Sleeve gastrectomy as a bridge to maternity in a patient with obesity, infertility and tetraplegia. A case report

Traumatic spinal cord injury (SCI) is a major cause of severe and permanent disability in young adults. Overweight and obesity are commonly observed among patients affected with SCI, with reports of a prevalence of over 60 and 30% respectively. Case report: A 34 year-old woman suffering from tetraplegia after sustaining a traumatic injury to C5-C6 at age 23 as a result of a motor vehicle accident was presented to our hospital's multidisciplinary bariatric team due to class II obesity. At the time of presentation to the team, eleven years after the accident, her BMI was calculated to be 39 Kg/m2 (weight 97 kg, height 1.57 meters). She was diagnosed with infertility while seeking pregnancy, and referred to our bariatric unit for weight loss. In addition, she had overcome the physical limitations of her injury, had a regular job and was engaged in regular physical activities such as swimming. In May 2017, she underwent laparoscopic sleeve gastrectomy (LSG) without complications and was discharged on postoperative day 2. 17 months following LSG, with a normal BMI, she became naturally pregnant. She had emergency cesarean at 35 weeks due to pneumonia but both patient and child recovered without sequelae. Currently, 4 years after surgery she maintains 37.11% total weight loss (weight 61 kg). She reports having a better quality of life with fewer medical intercurrencies. Conclusions: Patients with SCI and obesity, particularly women seeking to conceive, may be benefited by being referred to bariatric teams for assessment and treatment to improve results associated with sustained weight reduction.

[Surgical reconstruction of arm and hand functions in tetraplegia : Current concepts]

The reconstruction of arm and hand functions is of enormous importance for tetraplegic patients as it enables at least some degree of independence. Depending on the level of the spinal cord injury, certain residual functions are present in the arms which can be used for surgical reconstruction of upper extremity functions. By utilizing tendon and nerve transfers missing functions can at least be partially reconstructed. Tendon transfers are a proven technique with reliable results that can be performed at any time regardless of the type of accident. Due to the frequent presence of lower motor neuron damage, it is essential to consider the optimal time window for nerve transfer interventions. From the multitude of surgical options, an individual reconstruction plan must be created for each patient, which considers multiple factors. The combination of nerve transfers and later completing the functional reconstruction by tendon transfers is the preferred concept of the authors of this article.

The Surgical Restoration of Arm and Hand Function in Tetraplegic Patients

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.

Restoration of elbow extension and construction of a "key grip" in people with tetraplegia. Comparative study of a surgical plan in one or two stages

AIM

We report the comparative results of functional upper extremity surgery plans in patients with tetraplegia, including restoration of elbow extension and construction of a key grip in a "one-stage" or "two-stage" operation.

MATERIALS AND METHODS

A series of 36 patients with tetraplegia, with a total of 45 operated upper limbs, was analyzed retrospectively with a mean follow-up of 23 months (13-39 months). We evaluated the analytical strength of elbow extension using the MRC (Medical Research Council) score, the strength of the key grip (kg/F) as well as the autonomy of the patients using functional scores; Lamb (/100) and QIF (Quadriplegia Index of Function) (/100).

RESULTS

Sixteen upper limbs were included in the "one-stage" group and 29 in the "two-stage" group. The groups were comparable preoperatively. Elbow extension strength was 3.6/5 in the one-stage group versus 3.7/5, p=0.74. Grip strength was 1.8kg/F in the one-stage group versus 1.3kg/F, p=0.22. Regarding the functional scores, there was no statistically significant difference between the two groups for the Lamb score (p=0.46) and the QIF (p=0.42). There was no statistically significant difference in terms of the frequency of complications for the elbow (p=0.49) and for the hand (p=0.17). The total duration of the one-stage surgery plan averaged 7.5 months compared to 24.7 months for the two-stage plan, p<0.01. The mean follow-up for the one-stage group was 21 months versus 24 months for the two-stage group.

CONCLUSION

The results of both plans are similar and indicate that the "one-stage" plan is a reliable option. This all-in-one surgical option reduces postoperative follow-up and dropout rates for patients during the plan timeframe.

LEVEL OF EVIDENCE

IV; retrospective clinical series.

Grasp and Release Test for Tetraplegic Hand Assessment: an update of the Grasp and Release Test

The Grasp and Release Test (GRT) was originally developed to measure effectiveness of an implanted neuroprosthesis in people with tetraplegia. Its ease of use and lack of floor and ceiling effects culminated in recommendations for inclusion in a battery of tests to measure outcome following upper limb reconstructive surgery. However, the length of time taken to administer the GRT in a clinical setting, lack of instructions of accepted grasp patterns in the upper limb reconstructive surgery population and scoring procedures lead to differences in reporting outcomes using this measure. In order to ensure clinical utility for the upper limb reconstructive surgery population, revisions of the original test instructions have been made and are reported in this article. Further testing of the psychometric properties of the new measure are currently underway.

Predicting strength outcomes for upper limb nerve transfer surgery in tetraplegia

We report a retrospective study of 112 nerve transfers in 39 participants to investigate predictors of strength outcomes after nerve transfer surgery for upper limb reanimation in tetraplegia. We measured clinical and pre- and intraoperative neurophysiological assessment variables and compared them with strength outcomes 2 years after nerve transfer surgery. We found statistically significant improvement in Medical Research Council strength grades after nerve transfer surgery with lower cervical spine injuries (between one and two grades), lower donor nerve stimulation thresholds (half of a grade), greater motor evoked potential activity in recipient nerves (half of a grade) and greater muscle responses to intraoperative stimulation of donor (half of a grade) and recipient nerves (half of a grade).Level of evidence: III.

