Review of Upper Extremity Nerve Transfer in Cervical Spinal Cord Injury

Symptomatic Treatment of Myelopathy

OBJECTIVE

This article discusses the effects of myelopathy on multiple organ systems and reviews the treatment and management of some of these effects.

LATEST DEVELOPMENTS

Recent advances in functional electrical stimulation, epidural spinal cord stimulation, robotics, and surgical techniques such as nerve transfer show promise in improving function in patients with myelopathy. Ongoing research in stem cell therapy and neurotherapeutic drugs may provide further therapeutic avenues in the future.

ESSENTIAL POINTS

Treatment for symptoms of spinal cord injury should be targeted toward patient goals. If nerve transfer for upper extremity function is considered, the patient should be evaluated at around 6 months from injury to assess for lower motor neuron involvement and possible time limitations of surgery. A patient with injury at or above the T6 level is at risk for autonomic dysreflexia, a life-threatening condition that presents with elevated blood pressure and can lead to emergent hypertensive crisis. Baclofen withdrawal due to baclofen pump failure or programming errors may also be life-threatening. Proper management of symptoms may help avoid complications such as autonomic dysreflexia, renal failure, heterotopic ossification, and fractures.

Caregiving for People With Spinal Cord Injury Undergoing Upper Extremity Reconstructive Surgery: A Prospective Exploration of Lived Experiences, Perioperative Care, and Change Across Time

Background

Nerve transfer (NT) and tendon transfer (TT) surgeries can enhance upper extremity (UE) function and independence in individuals with cervical spinal cord injury (SCI). Caregivers are needed to make this surgery possible, yet caregivers experience their own set of challenges.

Objectives

This comparative study explored the perioperative and nonoperative experiences of caregivers of individuals with cervical SCI, focusing on daily life activities, burden, and mental health.

Methods

Caregivers of individuals with cervical SCI were recruited and grouped by treatment plan for the person with SCI: (1) no surgery (NS), (2) TT surgery, and (3) NT surgery. Semistructured interviews were conducted at baseline/preoperative, early follow-up/postoperative, and late follow-up/postoperative. Caregivers were asked about their daily life, mental health, and challenges related to caregiving. Interviews were audio recorded, transcribed verbatim, and analyzed using thematic analysis. Quantitative, single-item standardized burden score (0-100) data were collected at each timepoint.

Results

Participants included 23 caregivers (18 family members, 4 friends, 1 hired professional). The surgeries often brought hope and motivation for caregivers. Caregivers reported increased burden immediately following surgery (less for the NT compared to TT subgroup) yet no long-term changes in the amount and type of care they provided. NS caregivers discussed social isolation, relationship dysfunction, and everyday challenges.

Conclusion

Health care providers should consider the changing needs of SCI caregivers during perioperative rehabilitation. As part of the shared surgical decision-making approach, providers should educate caregivers about the postoperative process and the extent and potential variability of short- and long-term care needs.

Characterization of Spinal Cord Injury Patients for Arm Functional Restoration through Nerve Transfer

INTRODUCTION

Traumatic spinal cord injuries (tSCI) are common, often leaving patients irreparably debilitated. Therefore, novel strategies such as nerve transfers (NT) are needed for mitigating secondary SCI damage and improving function. Although different tSCI NT options exist, little is known about the epidemiological and injury-related aspects of this patient population. Here, we report such characteristics to better identify and understand the number and types of tSCI individuals who may benefit from NTs.

MATERIALS AND METHODS

Two peripheral nerve experts independently evaluated all adult tSCI individuals < 80 years old admitted with cervical tSCI (C1-T1) between 2005 and 2019 with documented tSCI severity using the ASIA Impairment Scale for suitability for NT (nerve donor with MRC strength ≥ 4/5 and recipient ≤ 2/5). Demographic, traumatic injury, and neurological injury variables were collected and analyzed.

RESULTS

A total of 709 tSCI individuals were identified with 224 (32%) who met the selection criteria for participation based on their tSCI level (C1-T1). Of these, 108 (15% of all tSCIs and 48% of all cervical tSCIs) were deemed to be appropriate NT candidates. Due to recovery, 6 NT candidates initially deem appropriate no longer qualified by their last follow-up. Conversely, 19 individuals not initially considered appropriate then become eligible by their last follow-up.

CONCLUSION

We found that a large proportion of individuals with cervical tSCI could potentially benefit from NTs. To our knowledge, this is the first study to detail the number of tSCI individuals that may qualify for NT from a large prospective database.

