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Dengler J, Perlman M, Jennett M, Marcon E, Guilcher S. An Examination of Utilization Rates Over Time of Nerve and Tendon Transfers in Canada to Improve Upper Limb Function in Cervical Spinal Cord Injury. Plast Surg (Oakv) 2024; 32:367-373. [PMID: 39104933 PMCID: PMC11298141 DOI: 10.1177/22925503221120544] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 05/20/2022] [Accepted: 06/01/2022] [Indexed: 08/07/2024] Open
Abstract
Introduction: Upper limb function loss in cervical spinal cord injury (SCI) contributes to substantial disability, and negatively impacts quality of life. Nerve transfer and tendon transfer surgery can provide improved upper limb function. This study assessed the utilization of nerve and tendon transfer surgery for individuals with tetraplegia in Canada. Methods: Data from the Canadian Institute for Health Information's Discharge Abstracts Database and the National Ambulatory Care Reporting System were used to identify the nerve and tendon transfer procedures performed in individuals with tetraplegia (2004-2020). Cases were identified using cervical SCI ICD-10-CA codes and Canadian Classification of Intervention codes for upper extremity nerve and tendon transfers. Data on sex, age at time of procedure, province, and hospital stay duration were recorded. Results: From 2004 to 2020, there were ≤80 nerve transfer procedures (81% male, mean age 38.3 years) and 61 tendon transfer procedures (78% male, mean age 45.0 years) performed (highest in Ontario and British Columbia). Using an estimate of 50% eligibility, an average of 1.3% of individuals underwent nerve transfer and 1.0% underwent tendon transfer. Nerve transfers increased over time (2004-2009, n = <5; 2010-2015, n = 27; 2016-2019, n = 49) and tendon transfers remained relatively constant. Both transfer types were performed as day-surgery or single night stay. Conclusions: Nerve and tendon transfer surgery to improve upper limb function in Canadians with tetraplegia remains low. This study highlights a substantial gap in care for this vulnerable population. Identification of barriers that prevent access to care is required to promote best practice for upper extremity care.
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Affiliation(s)
- Jana Dengler
- Division of Plastic and Reconstructive Surgery, Tory Trauma Program, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Translational Research Program, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Maytal Perlman
- Translational Research Program, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Michelle Jennett
- Translational Research Program, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Edyta Marcon
- Translational Research Program, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Sara Guilcher
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
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Harhaus L, Aman M, Pennekamp A, Weidner N, Panzram B, Gohritz A. The Surgical Restoration of Arm and Hand Function in Tetraplegic Patients. DEUTSCHES ARZTEBLATT INTERNATIONAL 2023; 120:627-632. [PMID: 37378597 PMCID: PMC10600922 DOI: 10.3238/arztebl.m2023.0141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 05/23/2023] [Accepted: 05/23/2023] [Indexed: 06/29/2023]
Abstract
BACKGROUND There are approximately 140 000 people in Germany with spinal cord injury, with approximately 2400 new patients each year. Cervical spinal cord injuries cause, to varying degrees, weakness and impairment of everyday activities of the limbs (tetraparesis, tetraplegia). METHODS This review is based on relevant publications retrieved by a selective search of the literature. RESULTS From among 330 initially screened publications, 40 were included and analyzed. Muscle and tendon transfers, tenodeses, and joint stabilizations yielded reliable functional improvement of the upper limb. Tendon transfers improved the strength of elbow extension from M0 to an average of M3.3 (BMRC) and grip strength to approximately 2 kg. In the long term, 17-20% of strength is lost after active tendon transfers and slightly more after passive ones. Nerve transfers improved strength to M3 or M4 in over 80% of cases, with the best results overall in patients under 25 years of age who underwent early surgery (within 6 months of the accident). Combined procedures in a single operation have been found to be advantageous compared to the traditional multistep approach. Nerve transfers from intact fascicles at segmental levels above that of the spinal cord lesion have been found to be a valuable addition to the established varieties of muscle and tendon transfer. The reported long-term patient satisfaction is generally high. CONCLUSION Modern techniques of hand surgery can help suitably selected tetraparetic and tetraplegic patients regain the use of their upper limbs. Competent interdisciplinary counseling about these surgical options should be offered as early as possible to all affected persons as an integral part of their treatment plan.
