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11.05.2013

Surgeons Perform World’s First Nerve Graft to Repair Peripheral Nerve Injury

When Danielle Press went boating off Key Biscayne the afternoon of September 14, she didn’t realize she would be severely injured in a boating accident and make medical history. One month after being rushed to Ryder Trauma Center, surgeons from the Miller School of Medicine/Jackson Memorial Hospital performed the world’s first nerve graft using a combination of Press’ own nerve and Schwann cells to repair her severely injured sciatic nerve.

The team of surgeons who saved Danielle’s life and performed the historic procedure gathered with the 26-year-old and her parents October 29 to share the story with news media. In a wheelchair with her leg immobilized, Danielle said the details of the accident were a blur, but she now “takes every day as a gift.” Her father, Charles Press, Chief of the Key Biscayne Police Department, credited first responders and the “fantastic team of doctors” at UM/Jackson. “To this day,” said Press, “we know that’s why she has survived to now.”

The 26 year-old was in the water when a boat propeller lacerated her upper leg. She lost nearly half her blood and almost died. UM/Jackson trauma surgeon Gabriel Ruiz, M.D., assistant professor of surgery, was the first to operate on Danielle when she arrived. He said the first priority was to save her life and then her leg. Doctors discovered that the sciatic nerve in her left leg, which controls the majority of movement and sensation in the legs, had been completely cut and separated. Danielle, a college graduate who taught English in South Korea, was told that she may never regain any feeling or movement in her leg as a result of the injury.

Repairing the sciatic nerve – the largest nerve in the human body – presents one of the most difficult challenges in nerve surgery, particularly when a significant gap exists, like in Danielle’s case. One of the major limiting factors is the absence or lack of donor nerve material. Even in cases in which a relatively small gap exists, the donor nerves of the lower leg that are harvested used for the repair are rapidly depleted. Insufficient autologous nerves are a major obstacle in successful repair strategies for sciatic nerve injuries with large gaps.

A specialist in the field of spine and peripheral nerve surgery, Allan Levi, M.D., Ph.D., professor of neurological surgery, considered traditional nerve grafting, but felt that Danielle may have a better outcome with alternative treatment options, such as using her own Schwann cells, expanded in number using cell culture techniques. Schwann cells are involved in many important aspects of peripheral nerve biology, including the conduction of nervous impulses along axons, nerve development, and regeneration. Levi and his team are leading an FDA approved Phase 1 clinical trial at the Miller School of Medicine’s Miami Project to Cure Paralysis using a patient’s own Schwann cells for acute spinal cord injuries. Pre-clinical work suggested that the use of Schwann cells could also be beneficial in Danielle’s unique case.

Levi obtained approval from the FDA for the procedure to combine standard nerve grafting with autologous human Schwann cells, with the goal of providing Danielle with an opportunity to maximize nerve regeneration and restoration of function.

“At the University of Miami and Jackson Memorial Hospital we always provide not only the standard of care, but try to think outside the box in order to change the practice of medicine and better people’s lives,” Levi said. “We felt it was extremely important to literally utilize everything in our toolbox to make an effort to give this young lady a chance at recovering some function and sensation in her leg.”

The historic procedure, a nerve graft combining Danielle’s nerves with her own Schwann cells, was performed by Levi at Jackson Memorial Hospital on October 14. The hope is that over time, the cells will regenerate and fill in the nearly three-inch gap created by the injury.

Ruiz said “to know where we were and where she is now is just the most amazing thing in the world.”

Danielle said she feels fortunate. “When I put things in perspective, I feel I’ve made progress. It’s an extraordinary opportunity.”

As a research subject, Danielle will be followed for the next five years. As her condition improves over the next several months, she will begin physical rehabilitation.

“She has a long way to go,” Levi said, “but she has done well.”

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