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''2396, Vol. 323, No. 3 ''<br />

<br>

<font size=5>'''Alternate Control Technology Methodologies for Cybernetic Prosthesis'''</font>
<br> 
<font size=3>Addison MacKenzie, M.D., Ph.D., FASFS & Geoffrey Teller, Starfleet Corps of Engineers</font>

<br>

__TOC__

<h3>Introduction</h3>

At present, when attending to cases of extremity loss, Federation physicians have limited options available to them when it comes to limb replacement and subsequent physical therapy.  While bio-grafting and ninth-generation cybernetic limbs are versatile and proven therapeutic approaches, they do have limitations and fundamentally rely on the patient’s existing nervous system for functionality.  While this is typically viewed favorably as it keeps rejection rates extremely low, there are some cases where typical neuro-servo control apparatuses are non-suitable.  While this group has historically been statistically small, it is still a significant underserved patient base.

<br>Prior experimentation with alternate control apparatuses have been hampered by the size of existing components and their suitability for safe installation.  This kept most alternates from moving beyond the prototype or early trial stage, and had remained an unresolved challenge for a subset of patients.  

<br><h3>Abstract</h3>

After atypical nervous system damage suffered while on duty as a Starfleet security officer, a 26-year-old (Earth Standard) female metagenetic Klingon suffered a loss of prosthetic control concurrent with severe physical discomfort.  Due to the extensive nature of the nervous system damage, standard prosthetic control methodologies were discovered to be non-viable.  Working in tandem with the primary attending physician, the Engineering team of the USS Veritas (Starfleet Registry NCC-95035) designed, tested and implanted a novel transceiver module which provides positive prosthetic control without further stress on the patient’s nervous system.  This module, after proper peer review, will allow for a radical new archetype in prosthetic design and implementation in humanoid subjects.

<br><h3>Case Presentation</h3>

A 26-year-old (Earth Standard) metagenetic Klingon female Starfleet security officer, was critically injured in the line of duty on Stardate 239601.12 when her right arm was severed by an indigenous predator on the previously uncharted world Limbo.<ref>[https://wiki.starbase118.net/wiki/index.php?title=Limbo_(Veritas) "Limbo (Veritas)"] Starbase 118, Stardate 239601.12</ref>   Field conditions did not allow for the standard therapeutic treatments of bio-grafting, and the subject was forced to remain in an injured state for several months with only minimal medical resources available to control shock, blood loss, and infection. Subsequent infections resulted in the complete amputation of the arm.[[File:Cyberarm.JPG|right|thumb|225px|Patient's original prosthetic.]]

<br>When the patient was successfully evacuated to a specialized medical facility, extensive surgical intervention was required to successfully remove subsequent necrotic tissue from the original injury site prior to the installation of a type eleven scapula supplement mount, connected across the remaining bone tissue with microsutures and several hundred tritanium self-sealing micro-anchors.  The brachial plexus was found to be in acceptable condition to support a standard neuro-servo control interface, although the axial and ulnar nerve sheaths had been damaged.  The interface was surgically implanted and tested successfully by the attending surgeon at the time.  During subsequent physical reconditioning, the patient expressed frustration and discomfort, which required additional therapeutic focus to overcome.  After several weeks, she was discharged and returned to duty with instructions to work closely with her shipboard medical staff for any further issues.

[[File:Nerves_of_the_Arm.gif|left|thumb|150px|Nerves in the typical humanoid arm.]]<br>In the course of her duties, the patient’s prosthetic was directly exposed to multiple exotic high energy discharges, which radiated from the prosthetic through the patient’s entire central nervous system, initially presenting symptoms of mild electrocution.  Medical staff were engaged subsequent to this exposure and, aside from minor symptoms that were attributed to the incident itself, the patient was discharged with a clean bill of health and continued to perform her duties without interruption for several additional days.