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Affiliation(s)
- Leila Harhaus
- Department of Hand Surgery, Peripheral Nerve Surgery and Rehabilitation, Department of Hand and Plastic Surgery, Heidelberg University, BG Trauma Center Ludwigshafen
| | - Martin Aman
- Department of Hand Surgery, Peripheral Nerve Surgery and Rehabilitation, Department of Hand and Plastic Surgery, Heidelberg University, BG Trauma Center Ludwigshafen
| | - Anna Pennekamp
- Department of Hand Surgery, Peripheral Nerve Surgery and Rehabilitation, Department of Hand and Plastic Surgery, Heidelberg University, BG Trauma Center Ludwigshafen
| | - Norbert Weidner
- Department of Paraplegiology—Spinal Cord Injury Center, University Hospital Heidelberg:
| | - Benjamin Panzram
- Upper Limb Section, Department of Orthopedics, University Hospital Heidelberg
| | - Andreas Gohritz
- Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, University Hospital, Basel, Switzerland
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Francoisse CA, Russo SA, Skladman R, Kahn LC, Kennedy C, Stenson KC, Novak CB, Fox IK. Quantifying Donor Deficits Following Nerve Transfer Surgery in Tetraplegia. J Hand Surg Am 2022; 47:1157-1165. [PMID: 36257880 DOI: 10.1016/j.jhsa.2022.08.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 06/09/2022] [Accepted: 08/11/2022] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Caitlin A Francoisse
- Division of Plastic Surgery, St. Louis University School of Medicine, St. Louis, MO
| | - Stephanie A Russo
- Department of Orthopedic Surgery, Akron Children's Hospital, Akron, OH
| | - Rachel Skladman
- Division of Plastic and Reconstructive Surgery, Washington University, St. Louis, MO
| | - Lorna C Kahn
- Division of Plastic and Reconstructive Surgery, Washington University, St. Louis, MO
| | - Carie Kennedy
- Division of Plastic and Reconstructive Surgery, Washington University, St. Louis, MO
| | | | - Christine B Novak
- Division of Plastic and Reconstructive Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Ida K Fox
- VA St. Louis Healthcare System, St. Louis, MO.
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Dengler J, Steeves JD, Curt A, Mehra M, Novak CB, Fox IK. Spontaneous Motor Recovery after Cervical Spinal Cord Injury: Issues for Nerve Transfer Surgery Decision Making. Spinal Cord 2022; 60:922-927. [PMID: 35896613 DOI: 10.1038/s41393-022-00834-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 06/28/2022] [Accepted: 06/30/2022] [Indexed: 11/09/2022]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVES To quantify spontaneous upper extremity motor recovery between 6 and 12 months after spinal cord injury (SCI) to help guide timing of nerve transfer surgery to improve upper limb function in cervical SCI. SETTING Nineteen European SCI rehabilitation centers. METHODS Data was extracted from the European Multicenter Study of SCI database for individuals with mid-level cervical SCI (N = 268). Muscle function grades at 6 and 12 months post-SCI were categorized for analysis. RESULTS From 6 to 12 months after SCI, spontaneous surgically-relevant recovery was limited. Of all limbs (N = 263) with grade 0-2 elbow extension at 6 months, 4% regained grade 4-5 and 11% regained grade 3 muscle function at 12 months. Of all limbs (N = 380) with grade 0-2 finger flexion at 6 months, 3% regained grade 4-5 and 5% regained grade 3 muscle function at 12 months. CONCLUSION This information supports early (6 month) post-injury surgical consultation and evaluation. With this information, individuals with SCI can more fully engage in preference-based decision-making about surgical intervention versus continued rehabilitation and spontaneous recovery to gain elbow extension and/or hand opening and closing.
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Affiliation(s)
- Jana Dengler
- Division of Plastic and Reconstructive Surgery, Tory Trauma Program, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.,University of Toronto, Division of Plastic & Reconstructive Surgery, Toronto, Ontario, Canada
| | - John D Steeves
- ICORD, University of British Columbia, Vancouver British Columbia, Vancouver, Canada
| | - Armin Curt
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
| | - Munish Mehra
- Tigermed-BDM Inc, Gaithersburg Maryland, Maryland, USA
| | - Christine B Novak
- University of Toronto, Division of Plastic & Reconstructive Surgery, Toronto, Ontario, Canada
| | | | | | - Ida K Fox
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St Louis Missouri, USA. .,VA St. Louis Healthcare System, St Louis Missouri, USA.
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Donor activation focused rehabilitation approach to hand closing nerve transfer surgery in individuals with cervical level spinal cord injury. Spinal Cord Ser Cases 2022; 8:47. [PMID: 35487892 PMCID: PMC9055048 DOI: 10.1038/s41394-022-00512-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 04/11/2022] [Accepted: 04/13/2022] [Indexed: 01/15/2023] Open
Abstract
STUDY DESIGN Case Series. OBJECTIVES To describe the donor activation focused rehabilitation approach (DAFRA) in the setting of the hand closing nerve transfers in cervical spinal cord injury (SCI) so that therapists may apply it to treatment of individuals undergoing this procedure. SETTING United States of America-Academic Level 1 Trauma Center. METHODS We reviewed the records of individuals with cervical SCI who underwent nerve transfer to restore hand closing and post-surgery DAFRA therapy at our institution. The three post-surgery phases of DAFRA included (1) early phase (0-12 months) education, limb preparation, and donor activation exercises, (2) middle phase (12-24 months) volitional recipient muscle activation and (3) late phase (18 + months) strengthening and incorporation of motion in activities of daily living. RESULTS Subtle gains in hand closing were first observed at a mean of 8.4 months after hand closing nerve transfer surgery. Remarkable improvements including discontinuation of assistive devices, independence with feeding and urinary function, and measurable grip were observed. Function continued to improve slowly for one to two more years. CONCLUSIONS A deliberate, slow-paced (monthly for >2 years post-surgery) and incremental therapy program-DAFRA-can be used to improve outcomes after nerve transfer to restore hand closing in cervical SCI. SPONSORSHIP This work was made possible by funding from the Craig H. Neilsen Foundation Spinal Cord Injury Research on the Translation Spectrum (SCIRTS) Grant: Nerve Transfers to Restore Hand Function in Cervical Spinal Cord Injury (PI: Ida Fox).
