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Surgical restoration of the upper limb in cervical spinal cord injury patients
Abstract
Prior to the 1950s, relatively few patients who suffered a transection of the cervical spinal cord survived their injury. Improved medical care and better coordination have resulted in greater numbers of patients surviving and leaving the hospital. The pioneering work of individual surgeons during the 1960s and 1970s stimulated interest in surgical restoration of upper limb function in tetraplegic patients. Since the publication of Moberg’s monograph in 1978, surgical improvement of the upper limbs is regarded as one of the options that should be offered to tetraplegic individuals to improve their function. Patients are classified according to the level of spinal cord injury and the residual motor function (international classification: groups 1 to 9). Surgical procedures are adapted to the motor level for each group of patients. Indications for these procedures are well standardized, the techniques are well mastered, and predictable results can be expected. New nerve transfer techniques have been developed in recent years; they are currently being evaluated.
... 10,11 Informed decision-making about whether to undergo surgery and when is incredibly important, as both surgeries require coordination of perioperative care, therapy, activity restrictions, and transportation to appointments. TT surgery requires strict non-weight-bearing and immobilization in protective splints after surgery, 12 whereas NT surgery has a shorter period of activity restriction but still requires some perioperative assistance. 7 The caregiver role may become even more challenging during the perioperative period due to these restrictions. ...
Background
Nerve transfer (NT) and tendon transfer (TT) surgeries can enhance upper extremity (UE) function and independence in individuals with cervical spinal cord injury (SCI). Caregivers are needed to make this surgery possible, yet caregivers experience their own set of challenges.
Objectives
This comparative study explored the perioperative and nonoperative experiences of caregivers of individuals with cervical SCI, focusing on daily life activities, burden, and mental health.
Methods
Caregivers of individuals with cervical SCI were recruited and grouped by treatment plan for the person with SCI: (1) no surgery (NS), (2) TT surgery, and (3) NT surgery. Semistructured interviews were conducted at baseline/preoperative, early follow-up/postoperative, and late follow-up/postoperative. Caregivers were asked about their daily life, mental health, and challenges related to caregiving. Interviews were audio recorded, transcribed verbatim, and analyzed using thematic analysis. Quantitative, single-item standardized burden score (0-100) data were collected at each timepoint.
Results
Participants included 23 caregivers (18 family members, 4 friends, 1 hired professional). The surgeries often brought hope and motivation for caregivers. Caregivers reported increased burden immediately following surgery (less for the NT compared to TT subgroup) yet no long-term changes in the amount and type of care they provided. NS caregivers discussed social isolation, relationship dysfunction, and everyday challenges.
Conclusion
Health care providers should consider the changing needs of SCI caregivers during perioperative rehabilitation. As part of the shared surgical decision-making approach, providers should educate caregivers about the postoperative process and the extent and potential variability of short- and long-term care needs.
In case of neurologically stabilized tetraplegia, it is possible to restore an elementary grip function by tendon transfer. The surgical program depends directly on the neurological level of the patient and must respect a precise chronological order:
Vicious attitudes of the elbow and forearm correction. The most frequent being the flessum of the elbow and the supinated attitude of the forearm treated in the reducible forms by the use of the biceps brachii to restore the active elbow extension or in the fixed forms by a pronator osteotomy of the radius.
Active elbow extension is essential for the patient in a wheelchair to reach objects in height and to stabilize this joint in extension. The posterior deltoid or biceps brachii can be used.
Grip construction ultimate goal of the surgical program. At least the construction of a pollici-digital terminolateral clamp (key grip) which can be only passive activated by the tenodesis effect of the wrist or active by the transfer of the brachioradialis or the pronator-teres. In more favorable cases, a palmo-digital grasp can be performed by transferring the extensor carpi radialis longus to the flexors digitorum profondus and for the opening of the fingers either a simple tenodesis of the common extensors on the dorsal side of the radius or an active transfer of the brachioradialis.
The indications of the muscles to be transferred are now well-codified, but new techniques of nerve transfers performed earlier are being developed and evaluated.
