‘It’s huge’: Innovation heals nerves in people with abdominal injuries

A surgical team at MUSC Health has become the first in the country to test for and repair nerve damage in people with rib injuries and/or abdominal wall trauma before it’s too late. The nerves are important because they tell the stomach muscle to contract, which keeps abdominal organs from causing the belly to bulge.

“The procedure itself is a culmination of multiple specialists getting together and talking about a condition that's been forgotten,” said Evert Eriksson, M.D., the trauma and critical care surgeon leading the effort. “It’s huge.”

 

The condition is called “denervation of the abdominal wall that results from trauma to intercostal nerves,” he said. Denervation means something has caused the nerve to stop working. Intercostal means between the ribs. 

“The intercostal nerves, nerves that affect the belly, run along the ribs. Specifically, ribs seven through 12 have a nerve that runs on the bottom of every rib that goes around and gives input to the muscles of the belly to contract,” he said.

“If you break your ribs or have surgery on your ribs or you have spine surgery and they end up breaking your ribs or removing your ribs, you're at risk for injury to those nerves. If you injure those nerves, then the belly doesn't contract. If the belly doesn't contract, it'll continue to get bigger and bulge because of the pressure of the organs inside the abdomen. And the muscle loses all of its tension.”

That creates what he called a pseudo-hernia. “It's not a real hernia, where the guts are poking out of the belly, but the guts can push the abdominal wall out because there's no muscle to pinch down and push them.”

Eriksson said the problem doesn’t become visible right away. The damage usually goes undetected for about a year. “And by that time, the nerves are dead, and there's nothing we can do about it. That's why everybody's kind of ignored it for a long time. But we've just recently started to identify it more in patients who have rib fractures or penetrating trauma to the lower chest wall and been specifically looking for it.”

 

Identifying and repairing that damage is possible through Eriksson’s collaboration with a pair of other doctors. 

First, physical medicine and rehabilitation specialist Matthew Sherrier, M.D., does electromyography testing to see if the intercostal nerves work. Electromyography, or EMG, detects issues with nerves and muscles. 

If the answer is yes, there is nerve damage, that’s where hand surgeon Dane Daley, M.D., comes in. He has expertise in fixing damaged nerves and works with Eriksson to repair the intercostal nerves.

Recent patient

They recently did the procedure on 19-year-old Bralyn Padgett of Colleton County. She was recovering from a car crash that left her with nerve damage. “We did the nerve reconnection surgery for her as well as a rib graft to protect the nerve. We'll continue to follow her in the future to look at her ultimate recovery,” Eriksson said. 

“Having your abdominal wall not function anymore at the ripe old age of 19 is a pretty morbid injury for someone with that much life ahead of them. So her outlook is good, provided that the nerve graft takes. If the nerve graft takes, her abdominal wall will get weaker over the next year, but then, when it starts kicking back in, she should be able to restrengthen those muscles and have a good recovery.”

Spreading the word

He wants that kind of recovery for more patients, and not just in South Carolina. So Eriksson recently presented data on the procedures, which he’s done on about 10 patients, at a meeting of the Chest Wall Injury Society. He’s president of the organization, which has about 850 members from around the world. “We wanted to raise awareness of what we’re doing.”

And what they’re doing is more than nerve repair. 

Rib fracture repairs

Eriksson said his team also repairs rib fractures that might otherwise be left untreated. “We need people to know that there are surgical options for patients with rib fractures and we can make people with rib fractures feel better.”

And his team is one of just a handful in the United States to repair what are known as nonunion rib fractures. Nonunion means the bone’s parts haven’t grown back together as expected.

Expansion of nerve repair program

Meanwhile, plans are in the works to expand the nerve repair program.“We've developed new physical exam techniques to try to identify these nerve injuries early on. We're in preliminary talks with other centers from around the Southeast about screening their patients for us. If they screen positive, they can send them to us with an ASAP referral to get into our clinic to try to address the problem,” Eriksson said.

“We've kind of rewritten the book here, doing new things and really innovating quickly instead of waiting for the rest of the world to show us what to do.”