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Waris E, Palmgren-Soppela T, Sommarhem A. Nerve Transfer of Brachialis Branch to Anterior Interosseus Nerve Using In Situ Lateral Antebrachial Cutaneous Nerve Graft in Tetraplegia. J Hand Surg Am 2022; 47:390.e1-390.e7. [PMID: 34217555 DOI: 10.1016/j.jhsa.2021.04.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 02/21/2021] [Accepted: 04/28/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE Reconstruction of finger motion is a therapeutic goal in tetraplegic patients. Although nerve transfer of the brachialis branch of the musculocutaneous nerve to the anterior interosseus nerve has been previously described, this results in unreliable reinnervation because the donor nerve is proximal to the target muscle. We describe an alternative technique in which nerve transfer is performed using the lateral antebrachial cutaneous nerve as a vascular in situ nerve graft. The clinical results are reported. METHODS Nine upper limbs of 6 patients (mean age 25 years) with tetraplegia were subjected to brachialis-to-anterior interosseus nerve transfer using the lateral antebrachial cutaneous nerve as a vascular in situ nerve graft, at a mean of 6 months after injury. Additional supinator branch transfer to the posterior interosseous nerve was performed for 6 upper limbs and to the flexor digitorum superficialis motor branch for 1 upper limb. RESULTS At a mean of 2 years of follow-up, thumb and finger flexion strength scored M3-M4 in 5 of the 9 limbs according to the Medical Research Council scale. Key pinch and grip pinch averaged 0.6 kg (range, 0-1.0 kg) and 2.2 kg (range, 0-8 kg), respectively. No donor-site deficit was observed. CONCLUSIONS Brachialis-to-anterior interosseus nerve transfer with an in situ lateral antebrachial cutaneous nerve graft can be used to reconstruct thumb and finger flexion in tetraplegic patients. Combined with supinator-to- posterior interosseous nerve transfer, simultaneous active extension of the fingers can be achieved. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic V.
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Affiliation(s)
- Eero Waris
- Department of Hand Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
| | - Tove Palmgren-Soppela
- Department of Hand Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Antti Sommarhem
- Department of Children's Orthopedics and Traumatology, New Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Dengler J, Mehra M, Steeves JD, Fox IK. Evaluation of Functional Independence in Cervical Spinal Cord Injury: Implications for Surgery to Restore Upper Limb Function. J Hand Surg Am 2021; 46:621.e1-621.e17. [PMID: 33454154 DOI: 10.1016/j.jhsa.2020.10.036] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Revised: 08/18/2020] [Accepted: 10/22/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To help individuals make informed choices regarding the optimal type and timing of restorative surgical treatment for cervical spinal cord injury (SCI), more precise information is needed on their ability to perform activities of daily living. The goal of this work was to describe functional independence achieved by individuals with differing levels of cervical SCI. METHODS Using the comprehensive European Multicenter Study of Spinal Cord Injury dataset, analysis was undertaken of individuals with traumatic SCI, motor-level C5-C8. Data on feeding, bladder management, and transfers (bed to wheelchair) were compared between individuals with different levels of injury. Subgroup analyses of symmetrical and asymmetrical SCI and between complete and incomplete SCI were performed. The impact of age, sex, and time postinjury on functional independence was ascertained. RESULTS Data were available for individuals with symmetrical (n = 204) and asymmetrical (n = 95) patterns of SCI. Independence with feeding, urinary function, and transfer ability was increased in individuals with strong finger flexion. Unexpectedly, the presence of strong elbow extension did not uniformly result in the ability to transfer independently. There was no change in any of the analyzed activities between 6 and 12 months postinjury. CONCLUSIONS People with cervical SCI who gain finger flexion have greater independence with feeding, urinary, and transfer activities. Restoration of finger flexion should be a reconstructive priority for individuals with midcervical-level SCI. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic IV.
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Affiliation(s)
- Jana Dengler
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Toronto, Toronto, Ontario
| | | | - John D Steeves
- ICORD, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Ida K Fox
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO; VA St. Louis Healthcare System, St. Louis, MO.
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Emamhadi M, Haghani Dogahe M, Gohritz A. Nerve transfers in tetraplegia: a review and practical guide. J Neurosurg Sci 2021; 65:431-441. [PMID: 33870671 DOI: 10.23736/s0390-5616.21.05312-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Spinal cord injury (SCI) may lead to tetraplegia. Several nerve transfers have been successfully used for the restoration of the upper limb in tetraplegia. Reconstruction of an upper limb is individualized based on the functional level. In this study, the authors reviewed nerve transfers based on the injury level for the restoration of upper limb function in tetraplegia. EVIDENCE ACQUISITION We performed this study to review nerve transfers in tetraplegia by searching MEDLINE and EMBASE databases to identify relevant articles published through December 2020. We selected studies that reported cases in tetraplegia and extracted information on demographic data, clinical characteristics, operative details, and strength outcomes based on each injury level after surgery. EVIDENCE SYNTHESIS Total of 29 journal articles reporting on 275 nerve transfers in 172 upper limbs of 121 patients were included in the review. The mean time between SCI and nerve transfer surgery was 21.37 months (range: 4-156 months), and the follow-up time was 21.34 months (range: 3-38 months). The best outcomes were achieved for the restoration of wrist/finger extension and elbow extension. CONCLUSIONS Nerve transfer can provide a new function in tetraplegic patients' upper limbs to improve daily living activities. The type of surgical procedure should be performed based on the functional level of SCI and the individual's needs. Functional recovery occurs more in extensor muscles than flexors. Nerve transfer is a promising option in the reconstruction of upper limb function in tetraplegia.
