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Zheng MX, Hua XY, Feng JT, Li T, Lu YC, Shen YD, Cao XH, Zhao NQ, Lyu JY, Xu JG, Gu YD, Xu WD. Trial of Contralateral Seventh Cervical Nerve Transfer for Spastic Arm Paralysis. N Engl J Med 2018; 378:22-34. [PMID: 29262271 DOI: 10.1056/nejmoa1615208] [Citation(s) in RCA: 118] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Spastic limb paralysis due to injury to a cerebral hemisphere can cause long-term disability. We investigated the effect of grafting the contralateral C7 nerve from the nonparalyzed side to the paralyzed side in patients with spastic arm paralysis due to chronic cerebral injury. METHODS We randomly assigned 36 patients who had had unilateral arm paralysis for more than 5 years to undergo C7 nerve transfer plus rehabilitation (18 patients) or to undergo rehabilitation alone (18 patients). The primary outcome was the change from baseline to month 12 in the total score on the Fugl-Meyer upper-extremity scale (scores range from 0 to 66, with higher scores indicating better function). Results The mean increase in Fugl-Meyer score in the paralyzed arm was 17.7 in the surgery group and 2.6 in the control group (difference, 15.1; 95% confidence interval, 12.2 to 17.9; P<0.001). With regard to improvements in spasticity as measured on the Modified Ashworth Scale (an assessment of five joints, each scored from 0 to 5, with higher scores indicating more spasticity), the smallest between-group difference was in the thumb, with 6, 9, and 3 patients in the surgery group having a 2-unit improvement, a 1-unit improvement, or no change, respectively, as compared with 1, 6, and 7 patients in the control group (P=0.02). Transcranial magnetic stimulation and functional imaging showed connectivity between the ipsilateral hemisphere and the paralyzed arm. There were no significant differences from baseline to month 12 in power, tactile threshold, or two-point discrimination in the hand on the side of the donor graft. RESULTS The mean increase in Fugl-Meyer score in the paralyzed arm was 17.7 in the surgery group and 2.6 in the control group (difference, 15.1; 95% confidence interval, 12.2 to 17.9; P<0.001). With regard to improvements in spasticity as measured on the Modified Ashworth Scale (an assessment of five joints, each scored from 0 to 5, with higher scores indicating more spasticity), the smallest between-group difference was in the thumb, with 6, 9, and 3 patients in the surgery group having a 2-unit improvement, a 1-unit improvement, or no change, respectively, as compared with 1, 6, and 7 patients in the control group (P=0.02). Transcranial magnetic stimulation and functional imaging showed connectivity between the ipsilateral hemisphere and the paralyzed arm. There were no significant differences from baseline to month 12 in power, tactile threshold, or two-point discrimination in the hand on the side of the donor graft. CONCLUSIONS In this single-center trial involving patients who had had unilateral arm paralysis due to chronic cerebral injury for more than 5 years, transfer of the C7 nerve from the nonparalyzed side to the side of the arm that was paralyzed was associated with a greater improvement in function and reduction of spasticity than rehabilitation alone over a period of 12 months. Physiological connectivity developed between the ipsilateral cerebral hemisphere and the paralyzed hand. (Funded by the National Natural Science Foundation of China and others; Chinese Clinical Trial Registry number, 13004466 .).
