Upper limb surgery for tetraplegia: a 10-year re-review of hand function

PURPOSE

To perform a 10-year re-review of hand function outcome for 24 tetraplegic persons who had received bilateral tendon transfers and tenodeses.

METHODS

The Lamb and Chan questionnaire with additional questions, the Quadriplegic Index of Function (QIF), the Swanson sphygmomanometer technique for hook grip, the Preston Pinch Meter (PP) for key pinch, and a digital analyzer (DA) for both hook and key pinch were the test instruments used. The QIF and DA had not been used previously.

RESULTS

Levels of functional independence and expectations were maintained. Mean hook grip values were maintained for the right hand but increased significantly for the left to reach right hand values. Mean pinch grip values decreased significantly. DA measurements confirmed similar hook grip values for both hands but key pinch values were significantly higher than the PP values. Active transfers averaged approximately twice the strength of tenodeses.

CONCLUSIONS

Hand function improvements gained from tendon transfers and tenodeses are maintained over time.

Use of the ring fixator in the treatment of fractures of the lower extremity in long-term paraplegic and tetraplegic patients

STUDY DESIGN

Retrospective study.

OBJECTIVES

To examine the value of operative fracture stabilization by means of the ring fixator in fractures of the lower extremity in the presence of chronic paralysis caused by transverse lesions of the spinal cord.

SETTING

A specialist center for the treatment of spinal cord injuries in Germany.

METHODS

Clinical examination of the lower extremities with side-for-side comparison, radiological investigation of the fractures, patient survey.

PATIENTS

In 21 patients with chronic spinal cord lesions, 22 fractures of the lower extremities were treated with the ring fixator.

RESULTS

At follow-up a mean of 41.5 months after fracture healing it could be shown that movement in the knee and ankle joints on the same side as the fracture was not restricted by more than 10 degrees in any of our patients. No losses affecting activities of daily living were reported, and 19 of the 21 patients were satisfied with the result achieved with this technique. After four of the 22 operations there were complications. Malalignments were visible radiologically following five of the fractures.

CONCLUSIONS

In osteoporosis-induced fractures of the lower extremities in chronically paraplegic and tetraplegic patients, fracture stabilization with the ring fixator, with fewer complications and better results in terms of joint mobility, is superior to the conservative treatment so far given preference in the literature. It should be offered as an alternative to conservative treatment in the case of pathological fractures.

Analysis of posterior deltoid function one year after surgical restoration of elbow extension

PURPOSE

The purpose of this study was to measure the extent and timing of elbow extension torque recovery after posterior deltoid-to-triceps tendon transfer.

METHODS

Elbow extension moment was measured in 40 limbs from 23 patients who underwent surgical restoration using the posterior deltoid-to-triceps tendon transfer at times ranging from 8 weeks to 1 year after surgery. For comparison purposes, elbow extension moment also was measured in healthy controls and persons with C7 spinal cord injuries.

RESULTS

Maximum extension moment was 5.89 +/- 0.24 Nm (mean +/- standard error of mean, n = 40), which corresponds to approximately 65% of the predicted posterior deltoid force and provided an adequate moment to oppose gravity. Based on the shape of the moment-joint angle curve and using a biomechanical model, it was predicted that posterior deltoid was inserted at a relatively short muscle length of 123.1 mm and thus operated exclusively on the ascending limb of the length-tension relationship.

CONCLUSIONS

These observations support an evolving model of muscle architecture in which connective tissue septa restrict muscle fiber elongation during surgical tensioning of the tendon transfer. This relatively short length would result in a significant force loss should any of the repair sites slip or stretch during rehabilitation. These data have implications for the reconstruction and rehabilitation of this patient population.

The role of upper limb surgery in tetraplegia

STUDY DESIGN

A retrospective follow-up study.

OBJECTIVES

To assess the value of surgery on the tetraplegic hand to improve its function.

SETTING

Spinal unit. Hospital La Fe. Valencia (Spain).

METHOD

We reviewed the functional results obtained in 15 patients (10 males and 5 females) operated on at our hospital between 1988 and 1997. We performed 66 surgical procedures on 20 upper limbs. After a year or more the patients were evaluated by two independent examiners not related with the surgeons, using the questionnaire of Lamb and Chan modified by Mohammed, taking into account the change in the performance of activities of daily living (ADL), the patient's satisfaction, and the fulfillment of their expectations.