Spinal Cord Injury: Epidemiology, Spontaneous Recovery, and Hand Therapy for the Reconstructive Hand Surgeon

People with spinal cord injury (SCI) prioritize hand function above all else as a reconstructive goal, yet remain a markedly undertreated population by hand surgeons. This review article provides an overview of the epidemiology of SCI and the unmet clinical need of these patients. Further, this article outlines the natural history of SCI, including the expected spontaneous recovery over time and the expectations of hand function when treated with hand therapy alone. This review aims to equip reconstructive hand surgeons with a sound understanding of the basic principles of SCI and recovery and provide a rationale for when to intervene with surgery. In the last decade, this field has changed dramatically with the advent of reliable nerve transfers, making referral and surgical intervention time-sensitive. Therefore this review aims to highlight the expectations from hand therapy alone in this group, the urgent need for early referral to allow nerve transfer options to be viable, and the strategies for overcoming the barriers to these referrals. This offers the opportunity for surgeons to expand their tetraplegia practices while maximizing the considerable contributions to the hand function and quality of life of these patients.

A Mixed Methods Approach as a Channel to Interpret Outcomes Research and Lived Experience Enquiry of Upper Extremity Elective Surgery for Tetraplegia

Cervical spinal cord injury (SCI) causing tetraplegia is extremely disabling. In such circumstances, restoration of upper extremity (UE) function is considered the highest priority. The advent of early nerve transfer (NT) procedures, in addition to more traditional tendon transfers (TT), warranted in-depth consideration given the time-limited nature of NT procedures. Potential surgery candidates may not yet have come to terms with the permanence of their disability. A mixed methods convergent design was utilized for concurrent analysis of the Aotearoa/New Zealand upper limb registry data from the clinical assessments of all individuals considering UE surgery, regardless of their final decision. The International Classification of Functioning, Disability and Health (ICF) taxonomy guided data interpretation during the three-phased study series. It was the integration of the findings using the Stewart Model of care drawn from palliative health that enabled the interpretation of higher order messages. It is clear the clinical assessment and selection processes in use require reconsideration given the complexities individuals face following onset of SCI. We draw attention to the higher order cognitive demands placed on individuals, the requirement for SCI peer involvement in decision making and the need for acknowledgment of interdependence as a relational construct when living with tetraplegia.

Quantifying Donor Deficits Following Nerve Transfer Surgery in Tetraplegia

PURPOSE

Nerve transfer (NT) surgery can improve function in people with cervical spinal cord injury (SCI). However, the impact of donor nerve deficits remains unclear. The purpose of this study was to quantify donor deficits experienced by individuals with cervical SCI following NT.

METHODS

This prospective single-arm, comparative study included people with SCI undergoing upper extremity NTs. Myometry was used to assess muscle strength at baseline and follow-up. The Spinal Cord Independence Measure was used to measure the ability to perform activities of daily living.

RESULTS

Ten individuals underwent 20 NTs to restore elbow extension (donor, posterior deltoid; n = 2), hand opening (donor, supinator; n = 7), and hand closing (donor, brachialis; n = 11). Shoulder abduction strength decreased (-5.6% at early and -4.5% late follow-up) in the elbow extension NT. Wrist extension strength decreased at early (-46.9% ± 30.3) and increased by late (76.4% ± 154.0) follow-up in the hand opening NT. No statistically significant change in elbow flexion strength was noted in the hand closing NT. Spinal Cord Independence Measure scores did not change significantly between baseline and early postoperative follow-up; they improved at late follow-up.

CONCLUSIONS

Use of expendable donor nerves with redundant function to perform NT surgery has relatively little impact on strength or capacity to perform activities of daily living, even in the unique and highly vulnerable SCI population. Early, temporary loss in wrist extension strength can be seen after the supinator to posterior interosseous nerve transfer. This study offers quantitative data about possible diminution of donor function after NT, enabling hand surgeons to better counsel individuals contemplating upper extremity reconstruction.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic I.

Use and evaluation of assistive technologies for upper limb function in tetraplegia

CONTEXT

More than half of all spinal cord injuries (SCI) occur at the cervical level leading to loss of upper limb function, restricted activity and reduced independence. Several technologies have been developed to assist with upper limb functions in the SCI population.

OBJECTIVE

There is no clear clinical consensus on the effectiveness of the current assistive technologies for the cervical SCI population, hence this study reviews the literature in the years between 1999 and 2019.