Purpose:
Cervical spinal cord injury (SCI) has a profound effect on upper-extremity function. Individuals with stiffness and/or spasticity may have more, or less, useful tenodesis function. This study examined the variability present before any reconstructive surgery.
Methods:
Tenodesis pinch and grasp were measured with the wrist in maximal active extension. Tenodesis pinch was the contact point of the thumb with the index finger proximal phalanx (T-IF:P1), middle phalanx (T-IF:P2), distal phalanx (T-IF:P3), or absent (T-IF:absent). Tenodesis grasp was the distance from the long finger to the distal palmar crease (LF-DPC). Activities of daily living function was assessed using the Spinal Cord Independence Measure (SCIM).
Results:
The study included 27 individuals (4 females, 23 males; mean age 36 years, mean time since SCI 6.8 years). The mean International Classification for Surgery of the Hand in Tetraplegia (ICSHT) group classification was 3. In the dominant hand, individuals with a T-IF tenodesis pinch to P1 or P2 had significantly higher total SCIM scores (43.7 and 34.2, respectively) compared to those with absent T-IF tenodesis pinch (SCIM 17.8). Shorter LF-DPC distance with tenodesis grasp (improved finger closing) also correlated with improved SCIM mobility and total scores. No association was found between the ICSHT group and SCIM score or tenodesis measures.
Conclusions:
Quantifying tenodesis with pinch (T-IF) and grasp (LF-DPC) is a simple method to characterize hand movement in individuals with cervical SCI. Better tenodesis pinch and grasp were associated with improved activities of daily living performance.
Clinical relevance:
Differences in grasp function have implications for mobility, and differences in pinch function have implications for all functions, particularly self-care. These physical measurements could be used to assess movement changes after nonsurgical and surgical treatment in tetraplegia.
Purpose:
Nerve transfer (NT) surgery can improve function in people with cervical spinal cord injury (SCI). However, the impact of donor nerve deficits remains unclear. The purpose of this study was to quantify donor deficits experienced by individuals with cervical SCI following NT.
Methods:
This prospective single-arm, comparative study included people with SCI undergoing upper extremity NTs. Myometry was used to assess muscle strength at baseline and follow-up. The Spinal Cord Independence Measure was used to measure the ability to perform activities of daily living.
Results:
Ten individuals underwent 20 NTs to restore elbow extension (donor, posterior deltoid; n = 2), hand opening (donor, supinator; n = 7), and hand closing (donor, brachialis; n = 11). Shoulder abduction strength decreased (-5.6% at early and -4.5% late follow-up) in the elbow extension NT. Wrist extension strength decreased at early (-46.9% ± 30.3) and increased by late (76.4% ± 154.0) follow-up in the hand opening NT. No statistically significant change in elbow flexion strength was noted in the hand closing NT. Spinal Cord Independence Measure scores did not change significantly between baseline and early postoperative follow-up; they improved at late follow-up.
Conclusions:
Use of expendable donor nerves with redundant function to perform NT surgery has relatively little impact on strength or capacity to perform activities of daily living, even in the unique and highly vulnerable SCI population. Early, temporary loss in wrist extension strength can be seen after the supinator to posterior interosseous nerve transfer. This study offers quantitative data about possible diminution of donor function after NT, enabling hand surgeons to better counsel individuals contemplating upper extremity reconstruction.
Type of study/level of evidence:
Prognostic I.
In tetraplegics, thumb and finger motion traditionally has been reconstructed via orthopedic procedures. Although rarely used, nerve transfers are a viable method for reconstruction in tetraplegia.
To investigate the anatomic feasibility of transferring the distal branch of the extensor carpi radialis brevis (ECRB) to the flexor pollicis longus (FPL) nerve and to report our first clinical case.
We studied the motor branch of the ECRB and FPL in 14 cadaveric upper limbs. Subsequently, a 24-year-old tetraplegic man with preserved motion in his shoulder, elbow, wrist, and finger extension, but paralysis of thumb and finger flexion underwent surgery. Seven months after trauma, we transferred the brachialis muscle with a tendon graft to the flexor digitorum profundus. The distal nerve of the ECRB was transferred to the FPL nerve.