RESULTS

A good or excellent result was obtained in 71.4% of our patients, 85.7% were satisfied with the operation and 57.2% said that the surgery did not meet their expectations. The bad results occurred in patients with previous joint rigidity, ocular sensibility, pain, and lack of motivation.

CONCLUSION

Hand surgery improved the function of tetraplegics and should be performed more frequently. The hands should be cared for from the very beginning to keep them supple. The information given to the patients should be realistic.

[Surgical rehabilitation of the upper limbs after traumatic tetraplegia]

Patients with a cervical spinal cord injury experience a complete paralysis of their lower limbs and a partial paralysis of their upper limbs associated with a dramatic decrease of upper limbs function. Twenty years ago, surgical rehabilitation of their upper limbs started to develop, based mainly on tendon transfer procedures. We report a consecutive series of 69 such patients operated in the past 12 years, amounting to 188 rehabilitation procedures on their upper limbs. Surgery was beneficial in all cases, there was no case of functional loss, and the patients were mostly satisfied with the procedures.

Factors associated with improved neurologic outcomes in patients with incomplete tetraplegia

STUDY DESIGN

Retrospective review of 412 patients with traumatic, incomplete, cervical spinal cord injuries, and an average follow-up period of 2 years.

OBJECTIVES

To determine what patient characteristics, injury variables, and management strategies are associated with improved neurologic outcomes. In particular, the effects of intravenous steroids (NASCIS II protocol), early definitive surgery (<24 hours after injury), early anterior decompression for burst fractures or disc herniations (<24 hours after injury), and surgical decompression for stenosis without fracture were assessed.

SUMMARY OF BACKGROUND DATA

Controversy surrounds the pharmacologic and surgical management of patients with spinal cord injuries.

METHODS

Neurologic data were collected retrospectively and classified using American Spinal Injury Association guidelines. This information was recorded at the time of injury, on admission to rehabilitation, on discharge from rehabilitation, and at 1, 2, and final year of follow-up evaluation. Outcome measures included change in motor score, change in sensory score, final motor score, and final sensory score. The SPSS v10.0.7 statistical software package was used for data analysis.

RESULTS

Neurologic recovery was not related to the following factors: gender, race, type of fracture, or mechanism of injury. Neurologic recovery also was not related to the following interventions: high-dose methylprednisolone administration, early definitive surgery, early anterior decompression for burst fractures or disc herniations, or decompression of stenotic canals without fracture. Improved neurologic outcomes were, however, noted in younger patients ( = 0.002), and those with either a central cord or Brown-Sequard syndrome ( = 0.019).

CONCLUSIONS

The most important prognostic variable relating to neurologic recovery in a patient with a spinal cord injury is the completeness of the lesion. When an incomplete cervical spinal cord lesion exists, younger patients and those with either a central cord or Brown-Sequard syndrome have a more favorable prognosis for recovery. In this study, no evidence was found to support high-dose steroid administration, routine early surgical intervention, or surgical decompression in stenotic patients without fracture.

Phrenic nerve pacing in a tetraplegic patient via intramuscular diaphragm electrodes

In patients with ventilator-dependent tetraplegia, phrenic nerve pacing (PNP) provides significant clinical advantages compared with mechanical ventilation. This technique however generally requires a thoracotomy with its associated risks and in-patient hospital stay and carries some risk of phrenic nerve injury. We have developed a method by which the phrenic nerves can be activated via intramuscular diaphragm electrodes. In one patient with ventilator-dependent tetraplegia, two intramuscular diaphragm electrodes were implanted into each hemidiaphragm near the phrenic nerve motor points via laparoscopic surgery. The motor points were identified employing a previously devised mapping technique. Because inspired volumes were suboptimal on the right, a second laparoscopic procedure was necessary to position electrodes near the anterior and posterior branches of the right phrenic nerve. During bilateral stimulation, inspired volume was 580 ml. After a reconditioning program of progressively increasing diaphragm pacing, maximum inspired volumes on the left and right hemidiaphragms increased significantly. Maximum combined bilateral stimulation was 1120 ml. Importantly, the patient has been able to comfortably tolerate full-time pacing. If confirmed in additional patients, PNP with intramuscular diaphragm electrodes via laparoscopic surgery may provide a less invasive and less costly alternative to conventional PNP.

Congenital reducible atlantoaxial dislocation: classification and surgical considerations

BACKGROUND

Reducible atlanto-axial dislocation (AAD) may cause severe motor and respiratory compromise due to recurrent spinal cord and/or brain stem impingement. To the best of the authors' knowledge, this is the first study concentrating on the classification, the protocol of the surgical management and the outcome of congenital, reducible AAD.