<br>Later, however, the patient awoke in significant physical discomfort and found that the prosthetic was no longer functioning in an acceptable manner.  In the course of seeking medical attention, the prosthetic malfunctioned significantly, causing the patient severe radiating pain and a total loss of limbic motor control.  Comprehensive medical examination revealed the prosthetic itself had been severely damaged by the high energy discharges, and this damage had spread to the neuro-servo control interface and the brachial plexus nerves themselves, causing significant peripheral neuropathy.  Coupled with the existing damage to the nerve tissues, this prevented the patient from generating adequate nervous system feedback to activate and control a standard neuro-servo interface, even after the damaged unit was removed and replaced.  Her prognosis for recovery and return to duty at this point was non-favorable.  

<br>[[File:Targeted Muscle Reinnervation.jpg|right|thumb|150px|Former techniques that the current methods are based on.]]
<br>Several Starfleet engineers serving with the patient became aware of her condition and began examining the data provided by attending medical staff regarding the component malfunctions.  Working in tandem with medical staff, the engineers began a comprehensive disassembly of the patient’s prosthetic, with which they already had some familiarity due to improvised repairs and upgrades conducted at an earlier juncture.  They discovered that numerous control components of the original prosthetic were severely damaged and began laboring to extract them in an attempt to save the existing unit.  In the course of their repairs, the nature and extent of the damage to the patient’s nervous system became clear, which led the team to the conclusion that standard surgical approaches were insufficient.  In an effort to provide an immediate, workable solution, the Engineering team approached the patient’s injuries in the same manner in which they’d approach shipboard damage control efforts - they attempted to bypass the damaged systems and reroute the nervous system control impulses.  After performing a series of simulations to verify their hypothesis, the Engineering team began modifying a pair of subspace transceivers to serve as a replacement for the standard neuro-servo control interface that would not rely on the damaged brachial nerves.  Subsequent assembly and testing was conducted rapidly and, post repairs, the patient was again able to manipulate her prosthetic effectively and without accidental input or injury.[[File:Vladislav-ociacia-hands-arm-wrestling-2.jpg|right|thumb|225px|Patient's new prosthetic.]]

<br><h3>Discussion</h3>

The patient has since taken a leave of absence from active duty but after significant nervous system rehabilitation, follow-up consultations with her medical team point to a full integration with this new interface design with a significant improvement in neural feedback levels over the existing standard.

<br>As the use of various types of prosthetic limbs becomes more extensive, the techniques and technologies employed in this case may be utilized, adapted, and developed to assist patients in maintaining their quality of life. As a result, we expect that Starfleet officers experiencing traumatic amputation in the line of duty will not face a mandatory reduction in their duties after successfully undergoing the above therapies.

<br><h3>Conclusion</h3>

While non-physically linked control of a prosthetic has been tested successfully in the past, limitations in micro-subspace transceiver design, bandwidth and power source have rendered experimental designs non-viable for implementation outside of controlled studies.  This new design builds on several recent breakthroughs in multiple scientific and engineering disciplines which, if successful long term, could point the way to a completely new means for injured patients to interface with and control prosthetic appendages.  The unconventional approach is readily adaptable to any extremity and may even serve in cases of plasma shock, neuro-electric cascade and other traumatic nervous system injuries.  


<h4>Stem Cells</h4>

[[File:Stem-cells.jpg|thumb|200px|right|Stem cells replicated in a lab.]]  The idea of using stem cells for the the purpose of regenerating organs was born in the early 21st century. Scientists studied creatures that were able to regenerate whole body parts in hopes of understanding how such a remarkable feat of biology could be applied to the human body. This research also revealed the amazing ability of the human liver to regenerate itself when a segment of it was removed. Though it never resumes its original shape, it regains its original mass <ref>[https://stemgenex.com/studies/multiple-sclerosis-stem-cell-studies/#tab-5. "Multiple Sclerosis Stem Cell Therapy"], StemGenex, Stardate 2393</ref>

Stem cells were explored for the treatment of multiple sclerosis, an autoimmune condition in which the immune system incorrectly saw the myelin sheath surrounding nerve cells as foreign and began attacking this protective coating, resulting in damage to the nerve cells and leading to slowing of messages to and from the brain. The use of mesenchymal stem cells has been shown to repair this damage as well as repairing the immune system, preventing further attacks. These cells are found in several places in the humanoid body, including in bone marrow, skin, and fat tissue and they produce cells that help other stem cells to function correctly. The theory behind the application of this method is that a scientist expands the cells in a laboratory and injects them into the space surrounding the spinal cord (intrathecal) with an end goal of inhibiting immune response and augmenting tissue repair <ref>[http://www.nationalmssociety.org/Research/Research-News-Progress/Stem-Cells-in-MS "Stem Cells in MS"], National Multiple Sclerosis Society, SD 2394</ref>.