The branch to the ECRB entered the muscle in its anterior and proximal third. After sending out a first collateral, the nerve runs for 2.4 cm alongside the muscle and bifurcates intramuscularly. A main branch from the anterior interosseous nerve, which entered the muscle 3 cm from its origin on the radius, innervated the FPL. The ECRB and FPL nerves had similar diameters (∼1 mm) and numbers of myelinated fibers (∼180). In our patient, 14 months after surgery, pinching and grasping were restored and measured 2 and 8 kg strength, respectively.
Transfer of the ECRB distal branch to the FPL is a viable option to reconstruct thumb flexion.
In spinal cord injuries at the C6 level, elbow extension is lost and needs reconstruction. Traditionally, elbow extension has been reconstructed by muscle transfers, which improve function only moderately. We have hypothesized that outcomes could be ameliorated by nerve transfers rather than muscle transfers. We anatomically investigated nerve branches to the teres minor and posterior deltoid as donors for transfer to triceps motor branches. In eight formalin-fixed cadavers, the axillary nerve, the teres minor branch, the posterior deltoid branch, the triceps long and upper medial head motor branches, and the thoracodorsal nerve were dissected bilaterally, their diameters measured and their myelinated fibers counted. To simulate surgery, using an axillary approach in two fresh cadavers, we transferred the teres minor or the posterior deltoid branch to the triceps long head and to the thoracodorsal nerve. The posterior division of the axillary nerve gave off the teres minor motor branch and then the branch to the posterior deltoid, terminating as the superior lateral brachial cutaneous nerve. The diameters of the teres minor motor branch, posterior deltoid, triceps long and upper medial head branches, and the thoracodorsal nerve all were ∼2 mm, with minimal variation. The nerves varied little in their numbers of myelinated fibers, being consistently about 1,000. Via an axillary approach, either the teres minor or the posterior deltoid branch could be transferred directly to the thoracodorsal nerve or to triceps branches without any tension.
We reviewed the results of reconstruction of 97 upper limbs in a consecutive series of 57 tetraplegic patients, treated from 1982 to 1990. Of these, 49 had functional and eight had cosmetic reconstructions. The principal functional objectives were to provide active elbow extension, hook grip, and key pinch. Elbow extension was provided in 34 limbs, using deltoid-to-triceps transfer. Hook grip was provided in 58 limbs, mostly using extensor carpi radialis longus to flexor pollicis longus transfer, and key pinch in 68, mostly using brachioradialis to flexor pollicis longus transfer. Many other procedures were employed. At an average follow-up of 37 months, 70% had good or excellent subjective results, and objective measurements of function compared favourably with other series. Revisions were required for 11 active transfers and three tenodeses, while complications included rupture of anastomoses and problems with thumb interphalangeal joint stabilisation and wound healing. We report a reliable clinical method for differentiating between the activity of extensor carpi radialis longus and brevis and describe a successful new split flexor pollicis longus tenodesis for stabilising the thumb interphalangeal joint. Bilateral simultaneous surgery gave generally better results than did unilateral surgery.
Multicentre retrospective 1-year survey during 2000.
To describe the network of physical medicine and rehabilitation units in France that care for people with traumatic spinal cord injuries (SCI), and secondly, to evaluate the incidence of SCI persons who have postinjury rehabilitation care.
Every rehabilitation unit involved in rehabilitation of SCI patients in metropolitan France.
During the first phase of the survey, a questionnaire was used to list the rehabilitation units that treat SCI people among a total of 380 centres. An additional survey was then carried out on a sample of 30 units that did not answer this questionnaire. In the second phase, the units involved were asked about the number of SCI patients received for a first rehabilitation stay during the year 2000 and their demographic and clinical characteristics. The incidence was calculated on the basis of the population census in metropolitan France aged 15 years, above.
Of the 275 respondent units, 148 declared that they treat SCI people on a regular or occasional basis. The survey on the sample of 30 randomly selected nonrespondents enabled us to estimate that 10% of the 105 nonrespondent units were concerned. Among the 148 units contributing to the study, 131 identified all the SCI patients received during the year 2000. After a series of adjustments, an extrapolation for all of metropolitan France leads to an annual incidence of 19.4 SCI persons per million inhabitants, or 934 new cases per year.