METHODS

109 patients with congenital, reducible AAD underwent posterior stabilization. Their preoperative disability was graded as: I (n=11, 10.09%) no functional disability (a history of minor trauma led to quadriparesis that subsequently improved); II (n=31, 28.44%) independent for activities of daily living with minor disability; III (n=42, 38.53%) partially dependent on others for their daily needs; and, IV (n=25, 22.93%) totally dependent. They were classified into 4 groups depending upon their association with: a normal odontoid and posterior arch of atlas (n=27); a dysplastic odontoid and normal posterior arch (n=25); an assimilated posterior arch (n=49); and, Arnold Chiari malformation type I (n=8). Nine patients with a dysplastic odontoid had a "hypermobile" AAD with an unrestricted backward and forward movement of the axis relative to the atlas in flexion as well as in extension of the neck, respectively. The surgical procedures included Brooks' (n=12) or modified Brooks' C1-2 fusion (n=39); Goel's C1-2 fusion (3); Ransford's contoured rod fusion (n=7); Jain's occipitocervical fusion (n=47); and, transoral decompression and Jain's occipitocervical fusion (n=1). There were 6 peri-operative mortalities in the series.

FINDINGS

At follow-up (ranging from 3 months to 6 years; n=86), 64 patients had shown improvement by one grade or more; 8 patients, who had a history of transient quadriparesis but were without neurological deficits at presentation, remained in grade I; 11 had achieved stabilization of neurological functions; while 3 had deteriorated despite adequate radiological reduction of AAD and fusion of the construct. A follow-up of 6 months or more was available in 79 of these 86 patients, in whom a dynamic intrathecal CT scan showed a good osseous union.

INTERPRETATION

The patients with congenital reducible AAD, depending on their surgical management, may be classified into four groups. Some patients with a dysplastic odontoid have a "hypermobile" AAD and require special care during intubation, positioning and stabilization. An assimilated posterior arch is often associated with asymmetrical lateral occipito-C1-C2 joint synostosis rendering transarticular screw placement difficult. The various causes of failure of constructs are discussed.

Improvements in activities of daily living following functional hand surgery for treatment of lesions to the cervical spinal cord: self-assessment by patients

STUDY DESIGN

Tetraplegic patients were tested for hand strength before and after hand surgery. They also answered questions about how they rated the results of surgery.

OBJECTIVES

Presentation of the efficacy of reconstruction of hand raising, lateral grip, and cylindrical grip in the tetraplegic hand.

SETTING

The study was conducted in the Werner Wicker Clinic, Bad Wildungen, Germany, from 1991 to 1998.

METHODS

The results of reconstruction surgery performed on 23 tetraplegic hands, as reflected in lifting the hand (n=3), lateral grip (n=21), and cylindrical grip (n=14), are presented. In a follow-up study in 22 patients, their management of activities of daily living 34.1 months (9-51 months) after the surgery is compared with the preoperative situation. Subjective satisfaction levels were elicited for each of the 22 patients by means of a questionnaire.

RESULTS

The gain in force corresponded to 893 g (150-1500 g) for cyclindrical grip and 488 g (100-1200 g) for lateral grip, while they were able to develop grade 4 force for lifting the hand. After the operation 28 aids/appliances that patients had formerly used regularly were no longer necessary. There were 75 separate activities listed in the questionnaire, and on average the 22 patients were able to perform 8.7 (0-20) more of these. Most patients (19) said they would advise others to have the operation and 18, that they would have the operation again. There were 12 complications in nine patients.

CONCLUSION

Reconstructive surgery on the hands of tetraplegic patients leads to gains in both cylindrical grip and lateral grip force and to increased manual dexterity. Patient satisfaction with the procedure is high.

Tendon transfer surgery: clinical implications of experimental studies

Tendon transfers commonly are used to restore arm and hand function after injury to the main motor nerves or after spinal cord injury. Surgeons traditionally use passive tension to determine the length at which a muscle should be attached during tendon transfer. The principles used to choose the length at which the transferred muscle should be attached still are relatively vague and have not been examined thoroughly. Misunderstanding of the sarcomere length-passive tension relationship can result in severe overstretch of the muscle and poor function. Upper extremity muscles have operating ranges that vary between synergists and antagonists, and recent architectural and biochemical data suggest that upper extremity muscles are designed to provide optimal control of joint position and stability. It is hypothesized that a significant functional improvement will be realized when muscles are reattached during tendon transfer procedures at the appropriate length and tension.

