leg.

It doesn't matter whether your hip's shattered by friendly fire or the real thing," says Derrick Goodrich. "You still can't walk." Goodrich, 23, joined the Army from his home in Gillette, Wyo., carrying on a family tradition. But last April, two weeks into his tour in Iraq near the Syrian border, the young man was struck by a bullet from close range-an accidental discharge from a gun behind him.

When Derrick Goodrich disappeared,
into the halls of U.S. Army medicine,
neurosurgeon Allen Belzberg never
got to check his recovery. Goodrich
reappaeared this summer. Belzberg
was more than delighted with the
soldier's progress.

Goodrich didn't know then -- they'd told him shock kept him from moving his leg -- but the impact had vaporized five inches of his sciatic nerve. It was stateside, at Walter Reed, that he learned the extent of his injury. Saving his leg looked hopeless. "They told me amputation and a prosthesis would make it easier for me to get around," he says. But Goodrich pressed his physicians to seek a second opinion.

And so it was that last November, Hopkins neurosurgeon Allan Belzberg, M.D., tried a gutsy approach to restoring sciatic nerve function. "This hadn't been tried here before," says Belzberg. "Even I thought it a little bold. Going near the spinal cord puts bladder and bowel function at risk. But Derrick had a chance. And I ran it by colleagues at several institutions. They said, Go for it."

The largest nerve in the body, the sciatic originates from lumbar and sacral spinal nerve offshoots that meet in one nerve sheath deep in the pelvis. "The pelvis is difficult real estate," says Belzberg -- a tough area to expose.

At first, Belzberg thought the nerve damage might be well away from where spinal nerves exit the pelvis. Then he could clip out the injured bit and join the cut ends by grafting a "filler" -- the sensory sural nerve -- harvested from Goodrich's lower leg. "We hoped Derrick's Army docs might have missed an uninjured part of the nerve close to the pelvis. So we traced every inch of it backward, beginning mid-thigh. Basically, we had to pull open the buttocks, which in itself is difficult. You'll damage the muscles if they're not split exactly right."

But a clean proximal end of the sciatic nerve didn't exist. "It started looking ratty as it entered the pelvis," says Belzberg. "And nerve grafts within the pelvis really don't work well." So he decided to bypass the nerve's natural pelvic route altogether, instead connecting the sural nerve graft directly to spinal nerves as they exit the spine at one end, and to the uninjured part of the sciatic nerve at the other.

A laminectomy freed the spinal cord from surrounding vertebral bone, giving access to the spinal nerves. Belzberg isolated the appropriate ones to join to the graft. He then threaded the sural nerve under Goodrich's skin and muscle, attaching the nerve ends with a microscope's help and the neural equivalent of super glue -- an eight-hour surgery. Then they waited.

"It was gradual, hard to notice, but a few months later, I bumped my shin against a chair and I could feel it," says Goodrich, obviously pleased. Now movement's returned to his hamstrings. He can stand and bend his leg. "It's too early to know what he'll regain below the knee," says Belzberg, "but things look very promising. Derrick's told me he's keen to tell the world that many nerve injuries can be repaired. He says, 'Tell them to stop cutting peoples' legs off!'"

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