Raysha Rivany and Billy Kurniawan on their wedding day. (Photograph by Christopher Liando)
Nerve injuries to the shoulders and arms can be severe and complicated, impairing a person’s quality of life. Sunnybrook’s new Complex Combined Upper Extremity Clinic takes a team approach to provide patients like Billy Kurniawan with a leading model of care.
Billy Kurniawan awoke last May not knowing how he ended up at Sunnybrook.
Told that he been unconscious for a number of days, he had no memory of the motorcycle crash that had brought him to Canada’s busiest trauma centre.
What the 39-year-old could recall, however, was that he was to be married to his fiancée, Raysha, in two months.
Billy soon realized he faced a challenging recovery from a long list of injuries. Because of his neck injury, he needed to wear a halo brace – a medical device that clamps around the head and attaches to the shoulders to stabilize the spine.
“But the real major [injury] was to my brachial plexus – a root of the nerves that attach to the spinal cord,” he explains. “Basically, the nerves that control my arm, hand and fingers were detached from my spinal cord.”
The injury, called a root avulsion, meant Billy had lost much of the sensation and use of his left arm. Suddenly everything in his life now seemed up in the air: the wedding, his job and whether he’d ever be able to use his arm again.
What was certain, however, was that Billy needed specialized care, and Sunnybrook was the right place. A year before his crash, Sunnybrook’s Complex Combined Upper Extremity Clinic opened with a mandate to treat serious nerve injuries like his.
“I am one of those lucky people – to be at Sunnybrook,” he says. “I am thankful to be alive and still able to walk.”
Billy is among several dozen Ontarians who have undergone treatment at the Complex Combined Upper Extremity Clinic since it opened in June 2017.
Plastic surgeon Dr. Paul Binhammer, one of the clinic’s specialists, says the idea for a specialized unit evolved out of the realization that care for patients with serious nerve injuries to their arms and hands was not as good as it could be.
“I felt like these patients weren’t being well served,” says Dr. Binhammer, one of Canada’s leading specialists for procedures to repair nerve injuries to the upper extremities.
Before Sunnybrook’s innovative new clinic, patients might have had to see several specialists at different locations over a number of weeks.
“I’m a positive person, so I wake up each day hoping for the best.”
– Billy Kurniawan
“That often would prolong the recovery process because patients go back and forth between specialists as they tried to solve the problem,” Dr. Binhammer says. “The clinic came about with the aim of having all the specialists for the patients in one place, so we can come up with solutions much more quickly.”
Time is a big factor with these kinds of injuries, he explains. The longer patients wait for care, the longer their recovery will be. Also, as time passes, the damage is more likely to become permanent, as muscles atrophy and joints become progressively more rigid.
The Complex Combined Upper Extremity Clinic aims to provide fast-tracked care. Patients first meet with the team, three specialists who include Dr. Binhammer, Toronto Western Hospital hand surgeon Dr. Heather Baltzer and physiatrist Dr. Larry Robinson. (Physiatrists are nerve, muscle and bone experts who diagnose and treat illnesses or injuries that affect movement.)
The clinic is part of a growing trend in health care acknowledging the importance of multidisciplinary treatment for patients with multifaceted injuries, Dr. Robinson says, who serves as chief of St. John’s Rehab at Sunnybrook.
“A big piece of doing that well is offering all the care in one place,” he says. “Because the surgeons and others – [including] physiatrists like myself – can have that interdisciplinary discussion, we’re bringing multiple viewpoints to the table, which allows us to reach a thoughtful recommendation much faster.”
Often Dr. Robinson’s role comes first in the care plan. He helps discover the extent of a patient’s injury by testing nerve function using electromyography, or EMG for short.
“In Billy’s case, using EMG, we were able to establish he had a complete injury because there was no signal getting through to his arm,” he says.
(Illustration by Trevor Johnston)
The initial electromyography test (EMG) shows the degree of injury to a nerve. Post-surgery, it measures how the nerve is growing.
The exam involves placing thin electrode needles into the muscle. These needles are wired to a device that receives electrical impulses from the nerve, measuring its functionality.
The nerve’s ability to conduct is measured by the machine below which displays the strength of the electrical signals.
In a muscle without a working nerve, there is no voluntary activity seen despite a full effort to contract the muscle. This reading is typical in a muscle with no nerve supply.
Above are electrical recordings of muscle fibres that are just starting to recover after a nerve injury. The three large spikes represent voluntary muscle activity from individual nerve fibres.
With the severity of Billy’s injury established, his surgical team could swiftly determine the next course of action: a nerve graft.
The aim of this surgical procedure was to restore most – but not all – movement and feeling to his left arm and hand.
“Typically with these complex cases, we can’t entirely make the limb and hand as it once was,” Dr. Binhammer says. “So we focus on things that are most important – like the fingers being able to flex and extend.”
Billy had to wait a few months for the surgery while his other injuries healed. In the meantime, his doctors gave him the go-ahead to walk down the aisle.
“We asked if we could remove the halo, but the doctors said it would be too dangerous, so it made for some interesting wedding photos,” Billy says with a laugh.
After the wedding, the procedure to repair the tear to his brachial plexus went ahead as planned. It involved Dr. Binhammer removing several centimetres of the sural nerve from Billy’s left leg.
“We steal that chunk of nerve and graft it like you’d splice an electrical wire to repair a damaged cord,” Dr. Binhammer explains. The sural nerve is often the ideal choice for grafts because patients can lose its function without affecting their quality of life much.
“They can still run, jump and lead active lives,” he says.
Once complete, the graft procedure does not restore function immediately because the grafted nerve fibre cannot carry signals from the spine down the arm just yet. Rather, it serves as a bridge for sprouting nerves in the spine to cross the gap to the brachial plexus and regrow down the arm.
“With this pathway in place, the nerves grow about a millimetre a day,” Dr. Binhammer says. “So my job, post-surgery, is to find out how the nerve is growing.”
For Billy, it will be a long recovery, involving a lot of hard work for both him and his wife. She helps with his daily exercises and with common tasks he used to take for granted, like zipping up his jacket.
“I’m so happy she’s by my side,” he says.
While it can be challenging to accept that his recovery may take up to three years, “I realize most motorcycle crashes of this nature have far worse outcomes,” Billy says.
“I’m a positive person, so I wake up each day hoping for the best.”
Illustration by Trevor Johnston
Sunnybrook’s Dr. Larry Robinson, who specializes in severe injuries to upper extremities, has an apt description for the brachial plexus: “It’s like the most complex freeway interchange you could ever imagine – one with multiple exit and entry ramps.”
Located where the shoulder connects to the spine, it is a nexus for five important nerve roots controlling sensation and movement in the shoulders, arms and hands. These nerves branch into three main neural circuits, or cords, that route signals to more than a dozen peripheral nerves.