This is the first nationwide survey aiming to estimate the incidence of SCI patients in France. The finding is based on the incidence of SCI persons treated in rehabilitation units. It therefore concerns the incidence of patients who will remain severely disabled.
Literature survey.
To provide an overview of the literature data on incidence, prevalence and epidemiology of spinal cord injury (SCI) worldwide and to study their evolution since 1977.
University Antwerp.
The literature from 1995 onwards was searched on Pubmed. To include evolutionary data, we incorporated the results of three older studies.
Two studies gave prevalence of SCI, and 17 incidence of SCI. The published data on prevalence of SCI was insufficient to consider the range of 223-755 per million inhabitants to be representative for a worldwide estimate. Reported incidence of SCI lies between 10.4 and 83 per million inhabitants per year. One-third of patients with SCI are reported to be tetraplegic and 50% of patients with SCI to have a complete lesion. The mean age of patients sustaining their injury at is reported as 33 years old, and the sex distribution (men/women) as 3.8/1.
There is a need for improved registration of SCI, and publication of the findings in many parts of the world. This survey pleads for uniformity in methodology. The data show that the reported incidence and prevalence have not changed substantially over the past 30 years. Data from Northern America and Europe show higher figures for incidence, but prevalence figures have remained the same. Epidemiology of SCI seems to have changed during the last decades with a higher percentage of tetraplegia and of complete lesions. If such evolution is present worldwide, how it could eventually be prevented needs to be studied.
Not applicable.
Background:
Loss of upper extremity function after cervical spinal cord injury greatly affects independence, including social, vocational, and community engagement. Nerve transfer surgery offers an exciting new option for the reanimation of upper limb function in tetraplegia. The aim of this study was to evaluate the outcomes of nerve transfer surgery used for the reanimation of upper limb function in tetraplegia.
Methods:
In this prospective case series, we consecutively recruited people of any age with early (<18 months post-injury) cervical spinal cord injury of motor level C5 and below, who had been referred to a single centre for upper extremity reanimation and were deemed suitable for nerve transfer. All participants underwent single or multiple nerve transfers in one or both upper limbs, sometimes combined with tendon transfers, for restoration of elbow extension, grasp, pinch, and hand opening. Participants were assessed at 12 months and 24 months post-surgery. Primary outcome measures were the action research arm test (ARAT), grasp release test (GRT), and spinal cord independence measure (SCIM).
Findings:
Between April 14, 2014, and Nov 22, 2018, we recruited 16 participants (27 limbs) with traumatic spinal cord injury, among whom 59 nerve transfers were done. In ten participants (12 limbs), nerve transfers were combined with tendon transfers. 24-month follow-up data were unavailable for three patients (five limbs). At 24 months, significant improvements from baseline in median ARAT total score (34·0 [IQR 24·0-38·3] at 24 months vs 16·5 [12·0-22·0] at baseline, p<0·0001) and GRT total score (125·2 [65·1-154·4] vs 35·0 [21·0-52·3], p<0·0001) were observed. Mean total SCIM score and mobility in the room and toilet SCIM score improved by more than the minimal detectable change and the minimal clinically important difference, and the mean self-care SCIM score improved by more than the minimal detectable change between baseline and 24 months. Median Medical Research Council strength grades were 3 (IQR 2-3) for triceps and 4 (IQR 4-4) for digital extensor muscles after 24 months. Mean grasp strength at 24 months was 3·2 kg (SD 1·5) in participants who underwent distal nerve transfers (n=5), 2·8 kg (3·2) in those who had proximal nerve transfers (n=9), and 3·9 kg (2·4) in those who had tendon transfers (n=8). There were six adverse events related to the surgery, none of which had any ongoing functional consequences.
Interpretation:
Early nerve transfer surgery is a safe and effective addition to surgical techniques for upper limb reanimation in tetraplegia. Nerve transfers can lead to significant functional improvement and can be successfully combined with tendon transfers to maximise functional benefits.
Funding:
Institute for Safety, Compensation, and Recovery Research (Australia).
To evaluate the effects of aging on hand function among patients with tetraplegia who had forearm tendon transfer surgery between 1982 and 1990.