How did intraoperative neuromonitorization prevent tetraplegia?

Patients with mucopolysaccharidosis type IVA (MPS IVA) have many risk factors for myelopathy and paresis. These are spinal cord compression, bone stenosis, and soft tissue thickening with ligament laxity, deformity, odontoid hypoplasia, and atlantoaxial instability. Although most patients with MPS IVA appear generally healthy at birth, patients often show skeletal deformities within a few years. Surgical indications are difficult to determine. Historically, many physicians have used prophylactic decompression and fusion in young, asymptomatic MPS IVA patients to prevent cord compression. Although spinal cord decompression is usually required at the craniocervical junction in patients with MPS IVA, decompression may be required at other spinal cord levels as well. There is a risk of developing neurological damage during surgery. The most common causes are ischemia secondary to cardiac output deteriorated in the prone position or due to artery damage, and local trauma due to neck movements or traction while bringing the patient to the prone position. Neurophysiological monitoring is very important during surgery to reduce the risk of neurological damage in spinal cord surgery. In this case report, a case with loss of lower extremity neuromonitorization motor evoked potential (MEP) responses in the early period of surgery without any intervention to the craniocervical junction after prone positioning will be presented.

Upper Limb Nerve Transfer Surgery in Patients With Tetraplegia

IMPORTANCE

Cervical spinal cord injury (SCI) causes devastating loss of upper extremity function and independence. Nerve transfers are a promising approach to reanimate upper limbs; however, there remains a paucity of high-quality evidence supporting a clinical benefit for patients with tetraplegia.

OBJECTIVE

To evaluate the clinical utility of nerve transfers for reanimation of upper limb function in tetraplegia.

DESIGN, SETTING, AND PARTICIPANTS

In this prospective case series, adults with cervical SCI and upper extremity paralysis whose recovery plateaued were enrolled between September 1, 2015, and January 31, 2019. Data analysis was performed from August 2021 to February 2022.

INTERVENTIONS

Nerve transfers to reanimate upper extremity motor function with target reinnervation of elbow extension and hand grasp, pinch, and/or release.

MAIN OUTCOMES AND MEASURES

The primary outcome was motor strength measured by Medical Research Council (MRC) grades 0 to 5. Secondary outcomes included Sollerman Hand Function Test (SHFT); Michigan Hand Outcome Questionnaire (MHQ); Disabilities of Arm, Shoulder, and Hand (DASH); and 36-Item Short Form Health Survey (SF-36) physical component summary (PCS) and mental component summary (MCS) scores. Outcomes were assessed up to 48 months postoperatively.

RESULTS

Twenty-two patients with tetraplegia (median age, 36 years [range, 18-76 years]; 21 male [95%]) underwent 60 nerve transfers on 35 upper limbs at a median time of 21 months (range, 6-142 months) after SCI. At final follow-up, upper limb motor strength improved significantly: median MRC grades were 3 (IQR, 2.5-4; P = .01) for triceps, with 70% of upper limbs gaining an MRC grade of 3 or higher for elbow extension; 4 (IQR, 2-4; P < .001) for finger extensors, with 79% of hands gaining an MRC grade of 3 or higher for finger extension; and 2 (IQR, 1-3; P < .001) for finger flexors, with 52% of hands gaining an MRC grade of 3 or higher for finger flexion. The secondary outcomes of SHFT, MHQ, DASH, and SF36-PCS scores improved beyond the established minimal clinically important difference. Both early (<12 months) and delayed (≥12 months) nerve transfers after SCI achieved comparable motor outcomes. Continual improvement in motor strength was observed in the finger flexors and extensors across the entire duration of follow-up.

CONCLUSIONS AND RELEVANCE

In this prospective case series, nerve transfer surgery was associated with improvement of upper limb motor strength and functional independence in patients with tetraplegia. Nerve transfer is a promising intervention feasible in both subacute and chronic SCI.

[The combination of nerve and tendon transfers offers good possibilities for hand function in patients with cervical spinal cord injury]

Regaining upper extremity function is a prioritized matter for patients with tetraplegia after a cervical spinal cord injury (cSCI). The purpose of this article is to describe the current evidence and treatment strategies for upper extremity reconstruction after cSCI at the Centre for Advanced Reconstruction of Extremities, Sahlgrenska University Hospital, Sweden. The specialized unit works in a multidisciplinary setting to optimize the care of the patient population. Preoperative planning and an individualized treatment according to the needs and abilities of the patient are considered key points to achieve the best possible outcome. The addition of nerve transfers to the established method of tendon transfers for grip reconstruction has led to increased possibilities to achieve both functional hand opening and grip. Here we present our preferred method of upper extremity reconstruction, which involves a two-staged procedure where the tendon-based grip reconstruction is preceded by nerve transfer of the supinator to posterior intraosseous nerve whenever possible. Important clinical aspects as well as future perspectives are discussed.