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Affiliation(s)
- Mou-Xiong Zheng
- From the Department of Hand Surgery, Huashan Hospital (M.-X.Z., X.-Y.H., J.-T.F., T.L., Y.-C.L., Y.-D.S., J.-G.X., Y.-D.G., W.-D.X.), the National Clinical Research Center for Aging and Medicine (M.-X.Z., X.-Y.H., J.-T.F., T.L., Y.-C.L., Y.-D.S., J.-G.X., Y.-D.G., W.-D.X.), Department of Biostatistics, School of Public Health (N.-Q.Z., J.-Y.L.), and State Key Laboratory of Medical Neurobiology (W.-D.X.), Fudan University, the Key Laboratory of Hand Reconstruction, Ministry of Health (M.-X.Z., X.-Y.H., J.-T.F., T.L., Y.-C.L., Y.-D.S., J.-G.X., Y.-D.G., W.-D.X.), the Shanghai Key Laboratory of Peripheral Nerve and Microsurgery (M.-X.Z., X.-Y.H., J.-T.F., T.L., Y.-C.L., Y.-D.S., J.-G.X., Y.-D.G., W.-D.X.), the Department of Hand and Upper Extremity Surgery, Jing'an District Central Hospital (M.-X.Z., X.-Y.H., J.-T.F., T.L., Y.-C.L., Y.-D.S., W.-D.X.), and the Key Laboratory of Brain Functional Genomics (Ministry of Education) and Shanghai Key Laboratory of Brain Functional Genomics, East China Normal University (X.-H.C.) - all in Shanghai, China
| | - Xu-Yun Hua
- From the Department of Hand Surgery, Huashan Hospital (M.-X.Z., X.-Y.H., J.-T.F., T.L., Y.-C.L., Y.-D.S., J.-G.X., Y.-D.G., W.-D.X.), the National Clinical Research Center for Aging and Medicine (M.-X.Z., X.-Y.H., J.-T.F., T.L., Y.-C.L., Y.-D.S., J.-G.X., Y.-D.G., W.-D.X.), Department of Biostatistics, School of Public Health (N.-Q.Z., J.-Y.L.), and State Key Laboratory of Medical Neurobiology (W.-D.X.), Fudan University, the Key Laboratory of Hand Reconstruction, Ministry of Health (M.-X.Z., X.-Y.H., J.-T.F., T.L., Y.-C.L., Y.-D.S., J.-G.X., Y.-D.G., W.-D.X.), the Shanghai Key Laboratory of Peripheral Nerve and Microsurgery (M.-X.Z., X.-Y.H., J.-T.F., T.L., Y.-C.L., Y.-D.S., J.-G.X., Y.-D.G., W.-D.X.), the Department of Hand and Upper Extremity Surgery, Jing'an District Central Hospital (M.-X.Z., X.-Y.H., J.-T.F., T.L., Y.-C.L., Y.-D.S., W.-D.X.), and the Key Laboratory of Brain Functional Genomics (Ministry of Education) and Shanghai Key Laboratory of Brain Functional Genomics, East China Normal University (X.-H.C.) - all in Shanghai, China
| | - Jun-Tao Feng
- From the Department of Hand Surgery, Huashan Hospital (M.-X.Z., X.-Y.H., J.-T.F., T.L., Y.-C.L., Y.-D.S., J.-G.X., Y.-D.G., W.-D.X.), the National Clinical Research Center for Aging and Medicine (M.-X.Z., X.-Y.H., J.-T.F., T.L., Y.-C.L., Y.-D.S., J.-G.X., Y.-D.G., W.-D.X.), Department of Biostatistics, School of Public Health (N.-Q.Z., J.-Y.L.), and State Key Laboratory of Medical Neurobiology (W.-D.X.), Fudan University, the Key Laboratory of Hand Reconstruction, Ministry of Health (M.-X.Z., X.-Y.H., J.-T.F., T.L., Y.-C.L., Y.-D.S., J.-G.X., Y.-D.G., W.-D.X.), the Shanghai Key Laboratory of Peripheral Nerve and Microsurgery (M.-X.Z., X.-Y.H., J.-T.F., T.L., Y.-C.L., Y.-D.S., J.-G.X., Y.-D.G., W.-D.X.), the Department of Hand and Upper Extremity Surgery, Jing'an District Central Hospital (M.-X.Z., X.-Y.H., J.-T.F., T.L., Y.-C.L., Y.-D.S., W.-D.X.), and the Key Laboratory of Brain Functional Genomics (Ministry of Education) and Shanghai Key Laboratory of Brain Functional Genomics, East China Normal University (X.-H.C.) - all in Shanghai, China