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Affiliation(s)
- Mohammadreza Emamhadi
- Brachial Plexus and Peripheral Nerve Injury Center, Department of Neurosurgery, Guilan University of Medical Sciences, Rasht, Iran -
| | - Mohammad Haghani Dogahe
- Brachial Plexus and Peripheral Nerve Injury Center, Department of Neurosurgery, Guilan University of Medical Sciences, Rasht, Iran
| | - Andreas Gohritz
- Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Basel, Switzerland
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Foley DP, Cox C, Suryavanshi J, Osemwengie B, MacKay BJ. Nerve allograft histology after banking following complicated reconstruction. Clin Case Rep 2021; 9:759-763. [PMID: 33598241 PMCID: PMC7869367 DOI: 10.1002/ccr3.3599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 11/04/2020] [Accepted: 11/13/2020] [Indexed: 11/12/2022] Open
Abstract
Burial of nerve allografts in muscle tissue for later use is a novel technique with no prior literature discussions. This may be a safe and effective technique for short-term preservation of nerve allograft removed from a prior reconstruction.
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Affiliation(s)
- David P. Foley
- Department of Orthopedic Surgery and RehabilitationTexas Tech Health Sciences CenterLubbockTXUSA
| | - Cameron Cox
- Department of Orthopedic Surgery and RehabilitationTexas Tech Health Sciences CenterLubbockTXUSA
| | - Joash Suryavanshi
- Department of Orthopedic Surgery and RehabilitationTexas Tech Health Sciences CenterLubbockTXUSA
| | - Bradley Osemwengie
- Department of Orthopedic Surgery and RehabilitationTexas Tech Health Sciences CenterLubbockTXUSA
| | - Brendan J. MacKay
- Department of Orthopedic Surgery and RehabilitationTexas Tech Health Sciences CenterLubbockTXUSA
- University Medical Center LubbockLubbockTXUSA
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Liew SK, Shim BJ, Gong HS. Upper Limb Reconstruction in Tetraplegic Patients: A Primer for Spinal Cord Injury Specialists. Korean J Neurotrauma 2020; 16:126-137. [PMID: 33163420 PMCID: PMC7607018 DOI: 10.13004/kjnt.2020.16.e48] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 09/11/2020] [Accepted: 09/23/2020] [Indexed: 11/15/2022] Open
Abstract
Cervical spinal cord injury (SCI) often causes debilitating loss of function of the upper limb. Upper extremity reconstruction surgery can restore some of the upper limb function in tetraplegic patients with SCI. The procedures are typically muscle-tendon unit transfer surgeries, which redistribute the remaining functional muscles to restore active elbow extension, key grip, and finger grasping. In addition to the tendon transfer surgeries, nerve transfers have emerged recently and are showing promising results. However, despite more than half of the tetraplegic patients can benefit from upper limb surgery, only a few of them receive the procedures. This missed opportunity may be due to the lack of communication between SCI specialists and hand surgeons, or the lack of awareness of such options among the specialists and patients. In this review, we provide a basic overview of upper limb reconstruction in tetraplegic patients with target audience of SCI specialists for their better understanding of the basic concept of surgery and information for patient consultation before referring to hand surgeons.
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Affiliation(s)
- Siew Khei Liew
- Department of Orthopedic Surgery, Hand and Reconstructive Microsurgery Division, Faculty of Medicine and Health Sciences, University Putra Malaysia, Selangor, Malaysia
| | - Bum Jin Shim
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seoul, Korea
| | - Hyun Sik Gong
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seoul, Korea
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Jain NS, Hill EJR, Zaidman CM, Novak CB, Hunter DA, Juknis N, Ruvinskaya R, Kennedy CR, Vetter J, Mackinnon SE, Fox IK. Evaluation for Late Nerve Transfer Surgery in Spinal Cord Injury: Predicting the Degree of Lower Motor Neuron Injury. J Hand Surg Am 2020; 45:95-103. [PMID: 31866150 DOI: 10.1016/j.jhsa.2019.11.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Revised: 09/12/2019] [Accepted: 11/05/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE Nerve transfer surgery is used to restore upper extremity function following cervical spinal cord injury (SCI) with substantial variation in outcomes. The injury pattern in SCI is complex and can include isolated upper motor neuron (UMN) and combined UMN/lower motor neuron (LMN) dysfunction. The purpose of the study was to determine the most effective diagnostic technique for determining suitable candidates for nerve transfer surgery in SCI. METHODS Medical records were reviewed of patients who had nerve transfers to restore upper extremity function in SCI. Data collected included (1) preoperative clinical examination and electrodiagnostic testing; (2) intraoperative neuromuscular stimulation (NMS); and (3) nerve histopathology. Preoperative, intraoperative, and postoperative data were compared to identify predictors of isolated UMN versus combined UMN/LMN injury patterns. RESULTS The study sample included 22 patients with 50 nerve transfer surgeries and included patients ranging from less than 1 year to over a decade post-SCI. Normal recipient nerve conduction studies (NCS) before surgery corresponded to the intraoperative presence of recipient NMS and postoperative histopathology that showed normal nerve architecture. Conversely, abnormal recipient NCS before surgery corresponded with the absence of recipient NMS during surgery and patterns of denervation on postoperative histopathology. Normal donor preoperative manual muscle testing corresponded with the presence of donor NMS during surgery and normal nerve architecture on postoperative histopathology. An EMG of corresponding musculature did not correspond with intraoperative donor or recipient NMS or histopathological findings. CONCLUSIONS NCS better predict patterns of injury in SCI than EMG. This is important information for clinicians evaluating people for late nerve transfer surgery even years post-SCI. TYPE OF STUDY/LEVEL OF EVIDENCE Diagnostic II.