[Skiing Accident with Temporary Tetraparesis]

Skiing Accident with Temporary Tetraparesis Abstract. Summary: We present the case of a 74-year-old patient who initially suffered transient tetraplegia after a skiing accident. On presentation to the general practitioner, pyramidal tract signs as well as disturbances of fine motor function in both hands could be observed. MRI examinations of the cervical spine revealed high-grade spinal stenosis at level C5 with myelon compression. Surgical decompression of the spial cord, followed by fusion of the corresponding cervical vertebral bodies, was performed. After surgery and three weeks of neurological rehabilitation, the patient feels well and has recovered except for still existing hypesthesia of the fingertips.

Quadriparesis Due to Delayed Tension Pneumoventricle

INTRODUCTION

Although pneumocephalus is very common after intracranial or spinal surgeries, pneumoventricle is uncommon. Tension pneumoventricle (tPV) occurs when air in the ventricles expands to cause neurological deficits or mass effect. It is usually seen with a combination of a ball-valve defect postoperatively that sucks in air and a ventriculoperitoneal shunt that drains cerebrospinal fluid and allows the ingress of air.

CASE REPORT

A young man developed delayed tPV after surgery for craniopharyngioma. He required multiple surgeries and occlusion of the ventriculoperitoneal shunt before the tPV resolved.

CONCLUSIONS

The probable mechanisms of tPV and the importance of early recognition and treatment are discussed. A review of the literature of this uncommon entity has also been performed.

Patterns of Upper Extremity Reconstruction for Patients With Tetraplegia Across the United States: A Retrospective Study

PURPOSE

The rates of upper extremity reconstruction for patients with tetraplegia remain low. We performed a retrospective study to assess recent reconstruction rates and delineate factors associated with the occurrence of reconstruction.

METHODS

We examined the National Inpatient Sample database (2012-2017) for the rate of reconstruction for patients with tetraplegia. The details of provider distribution characteristics and neighborhood attributes were obtained from the American Medical Association Physician Masterfile and based on the area deprivation index, respectively. We calculated the mean reconstruction rate per year and generated multivariable logistic regression models to examine the influence of patient factors, hospital characteristics, and provider distribution on the odds of undergoing functional reconstruction for tetraplegia patients.

RESULTS

Among 404,660 encounters with patients with tetraplegia, only 1,430 (0.4%) patients underwent upper extremity reconstruction from 2012 to 2017, with a mean rate of 238 procedures per year. We identified 5,450 hand surgeons, 12,751 physiatrists, and 444 spinal cord injury specialists, with variation in their national distribution. A greater number of surgeons near SCIS was associated with increased probability of reconstruction (odds ratio [OR] 1.07, 95% confidence interval [CI] 1.03-1.12). The odds of surgery were greater for patients receiving care at urban teaching (OR 5.00, 95% CI 3.35-7.47) or urban nonteaching (OR 1.71, 95% CI 1.11-2.63) hospitals, whereas those at private nonprofit (OR 0.67, 95% CI 0.58-0.78) or investor-owned (OR 0.65, 95% CI 0.52-0.82) hospitals had lower odds. Although most patients had insurance coverage, patients with a higher income or those who received subsidized care had greater odds of undergoing reconstruction.

CONCLUSIONS

Reconstruction rates remain low and are correlated with the environment of care, financial factors, and provider availability. Policies that focus on reducing these factors in addition to increasing interspecialty collaboration could improve access to surgery for patients with tetraplegia.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic I.

[Nerve transfer in patients with tetraplegia: improvement in hand function]

Reconstruction of arm and hand function in patients with a cervical spinal cord injury can improve their quality of life. Elbow extension, wrist extension, grip function and opening of the hand can be reconstructed. Traditionally, this has been done through tendon transpositions. Nerve transfer is a new technique. A functioning motor nerve branch is moved and connected to a muscle or muscle group damaged by the spinal cord injury. This technique has several advantages. Multiple functions can be restored by one nerve transfer, no long-term hand-rehabilitation is required and there is no risk of adhesions of the transposition. The most important disadvantage is the recovery time, as a results of the slow ingrowth of the nerve transfer, which takes at least 12 to 18 months. For each spinal cord injury patient, an individual action plan must be made, because not every patient has the same options and these are sometimes very limited.

Five years of follow-up of immediate quadriparesis caused by a large calcified mass in the ligamentum flavum: A case report

INTRODUCTION

Calcification of ligamentum flavum (CLF) is an important cause of spinal stenosis and spinal cord compression. CLF does not usually induce immediate quadriparesis. Here we describe a rare case of immediate quadriparesis due to a large calcified mass containing liquids in the ligamentum flavum, which was easily confused with gout crystals.

PATIENT CONCERNS

A 74-year-old Asian male felt progressive bilateral arm and leg weakness. On the fourth day, acute quadriparesis occurred.

DIAGNOSIS

Coronal and sagittal computerized tomography (CT) and magnetic resonance imaging (MRI) showed a large circular mass in the left posterior part of the cervical 3/4 spinal canal, protruding into the canal, and occupying one-half of the spinal canal.

INTERVENTIONS

Emergency laminectomy was performed at C3/4 level. The huge cyst was excised and 1 ml of white viscous liquid flowed out.