| | - Tie Li
- From the Department of Hand Surgery, Huashan Hospital (M.-X.Z., X.-Y.H., J.-T.F., T.L., Y.-C.L., Y.-D.S., J.-G.X., Y.-D.G., W.-D.X.), the National Clinical Research Center for Aging and Medicine (M.-X.Z., X.-Y.H., J.-T.F., T.L., Y.-C.L., Y.-D.S., J.-G.X., Y.-D.G., W.-D.X.), Department of Biostatistics, School of Public Health (N.-Q.Z., J.-Y.L.), and State Key Laboratory of Medical Neurobiology (W.-D.X.), Fudan University, the Key Laboratory of Hand Reconstruction, Ministry of Health (M.-X.Z., X.-Y.H., J.-T.F., T.L., Y.-C.L., Y.-D.S., J.-G.X., Y.-D.G., W.-D.X.), the Shanghai Key Laboratory of Peripheral Nerve and Microsurgery (M.-X.Z., X.-Y.H., J.-T.F., T.L., Y.-C.L., Y.-D.S., J.-G.X., Y.-D.G., W.-D.X.), the Department of Hand and Upper Extremity Surgery, Jing'an District Central Hospital (M.-X.Z., X.-Y.H., J.-T.F., T.L., Y.-C.L., Y.-D.S., W.-D.X.), and the Key Laboratory of Brain Functional Genomics (Ministry of Education) and Shanghai Key Laboratory of Brain Functional Genomics, East China Normal University (X.-H.C.) - all in Shanghai, China
| | - Ye-Chen Lu
- From the Department of Hand Surgery, Huashan Hospital (M.-X.Z., X.-Y.H., J.-T.F., T.L., Y.-C.L., Y.-D.S., J.-G.X., Y.-D.G., W.-D.X.), the National Clinical Research Center for Aging and Medicine (M.-X.Z., X.-Y.H., J.-T.F., T.L., Y.-C.L., Y.-D.S., J.-G.X., Y.-D.G., W.-D.X.), Department of Biostatistics, School of Public Health (N.-Q.Z., J.-Y.L.), and State Key Laboratory of Medical Neurobiology (W.-D.X.), Fudan University, the Key Laboratory of Hand Reconstruction, Ministry of Health (M.-X.Z., X.-Y.H., J.-T.F., T.L., Y.-C.L., Y.-D.S., J.-G.X., Y.-D.G., W.-D.X.), the Shanghai Key Laboratory of Peripheral Nerve and Microsurgery (M.-X.Z., X.-Y.H., J.-T.F., T.L., Y.-C.L., Y.-D.S., J.-G.X., Y.-D.G., W.-D.X.), the Department of Hand and Upper Extremity Surgery, Jing'an District Central Hospital (M.-X.Z., X.-Y.H., J.-T.F., T.L., Y.-C.L., Y.-D.S., W.-D.X.), and the Key Laboratory of Brain Functional Genomics (Ministry of Education) and Shanghai Key Laboratory of Brain Functional Genomics, East China Normal University (X.-H.C.) - all in Shanghai, China
| | - Yun-Dong Shen
- From the Department of Hand Surgery, Huashan Hospital (M.-X.Z., X.-Y.H., J.-T.F., T.L., Y.-C.L., Y.-D.S., J.-G.X., Y.-D.G., W.-D.X.), the National Clinical Research Center for Aging and Medicine (M.-X.Z., X.-Y.H., J.-T.F., T.L., Y.-C.L., Y.-D.S., J.-G.X., Y.-D.G., W.-D.X.), Department of Biostatistics, School of Public Health (N.-Q.Z., J.-Y.L.), and State Key Laboratory of Medical Neurobiology (W.-D.X.), Fudan University, the Key Laboratory of Hand Reconstruction, Ministry of Health (M.-X.Z., X.-Y.H., J.-T.F., T.L., Y.-C.L., Y.-D.S., J.-G.X., Y.-D.G., W.-D.X.), the Shanghai Key Laboratory of Peripheral Nerve and Microsurgery (M.-X.Z., X.-Y.H., J.-T.F., T.L., Y.-C.L., Y.-D.S., J.-G.X., Y.-D.G., W.-D.X.), the Department of Hand and Upper Extremity Surgery, Jing'an District Central Hospital (M.-X.Z., X.-Y.H., J.-T.F., T.L., Y.-C.L., Y.-D.S., W.-D.X.), and the Key Laboratory of Brain Functional Genomics (Ministry of Education) and Shanghai Key Laboratory of Brain Functional Genomics, East China Normal University (X.-H.C.) - all in Shanghai, China