METHODS

A systematic review was performed on the state-of-the-art assistive technology that supports and improves the function of impaired upper limbs in cervical SCI populations. Combinations of terms, covering assistive technology, SCI, and upper limb, were used in the search, which resulted in a total of 1770 articles. Data extractions were performed on the selected studies which involved summarizing details on the assistive technologies, characteristics of study participants, outcome measures, and improved upper limb functions when using the device.

RESULTS

A total of 24 articles were found and grouped into five categories, including neuroprostheses (invasive and non-invasive), orthotic devices, hybrid systems, robots, and arm supports. Only a few selected studies comprehensively reported characteristics of the participants. There was a wide range of outcome measures and all studies reported improvements in upper limb function with the devices.

CONCLUSIONS

This study highlighted that assistive technologies can improve functions of the upper limbs in SCI patients. It was challenging to draw generalizable conclusions because of factors, such as heterogeneity of recruited participants, a wide range of outcome measures, and the different technologies employed.

Spontaneous Motor Recovery after Cervical Spinal Cord Injury: Issues for Nerve Transfer Surgery Decision Making

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.

Pre-operative electrodiagnostic planning for upper limb peripheral nerve transfers in cervical spinal cord injury: A Narrative Review

Peripheral nerve transfer (PNT) to improve upper limb function following cervical spinal cord injury (SCI) involves the transfer of supralesional donor nerves under voluntary control to intralesional or sublesional lower motor neurons not under voluntary control. Appropriate selection of donor and recipient nerves and surgical timing impact functional outcomes. While the gold standard of nerve selection is intra-operative nerve stimulation, preoperative electrodiagnostic (EDX) evaluation may help guide surgical planning. Currently there is no standardized preoperative EDX protocol. This study reviews the EDX workup preceding peripheral nerve transfer surgery in cervical SCI, and proposes an informed EDX protocol to assist with surgical planning. The PICO (Population, Intervention, Comparison, Outcome) framework was used to formulate relevant MeSH terms and identify published cases of PNT in cervical SCI in Medline, Embase, CINAHL, and Emcare databases in the last 10 years. The electrodiagnostic techniques evaluating putative donor nerves, recipient nerve branches, time-sensitivity of nerve transfer and other electrophysiological parameters were summarized to guide creation of a preoperative EDX protocol. Needle electromyography (EMG) was the most commonly used EDX technique to identify healthy donor nerves. Although needle EMG has also been used on recipient nerves, compound muscle action potential (CMAP) amplitudes may provide a more accurate determination of recipient nerve health and time-sensitivity for nerve transfer. While there has been progress in pre-surgical EDX evaluation, EMG and NCS approaches are quite variable, and each has limitations in their utility for pre-operative planning. There is need for standardization in the EDX evaluation preceding peripheral nerve transfer surgery to assist with donor and recipient nerve selection, surgical timing and to optimize outcomes. Based on results of this review, herein we propose the PreSCIse (PRotocol for Electrodiagnosis in SCI Surgery of the upper Extremity) pre-operative EDX panel to achieve said goals through an interdisciplinary and patient-centered approach. This article is protected by copyright. All rights reserved.

Surgery to Restore Upper Extremity Function in Tetraplegia-Preferences for Early and Frequent Access to Information

INTRODUCTION

People with cervical spinal cord injury (SCI) identify improving upper extremity (UE) function as a top priority. In addition to comprehensive rehabilitation, UE surgeries, including nerve and tendon transfers, enhance function. However, barriers exist to disseminating information about surgical options to enhance UE function.

OBJECTIVE

To assess the experiences and preferences of people with cervical SCI and their caregivers in accessing information about surgery to enhance UE function.

DESIGN

Prospective cohort study. Participants were followed for 24 months and completed up to three interviews.

SETTING

Tertiary care at academic and affiliated Veterans Administration Health Care Centers.

PARTICIPANTS

Adults with cervical SCI (n=35) ages 18 to 80 years with mid-cervical SCI American Spinal Injury Association Impairment Scale A, B, or C (at least six months post-injury) and their caregivers (n=23) were eligible to participate. Participants were enrolled in three groups: nerve transfer, tendon transfer, or no UE reconstructive surgery.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Semi-structured interviews about surgical knowledge and experiences.

RESULTS

Data were analyzed and three themes were identified. First, providing information about UE surgical options early post-injury was recommended. The acute or inpatient rehabilitation phases of recovery were the preferred times to receive surgical information. Second, challenges with information dissemination were identified. Participants learned about UE surgery through independent research, medical provider interactions, or peers. Third, peers were identified as valuable resources for SCI needs and surgical information.