OUTCOMES

After operation, CT and MRI showed a full laminectomy of C3/4 and complete decompression of the cervical spinal cord. Hematoxylin-eosin (HE) staining showed that large amounts of calcium was deposited around cystic tissues. Five-year follow-up after laminectomy showed good recovery.

CONCLUSION

This case of immediate quadriparesis, caused by a large calcified mass containing fluid, is very rare. It should be at the earliest stage of calcification. Laminectomy is an effective treatment. This calcification was deceptive and was easily confused with gout crystals. It can help to understand the exact pathophysiology of CLF.

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).

The golden year: How functional recovery sets the stage for tendon transfer surgery among patients with tetraplegia-a qualitative analysis

BACKGROUND

Tendon transfer surgery can effectively improve hand function for patients with tetraplegia but remains poorly utilized. Little is known regarding how patients' rehabilitation experiences influence their perception of function, identity, and coping to shape their reconstructive context.

METHODS

We performed a cross-sectional qualitative analysis of 19 participants with C4-C7 cervical spinal injuries: 9 patients had undergone reconstruction; 10 had not. Semistructured interviews were conducted using an interview guide focusing on rehabilitation experience, the relationship between function and identity, and how patient experience evolved. Interview transcripts were analyzed using grounded theory.

RESULTS

The study sample was predominantly male (79%), white (89%), and American Spinal Injury Association grades A-D (grade A: 42%; grade B: 32%; grade C: 16%; grade D: 10%). Recognizing rehabilitation's necessity, functional gains, and constructive patient-therapist relationships promoted engagement in therapy. Poor insurance coverage and financial constraints decreased rehabilitation access. Function affected identity through the degree to which it tied participants to a "patient" role. Early in recovery, patients' function, roles, and attitudes were fluid but solidified over time; how satisfied patients were with these final positions influenced how they coped.

CONCLUSION

The balance of patients' positive and negative coping has been found to influence patients' progression to surgery. This study describes how function and identity contribute to coping. Participants' function and identity evolved during a finite period we call "the golden year," before reaching a fixed point around which they built their lives. The norms patients establish during this time may affect receptiveness to surgery.

Double Motor Nerve Transfer for All Finger Flexion in Cervical Spinal Cord Injury: An Anatomical Study and a Clinical Report

PURPOSE

To explore the feasibility of restoring all finger flexion after a cervical spinal cord injury.

METHODS

Double nerve transfer was conducted in 22 cadaver upper extremities. Donor nerves were the brachialis branch of the musculocutaneous nerve and the extensor carpi radialis brevis (ECRB) branches of the radial nerve. Recipient nerves were the anterior interosseous nerve (AIN) and the flexor digitorum profundus (FDP) branch of ulnar nerve (ulnar-FDP). Nerve transfers were evaluated on 3 parameters: surgical feasibility, donor-to-recipient axon count ratio, and distance from the coaptation site to the muscle entry of recipient nerve. A complete C6 spinal cord injury reconstruction was accomplished in a patient using a double nerve transfer of ECRB to ulnar-FDP and brachialis to AIN.

RESULTS

In the cadaver study, nerve transfers from ECRB to AIN, brachialis to AIN, and ECRB to ulnar-FDP were all feasible. The transfer from the brachialis to ulnar-FDP was not possible. Mean myelinated axon counts of AIN, brachialis, ulnar-FDP, and ECRB were 2,903 ± 1049, 1,497 ± 606, 753 ± 364, and 567 ± 175, respectively. The donor-to-recipient axon count ratios of ECRB to AIN, brachialis to AIN, and ECRB to ulnar-FDP were 0.24 ± 0.15, 0.55 ± 0.38, and 0.98 ± 0.60, respectively. The distance from coaptation of the ECRB to the ulnar-FDP muscle entry was shorter than for the other nerve transfers (54 ± 14.29 mm). At 18 months, there was restoration of flexion in all fingers and functional improvement from double nerve transfer of the brachialis to the AIN and the ECRB to the ulnar-FDP.

CONCLUSIONS

Restoration of all finger flexion may be feasible by the ECRB to ulnar-FDP and brachialis to AIN double nerve transfer.

CLINICAL RELEVANCE

Double nerve transfer can be used in C6-C7 spinal cord injury and patients with lower arm-type brachial plexus injury who have no finger flexion but have good brachialis and ECRB.

Restoration of the corticoreticular pathway following shunt operation for hydrocephalus in a stroke patient

RATIONALE

We report on a stroke patient who showed restoration of discontinued corticoreticular pathways (CRPs) on serial diffusion tensor tractography (DTT) concurrent with recovery of gait disturbance following shunt operation for hydrocephalus.

PATIENT CONCERNS

A 67-year-old female patient underwent stereotactic drainage for management of intraventricular hemorrhage due to a rupture of the left posterior communicating artery.

DIAGNOSES

After 4 weeks from onset, the patient exhibited quadriparesis with more severe weakness in the proximal muscles and could not even stand or walk. She underwent comprehensive rehabilitation for 3 weeks. Her quadriparesis, as a result of hydrocephalus, did not improve significantly.

INTERVENTIONS

On the pre-op DTT, discontinuations (the right CRP: at subcortical white matter level, and the left CRP: at the midbrain level) of the CRP fibers from the premotor cortex were observed in both hemispheres.