Tendon transfers as applied to tetraplegia

The techniques of the tendon transfers that are used primarily for the functional rehabilitation of upper limbs in tetraplegia are described in this article. The restoration of active elbow extension can be obtained either by biceps-to-triceps or by deltoid-to-triceps transfers. Grasp and key grip can be restored either by active or by passive tendon transfers. The usual motors of active transfer are the BR and ECRL. The usual tenodesis involve the FDS (via lassos), EDC, EPL, FPL, and APL.

Injured metamere and functional surgery of the tetraplegic upper limb

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.

Reconstruction of the upper extremity in the child with tetraplegia

According to Howard H. Steel, the orthopedic surgeon who first recognized the need for special care for children with spinal cord injury (SCI), and who persuaded Shriners Hospitals to establish specialized programs for these children over 20 years ago, no field of the health sciences is the statement "a child is not a small adult" more apropos than in the arena of trauma to the spinal cord. Children and adolescents with tetraplegia differ in many ways from adults with the disease. The dissimilarities that influence the outcome of surgical reconstruction of the upper extremity are the focus of this article.

Tetraplegia: update on assessment

The overall assessment in the tetraplegic patient should be comprehensive and detailed. This paper discusses aspects of the medical and physical assessment that normally may go unrecognized but are extremely important in the outcome of the tetraplegic patient. A comprehensive classification also is provided as a new guideline for rehabilitation and surgery. Additionally, the power of [figure: see text] cultural, social, and personal dimensions of disability are illustrated and the importance of these dimensions as they relate to assessment is examined. Finally, the COPM is introduced as an outcome measure capable of crossing cultural [table: see text] boundaries and allowing for the comparison of interventions.

Elbow extension

Reconstruction of elbow extension is an established treatment with a high degree of patient satisfaction. The D-T transfer is the most common method and has the advantage of inducing no serious complications; however, it necessitates a long period of healing and recovery. The Bi-T transfer is used much less frequently and, in the author's opinion, has few advantages compared with the D-T transfer. It is somewhat less time consuming to perform, and the rehabilitation period is a few weeks shorter. This method, however, has several drawbacks, including difficulties in learning to use the muscle as an extensor and a reduction of elbow flexion strength, which might result in a subjective functional loss. What is the best treatment for patients with a posterior deltoid that has a strength grade of 2 or 3: a D-T or Bi-T transfer or functional electrical stimulation? Today, this question is impossible to answer. The author is convinced that the optimal postoperative regimen for a reconstructed elbow extension has not been found yet.

The unoperated hand: the role of passive forces in hand function after tetraplegia

Passive forces play a large role in hand function after tetraplegia. Most individuals with tetraplegia choose not to undergo surgical reconstruction of hand function and, therefore, depend on the passive properties of their musculoskeletal system to perform functional tasks. Knowledge of the levels of force needed to perform many of these tasks is lacking. Understanding the mechanics of producing passive force is important for designing adaptive tools and other devices for tetraplegic individuals. Knowledge of the passive properties of the upper extremity is important in forming treatment strategies. The passive forces produced for change to the tenodesis grasp are small but useful to the individual. Since these forces arise from basic anatomy and muscle function, they are important even after surgical restoration of hand function. Compensatory strategies for the unoperated hand probably play a role in the operated hand. The approach to surgical restoration of grasp must consider how passive forces contribute to functional outcome.

Midcervical tetraplegia with strong wrist extension: a two-stage synergistic reconstruction of the hand

Reconstructive surgery can restore appreciable function of the upper limb in tetraplegic patients. The magnitude of the function regained depends on several factors: (1) the level of the spinal cord lesion, (2) careful patient selection, (3) thoughtful application of the basic principles of tendon transfer, (4) absence of severe spasticity, (5) the remaining sensory function of the hand, and (6) the surgical program and the surgeon's expertise with this type of patient. Reconstructive surgery offers patients not only greater physical independence but also psychological benefits. This article refers to cases with midcervical spinal cord lesion where wrist extension is complete and strong (MRC grading 5). It describes the author's strategy and technical choices in these patients, based on an ever evolving experience of more than 30 years.