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Affiliation(s)
- Nirbhay S Jain
- Division of Plastic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Elspeth J R Hill
- Division of Plastic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Craig M Zaidman
- Department of Neurology, Washington University, St. Louis, MO
| | | | - Daniel A Hunter
- Division of Plastic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Neringa Juknis
- Department of Neurology, Washington University, St. Louis, MO
| | | | - Carie R Kennedy
- Division of Plastic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Joel Vetter
- Division of Plastic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Susan E Mackinnon
- Division of Plastic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Ida K Fox
- Division of Plastic Surgery, Washington University School of Medicine, St. Louis, MO; Plastic and Reconstructive Surgery Core, VA St. Louis Health Care System, St. Louis, MO.
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12
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Fox I, Hoben G, Komaie G, Novak C, Hamm R, Kahn L, Whitehead M, Juknis N, Ruvinskaya R, Mackinnon S, James A. Nerve transfer surgery in cervical spinal cord injury: a qualitative study exploring surgical and caregiver participant experiences. Disabil Rehabil 2019; 43:1542-1549. [PMID: 31560228 DOI: 10.1080/09638288.2019.1669225] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE To investigate perceptions of surgical participants and their caregivers regarding novel nerve transfer surgery to restore upper extremity function in cervical level spinal cord injury. MATERIALS AND METHODS A qualitative study design was used. A multidisciplinary team developed semi-structured interview guides. Interviews were recorded, transcribed and analyzed using basic text analysis. RESULTS Participants had limited information about procedures to improve function after spinal cord injury. When discussing their choice to undergo nerve (as compared to traditional tendon) transfer surgery, they describe a desire to avoid post-operative immobilization. Barriers included the pre-operative testing, cost and inconvenience of travel for surgery, and understanding complex health information related to the procedure. While expectations matched descriptions of outcomes among participants and were generally positive, caregivers expressed disappointment. The long time interval for gains in function to be realized and relatively incremental gains achieved were frustrating to all. CONCLUSIONS People with cervical spinal cord injury and their caregivers need more information about options to restore function and about realistic range of improvements with treatment. Further work to mitigate barriers and develop health information materials around nerve transfer surgery may improve medical decision making around and appropriate use of this newer treatment option.IMPLICATIONS FOR REHABILITATIONNerve transfer surgery is a novel and acceptable means of improving upper extremity function in the setting of cervical spinal cord injury.People with cervical spinal cord injury and their caregivers need information about options to restore hand and arm function and mitigation of barriers around these treatment options.
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Affiliation(s)
- Ida Fox
- Division of Plastic & Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, United States.,Division of Plastic Surgery, Veterans Administration Saint Louis Health Care System, Saint Louis, United States
| | - Gwendolyn Hoben
- Department of Plastic Surgery, Medical College of Wisconsin, Milwaukee, United States
| | - Goldie Komaie
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, Saint Louis, United States
| | - Christine Novak
- Division of Plastic & Reconstructive Surgery, University of Toronto, Toronto, Canada
| | - Rebecca Hamm
- School of Physical Therapy, Washington University School of Medicine, Saint Louis, United States
| | - Lorna Kahn
- Milliken Hand Rehabilitation Center, Department of Occupational Therapy, Washington University School of Medicine, Saint Louis, United States
| | - Meredith Whitehead
- School of Physical Therapy, Washington University School of Medicine, Saint Louis, United States
| | - Neringa Juknis
- Division of Neurorehabilitation, Department of Neurology, Washington University School of Medicine, Saint Louis, United States
| | - Rimma Ruvinskaya
- Division of Neurorehabilitation, Department of Neurology, Washington University School of Medicine, Saint Louis, United States
| | - Susan Mackinnon
- Division of Plastic & Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, United States
| | - Aimee James
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, Saint Louis, United States
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Combining nerve and tendon transfers in tetraplegia: a proposal of a new surgical strategy based on literature review. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2018; 29:521-530. [DOI: 10.1007/s00590-018-2352-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 12/03/2018] [Indexed: 11/25/2022]
