Update on Erik's shoulder - THIRD blog post ever!

Job.  An amazing man with amazing faith.  Now, I wouldn't say I'm "suffering," but even if I was, this helps put it all in perspective.  I got nothing on that guy.

For starters, if you need to catch up on any of the back-story, here are links to the first and second posts.  Now, onto the news...

On Tuesday, 4 months to the day, I had my second EMG.  I always say it, but I have to give props to all the support I have.  I am continually grateful to my residency program and friends in Rochester, as well as Kara's support network including her friends from Side-by-Side, a sibling to the Christian Medical and Dental Association (CMDA) for medical spouses and significant others.  For the week prior to big day, I had my annual training at Camp Ripley for the Army, and the support I have from my Commander and everyone else in my Unit is just one more thing for which I am thankful.


This repeat EMG was originally scheduled for June, but I had an appointment mid-April when we decided to move it up.  My patience was thinning and, while nerve healing is a "slow process" (how many times have I heard that?!), I was anxious to move beyond the uncertainty.  In retrospect, I was also somewhat pessimistic since it was nearly 3 months after the accident and I still didn't have any significant improvement, so I thought, "Why put off the inevitable?"  That being surgery.


The anxiety-provoking uncertainty seems to ebb and flow in relation to my appointments, which I suppose is normal for anyone going through a serious injury or illness, so as the second EMG was approaching, my thoughts about the anticipated results became more frequent.  Interestingly, this created an internal dilemma.  What was it that I was really hoping the EMG to show?  Over the past 4 months there really hadn't been any significant improvements in strength of my left deltoid, tricep, or spinati, and the skin over my left upper arm was still numb.  It might seem like a no-brainer that I would want to see a change in the EMG to show at least some return of muscular function at the cellular level.  However, this "good news" of healing doesn't really help with the uncertainty issue, as it would be an indication for more watchful waiting without knowing to what extent the healing might continue.  The bottom line is that I want this to be better as soon as possible, which might be faster if the EMG showed no improvement and we pursued surgical intervention.  More importantly, though (so, the bottomer line), is that I also want the best possible outcome, which would probably come from my body healing itself, particularly with this mechanism of blunt trauma and the fact that it's a partial injury with retention of distal function (i.e. my wrist and hand work well).

As the appointment approached, that ebb and flow was ramping up, and my anticipation started to become more one-sided.  I was really hoping for improvement on the EMG.  Even if I had to struggle with this injury a little longer, but 10 years down the road I had a higher degree of recovery, it would be worth the immediate bother.

[This is my third blog post ever, and I think I've picked it up quite quickly.  None of you really care about all the yada yada above (no pictures even!) -- "just show me the money!"]

Supraspinatus above the scapular spine.
Infraspinatus below the scapular spine.

To get to the point of this post, the EMG didn't show any changes in nerve conduction or myocyte activity.  I had a different neurologist this time who also used ultrasound at the bedside primarily to evaluate muscle architecture and visually watch for contraction, or flattening, of the muscle in real-time.  One positive thing from the appointment was his comment that my muscles appeared to have normal, but diminished, architecture still.  He also did two other things this time.  One was to test the supraspinatus, which wasn't done last time, just the infraspinatus.  The supraspinatus is buried underneath the trapezius muscle, which was another benefit to using ultrasound.  As expected, this didn't show any activity, either.  Really just confirming what we already knew.  He also stabbed me closer to the spinal root and said the paraspinal muscles looked normal on EMG, which is a good sign and is evidence against a complete axonal injury, such as an avulsion of the nerve.

After my EMG, I had an appointment with the Brachial Plexus Guys.  It was a pretty brief appointment and we got right to the point.  We scheduled surgery for July with an MRI of the brachial plexus (the first MRI was just of the shoulder joint, not the nerves), another EMG, and another appointment the day before to have a solid game plan in place.  At this time, they still don't know if it will be a nerve transfer or a nerve graft, though it sounded more likely to be a transfer.  What is the difference, you ask?  Washington University has a really good website describing nerve transfers and nerve grafts with a lot of other really good information on the left side of the screen.  I like this description:

Nerve transfers involve taking local nerves with less important or redundant functions and “transferring” them to restore function in a more crucial nearby nerve that has been severely damaged. The surgeon will use functioning nerves that are close to the target muscle or sensory area, and these nerves are transferred or “plugged in” to the injured nerve that no longer functions. The nerve that has been “plugged in” now supplies that function. For example, if a breathing nerve is used to restore elbow flexion, the patient may initially have to take a deep breath to move the arm. The brain then learns this trick and soon the patient is able to move the arm simply by thinking about moving the arm.

An example of re-routing the median nerve to the radial nerve in the forearm
(not something that I will have done, just an example of a nerve transfer).

If you browse around their site a little bit, you'll find this page describing the spinal accessory nerve transfer.  This is a good description of what they're planning on doing with me since my suprascapular nerve isn't working (innervating the spinati muscles).  It will be interesting, to say the least, to see how long it takes to train my brain to understand the re-routing of my nerves.  Speaking of recovery time, here was another quote that was on that site.  Something that reiterates something I've been told before:

Recovery of function after any nerve reconstruction can be a long process. Some patients have seen small signs of recovery as early as two months after the operation, but in most cases, return of function begins somewhere around six months, with full recovery in about two years.

This is when I shake my head, take a deep breath, and say, "Man!  This stinks!"

They're also talking about possibly transferring some intercostal nerves from my chest to restore some function (maybe to my tricep?).  Imagine watching me take a deep breath every time I need to extend my arm!

I said this last time, but I feel so fortunate to be at the WFMC with the world experts in this specific, somewhat rare, brachial plexus injury.  Something I heard last year at my interview was that while zebras (what we term rare medical conditions) are maybe a quarter-percent (0.25%) for the rest of the world, they're maybe 1-2% here.  These injuries are still rare, but anytime you have enough volume to create a specific schedule for "The Brachial Plexus Clinic," it's pretty impressive.  This sort of super-sub-specialization is a huge benefit to their patients (me!).  This is the time of year when they have the winter sports accidents getting scheduled for surgery after the 4-6 months of waiting time has proven ineffective, and they have "a bunch" of these surgeries lined up over the next month.  [This is another paragraph of yada yada to earn me some blogging clout, but here's the kicker...]  Seeing as how there are a few of these surgeries, granted they will all be slightly unique, and I've never actually seen a nerve transfer, I asked the NP (with whom I also went to St. Olaf, coincidentally -- and one of the main Guys is also an Ole) if I'd be able to scrub in on one of the upcoming cases.  She enthusiastically replied with a, "Yeah!" and she went to ask the other, non-Ole, Guy when would be the best time.  They had 3 cases the next day and I appreciated his response when he said a different day would be better so they could talk with me about the cases and do more teaching.  I thought that was neat and I'm hoping it works out to see how exactly it all works behind the scenes.

So, that's the plan.  Surgery in July.  More uncertainty.  More praying.

The last EMG doesn't give much information about how much interval healing has taken place, just whether the nerves are functional again.  So please keep praying because I have 6 weeks to get some progress or I will be subject to a Bard-Parker (i.e. "knife" -- it's a brand of surgical scalpels, like Kleenex is to tissues).  Also pray for patience.

Yet what we suffer now is nothing compared to the glory he will reveal to us later.  Romans 8:18