<h4>Nanotechnology</h4>

[[File:Borg-nanoprobe.jpg|left|thumb|200px|Nanotechnology schematics.]] Nanotechnology has also found applications in medicine since the early 21st century when mankind first imagined the use of nano (mini) robots to repair the body at a cellular level. One of the most progressive uses of the technology was engineered nanoparticles designed to deliver a variety of elements such as heat and drugs to specific cells, leading to direct treatment of these cells in hopes of reducing damage to healthy cells in the body and allowing for earlier detection of disease or mutations in cells. <ref>[http://www.understandingnano.com/medicine.html "Nanotechnology in Medicine: Nanomedicine"], Understanding Nano, SD 2394</ref> 

Another important aspect of the field, nano-gel, injected as a liquid into the spinal column, supports stem cells in that it not only prevents scar tissue from forming as an injury site heals, it also encourages the stem cells to create new cells that produce myelin, the material that surrounds the nerves of the spinal cord and prevents them from being damaged. The gel is often used in combination with stem cell therapies to heal spinal cord injuries, including severed nerve fibers and supports the growth of axioms both up into the brain and down to the legs, bridging the connection. Patients who were previously paralyzed are able to regain some, if not all of their mobility. <ref>[https://www.sciencedaily.com/releases/2008/04/080402114819.htm  "Promising New Nanotechnology For Spinal Cord Injury"], ScienceDaily, SD 2385</ref>

[[File:Genetronicreplicator.jpg|right|thumb|70px| Genetronic replicator designed by Dr. Russel.]] 

<h4>Genetronics</h4>

Innovations in this field are fairly recent. The first functioning genetronic replicator was designed and constructed by Doctor Toby Russel in the mid-24th century. Dr. Russel's theory was that the device could scan a person's DNA and damaged organs, then using this information to replicate a new healthy organ. The first recipient to survive the use of this technology was a Klingon male, Worf, in 2368. He was struck by a falling container and, as a result, was partially paralyzed when the container broke his spine. In the case of the Klingon male, Dr. Russel proposed the replication of a new spinal column to give the male full mobility back. The patient nearly died during the operation, but survived due to redundancies in his biological systems. The process was later refined by Doctor Simon Tarses when it was used in combination with nanotechnology to repair the damaged portions of a Bajoran female's spine when it was severed by Taran'atar's attack <ref>[http://memory-beta.wikia.com/wiki/Genitronic_replication "Genetronic Replication"], Memory Beta, SD 2394</ref> 

[[File:Laelspinalinjury_postsurgery.jpeg|100px|left|thumb|Lael's spinal injury after surgery.]]

<h3>Conceptual Framework</h3>

The patient suffered broken lower lumbar vertabrae and nerve damage as a result of her fall. Though doctors<br />were able to reconstruct most of her damaged spinal column, the fragile nature of the vertabrae combined with the severe nerve damage offered no hope that the patient would be able to regain her mobility. This was only achieved by the introduction of specifically-programmed nanites which were able to reverse the nerve damage and strengthen the vertabrae. However, the nature of the injury resulted quicker-than-usual degradation of nerve fibers and already-weak bone. Despite daily injections of nanites with the intention of slowing the damage, all attempts have proven to do so only temporarily. It was estimated that without drastic action, the patient would lose mobility completely by age 30. 

As stated previously, factors that could impact the result of the procedures proposed in the methods section include the patient's hybrid physiology, age, gender, diet and exercise routines, and the unique nature of the patient's injuries. Another factor that could have a radical effect is the specific programming of the nanites currently in the patient's body. As with multiple sclerosis, there is concern that the nanites' attempts to repair damage to the nerve fibers is moot in that the myelin sheath surrounding these fibers is degrading to a point that messages to and from the brain are being slowed, resulting in decreased mobility. 