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The Use of Nerve Transfers to Restore Upper Extremity Function in Cervical Spinal Cord Injury. PM R 2018; 10:1173-1184.e2. [PMID: 29551672 DOI: 10.1016/j.pmrj.2018.03.013] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 02/21/2018] [Accepted: 03/02/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND Nerve transfer surgery to restore upper extremity function in cervical spinal cord injury (SCI) is novel and may transform treatment. Determining candidacy even years post-SCI is ill defined and deserves investigation. OBJECTIVE To develop a diagnostic algorithm, focusing on electrodiagnostic (EDX) studies, to determine eligibility for nerve transfer surgery. DESIGN Retrospective descriptive case series. SETTING Tertiary university-based institution. PATIENTS Individuals with cervical SCI (n = 45). METHODS The electronic medical records of people referred to the Plastic Surgery Multidisciplinary Upper Extremity Surgery in SCI clinic from 2010-2015 were reviewed. People were considered for nerve transfers to restore elbow extension or finger flexion and/or extension. Data including demographic, clinical evaluation, EDX results, surgery, and outcomes were collected and analyzed. MAIN OUTCOME MEASUREMENTS EDX data, including nerve conduction studies and electromyography, for bilateral upper extremities of each patient examined was used to assess for the presence of lower motor neuron injury, which would preclude late nerve transfer. RESULTS Based on our criteria and the results of EDX testing, a substantial number of patients presenting even years post-SCI were candidates for nerve transfers. Clinical outcome results are heterogeneous but promising and suggest that further refinement of eligibility, long-term follow-up, and standardized assessment will improve our understanding of the role of nerve transfer surgery to restore function in people with midcervical SCI. CONCLUSIONS Many patients living with SCI are candidates for nerve transfer surgery to restore upper extremity function. Although the ultimate efficacy of these surgeries is not yet determined, this study attempts to report the criteria we are using and may ultimately determine the timing for intervention and which transfers are most useful for this heterogeneous population. LEVEL OF EVIDENCE IV.
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Nerve Transfers in Patients with Brown-Séquard Pattern of Spinal Cord Injury: Report of 2 Cases. World Neurosurg 2018; 110:152-157. [DOI: 10.1016/j.wneu.2017.10.169] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2017] [Revised: 10/28/2017] [Accepted: 10/31/2017] [Indexed: 11/24/2022]
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Fox IK, Miller AK, Curtin CM. Nerve and Tendon Transfer Surgery in Cervical Spinal Cord Injury: Individualized Choices to Optimize Function. Top Spinal Cord Inj Rehabil 2018; 24:275-287. [PMID: 29997430 PMCID: PMC6037328 DOI: 10.1310/sci2403-275] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background: Recent adaption of nerve transfer surgery to improve upper extremity function in cervical spinal cord injury (SCI) is an exciting development. Tendon transfer procedures are well established, reliable, and can significantly improve function. Despite this, few eligible surgical candidates in the United States undergo these restorative surgeries. Evidence Acquisition: The literature on these procedures was reviewed. Results: Options to improve function include surgery to restore elbow extension, wrist extension, and hand opening and closing function. Tendon transfers are reliable and well tolerated but require weeks of immobilization and limits on extremity use. The role of nerve transfers is still being established. Early results indicate variable return of meaningful function with less immobilization but longer periods (up to years) required to gain appreciable function. Conclusion: Nerve and tendon transfer surgery sacrifice an expendable donor to restore a missing and more critical function. These procedures are well described in hand surgery; are reliable, well tolerated, and covered by insurance; and should be part of the SCI rehabilitation discussion.
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Affiliation(s)
- Ida K. Fox
- Department of Surgery, Washington University, St. Louis, Missouri
| | - Amanda K. Miller
- Department of Neurology, Washington University, St. Louis, Missouri
| | - Catherine M. Curtin
- Department of Surgery, Veterans Affairs Healthcare System, Palo Alto, California
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Bertelli JA, Ghizoni MF. Nerve and Free Gracilis Muscle Transfers for Thumb and Finger Extension Reconstruction in Long-standing Tetraplegia. J Hand Surg Am 2016; 41:e411-e416. [PMID: 27593485 DOI: 10.1016/j.jhsa.2016.08.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Revised: 05/09/2016] [Accepted: 08/01/2016] [Indexed: 02/02/2023]
Abstract
PURPOSE With spinal cord injuries, muscles below the level of the lesion remain innervated despite the absence of volitional control. This persistent innervation protects against denervation atrophy and may allow for nerve transfers to treat long-standing lesions within the spinal cord. We tested the hypothesis that in chronic spinal cord lesions, muscles remained viable for reinnervation. METHODS To test this hypothesis, we operated on 7 patients with tetraplegia to reconstruct thumb and finger extension after a mean interval of 5 years since injury. During surgery, if electrical stimulation of the posterior interosseous nerve (PIN) produced muscle contraction, the nerve to the supinator (NS) was transferred to the PIN. If no contractions were demonstrated, the muscles of the extensor compartment of the forearm were replaced via a free gracilis transfer with innervation supplied by the NS. RESULTS After an average of 26 months, M3 recovery of thumb and finger extension was observed in the 3 upper limbs from the 2 youngest patients who underwent a nerve transfer. None of the free gracilis-treated patients achieved scores above M2. CONCLUSIONS In our youngest patients aged 27 and 34 years, who were operated on 6 years after spinal cord injury, transfer of the NS to the PIN partially restored hand span. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic V.