OUTCOMES

She underwent a ventriculo-peritoneal shunt operation and her quadriparesis improved, especially the proximal muscles. Consequently, she could walk with mild assistance on an even floor at 5 days and walk on stairs at 4 weeks after the shunt operation. On the post-op DTT, the discontinued CRP fibers were elongated to the premotor cortex in both hemispheres.

LESSONS

Restoration of discontinued CRPs concurrent with recovery of gait disturbance following shunt operation for hydrocephalus was demonstrated in a stroke patient.

Spinal cord injury without radiographic abnormality (SCIWORA) in adults: A report of two cases

Spinal cord injury without any radiographic abnormality (SCIWORA) is rare in adults. We describe here two case reports of adult patients, who presented to us with quadriplegia, following a road traffic accident. Plain radiography and computed tomography (CT) of cervical spine were normal. Hence the patients were diagnosed as cases of adult SCIWORA. However, subsequent magnetic resonance imaging (MRI) of the two patients revealed cervical cord injury in the form of cord contusion and disc protrusion, respectively. Patient with cord contusion was managed medically, whereas the patient with disc lesion was treated with discectomy. Patient treated with discectomy showed marked improvement. Therefore, patients having no osseous injury on X ray and CT scan should have an MRI study done to look for surgically correctable pathology. As in such rare patients of SCIOWRA an early diagnosis and timely intervention is crucial; with MRI playing a pivotal role.

Checkpoints to Progression: Qualitative Analysis of the Personal and Contextual Factors That Influence Selection of Upper Extremity Reconstruction Among Patients With Tetraplegia

PURPOSE

Patients with tetraplegia consistently rank better use of the upper extremity as their top functional priority. Multiple case series have demonstrated that upper extremity reconstruction (UER) is well-tolerated and can produce substantial functional improvements for appropriate candidates; however, UER remains critically underutilized. The mechanisms that drive differences in provider practice and referral patterns have been studied, but comprehensive examination of the patient factors that influence UER decisions has not been performed for American patients.

METHODS

Nineteen patients with C4-8 cervical spinal injuries were selected using purposive sampling: 9 patients had undergone UER, 10 had not undergone UER. Semistructured interviews were conducted and transcripts evaluated using grounded theory methodology.

RESULTS

Our study yielded a conceptual model that describes the characteristics common to all patients who undergo UER. Patients who selected reconstruction proceeded stepwise through a shared sequence of steps: (1) functional dissatisfaction, (2) awareness of UER, and (3) acceptance of surgery. Patients' ability to meet these criteria was determined by 3 checkpoints: how well they coped, their access to information, and the acceptability of surgery. Extremely positive or negative coping prevented patients from moving from the Coping to the Information Checkpoint; thus, they remained unaware of UER and did not undergo surgery. A lack of knowledge regarding reconstruction was the strongest barrier to surgery among our participants.

CONCLUSIONS

We built a conceptual model that outlines how patients' personal and contextual factors drive their progression to UER. Moving from functional dissatisfaction to understanding that they were candidates for UER was a substantial barrier for participants, particularly those with very high and very low coping skills.

CLINICAL RELEVANCE

To improve utilization for all patients, interventions are needed to increase UER awareness. Standardizing introduction to UER during the rehabilitation process or improving e-content may represent key awareness access points.

Decision-Making About Upper Limb Tendon Transfer Surgery by People With Tetraplegia for More Than 10 Years

OBJECTIVES

To quantify time from spinal cord injury to upper limb reconstructive surgery for individuals with tetraplegia; to explore influences on decision-making about surgery for persons with long-standing (>10y) tetraplegia; and to determine the applicability of our previously developed conceptual framework that described the decision-making processes for people with tetraplegia of <5 years.

DESIGN

Quantitative-qualitative mixed-methods study.

SETTING

Community based in New Zealand.

PARTICIPANTS

People (N=9) living with tetraplegia for >10 years.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

An audit of time frames between injury, assessment, and surgery for people with tetraplegia was undertaken. Interviews of people with tetraplegia were analyzed using constructivist grounded theory.

RESULTS

Sixty-two percent of people with tetraplegia assessed for surgery had upper limb reconstructive surgery. Most were assessed within the first 3 years of spinal cord injury. Over half had surgery within 4 years after injury; however, 20% waited >10 years. Changes in prioritized activities, and the identification of tasks possible with surgery, were influential in the decision-making process. Participants were aware of surgery, but required a reoffer from health professionals before proceeding. The influence of peers was prominent in reinforcing the improvement in prioritized activities possible after surgery.

CONCLUSIONS

Findings confirmed that the previously developed conceptual framework for decision-making about upper limb reconstructive surgery was applicable for people with tetraplegia of >10 years. Similarities were seen in the influence of goals and priorities (although the nature of these might change) and information from peers (although this influence was greater for those injured longer). Repeat offers for surgery were required to allow for changes in circumstances over time.

Restoration of reaching and grasping movements through brain-controlled muscle stimulation in a person with tetraplegia: a proof-of-concept demonstration

BACKGROUND

People with chronic tetraplegia, due to high-cervical spinal cord injury, can regain limb movements through coordinated electrical stimulation of peripheral muscles and nerves, known as functional electrical stimulation (FES). Users typically command FES systems through other preserved, but unrelated and limited in number, volitional movements (eg, facial muscle activity, head movements, shoulder shrugs). We report the findings of an individual with traumatic high-cervical spinal cord injury who coordinated reaching and grasping movements using his own paralysed arm and hand, reanimated through implanted FES, and commanded using his own cortical signals through an intracortical brain-computer interface (iBCI).

