Dan Cioch, a 48-year-old home inspector, had finally put his neck cancer surgery, radiation and interferon treatments behind him. In the spring of 2011, he was back to work climbing ladders and holding flashlights - until he began to lose the function of his right arm.
Dan’s symptoms were the result of a hardening of the tissue around the nerves of the brachial plexus, a network of nerves that originate near the neck and shoulder and drive arm movement.
The diagnosis that Dan received, called radiation-induced brachial plexopathy, as distressing as it was, came as a relief. For Dan, a husband and father of two school aged children, knowing the cause of his paralysis, something that had eluded experts for months, brought him a step closer to finding a solution. When the numbness first began, he had thought it was a touch of carpal tunnel syndrome, and consulted several doctors, all of whom were uncertain about its cause. Over time, weakness ensued and with it came pain too. Soon, everyday tasks were hard to perform. Each of the several doctors he consulted nearby his Westfield, Mass. home, as well as farther afield, were puzzled by his symptoms, including an orthopedist, an internist, a neurologist, his oncologist and his radiation oncologist.
Eventually, a nerve study or EMG (electromyography test), showed that Dan was suffering from a brachial plexopathy, the result of the radiation treatments he underwent to help wipe out his cancer. This condition occurs in approximately one to three percent of patients who have undergone radiation.
Dan’s relief about finally having a diagnosis was short lived. “No one had a clear idea for treatment. They seemed satisfied that the numbness was not due to cancer and sent me on my way.” Every day, Dan’s arm worsened. “I couldn’t raise my arm, brush my teeth, comb my hair, or function at work. It’s hard to take notes on a clipboard with one arm.”
By Christmas Eve of 2011, the movement in his arm disappeared entirely. Devastated, Dan took to scouring the Internet for answers. “I knew that there were specialists out there who could stitch together nerves. But I wasn’t sure what I was looking for.” His research turned up a name of a specialist, and during a consultation, Dan learned that the treatment for his condition was a nerve transfer surgery.
“Once I had a definition, I was off,” recalls Dan. He found a surgeon who specialized in the procedure and went for another consultation. During his appointment, the specialist told him he didn’t think an EMG was necessary as part of his evaluation. “Something stuck in my mind about that,” Dan says. “I had a bad feeling.” Dan decided against this surgeon and continued his search.
He returned to the Internet where he found the name of a specialist in New York City, Scott W. Wolfe, M.D., director of the Center for Brachial Plexus and Traumatic Nerve Injury at Hospital for Special Surgery. “I called the office, faxed them 30 pages of records and within a week, they’d scheduled an appointment,” recalls Dan, who then made plans to travel from Westfield, Mass. to New York City to see him.
For Dan, everything about his experience at Special Surgery was different. “When I met with Dr. Wolfe, his approach was more thorough. For instance, I underwent EMG testing as part of my initial evaluation. He listened to me, took his time explaining things.”
The nerve transfer surgery that Dr. Wolfe described was different from the one the earlier surgeon had recommended. “Dr. Wolfe told me that the nerve transfer surgery would take eight hours rather than four, because he would do a double nerve transfer to the bicep not a single one, which would improve my chances of recovering movement. Also, the other surgeon I had considered said that my ability to shrug my shoulder would be lost, but Dr. Wolfe said, no, that wouldn’t happen.”
After the first meeting, Dan says, “There was no turning back.”
A month later, Dan underwent the surgery performed by Dr. Wolfe, Dr. Steve K. Lee, his Center surgical colleague, and physiatrist Dr. Joseph H. Feinberg, who conducted the EMG testing. “The surgery involved transferring nerves from the forearm to the bicep muscle,” explains Dr. Wolfe. “We harvested a piece of healthy, expendable nerve from this other location and used it to reconnect the ends of the damaged nerves to help restore the patient’s ability to move his elbow and perform lifting.”
Dan was fortunate to have identified the problem and pursued finding a treatment when he did. “Patients are often referred too long after their injury,” says Dr. Lee. “Studies show that if nerve reconstruction surgery is done within six months after a nerve is damaged, patients do far better.”
Dan stayed overnight at Special Surgery and then kept his arm in a sling for six weeks while he recovered at home. Soon after the procedure, he began physical therapy. Three months post-surgery, Dan felt a flicker in his arm where he hadn’t felt anything for months. This flicker is usually the first sign that the surgery has worked. Since then, Dan’s brain has been learning to reconnect to the nerves that have been transferred, and more and more of his mobility has returned, including his ability to lift a glass, turn a key and open a door, button his shirt and, yes, shrug his shoulders.
“All I can think about is how people told me that nothing could be done, while every day my arm got worse,” says Dan. “Now, I have movement where there had been nothing. Finally, I feel like things are getting better and better.”