Surgical strategy: matching the patient with the procedure

The general indications, timing, and choice of procedure can be determined by asking and answering the following questions appropriately: 1. Has the patient achieved neurologic, emotional, and social stability? 2. What is the patient's current level of motor and sensory resources and function? The number and strength of muscles remaining under good voluntary control are the most important variables. 3. Are the patient's expectations realistic? 4. Does the patient possess the necessary intelligence and motivation? Some procedures, such as arthrodesis of a specific joint, require little motivation to succeed; however, a complex set of muscle-tendon transfers requires a great deal of motor reeducation for the patient to achieve an optimal result. 5. Does the patient have the necessary time to invest in achieving a good result? The patient must be able to set aside the time necessary for postoperative immobilization in a cast or splint and for therapy and reeducation. 6. Are the necessary support services and personnel available and committed? 7. Have all preoperative obstacles to success been considered and has a plan developed to overcome any remaining obstacles? 8. Does the patient understand the potential complications and benefits? 9. Can the patient and professional team tolerate a complication, failure, or suboptimal result? Both the medical staff and the patient must be prepared for complications that may lead to a suboptimal outcome or frank failure. 10. Are the patient's current health and well-being ideal? 11. Is the surgical plan consistent with the patient's physical resources, goals, and expectations? 12. Does an alternate plan exist? 13. Does the surgeon understand the scope of the complications and how to salvage an acceptable result should a complication occur?

General indications for functional surgery of the hand in tetraplegic patients

General indications for surgery of the upper limb cannot be codified and do not follow any general rules. Each case is different, and a successful outcome depends on the experience acquired by a specialized surgeon, the team that surrounds the patient, and the customization of treatment to the personality and wishes of the patient. In addition, direct and caring human contract between the surgeon and his patient are fundamental. Today, many tetraplegic patients who are confined to their wheelchairs spend much of their time on the computer, eager to obtain as much information as possible about their condition from the Internet. One must stress, however, the risks of the false and partial information they might find. Surgical indications should be assessed only after a clinical evaluation and a long and personal discussion between the surgeon and the patient, who in this way establish a covenant between them. In the 21st century, patients will continue to become better informed, but the surgeon will maintain his role as mediator between the patient and surgery.

Surgical rehabilitation for the weaker patients (groups 1 and 2 of the International Classification)

We have benefited from having had an initial large experience with the straightforward and predictable FPL tenodesis procedure and, after gaining experience, have continually modified it with the goal of customizing procedures to particular patients. We have moved toward reconstructing a dynamic pinch by tendon transfer when the brachioradialis is not needed to augment wrist extension. In any case, any patient and any hand are different. There is no such thing as a "standard procedure" when dealing with tetraplegic patients, and available procedures must be discussed in view of each patient's needs, desires, and specific circumstances.

Strategy for improving hand opening in the tetraplegic upper limb

In the tetraplegic patient, restoring an adequate grip requires primary restoration of proper hand opening. This opening (or "extensor") surgical stage is performed 3 or 4 months before the closing (or "flexor") stage. Surgical strategy is based on group 5 of the IC, which represents a turning point. Above this group (i.e., in IC groups 2-4), opening is essentially based on passive procedures (such as tenodesis and arthrodesis). Starting at group 5, restoration of active digital extension is [table: see text] feasible, as well as active stabilization of the thumb ray in lower groups. In those lower groups, all efforts should aim at re-establishing an intrinsic balance, keeping in mind the difference between supple and rigid claw deformities, which require different corrective procedures (Table 1).

Evolution of surgery for tetraplegic hands in Japan

In Japan, reconstructive surgery for the tetraplegic hand has developed mainly with Tsuge, Yabe, and their students for a little more than 30 years. They mostly used Zancolli's classification and, consequently, followed his treatment guidelines. Some unique procedures and techniques, however, have been devised based on their own experiences, including a static opponens tenodesis using FCR tendon, a modified lasso procedure to anchor a paralyzed flexor superficialis tendon through A2 pulley rather than A1 pulley, one-stage reconstruction of both extensor and flexor tendons, and the percutaneous functional electrical stimulation (FES) system.

History of surgery in the rehabilitation of the tetraplegic upper limb

Surgery in the tetraplegic upper limb made tremendous strides during the last half of the 20th century, inspiring the motivation and creativity of hand surgeons to restore upper limb functions in one of the most unfortunate complications of trauma. Undoubtedly, the future will provide new tools to improve the surgeons' challenge. Meanwhile, they must proceed with meticulous clinical examinations, determine the level of the spinal cord lesion and the muscles available for transfer, and select the most appropriate and proven surgical procedures for each patient.