<br>

<h3>Method</h3>

<h4>Participant</h4>

The patient, an otherwise healthy Al-Leyan/Human female in her late 20s, choose to participate in this study due to her rapidly decreasing mobility and the limited number of options available to her due to the nature of her injury. Her career as a Starfleet officer requires that she be in good physical condition and overall good health. She eats a balanced diet and engages in daily exercise ranging from weight-lifting to martial arts sparring sessions. The patient has no family history of cancer or otherwise debilitating illnesses. However, the patient had expressed a recently discovered allergy to Hyronalyn medications used to treat radiation poisoning, contact with the medication resulting in seizures. The patient was prescribed regular doses of Pregabalin to counter the seizures. Further, the patient had an O- blood type, which could have presented complications if she received anything other than O+ or O- blood. 

<h4>Materials, Design, and Procedures</h4>

Scans were taken of the patient's spinal column prior to treatment to ascertain the extent of the damage and to determine if the proposed treatment options made sense for the patient's particular injury. This data revealed that, despite the risks, the patient was a good candidate for the procedure. The patient elected to undergo spinal replacement surgery via the use of a genetronic replicator, which would create a new spinal column using the patient's DNA profile. Developed initially by Dr. Russel in 2368, this technology would eliminate the weak bone variable while the nanites would continue the process of repairing damaged nerve fibers. The mesenchymal stem cells would then, with the aid of the nanites and the nano-gel injected together into the space surrounding the spinal column, begin the process of repairing and creating the destroyed myelin sheath surrounding the nerve fibers. Repair of the myelin sheath would slow the damage to the nerve fibers exponentially, to a minute enough degree that the programmed nanites would be able to keep pace with the normal degradation with quarterly injections of new nanites.

During surgery, the patient received an anesthetic to render her unconscious. Her biosigns were closely monitored. It was necessary to cut through some of the nerve fibers in order to remove the original spine, so the patient was placed on temporary life support. Once the new spinal column had been replicated, it was placed carefully into position and fused at both the upper and lower vertabrae. The patient was then closed up and injected with nanites and stem cells into the space surrounding the spinal column to begin the regeneration process. 

[[File:Laelspine_postreplacementsurgery.jpg|75px|right|thumb|Lael's spine after the replacement surgery.]] 

<h3>Discussion & Conclusions</h3>

Prior to her surgery, the patient experienced significant difficulties with mobility that, at times, impeded her ability to perform her duties. The patient also experienced chronic pain at the site of the injury and stiffening of her limbs. The continued degradation of the nanites used to keep the patient mobile meant that had she not attempted the procedure, she would have experienced near complete paralysis and would likely have been confined to a hoverchair until an alternate solution could be found. Post-surgery, the patient reports a drastic decrease in pain as well as increased mobility. The use of physical therapy techniques has helped the patient to regain much of her previous mobility and she continues to make excellent progress. The patient has reported only mild side effects from the procedure such as moderate at the surgical site, fatigue, and headaches, none of which are unexpected. The patient attends twice month appointments to monitor healing progress via deep scans and evaluate for potential signs of Failed Back Surgery Syndrome (FBSS) <ref>[https://www.laserspineinstitute.com/back_problems/fbss/ "What Is Failed Back Surgery Syndrome (FBSS)?"] Laser Spine Institute, Stardate 2394</ref>, in which the patient experiences unusual chronic pain post-surgery. Despite these risks, the patient's primary physician anticipates that she will make a full recovery.


[[Category:Journal of Starfleet Medicine]]
[[Category:Addison MacKenzie|Alternate Control Technology Methodologies for Cybernetic Prosthesis]]
[[Category:Geoffrey Teller|Alternate Control Technology Methodologies for Cybernetic Prosthesis]]
[[Category:Cybernetics]]
[[Category:Prosthetics]]
[[Category:Neurology]]