Question
I had a surgery 5 weeks ago to repair a shattered patella from a fall. I started
physical therapy 3 weeks ago and regained some leg strength. I am  at
20% ROM for at least 2 -3 more weeks. However, I still cannot lift my leg at
all.  The quads simply won't fire on command. If and when they do, it seems
pretty random.    An EMG showed that there could be  compression nerve
damage at the  groin where the surgeon had placed a tourniquet during
surgery. He says he's very conservation and used the tourniquet for a
minimal time (15-20 minutes?).   I'm (was) a very active 50 year old. I hike
and bike a lot. I have young kids and a full time consulting job and was in
fairly good shape prior to this.  

Since I CAN occasionally get the quads to fire,  what can I do to help the
regeneration process?  I already take 100mg B6 and b-12 daily.

Answer
Dear Laura,

The first thing to consider is how bad is the injury.  The fact that you can still fire the quad muscles is a good sign...it means that some neurological function still exists, and the affected nerve growth has an improved change for full regeneration.  I am sorry but the rest of this answer will be complicated...here goes.

Grading of peripheral nerve injury has been well documented in the scientific literature.  It is my opinion that these nerve injuries are often neuropraxic in orientation rather having frank compression, although in your case the tourniquet may have caused more damage.  These injuries can be made worse if significant compression of the nerve fibers continues after the initial insult through increased local inflammation or increased hip flexion which may result in local capillary compression of the vaso nervorum (blood flow to the nerve) and create continued tissue ischemia (lack of oxygen and nutrients).  

Segmental demyelination (loss of nerve covering) or axonal narrowing will result in slowing of conduction. Metabolic alteration of the membrane will result in a block of conduction, as will telescoping of the nodes of Ranvier. A reduced or absent response may be seen in instances of "Wallerian degeneration"--the so-called "dying-back neuropathy."  For better representation, a classification of nerve injuries was suggested by Seddon in 1943 and is still in use today. It is as follows:

1)  Neuropraxia represents a local conduction block with axons remaining intact. Discontinuity of the myelin sheath is the main issue and it will regenerate over time.

2)  Axonotmesis implies a more advanced compression or traction injury in which axons are disrupted.  Persistent abnormal EMG findings are common even after rehab techniques are applied for strengthening

3)  Neurotmesis implies a complete severance of the nerve, in which a nerve lesion preserves its appearance of integrity but is, in fact, totally disorganized.  Atrophy is always present.

Injury to the peripheral nervous system immediately elicits the migration of phagocytic cells, Schwann cells, and macrophages to the lesion site in order to clear away debris such as damaged tissue. When a nerve axon (functional unit of the nerve...carries the impulses) is severed, the end still attached to the cell body is labeled the proximal segment, while the other end is called the distal segment. After injury, the proximal end swells and experiences some degeneration, but once the debris is cleared, it begins to sprout new axons and the presence of new growth can be detected. The proximal axons are able to regrow as long as the cell body is intact, and they have made contact with special cells in the endoneurial channel (inner nerve channels of the axon).

Human axon growth rates can reach 2 mm/day in small nerves and 5 mm/day in large nerves. The distal segment, however, experiences Wallerian degeneration within hours of the injury; the axons and myelin degenerate, but the endoneurium remains. In the later stages of regeneration the remaining endoneurial tube directs axon growth back to the correct targets. During Wallerian degeneration, Schwann cells (cells that produce the myelin covering of the axon) grow in ordered columns that protects and preserves the endoneurial channel. Also, macrophages and Schwann cells release neurotrophic factors that enhance re-growth.

There are many proposed factors in which have been studied for their effect on nerve growth such as muscle stimulation, laser therapy, infra-red and surgical repair.  Most of these factors are used in the clinical setting rather than at home.  However, nutritionally, you are on the right track.  I would suggest that you utilize a B complex rather than just B6 and B12 as the B vitamins all work together...Folic acid and niacinimide is also important. It is important to realize that you should be in physical therapy so that the muscles of the legs do not atrophy...even if they need to stimulate them for you electronically or place you on an automated exercycle...this is just as important as nutritional aspects.

In our clinic we utilize Standard Process and Medi-Herb products...you can only purchase these through physicians.  The protocol we give in these cases includes whole food vitamins, herbs, and glandular formulas, and works pretty well.  The products are:  Catalyn, Neuroplex, Neurotrophin PMG, Folic Acid-B12, Cataplex B, St. John's Wort, Boswelia complex and Oat seed.  I would try to find a physiscan in your area who utilizes Standard Process and get use these products for the next 3-6 months.  If you cannot, feel free to call our clinic and we will order them for you if you wish, and send the guidelines on how much and when to take them.  

Additionally, below are some webpages that I have found to have useful and interesting information concerning nerve regeneration.

http://findarticles.com/p/articles/mi_m0HKP/is_2001_Summer-Fall/ai_81596693

http://www.healinglightseminars.com/biolibrary/NerveRegeneration.pdf

I know this information is complicated and may seem overwhelming, but I hope it helps.  Realize that all nerve injuries can be different and may take a substantial amount of time to recover lost function.  The other problem lies wherein the medical research on this topic is still lacking...there are so many things that research and technology have not been able to understand or explain about tissue injury to the nervous system.  Good Luck Laura.

Respectfully,
Dr. J. Shawn Leatherman
www.suncoasthealthcare.net