CONCLUSIONS

Following cervical SCI, information about UE reconstructive surgeries should be a standard component of education during rehabilitation. An increased understanding of the reconstructive options available to improve UE function is necessary to educate stakeholders. Future research is needed to support the development of strategies to effectively present surgical information to individuals with SCI and healthcare providers. This article is protected by copyright. All rights reserved.

Donor activation focused rehabilitation approach to hand closing nerve transfer surgery in individuals with cervical level spinal cord injury

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).

Restoring hand functions in people with tetraplegia through multi-contact, fascicular and auto-pilot stimulation: a proof-of-concept demonstration

Two multi-contact epineural electrodes were placed around radial and median nerves of 2 subjects with high tetraplegia C4, AIS A, group 0 of the International Classification for Surgery of the Hand in Tetraplegia. The purpose was to study the safety and capability of these electrodes to generate synergistic motor activation and functional movements and to test control interfaces that allow subjects to trigger pre-programmed stimulation sequences. The device consists of a pair of neural cuff electrodes and percutaneous cables with two extracorporeal connection cables inserted during a surgical procedure and maintained for 28 days. Continuity tests of the electrodes, selectivity of movements induced, motor capacities for grasping and gripping, conformity of the control order, tolerance and acceptability were assessed. Neither of the 2 participants showed general and local comorbidity. Acceptability was optimal. None of the stimulation configurations generated contradictory movements. The success rate in task execution by the electro-stimulated hand exceeded the target of 50% (54% and 51% for patient 1 and 2 respectively). The compliance rate of the control orders in both patients was > 90% using motion IMU-based detection and 100% using EMG-based detection in patient 1. These results support the relevance of neural stimulation of the tetraplegic upper limb with a more selective approach, using multi-contact epineural electrodes with 9 and 6 contact points for the median and radial nerve respectively.

Optimizing the timing of peripheral nerve transfers for functional re-animation in cervical spinal cord injury: a conceptual framework

Loss of upper extremity function following spinal cord injury (SCI) can have devastating consequences on quality of life. Peripheral nerve transfer surgery aims to restore motor control of upper extremities following cervical SCI and is poised to revolutionize surgical management in this population. The surgery involves dividing an expendable donor nerve above the level of the spinal lesion and coapting it to a recipient nerve arising from the lesional or infralesional segment of the injured cord. In order to maximize outcomes in this complex patient population, refinements in surgical technique need to be integrated with principles of spinal cord medicine and basic science. Deciding on the ideal timing of nerve transfer surgery is one aspect of care that is critical to maximizing recovery and has received very little attention to date in the literature. This complex topic is reviewed, with a focus on expectations for spontaneous recovery within upper motor neuron components of the injury, balanced against the need for expeditious reinnervation for lower motor neuron elements of the injury. The discussion also considers the case of a patient with C6 motor complete SCI where myotomes without electrodiagnostic evidence of denervation spontaneously improved by 6 months post-injury, thereby adjusting the surgical plan. The relevant concepts are integrated into a clinical algorithm with recommendations that consider maximal opportunity for spontaneous clinical improvement post-injury while avoiding excessive delays that may adversely affect patient outcomes.

The accuracy of needle electrode placement by trainees in selected forearm muscles using verification by neuromuscular ultrasound

INTRODUCTION

Anatomic landmarks alone may not always be sufficient to accurately guide electromyography (EMG) electrode needle placement.

METHODS

Senior residents and fellows (n = 11) targeted 4 forearm muscles with anatomic landmarks alone versus with audiovisual EMG feedback. Accuracy of EMG needle placement was verified using neuromuscular ultrasound imaging.

RESULTS

While relatively large and superficial FCR muscle was sampled at a rate of 100% with and without audiovisual EMG feedback, accuracy of deeper and/or smaller forearm muscles (FPL, EIP, and SUP) diminished significantly without audiovisual EMG feedback.

DISCUSSION

Our study suggests that in clinical scenarios in which an electrodiagnostician relies on anatomic landmarks alone to target small and deep muscles, the risk of misplacement of needle electrode is increased. Consideration for neuromuscular ultrasound to augment training and/or real time guidance in EMG practice may be appropriate.

Evaluation of Functional Independence in Cervical Spinal Cord Injury: Implications for Surgery to Restore Upper Limb Function

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.