The study used a longitudinal cohort design that compared hand function outcomes in 2012 with those obtained 11 years earlier. A digital analyzer was used to measure key pinch and grip strength, and results were compared with those obtained in 2001 to determine changes in strength over time. The study also evaluated changes in participant's employment status, wheelchair use, and subjective changes in function using the Lamb and Chan questionnaire.
Participants had a mean key pinch strength force between 11.5 N (tenodeses) and 32.9 N (active transfers) and grip strength forces between 23 N (tenodeses) and 59 N (active transfers). Since 2001, people with active transfers either maintained strength or experienced decreased strength of 5% to 14%. Thumb tenodesis power decreased 40% to 51%, whereas finger tenodeses power increased 32% to 70%. Three activities in the Lamb and Chan questionnaire were identified by the majority of participants as being worse or much worse over the past 11 years. These were performing a pressure relief and propelling a manual wheelchair on level ground and up a ramp. These findings correspond with the increased number of participants who used a power wheelchair in 2012 (64%) compared with 2001 (26%). Close to half of the participants (46%) were employed compared with the 90% in 2001.
Tendon transfers continued to provide pinch and grip function for individuals with tetraplegia for many years following spinal cord injury. The decrease in strength of those with active transfers over the 11-year period was within the reported aging loss for the normal population. The small number of participants with tenodesis, however, limited our ability to draw meaningful conclusions for this group.
Prognostic III.
Purpose:
To evaluate the outcomes of our technique for single-stage grip-release reconstruction and compare it with previous 1- and 2-stage grip reconstructions in tetraplegia.
Methods:
A total of 14 patients (16 hands) with tetraplegia underwent a single-stage combination of operations to provide pinch, grip, and release function. We compared the study group with a historical control group of 15 patients (18 hands) who had been treated with staged flexion-extension grip-release reconstructions. Both groups were classified as ocular cutaneous 4. Assessment parameters included grip and pinch strength, maximal opening of the first webspace, and Canadian Occupational Performance Measurement. Both groups were rehabilitated with early active mobilization beginning the first day after surgery.
Results:
Grip strength and opening of the first webspace were significantly greater in the single-stage group than in the comparative group. Pinch strength was not significantly different between groups. On the Canadian Occupational Performance Measurement score, patients belonging to the single-stage group were highly satisfied (increase of 3.7 points) and could perform several of their self-selected goals (3.5 points of improvement).
Conclusions:
The single-stage grip-release reconstruction provides people who have spinal cord injuries and tetraplegia with improved and reliable grip function; active finger flexion, active thumb flexion, passive thumb extension, and passive interossei function can all be achieved through this procedure. Early active mobilization is particularly important in improving functional outcome after this combination of grip reconstruction procedures.
Type of study/level of evidence:
Therapeutic III.
Background:
Spinal cord injury (SCI) is a devastating condition, which beleaguers its victims with long-term health issues. Nerve transfer is a feasible option for restoration of critical limb function in patients with SCI that potentially improves independence and quality of life.
Methods:
This article delineates the general principles of nerve transfer and its specific application pertinent to SCI. The available nerve transfer strategies are described based on the targeted limb function, mostly involving critical upper extremity function. The role of nerve transfer for paraplegia, diaphragm reanimation, and bladder reinnervation is also discussed.
Results:
Nerve transfer offers several advantages over the traditionally used tendon transfer.
Conclusions:
Nerve transfer does not require prolonged immobilization and provides greater functional gain for a given transfer. Reconstruction of several facets of upper limb function potentially can be performed in a single stage. The merits of nerve transfer deserve further study to evaluate its value for spinal cord injury in humans.
PURPOSES OF FUNCTIONAL ASSESSMENT
(C) 1986 Aspen Publishers, Inc.
Spinal cord injury (SCI) remains a significant public health problem. Despite advances in understanding of the pathophysiological processes of acute and chronic SCI, corresponding advances in translational applications have lagged behind. Nerve transfers using an expendable nearby motor nerve to reinnervate a denervated nerve have resulted in more rapid and improved functional recovery than traditional nerve graft reconstructions following a peripheral nerve injury. The authors present a single case of restoration of some hand function following a complete cervical SCI utilizing nerve transfers.