METHODS

We recruited a participant into the BrainGate2 clinical trial, an ongoing study that obtains safety information regarding an intracortical neural interface device, and investigates the feasibility of people with tetraplegia controlling assistive devices using their cortical signals. Surgical procedures were performed at University Hospitals Cleveland Medical Center (Cleveland, OH, USA). Study procedures and data analyses were performed at Case Western Reserve University (Cleveland, OH, USA) and the US Department of Veterans Affairs, Louis Stokes Cleveland Veterans Affairs Medical Center (Cleveland, OH, USA). The study participant was a 53-year-old man with a spinal cord injury (cervical level 4, American Spinal Injury Association Impairment Scale category A). He received two intracortical microelectrode arrays in the hand area of his motor cortex, and 4 months and 9 months later received a total of 36 implanted percutaneous electrodes in his right upper and lower arm to electrically stimulate his hand, elbow, and shoulder muscles. The participant used a motorised mobile arm support for gravitational assistance and to provide humeral abduction and adduction under cortical control. We assessed the participant's ability to cortically command his paralysed arm to perform simple single-joint arm and hand movements and functionally meaningful multi-joint movements. We compared iBCI control of his paralysed arm with that of a virtual three-dimensional arm. This study is registered with ClinicalTrials.gov, number NCT00912041.

FINDINGS

The intracortical implant occurred on Dec 1, 2014, and we are continuing to study the participant. The last session included in this report was Nov 7, 2016. The point-to-point target acquisition sessions began on Oct 8, 2015 (311 days after implant). The participant successfully cortically commanded single-joint and coordinated multi-joint arm movements for point-to-point target acquisitions (80-100% accuracy), using first a virtual arm and second his own arm animated by FES. Using his paralysed arm, the participant volitionally performed self-paced reaches to drink a mug of coffee (successfully completing 11 of 12 attempts within a single session 463 days after implant) and feed himself (717 days after implant).

INTERPRETATION

To our knowledge, this is the first report of a combined implanted FES+iBCI neuroprosthesis for restoring both reaching and grasping movements to people with chronic tetraplegia due to spinal cord injury, and represents a major advance, with a clear translational path, for clinically viable neuroprostheses for restoration of reaching and grasping after paralysis.

FUNDING

National Institutes of Health, Department of Veterans Affairs.

Voluntary activation of biceps-to-triceps and deltoid-to-triceps transfers in quadriplegia

The biceps or the posterior deltoid can be transferred to improve elbow extension function for many individuals with C5 or C6 quadriplegia. Maximum strength after elbow reconstruction is variable; the patient’s ability to voluntarily activate the transferred muscle to extend the elbow may contribute to the variability. We compared voluntary activation during maximum isometric elbow extension following biceps transfer (n = 5) and deltoid transfer (n = 6) in three functional postures. Voluntary activation was computed as the elbow extension moment generated during maximum voluntary effort divided by the moment generated with full activation, which was estimated via electrical stimulation. Voluntary activation was on average 96% after biceps transfer and not affected by posture. Individuals with deltoid transfer demonstrated deficits in voluntary activation, which differed by posture (80% in horizontal plane, 69% in overhead reach, and 70% in weight-relief), suggesting inadequate motor re-education after deltoid transfer. Overall, individuals with a biceps transfer better activated their transferred muscle than those with a deltoid transfer. This difference in neural control augmented the greater force-generating capacity of the biceps leading to increased elbow extension strength after biceps transfer (average 9.37 N-m across postures) relative to deltoid transfer (average 2.76 N-m across postures) in our study cohort.

Eight years of follow-up after laminectomy of calcium pyrophosphate crystal deposition in the cervical yellow ligament of patient with Coffin-Lowry syndrome: A case report

BACKGROUND

We report 8 years of follow-up after decompression to treat cervical myelopathy in a patient with Coffin-Lowry syndrome (CLS). CLS is a rare X-linked semidominant syndrome associated with growth and psychomotor retardation, general hypotonia, and skeletal abnormalities. In this patient, the spinal cord was compressed by calcium pyrophosphate crystal deposition in the cervical yellow ligament (YL). To date, only 1 report has described clinical features after surgery for calcified cervical YL in CLS.

METHODS

A 15-year-old male with tetraplegia secondary to compression of the cervical spinal cord induced by a hypoplastic posterior arch of C1 and calcification of the YL from C2 to C7 was treated surgically with laminectomy from C1 to C7. The patient's history, clinical examination, imaging findings, and treatment are reported. The patient was incapable of speech because of mental retardation, so he could not describe his symptoms. Gait disturbance worsened over the 2 months before admission to our hospital. At admission, the patient could not move his extremities, and tendon reflexes of the upper and lower extremities were significantly increased. Computed tomography of the cervical spine showed YL calcification from C2 to C7. Magnetic resonance imaging showed consecutive compression of the cervical spinal cord. We diagnosed quadriplegia secondary to cervical cord damage and performed emergency surgery.