Nerve transfers in tetraplegia: a review and practical guide

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.

Upper Limb Reconstruction in Tetraplegic Patients: A Primer for Spinal Cord Injury Specialists

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.

Hand Reconstruction in Children with Spinal Cord Injury

Comprehensive programs for children who sustain traumatic spinal cord injury should incorporate optimizing hand and upper extremity function along with the other traditional pillars of rehabilitation. Children's smaller anatomy, open growth plates, and future skeletal growth, combined with the age-related psychosocial impact of these injuries, require protocols suited to these age-related issues. There is a role for surgical reconstruction, as is the case for adults with traumatic tetraplegia, and surgical outcomes are equally beneficial and long lasting. Strict adherence to surgical indications, and surgical strategies and protocols that incorporate their age-related challenges, are the keys to successful management.

Nothing to lose: a phenomenological study of upper limb nerve transfer surgery for individuals with tetraplegia

Purpose: For individuals with tetraplegia, regaining upper limb function forms the highest priority for improving quality of life. Use of nerve transfers to reconstruct upper limb function is increasing, however little is known about individual's decision to have and experience of the surgery and associated rehabilitation outcomes. This qualitative study aimed to understand the experience of surgery on the lives of individuals with tetraplegia 18 months post-surgery.Method: In-depth, semi-structured interviews were conducted with five purposively selected individuals who have undergone upper limb nerve transfers at a metropolitan health service, Melbourne, Australia, specializing in spinal cord injury rehabilitation. Collaizi's phenomenological framework guided data analysis, resulting in an essence statement describing the individuals' experience.Results: An essence statement comprising three themes; Deciding on Surgery, Facing Challenges: Surgery to Recovery and Evaluating Surgical Outcomes, was developed.Conclusion: The study suggests that for individuals with tetraplegia, hope to regain lost upper limb function forms a core consideration in the decision to have surgery. For clinicians supporting patient's decision, balancing hope with the realities of surgery is important. Even small changes in upper limb function had an important influence on participant's confidence in social situations through enhanced participation in a range of everyday activities.IMPLICATIONS FOR REHABILITATIONIn making a decision to have surgery, individuals with tetraplegia benefit from two way discussions with the healthcare team and others who have already undergone surgery.Healthcare teams need to help prepare individuals for the challenges of surgery including: expectations of pain, hospital stay, initial loss of independence and the time it may take to see re-innervation of target muscles and subsequent functional changes.Surgery should be routinely considered as individuals' report that even small changes in upper limb function positively increases participation in everyday tasks and confidence in social situations.When evaluating changes in upper limb function, patient-centered measures should be used.

Reanimating hand function after spinal cord injury using nerve transfer surgery

Loss of arm and hand function is a devastating consequence of cervical spinal cord injury. Tendon transfer surgery has traditionally been used to restore key functions including elbow extension, wrist extension and grasp and pinch. The more recent development of nerve transfer surgery enables direct restoration of voluntary control of these functions. While both types of surgery are safe and effective, nerve transfer surgery results in a more open, flexible and natural hand, with more subtle control for a range of activities of daily living.

Evaluation for Late Nerve Transfer Surgery in Spinal Cord Injury: Predicting the Degree of Lower Motor Neuron Injury

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.

Practical Application of Recent Advances in Diagnostic, Prognostic, and Therapeutic Modalities for Spinal Cord Injury

OBJECTIVE

Spinal cord injury remains a highly morbid entity, with limited treatment modalities in both acute and chronic settings. Clinical research efforts to improve therapeutic guidelines are confounded by initial evaluation inaccuracies, as presentations are frequently complicated by trauma and objective diagnostic and prognostic methods are poorly defined. The purpose of our study was to review recent practical advances for further delineation of these injuries and how such classification may benefit the development of novel treatments.

METHODS

A review was carried out of recent studies reported within the last 5 years for prognostic and diagnostic modalities of acute spinal cord injury.

RESULTS

Substantial efforts have been made to improve the timeliness and accuracy of the initial assessment, not only for the purpose of enhancing prognostication but also in determining the efficacy of new treatments. Whether it be applying traumatic brain injury principles to limit injury extent, external stimulators used for chronic pain conditions to enhance the effects of physical therapy, or creative algorithms incorporating various nerve or muscle transfer techniques, innovative and practical solutions continue to be developed in lieu of definitive treatment. Further development will benefit from enhanced stratification of injury from accurate and practical assessment modalities.

