‘This is really weird. Who wakes up and their hand doesn’t work?’

By Sandra G. Boodman

September 3, 2022

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The act was so routine Michael Brenner never thought about it − until the Sunday morning in June 2021 when he ambled over to his computer to type a quick note and discovered he !$ underset{......}{I} !$. Brenner, who is right-handed, was unable to lift or extend his fingers, which felt inexplicably stiff. His left hand was unaffected. He thought it might be carpal tunnel syndrome, a common condition resulting from a pinched nerve in the wrist.

A week later, his condition unchanged, he saw his internist for what he assumed was a minor, and easily fixable, problem. He soon discovered it was neither trivial nor easy to diagnose; he had no idea how tricky it would be to treat.

Over the next 10 months, Brenner would consult an orthopedic hand surgeon; a physiatrist, a medical doctor who specializes in physical rehabilitation; multiple neurologists; a neurosurgeon and a plastic surgeon in a circuitous, time-sensitive effort to fix his partially paralyzed hand.

The hand surgeon recommended a radial tunnel release, an outpatient procedure to alleviate pressure on the nerve. After the operation in July, the surgeon told Brenner his nerve had been extremely compressed and that he should slowly improve with physical therapy (PT).

In early November after four months of PT, Brenner was no better than he’d been before surgery. The hand surgeon sent him to a physiatrist for electromyography (EMG) and a nerve conduction study, tests that evaluate the functioning of nerves and muscles.

Midway through the EMG, the doctor’s reassuring manner changed. He left the exam room saying he needed to check a textbook. Upon his return he announced that he had detected nerve damage on a part of the radial nerve where the surgeon had not operated. Brenner said the physiatrist told him he’d probably need a second operation.

As the weeks passed, he worried increasingly that the paralysis might spread to his left hand.

He consulted a neurologist who ordered extensive blood tests. All were normal, The neurologist told Brenner she didn’t know what was wrong and referred him to neurosurgeon Allan Belzburg, chief of peripheral nerve surgery at Johns Hopkins Hospital in Baltimore.

After examining Brenner and reviewing his test results, Belzburg told him the nerve damage was most likely the result of Parsonage-Turner syndrome (PTS), an uncommon and little understood disorder also known as neuralgic amyotrophy. Belzburg recommended nerve transfer surgery, which would involve taking a healthy, redundant nerve from Brenner’s wrist and connecting it to the damaged nerve, allowing it to function. Belzburg told Brenner that he performs such procedures with plastic and reconstructive surgeon Sami Tuffaha, who has advanced training in hand surgery.

Brenner met with Tuffaha, who agreed that nerve transfer offered the best hope for recovery.

When the surgeons opened Brenner’s arm, in January, they discovered what appeared to be a severed nerve at the site of his first surgery. Closer examination revealed a possible hourglass-like constriction, a rare deformity sometimes seen in PTS patients, caused by a band that tightly encircles the nerve making it resemble an hourglass.

Tuffaha said that the Hopkins surgeons had not previously encountered this, but reached out to someone who had: Surgeon Scott W. Wolfe of New York’s Hospital for Special Surgery, who was looped into the operating room at the last minute via video call. Wolfe co-authored a 2021 study describing successful surgery performed on 11 PTS patients with hourglass constrictions.

Tuffaha said, “He convinced us that microneurolysis should work.” Wolfe recommended wrapping the damaged nerve in connective tissue harvested from Brenner’s wrist to protect it.

At the end of the four-hour operation, Tuffaha was hopeful but unsure the novel approach would work.

But Brenner was overjoyed when the post-operative EMG test detected the first flickers of activity.

Brenner said he wishes he had seen a neurologist early on, which might have expedited the diagnosis.

(Adapted from https://www.washingtonpost.com)