RESULTS

During C1-C7 laminectomy, YL calcification in C2-C7 was observed. The calcification was confirmed as calcium pyrophosphate by crystal analysis. Quadriplegia gradually resolved, and almost disappeared by 2 weeks after the operation. Cervical hyperlordosis was observed in radiographs starting from 1 month after the operation, but it has not progressed and is not associated with any symptoms.

CONCLUSIONS

The efficacy of decompression continued, and no postoperative complications have occurred during at least 8 years of follow-up.

Tetraplegia after thyroidectomy in a patient with cervical spondylosis: a case report and literature review

Cervical spondylosis is degeneration of the cervical spine that occurs during the normal course of aging, and may progress into compression of the spinal cord, or cervical spondylotic myelopathy (CSM), which can cause neurologic dysfunction. Cervical spondylosis can be identified in the majority of people older than 50 years. Many people with cervical spondylosis or CSM are asymptomatic. However, patients with CSM are at higher risk of spinal cord injury (SCI) following minor injury.A 60-year-old woman with asymptomatic cervical spondylosis underwent an elective subtotal thyroidectomy for thyroid nodules. After the surgery, she developed tetraplegia. MRI revealed spinal cord compression and injury. Main diagnoses, therapeutics interventions, and outcomes: Acute cervical SCI was diagnosed. After an emergency anterior cervical corpectomy and fusion surgery, she almost completely recovered.Iatrogenic cervical SCI after nonspinal surgeries that requires neck hyperextension is rarely reported, probably due to underdiagnosis and underreport. Among the 14 cases (including ours) published in the literature, most patients had cervical spondylosis and were senior men. Five patients had diabetes. Four patients had long-term hemodialysis. Seven patients had undergone coronary artery bypass surgery that requires prolonged operative time. Only 3 patients had almost complete recovery. Most patients were disabled. Two patients required tracheostomy for long-term ventilator support. Two patients died. These cases reiterate the potential risk of iatrogenic SCI in people with predisposing conditions such as cervical spondylosis, especially considering the rising prevalence and severity of cervical spondylosis caused by the aging of the population and modern sedentary lifestyle. Surgeries requiring prolonged neck hyperextension put patients with cervical spondylosis at risk for SCI. Failure to recognize the potential occurrence of iatrogenic SCI might endanger patients' lives.

[An almost fatal airway obstruction caused by a secretion plug in an endotracheal tube]

Airway obstruction caused by a secretion plug in an endotracheal tube or a tracheostomy cannula can be a serious complication to mechanical ventilation. This case describes an event caused by a mucus plug localized to the distal part of a tracheostomy tube in a tetraplegic patient. The plug functioned as a check valve, allowing air to pass in - but not out - of the patient. A suction catheter could be passed through the airway without any resistance, and thus the airway was believed to be free. The event, which had an almost fatal outcome due to hyperinflation of the lungs, was relieved by replacement of the tracheostomy cannula.

The extensor pollicis longus-loop-knot (ELK) procedure for dynamic balance of the paralyzed thumb interphalangeal joint

Hyperflexion of the thumb interphalangeal (IP) joint interferes significantly with pinching between the thumb and the index finger in a paralyzed hand. The extensor pollicis longus-loop-knot (ELK) procedure was used successfully in 7 tetraplegic patients to balance the IP joint between strong restored flexor function and lacking or weak antagonism of the thumb extensors. A V-shaped incision was made over the extensor hood at the level of the IP joint, the extensor pollicis longus (EPL) tendon was elevated, a loop was formed, secured by sutures, and then turned proximally onto the EPL tendon itself and fixed on both sides. The operation reliably limited the maximum range of IP flexion at 20 to 30 degrees from neutral. Postoperative problems did not occur. The ELK procedure is easy and quick and secures the optimal setting of IP flexion with limited flexibility, which is advantageous compared with rigid bony arthrodesis. It also avoids certain disadvantages of the commonly used flexor pollicis longus split tenodesis and is therefore a valuable alternative for the correction of Froment's sign due to intrinsic or extrinsic paralysis of the thumb.

Wrist fusion in patients with severe quadriplegic cerebral palsy

We report clinical and radiographic outcomes of wrist fusion achieved with pin or plate fixation in 14 patients with severe quadriplegic cerebral palsy (CP) (19 wrists). Average patient age at the time of surgery was 16.8 ± 1.7 years (14-20 years). Mean follow-up time for the 14 patients was 5.9 ± 3.1 years (range, 1-11 years). Indication for surgery was severe wrist deformity that interfered with hygienic care. Few complications occurred, and outcomes were satisfactory. Statistically significant mean difference was shown between the pre- and postoperative radiographic angles (37°, P = 0.001, and 24°, P = 0.04, for lateral and anteroposterior views, respectively). Caregivers reported that appearance was the most perceived rationale for surgery (63 %). Improved hygienic care was the primary perceived benefit. The majority (88 %) were satisfied with the results. We recommend wrist fusion to improve hygienic care, positioning, and appearance of the wrist, hand, and fingers in patients with severe quadriplegic CP.

[Surgery of the upper limbs can improve functional ability of a tetraplegic patient]

A tetraplegic patient loses most of the muscle function and sensation, although some recovery often takes place after the acute stage. Better functioning of the upper limbs has proved to be the greatest desire of these patients. Procedures restoring and improving upper limb functions have developed over the past decades. New surgical techniques and procedural combinations enable reconstructions allowing significant improvement of functional capacity and independence in daily life. The surgical operation is planned on the basis of the patient's remaining muscles with function and strength. Needs of the patient for upper limb function are considered individually.