CONCLUSIONS

Recent advances in accurate, timely, and practical classification methods of acute spinal cord injury will assist in the development of novel treatment approaches for both acute and chronic injury alike.

Evidence for efficacy of new developments in reconstructive upper limb surgery for tetraplegia

Nerve transfers are increasingly utilized for upper limb reconstruction in tetraplegia. We reviewed the literature for results achieved by nerve transfers for elbow extension, wrist control and finger and thumb flexion and extension. Muscle strength grading was the only outcome measure consistently reported. The results confirm that nerve transfers can effectively reanimate muscles in selected cases, with comparable strength with those achieved with tendon transfer for elbow extension but inferior strength for finger and thumb flexion. Transfer of supinator nerve branches to the posterior interosseous nerve appears to be reliable and offers increased span and better hand opening than is observed after tendon transfers. Only one publication demonstrated how reinnervation of muscles with nerve transfers translated into improved function, activity and participation for patients. More prospective studies, using standardized outcome measures, are needed to define the precise role of nerve transfers.

Nerve transfers in the upper extremity following cervical spinal cord injury. Part 1: Systematic review of the literature

OBJECTIVE

Patients with cervical spinal cord injury (SCI)/tetraplegia consistently rank restoring arm and hand function as their top functional priority to improve quality of life. Motor nerve transfers traditionally used to treat peripheral nerve injuries are increasingly being used to treat patients with cervical SCIs. In this study, the authors performed a systematic review summarizing the published literature on nerve transfers to restore upper-extremity function in tetraplegia.

METHODS

A systematic literature search was conducted using Ovid MEDLINE 1946-, Embase 1947-, Scopus 1960-, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and clinicaltrials.gov to identify relevant literature published through January 2019. The authors included studies that provided original patient-level data and extracted information on clinical characteristics, operative details, and strength outcomes after nerve transfer procedures. Critical review and synthesis of the articles were performed.

RESULTS

Twenty-two unique studies, reporting on 158 nerve transfers in 118 upper limbs of 92 patients (87 males, 94.6%) were included in the systematic review. The mean duration from SCI to nerve transfer surgery was 18.7 months (range 4 months-13 years) and mean postoperative follow-up duration was 19.5 months (range 1 month-4 years). The main goals of reinnervation were the restoration of thumb and finger flexion, elbow extension, and wrist and finger extension. Significant heterogeneity in transfer strategy and postoperative outcomes were noted among the reports. All but one case report demonstrated recovery of at least Medical Research Council grade 3/5 strength in recipient muscle groups; however, there was greater variation in the results of larger case series. The best, most consistent outcomes were demonstrated for restoration of wrist/finger extension and elbow extension.

CONCLUSIONS

Motor nerve transfers are a promising treatment option to restore upper-extremity function after SCI. Flexor reinnervation strategies show variable treatment effect sizes; however, extensor reinnervation may provide more consistent, meaningful recovery. Despite numerous published case reports describing good patient outcomes with nerve transfers, there remains a paucity in the literature regarding optimal timing and long-term clinical outcomes with these procedures.

Nerve transfers in the upper extremity following cervical spinal cord injury. Part 2: Preliminary results of a prospective clinical trial

OBJECTIVE

Patients with cervical spinal cord injury (SCI)/tetraplegia consistently rank restoring arm and hand function as their top functional priority to improve quality of life. Motor nerve transfers traditionally used to treat peripheral nerve injuries are increasingly used to treat patients with cervical SCIs. In this article, the authors present early results of a prospective clinical trial using nerve transfers to restore upper-extremity function in tetraplegia.

METHODS

Participants with American Spinal Injury Association (ASIA) grade A-C cervical SCI/tetraplegia were prospectively enrolled at a single institution, and nerve transfer(s) was performed to improve upper-extremity function. Functional recovery and strength outcomes were independently assessed and prospectively tracked.