| | - Xiao-Hua Cao
- From the Department of Hand Surgery, Huashan Hospital (M.-X.Z., X.-Y.H., J.-T.F., T.L., Y.-C.L., Y.-D.S., J.-G.X., Y.-D.G., W.-D.X.), the National Clinical Research Center for Aging and Medicine (M.-X.Z., X.-Y.H., J.-T.F., T.L., Y.-C.L., Y.-D.S., J.-G.X., Y.-D.G., W.-D.X.), Department of Biostatistics, School of Public Health (N.-Q.Z., J.-Y.L.), and State Key Laboratory of Medical Neurobiology (W.-D.X.), Fudan University, the Key Laboratory of Hand Reconstruction, Ministry of Health (M.-X.Z., X.-Y.H., J.-T.F., T.L., Y.-C.L., Y.-D.S., J.-G.X., Y.-D.G., W.-D.X.), the Shanghai Key Laboratory of Peripheral Nerve and Microsurgery (M.-X.Z., X.-Y.H., J.-T.F., T.L., Y.-C.L., Y.-D.S., J.-G.X., Y.-D.G., W.-D.X.), the Department of Hand and Upper Extremity Surgery, Jing'an District Central Hospital (M.-X.Z., X.-Y.H., J.-T.F., T.L., Y.-C.L., Y.-D.S., W.-D.X.), and the Key Laboratory of Brain Functional Genomics (Ministry of Education) and Shanghai Key Laboratory of Brain Functional Genomics, East China Normal University (X.-H.C.) - all in Shanghai, China
| | - Nai-Qing Zhao
- From the Department of Hand Surgery, Huashan Hospital (M.-X.Z., X.-Y.H., J.-T.F., T.L., Y.-C.L., Y.-D.S., J.-G.X., Y.-D.G., W.-D.X.), the National Clinical Research Center for Aging and Medicine (M.-X.Z., X.-Y.H., J.-T.F., T.L., Y.-C.L., Y.-D.S., J.-G.X., Y.-D.G., W.-D.X.), Department of Biostatistics, School of Public Health (N.-Q.Z., J.-Y.L.), and State Key Laboratory of Medical Neurobiology (W.-D.X.), Fudan University, the Key Laboratory of Hand Reconstruction, Ministry of Health (M.-X.Z., X.-Y.H., J.-T.F., T.L., Y.-C.L., Y.-D.S., J.-G.X., Y.-D.G., W.-D.X.), the Shanghai Key Laboratory of Peripheral Nerve and Microsurgery (M.-X.Z., X.-Y.H., J.-T.F., T.L., Y.-C.L., Y.-D.S., J.-G.X., Y.-D.G., W.-D.X.), the Department of Hand and Upper Extremity Surgery, Jing'an District Central Hospital (M.-X.Z., X.-Y.H., J.-T.F., T.L., Y.-C.L., Y.-D.S., W.-D.X.), and the Key Laboratory of Brain Functional Genomics (Ministry of Education) and Shanghai Key Laboratory of Brain Functional Genomics, East China Normal University (X.-H.C.) - all in Shanghai, China
| | - Jia-Ying Lyu
- From the Department of Hand Surgery, Huashan Hospital (M.-X.Z., X.-Y.H., J.-T.F., T.L., Y.-C.L., Y.-D.S., J.-G.X., Y.-D.G., W.-D.X.), the National Clinical Research Center for Aging and Medicine (M.-X.Z., X.-Y.H., J.-T.F., T.L., Y.-C.L., Y.-D.S., J.-G.X., Y.-D.G., W.-D.X.), Department of Biostatistics, School of Public Health (N.-Q.Z., J.-Y.L.), and State Key Laboratory of Medical Neurobiology (W.-D.X.), Fudan University, the Key Laboratory of Hand Reconstruction, Ministry of Health (M.-X.Z., X.-Y.H., J.-T.F., T.L., Y.-C.L., Y.-D.S., J.-G.X., Y.-D.G., W.-D.X.), the Shanghai Key Laboratory of Peripheral Nerve and Microsurgery (M.-X.Z., X.-Y.H., J.-T.F., T.L., Y.-C.L., Y.-D.S., J.-G.X., Y.-D.G., W.-D.X.), the Department of Hand and Upper Extremity Surgery, Jing'an District Central Hospital (M.-X.Z., X.-Y.H., J.-T.F., T.L., Y.-C.L., Y.-D.S., W.-D.X.), and the Key Laboratory of Brain Functional Genomics (Ministry of Education) and Shanghai Key Laboratory of Brain Functional Genomics, East China Normal University (X.-H.C.) - all in Shanghai, China
| | - Jian-Guang Xu