The recovery of hand function is consistently rated as the highest priority for persons with tetraplegia. Recovering even partial arm and hand function can have an enormous impact on independence and quality of life of an individual. Currently, tendon transfers are the accepted modality for improving hand function. In this procedure, the distal end of a functional muscle is cut and reattached at the insertion site of a nonfunctional muscle. The tendon transfer sacrifices the function at a lesser location to provide function at a more important location. Nerve transfers are conceptually similar to tendon transfers and involve cutting and connecting a healthy but less critical nerve to a more important but paralyzed nerve to restore its function.
We present a case of a 28-year-old patient with a C5-level ASIA B (international classification level 1) injury who underwent nerve transfers to restore arm and hand function. Intact peripheral innervation was confirmed in the paralyzed muscle groups corresponding to finger flexors and extensors, wrist flexors and extensors, and triceps bilaterally. Volitional control and good strength were present in the biceps and brachialis muscles, the deltoid, and the trapezius. The patient underwent nerve transfers to restore finger flexion and extension, wrist flexion and extension, and elbow extension. Intraoperative motor-evoked potentials and direct nerve stimulation were used to identify donor and recipient nerve branches.
The patient tolerated the procedure well, with a preserved function in both elbow flexion and shoulder abduction.
Nerve transfers are a technically feasible means of restoring the upper extremity function in tetraplegia in cases that may not be amenable to tendon transfers.
We conducted a systematic review of the literature to summarize the available data on reconstructive surgeries involving pinch reconstruction and elbow extension restoration in people with tetraplegia.
English-language and French-language articles and abstracts published between 1966 and February 2007, identified through MEDLINE and EMBASE searches, bibliography review, and expert consultation, were reviewed for original reports of outcomes with pinch reconstruction and elbow extension restoration in tetraplegic patients after a spinal cord injury. Two reviewers independently extracted data on patient characteristics, surgical methods, and patient outcomes.
Our search identified 765 articles, of which 37 met eligibility criteria (one article contained information on both elbow and pinch procedures). Results from 377 pinch reconstructions in 23 studies and 201 elbow extension restorations in 14 studies were summarized. The mean Medical Research Council score for elbow extension went from 0 to 3.3 after reconstruction. The overall mean postoperative strength measured after surgery for pinch reconstruction was 2 kg.
More than 500 patients having these procedures experienced a clinically important improvement for both procedures-one restoring elbow extension, and the other, pinch strength. Upper-limb surgeries markedly improved the hand function of people with tetraplegia.
Therapeutic IV.
A classification of quadriplegic patients based on available sensory receptors (ocular only or both ocular and hand sensibility) and motor function in each upper extremity greatly facilitates the planning and evaluation of surgical treatment. In forty hands of thirty-three patients with post-traumatic quadriplegia and cord lesions higher than those usually thought to be benefited by reconstructive surgery, three or more procedures were performed at one or more sittings to create an active wrist extensor and a thumb flexor grip, a function easier to provide and much more useful to these patients than tripod pinch. In these forty hands no function was lost and in all but two function was improved significantly if not greatly. A useful level of active elbow extension was restored in fifteen of sixteen extremities in quadriplegics by transfer of the posterior half of the deltoid to the triceps aponeurosis, lengthening the deltoid with free grafts from the toe extensors. Each upper extremity of quadriplegic patients of the type under consideration is a highly individualized problem. Successful treatment requires strict attention to every detail of preoperative evaluation, surgical treatment, and postoperative care.
The size of injured metamere (IM) in tetraplegia exhibits a high variability that explains the different clinical presentations in patients who have the same neurologic level. Even when functional electrical stimulation is not planned, the lower motor neuron (LMN) integrity of paralyzed muscles must be evaluated, especially in patients with high-level tetraplegia. During the acute phase, detecting the size of the IM is important to prevent supination contracture and stiffness of the thumb and finger joints. When planning functional surgery, the LMN integrity of intrinsic muscles helps the surgeon adapt his surgical procedures. Assessing IM size must be integrated systematically into the evaluation of tetraplegic patients.