RESULTS

Seventeen participants (94.1% males) with a median age of 28.4 years (range 18.2-76.3 years) who underwent nerve transfers at a median of 18.2 months (range 5.2-130.8 months) after injury were included in the analysis. Preoperative SCI levels ranged from C2 to C7, most commonly at C4 (35.3%). The median postoperative follow-up duration was 24.9 months (range 12.0-29.1 months). Patients who underwent transfers to median nerve motor branches and completed 18- and 24-month follow-ups achieved finger flexion strength Medical Research Council (MRC) grade ≥ 3/5 in 4 of 15 (26.7%) and 3 of 12 (25.0%) treated upper limbs, respectively. Similarly, patients achieved MRC grade ≥ 3/5 wrist flexion strength in 5 of 15 (33.3%) and 3 of 12 (25.0%) upper limbs. Among patients who underwent transfers to the posterior interosseous nerve (PIN) for wrist/finger extension, MRC grade ≥ 3/5 strength was demonstrated in 5 of 9 (55.6%) and 4 of 7 (57.1%) upper limbs 18 and 24 months postoperatively, respectively. Similarly, grade ≥ 3/5 strength was demonstrated in 5 of 9 (55.6%) and 4 of 7 (57.1%) cases for thumb extension. No meaningful donor site deficits were observed. Patients reported significant postoperative improvements from baseline on upper-extremity-specific self-reported outcome measures.

CONCLUSIONS

Motor nerve transfers are a promising treatment option to restore upper-extremity function after SCI. In the authors' experience, nerve transfers for the reinnervation of hand and finger flexors showed variable functional recovery; however, transfers for the reinnervation of arm, hand, and finger extensors showed a more consistent and meaningful return of strength and function.

Nerve transfer surgery in cervical spinal cord injury: a qualitative study exploring surgical and caregiver participant experiences

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.

Expanding traditional tendon-based techniques with nerve transfers for the restoration of upper limb function in tetraplegia: a prospective case series

BACKGROUND

Loss of upper extremity function after cervical spinal cord injury greatly affects independence, including social, vocational, and community engagement. Nerve transfer surgery offers an exciting new option for the reanimation of upper limb function in tetraplegia. The aim of this study was to evaluate the outcomes of nerve transfer surgery used for the reanimation of upper limb function in tetraplegia.

METHODS

In this prospective case series, we consecutively recruited people of any age with early (<18 months post-injury) cervical spinal cord injury of motor level C5 and below, who had been referred to a single centre for upper extremity reanimation and were deemed suitable for nerve transfer. All participants underwent single or multiple nerve transfers in one or both upper limbs, sometimes combined with tendon transfers, for restoration of elbow extension, grasp, pinch, and hand opening. Participants were assessed at 12 months and 24 months post-surgery. Primary outcome measures were the action research arm test (ARAT), grasp release test (GRT), and spinal cord independence measure (SCIM).

FINDINGS

Between April 14, 2014, and Nov 22, 2018, we recruited 16 participants (27 limbs) with traumatic spinal cord injury, among whom 59 nerve transfers were done. In ten participants (12 limbs), nerve transfers were combined with tendon transfers. 24-month follow-up data were unavailable for three patients (five limbs). At 24 months, significant improvements from baseline in median ARAT total score (34·0 [IQR 24·0-38·3] at 24 months vs 16·5 [12·0-22·0] at baseline, p<0·0001) and GRT total score (125·2 [65·1-154·4] vs 35·0 [21·0-52·3], p<0·0001) were observed. Mean total SCIM score and mobility in the room and toilet SCIM score improved by more than the minimal detectable change and the minimal clinically important difference, and the mean self-care SCIM score improved by more than the minimal detectable change between baseline and 24 months. Median Medical Research Council strength grades were 3 (IQR 2-3) for triceps and 4 (IQR 4-4) for digital extensor muscles after 24 months. Mean grasp strength at 24 months was 3·2 kg (SD 1·5) in participants who underwent distal nerve transfers (n=5), 2·8 kg (3·2) in those who had proximal nerve transfers (n=9), and 3·9 kg (2·4) in those who had tendon transfers (n=8). There were six adverse events related to the surgery, none of which had any ongoing functional consequences.

INTERPRETATION

Early nerve transfer surgery is a safe and effective addition to surgical techniques for upper limb reanimation in tetraplegia. Nerve transfers can lead to significant functional improvement and can be successfully combined with tendon transfers to maximise functional benefits.

FUNDING

Institute for Safety, Compensation, and Recovery Research (Australia).

Walking speed is not the best outcome to evaluate the effect of robotic assisted gait training in people with motor incomplete Spinal Cord Injury: A Systematic Review with meta-analysis

CONTEXT

While there are previous systematic reviews on the effectiveness of the use of robotic-assisted gait training (RAGT) in people with spinal cord injuries (SCI), as this is a dynamic field, new studies have been produced that are now incorporated on this systematic review (SR) with meta-analysis, updating the available evidence on this area.

OBJECTIVE

To synthesise the available evidence on the use of RAGT, to improve gait, strength and functioning.