- From the Department of Hand Surgery, Huashan Hospital (M.-X.Z., X.-Y.H., J.-T.F., T.L., Y.-C.L., Y.-D.S., J.-G.X., Y.-D.G., W.-D.X.), the National Clinical Research Center for Aging and Medicine (M.-X.Z., X.-Y.H., J.-T.F., T.L., Y.-C.L., Y.-D.S., J.-G.X., Y.-D.G., W.-D.X.), Department of Biostatistics, School of Public Health (N.-Q.Z., J.-Y.L.), and State Key Laboratory of Medical Neurobiology (W.-D.X.), Fudan University, the Key Laboratory of Hand Reconstruction, Ministry of Health (M.-X.Z., X.-Y.H., J.-T.F., T.L., Y.-C.L., Y.-D.S., J.-G.X., Y.-D.G., W.-D.X.), the Shanghai Key Laboratory of Peripheral Nerve and Microsurgery (M.-X.Z., X.-Y.H., J.-T.F., T.L., Y.-C.L., Y.-D.S., J.-G.X., Y.-D.G., W.-D.X.), the Department of Hand and Upper Extremity Surgery, Jing'an District Central Hospital (M.-X.Z., X.-Y.H., J.-T.F., T.L., Y.-C.L., Y.-D.S., W.-D.X.), and the Key Laboratory of Brain Functional Genomics (Ministry of Education) and Shanghai Key Laboratory of Brain Functional Genomics, East China Normal University (X.-H.C.) - all in Shanghai, China
| | - Yu-Dong Gu
- From the Department of Hand Surgery, Huashan Hospital (M.-X.Z., X.-Y.H., J.-T.F., T.L., Y.-C.L., Y.-D.S., J.-G.X., Y.-D.G., W.-D.X.), the National Clinical Research Center for Aging and Medicine (M.-X.Z., X.-Y.H., J.-T.F., T.L., Y.-C.L., Y.-D.S., J.-G.X., Y.-D.G., W.-D.X.), Department of Biostatistics, School of Public Health (N.-Q.Z., J.-Y.L.), and State Key Laboratory of Medical Neurobiology (W.-D.X.), Fudan University, the Key Laboratory of Hand Reconstruction, Ministry of Health (M.-X.Z., X.-Y.H., J.-T.F., T.L., Y.-C.L., Y.-D.S., J.-G.X., Y.-D.G., W.-D.X.), the Shanghai Key Laboratory of Peripheral Nerve and Microsurgery (M.-X.Z., X.-Y.H., J.-T.F., T.L., Y.-C.L., Y.-D.S., J.-G.X., Y.-D.G., W.-D.X.), the Department of Hand and Upper Extremity Surgery, Jing'an District Central Hospital (M.-X.Z., X.-Y.H., J.-T.F., T.L., Y.-C.L., Y.-D.S., W.-D.X.), and the Key Laboratory of Brain Functional Genomics (Ministry of Education) and Shanghai Key Laboratory of Brain Functional Genomics, East China Normal University (X.-H.C.) - all in Shanghai, China
| | - Wen-Dong Xu
- From the Department of Hand Surgery, Huashan Hospital (M.-X.Z., X.-Y.H., J.-T.F., T.L., Y.-C.L., Y.-D.S., J.-G.X., Y.-D.G., W.-D.X.), the National Clinical Research Center for Aging and Medicine (M.-X.Z., X.-Y.H., J.-T.F., T.L., Y.-C.L., Y.-D.S., J.-G.X., Y.-D.G., W.-D.X.), Department of Biostatistics, School of Public Health (N.-Q.Z., J.-Y.L.), and State Key Laboratory of Medical Neurobiology (W.-D.X.), Fudan University, the Key Laboratory of Hand Reconstruction, Ministry of Health (M.-X.Z., X.-Y.H., J.-T.F., T.L., Y.-C.L., Y.-D.S., J.-G.X., Y.-D.G., W.-D.X.), the Shanghai Key Laboratory of Peripheral Nerve and Microsurgery (M.-X.Z., X.-Y.H., J.-T.F., T.L., Y.-C.L., Y.-D.S., J.-G.X., Y.-D.G., W.-D.X.), the Department of Hand and Upper Extremity Surgery, Jing'an District Central Hospital (M.-X.Z., X.-Y.H., J.-T.F., T.L., Y.-C.L., Y.-D.S., W.-D.X.), and the Key Laboratory of Brain Functional Genomics (Ministry of Education) and Shanghai Key Laboratory of Brain Functional Genomics, East China Normal University (X.-H.C.) - all in Shanghai, China
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