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Affiliation(s)
- Jayme Augusto Bertelli
- Center of Biological and Health Sciences, Department of Neurosurgery, University of the South of Santa Catarina (Unisul), Tubarão, Santa Catarina, Brazil; Department of Orthopedic Surgery, Governador Celso Ramos Hospital, Florianópolis, Santa Catarina, Brazil.
| | - Marcos Flávio Ghizoni
- Center of Biological and Health Sciences, Department of Neurosurgery, University of the South of Santa Catarina (Unisul), Tubarão, Santa Catarina, Brazil
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Identification of patients with cervical SCI suitable for early nerve transfer to achieve hand opening. Spinal Cord 2016; 55:131-134. [DOI: 10.1038/sc.2016.128] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Revised: 05/31/2016] [Accepted: 07/09/2016] [Indexed: 11/09/2022]
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Morphology of Donor and Recipient Nerves Utilised in Nerve Transfers to Restore Upper Limb Function in Cervical Spinal Cord Injury. Brain Sci 2016; 6:brainsci6040042. [PMID: 27690115 PMCID: PMC5187556 DOI: 10.3390/brainsci6040042] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2016] [Revised: 09/19/2016] [Accepted: 09/21/2016] [Indexed: 11/21/2022] Open
Abstract
Loss of hand function after cervical spinal cord injury (SCI) impacts heavily on independence. Multiple nerve transfer surgery has been applied successfully after cervical SCI to restore critical arm and hand functions, and the outcome depends on nerve integrity. Nerve integrity is assessed indirectly using muscle strength testing and intramuscular electromyography, but these measures cannot show the manifestation that SCI has on the peripheral nerves. We directly assessed the morphology of nerves biopsied at the time of surgery, from three patients within 18 months post injury. Our objective was to document their morphologic features. Donor nerves included teres minor, posterior axillary, brachialis, extensor carpi radialis brevis and supinator. Recipient nerves included triceps, posterior interosseus (PIN) and anterior interosseus nerves (AIN). They were fixed in glutaraldehyde, processed and embedded in Araldite Epon for light microscopy. Eighty percent of nerves showed abnormalities. Most common were myelin thickening and folding, demyelination, inflammation and a reduction of large myelinated axon density. Others were a thickened perineurium, oedematous endoneurium and Renaut bodies. Significantly, very thinly myelinated axons and groups of unmyelinated axons were observed indicating regenerative efforts. Abnormalities exist in both donor and recipient nerves and they differ in appearance and aetiology. The abnormalities observed may be preventable or reversible.
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Abstract
Hand and upper extremity function is instrumental to basic activities of daily living and level of independence in cervical spinal cord injury (SCI). Nerve transfer surgery is a novel and alternate approach for restoring function in SCI. This article discusses the biologic basis of nerve transfers in SCI, patient evaluation, management, and surgical approaches. Although the application of this technique is not new; recent case reports and case series in the literature have increased interest in this field. The challenges are to improve function, achieve maximal gains in function, avoid complications, and to primum non nocere.
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Affiliation(s)
- Ida K Fox
- Division of Plastic Surgery, Washington University School of Medicine, 660 South Euclid Avenue, Box 8238, Saint Louis, MO 63110, USA.
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Pet MA, Lipira AB, Ko JH. Nerve Transfers for the Restoration of Wrist, Finger, and Thumb Extension After High Radial Nerve Injury. Hand Clin 2016; 32:191-207. [PMID: 27094891 DOI: 10.1016/j.hcl.2015.12.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
High radial nerve injury is a common pattern of peripheral nerve injury most often associated with orthopedic trauma. Nerve transfers to the wrist and finger extensors, often from the median nerve, offer several advantages when compared to nerve repair or grafting and tendon transfer. In this article, we discuss the forearm anatomy pertinent to performing these nerve transfers and review the literature surrounding nerve transfers for wrist, finger, and thumb extension. A suggested algorithm for management of acute traumatic high radial nerve palsy is offered, and our preferred surgical technique for treatment of high radial nerve palsy is provided.
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Affiliation(s)
- Mitchell A Pet
- Division of Plastic and Reconstructive Surgery, Harborview Medical Center, University of Washington School of Medicine, 325 9th Avenue, Mailstop #359796, Seattle, WA 98104, USA
| | - Angelo B Lipira
- Division of Plastic and Reconstructive Surgery, Harborview Medical Center, University of Washington School of Medicine, 325 9th Avenue, Mailstop #359796, Seattle, WA 98104, USA
| | - Jason H Ko
- Division of Plastic Surgery, Northwestern University Feinberg School of Medicine, 675 N. St. Clair Street, Suite 19-250, Chicago, IL 60611, USA.
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Abstract
…once the development was ended, the founts of growth and regeneration of the axons and dendrites dried up irrevocably. Santiago Ramón y Cajal Cajal's neurotropic theory postulates that the complexity of the nervous system arises from the collaboration of neurotropic signals from neuronal and non-neuronal cells and that once development has ended, a paucity of neurotropic signals means that the pathways of the central nervous system are "fixed, ended, immutable". While the capacity for regeneration and plasticity of the central nervous system may not be quite as paltry as Cajal proposed, regeneration is severely limited in scope as there is no spontaneous regeneration of long-distance projections in mammals and therefore limited opportunity for functional recovery following spinal cord injury. It is not a far stretch from Cajal to hypothesize that reappropriation of the neurotropic programs of development may be an appropriate strategy for reconstitution of injured circuits. It has become clear, however, that a significant number of the molecular cues governing circuit development become re-active after injury and many assume roles that paradoxically obstruct the functional re-wiring of severed neural connections. Therefore, the problem to address is how individual neural circuits respond to specific molecular cues following injury, and what strategies will be necessary for instigating functional repair or remodeling of the injured spinal cord.