METHODS

SR and meta-analysis following the Cochrane Handbook for Systematic Reviews of Interventions were implemented. Cochrane Injuries Group Specialized Register, PubMed, MEDLINE, EMBASE, CINAHL, ISIWeb of Science (SCIEXPANDED) databases were reviewed for the period 1990 to December 2016. Three researchers independently identified and categorized trials; 293 studies were identified, 273 eliminated; remaining 15 randomized clinical trials (RCT) and five SR. Six studies had available data for meta-analysis (222 participants).

RESULTS

The pooled mean demonstrated a beneficial effect of RAGT for WISCI, FIM-L and LEMS (3.01, 2.74 and 1.95 respectively), and no effect for speed.

CONCLUSIONS

The results show a positive effect in the use of RAGT. However, this should be taken carefully due to heterogeneity of the studies, small samples and identified limitations of some of the included trials. These results highlight the relevance of implementing a well-designed multicenter RCT powered enough to evaluate different RAGT approaches.

Management of Spinal Cord Injury-Induced Upper Extremity Spasticity

Spasticity affects more than 80% of patients with spinal cord injury. Neural mechanisms and musculotendinous alterations lead to typical upper extremity features including shoulder adduction/internal rotation, forearm pronation, and elbow, wrist, and finger flexion. Long-standing spasticity may lead to soft tissue and joint contractures and further impairment of upper extremity function. Surgical management involves tendon lengthening, release, and transfer, as well as selective neurotomy, in an effort to reduce spastic muscle hypertonicity, restore balance, prevent further contracture, and improve posture and function. This article summarizes surgical strategies to improve function of the upper extremity in patients with tetraplegia.

The Use of Nerve Transfers to Restore Upper Extremity Function in Cervical Spinal Cord Injury

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.

Nerve and Tendon Transfer Surgery in Cervical Spinal Cord Injury: Individualized Choices to Optimize Function

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.

Establishing reconstructive neurosurgery as a subspecialty

Neurosurgery is experiencing the emergence of a new subspecialty focused on function restoration. New, evolving, and reappraised surgical procedures have provided an opportunity to restore function to many patients with previously undertreated disorders. Candidates for reconstruction were previously limited to those with peripheral nerve and brachial plexus injuries, but this has been expanded to include stroke, spinal cord injury, and a host of other paralyzing disorders affecting both upper and lower motor neurons. Similar to the recent evolution of the well-established subdisciplines of spinal and vascular neurosurgery, reconstructive neurosurgery requires the adaptation of techniques and skills that were not traditionally a part of neurosurgical training. Neurosurgeons—as the specialists who already manage this patient population and possess the requisite surgical skills to master the required techniques—have a unique opportunity to lead the development of this field. The full development of this subspecialty will lay the foundation for the subsequent addition of emerging treatments, such as neuroprosthetics and stem cell–based interventions. As such, reconstructive neurosurgery represents an important aspect of neurosurgical training that can ameliorate many of the deficits encountered in the traditional practice of neurosurgery.

Morphology of Donor and Recipient Nerves Utilised in Nerve Transfers to Restore Upper Limb Function in Cervical Spinal Cord Injury

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.

Functional Priorities in Persons with Spinal Cord Injury: Using Discrete Choice Experiments To Determine Preferences

Major goals of rehabilitation and health interventions in people with spinal cord injury (SCI) are to improve functional independence, increase social participation, and enhance quality of life (QOL). Determining functional areas perceived by consumers as most important can assist in research prioritization, planning for delivery of health services, and policy development. Five high priority areas of functioning for the SCI population (arm/hand use, walking, bladder/bowel control, sexual function, and relief of pain) were chosen to determine the preferences for these five attributes. A discrete choice experiment was conducted involving 151 persons with SCI sampled from Australia and the United States of America. Consistent with prior research, arm/hand function had the highest preference, with odds ratios of subjects being 44-76% more likely to choose arm/hand function over the other four functions. Preference for normal arm/hand function was found to be significantly more preferred by the group with paraplegia compared with those with tetraplegia; that is, retaining and not trading off existing arm/hand function for other improved functions. There were no significant differences found in preferences between bladder/bowel function and walking or elimination of pain, although walking was preferred in earlier (≤ 10) post-injury years and pain amelioration became more important with a longer duration (>10 years) post-injury. Sexual function had the lowest preference when traded against the other four functions. Understanding the functional preferences of persons with SCI will help to inform future research design, as well as enabling successful translation of research into practice and health policy, meeting the needs of people with SCI.