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Affiliation(s)
- Edmund R Hollis
- Burke Medical Research Institute, White Plains, NY, USA.
- Brain and Mind Research Institute, Weill Cornell Medical College, New York, NY, USA.
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Bergmeister KD, Aman M, Riedl O, Manzano-Szalai K, Sporer ME, Salminger S, Aszmann OC. Experimental nerve transfer model in the rat forelimb. Eur Surg 2016; 48:334-341. [PMID: 28058042 PMCID: PMC5167219 DOI: 10.1007/s10353-016-0386-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Accepted: 01/13/2016] [Indexed: 11/30/2022]
Abstract
Background Nerve transfers are a powerful tool in extremity reconstruction, but the neurophysiological effects have not been adequately investigated. As 81 % of nerve injuries and most nerve transfers occur in the upper extremity with its own neurophysiological properties, the standard rat hindlimb model may not be optimal in this paradigm. Here we present an experimental rat forelimb model to investigate nerve transfers. Methods In ten male Sprague-Dawley rats, the ulnar nerve was transferred to the motor branch of long head of the biceps. Sham surgery was performed in five animals (exposure/closure). After 12 weeks of regeneration, muscle force and Bertelli test were performed and evaluated. Results The nerve transfer successfully reinnervated the long head of the biceps in all animals, as indicated by muscle force and behavioral outcome. No aberrant reinnervation occurred from the original motor source. Muscle force was 2,68 N ± 0.35 for the nerve transfer group and 2,85 N ± 0.39 for the sham group, which was not statically different (p = 0.436). The procedure led to minor functional deficits due to the loss of ulnar nerve function; this, however, could not be quantified with any of the presented measures. Conclusion The above-described rat model demonstrated a constant anatomy, suitable for nerve transfers that are accessible to standard neuromuscular analyses and behavioral testing. This model allows the study of both neurophysiologic properties and cognitive motor function after nerve transfers in the upper extremity.
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Affiliation(s)
- K D Bergmeister
- CD Laboratory for the Restoration of Extremity Function, Department of Surgery, Medical University of Vienna, Vienna, Austria ; Division of Biomedical Research, Medical University of Vienna, Vienna, Austria
| | - M Aman
- CD Laboratory for the Restoration of Extremity Function, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - O Riedl
- CD Laboratory for the Restoration of Extremity Function, Department of Surgery, Medical University of Vienna, Vienna, Austria ; Christian Doppler Laboratory for Restoration of Extremity Function, Division of Plastic and Reconstructive Surgery, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria
| | - K Manzano-Szalai
- CD Laboratory for the Restoration of Extremity Function, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - M E Sporer
- CD Laboratory for the Restoration of Extremity Function, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - S Salminger
- CD Laboratory for the Restoration of Extremity Function, Department of Surgery, Medical University of Vienna, Vienna, Austria ; Christian Doppler Laboratory for Restoration of Extremity Function, Division of Plastic and Reconstructive Surgery, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria
| | - O C Aszmann
- CD Laboratory for the Restoration of Extremity Function, Department of Surgery, Medical University of Vienna, Vienna, Austria ; Christian Doppler Laboratory for Restoration of Extremity Function, Division of Plastic and Reconstructive Surgery, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria
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Nerve Transfers to Restore Upper Extremity Function in Cervical Spinal Cord Injury: Update and Preliminary Outcomes. Plast Reconstr Surg 2015; 136:780-792. [PMID: 26397252 DOI: 10.1097/prs.0000000000001641] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Cervical spinal cord injury can result in profound loss of upper extremity function. Recent interest in the use of nerve transfers to restore volitional control is an exciting development in the care of these complex patients. In this article, the authors review preliminary results of nerve transfers in spinal cord injury. METHODS Review of the literature and the authors' cases series of 13 operations in nine spinal cord injury nerve transfer recipients was performed. Representative cases were reviewed to explore critical concepts and preliminary outcomes. RESULTS The nerve transfers used expendable donors (e.g., teres minor, deltoid, supinator, and brachialis) innervated above the level of the spinal cord injury to restore volitional control of missing function such as elbow extension, wrist extension, and/or hand function (posterior interosseous nerve or anterior interosseous nerve/finger flexors reinnervated). Results from the literature and the authors' patients (after a mean postsurgical follow-up of 12 months) indicate gains in function as assessed by both manual muscle testing and patients' self-reported outcomes measures. CONCLUSIONS Nerve transfers can provide an alternative and consistent means of reestablishing volitional control of upper extremity function in people with cervical level spinal cord injury. Early outcomes provide evidence of substantial improvements in self-reported function despite relatively subtle objective gains in isolated muscle strength. Further work to investigate the optimal timing and combination of nerve transfer operations, the combination of these with traditional treatments (tendon transfer and functional electrical stimulation), and measurement of outcomes is imperative for determining the precise role of these operations. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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