A single-stage operation for reconstruction of hand flexion, extension, and intrinsic function in tetraplegia: the alphabet procedure

Surgical reconstruction is an established method to restore grip and grasp function after traumatic cervical spinal cord injury and tetraplegia. It can offer the patient improved ability to perform activities of daily living. Traditionally, surgical reconstruction of hand function has required separate operations for flexors and extensors. Here, we present a combination of procedures that provides key pinch and finger flexion together with opening of hand as a 1-stage operation. This reconstruction includes 7 individual operations that are performed in the following order: (1) split flexor pollicis longus-extensor pollicis longus distal thumb tenodesis, (2) reconstruction of passive interossei, (3) thumb CMC arthrodesis (4) brachioradialis-flexor pollicis longus tendon transfer, (5) extensor carpi radialis longus-flexor digitorum profundus tendon transfer, (6) EPL tenodesis, and (7) extensor carpi ulnaris tenodesis. We have chosen to entitle this reconstruction the alphabet or ABCDEFG procedure, an abbreviation for Advanced Balanced Combined Digital Extensor Flexor Grip reconstruction. To reduce the risk of adhesions after this extensive surgery and to facilitate relearning the activation of transferred muscles with new functions, early active training is performed. It is concluded that this 1-stage combination of operations can reliably provide grip, grasp, and release function in persons with C6 tetraplegia, patient satisfaction is high, time and effort for patient and caregivers are less, and incidence of complications is comparable with other published treatment modalities.

Surgical technique: posterior deltoid-to-triceps transfer in tetraplegic patients

Several surgical techniques exist for restoring triceps function in tetraplegic patients. The goal is to establish a more synchronized, better controlled arm that allows increased self-sufficiency and further reconstructive surgery on the hand. To obtain the most secure fixation, adjust the tension, and allow early mobilization, the technique we prefer uses the central tendon of the triceps muscle and bony block fixation reinforced by the palmaris longus.

A simulation analysis of the combined effects of muscle strength and surgical tensioning on lateral pinch force following brachioradialis to flexor pollicis longus transfer

Biomechanical simulations of tendon transfers performed following tetraplegia suggest that surgical tensioning influences clinical outcomes. However, previous studies have focused on the biomechanical properties of only the transferred muscle. We developed simulations of the tetraplegic upper limb following transfer of the brachioradialis (BR) to the flexor pollicis longus (FPL) to examine the influence of residual upper limb strength on predictions of post-operative transferred muscle function. Our simulations included the transfer, ECRB, ECRL, the three heads of the triceps, brachialis, and both heads of the biceps. Simulations were integrated with experimental data, including EMG and joint posture data collected from five individuals with tetraplegia and BR-FPL tendon transfers during maximal lateral pinch force exertions. Given a measured co-activation pattern for the non-paralyzed muscles in the tetraplegic upper limb, we computed the highest activation for the transferred BR for which neither the elbow nor the wrist flexor moment was larger than the respective joint extensor moment. In this context, the effects of surgical tensioning were evaluated by comparing the resulting pinch force produced at different muscle strength levels, including patient-specific scaling. Our simulations suggest that extensor muscle weakness in the tetraplegic limb limits the potential to augment total pinch force through surgical tensioning. Incorporating patient-specific muscle volume, EMG activity, joint posture, and strength measurements generated simulation results that were comparable to experimental results. Our study suggests that scaling models to the population of interest facilitates accurate simulation of post-operative outcomes, and carries utility for guiding and developing rehabilitation training protocols.

[Posterior selective rhizotomy in the treatment of severe spastic syndrome in cerebral palsy]

BACKGROUND

Aim of this study was to optimize surgical technique of posterior selective rhizotomy for prevention of possible complications.

MATERIALS AND METHODS

11 patients (age 3-30 years) with severe spastic tetraparesis due to cerebral palsy were operated. Muscle tone in lower limbs reached 4-5 points (Ashworth scale). In all cases posterior selective rhizotomy of L1-S1 spinal roots was performed using laminoplasty and intraoperative electromyographic monitoring. Results were assessed in early postoperative period and during follow-up.

RESULTS

In all cases in the early postoperative period we observed decrease of muscle tone to 1-2 points and increase of volume of passive movements. In the follow-up period 4 patients developed improvement of locomotor status, in 6 no changes were observed. In 1 case spastic syndrome recurred. We had no complications due to orthopaedic deformities of spinal column, sensory and pelvic disorders, muscular hypotonia.

CONCLUSION

Posterior selective rhizotomy may be the method of choice in treatment of patients with severe spastic forms of cerebral palsy. Application of optimized surgical technique (laminoplasty, intraoperative stimulation electromyography) allows to decrease the risk of possible complications.

[Restoration of upper-limb function in patients with cervical spinal cord lesion]

PURPOSE OF THE STUDY

Injury to the spinal chord at the C5 level results in a severe handicap to the patient because of a loss of active motion of the wrist and hand. Selected surgical procedures can effectively restore active extension of the wrist and provide conditions for some vital pinching and gripping abilities. The deltoid muscle also has a potential for restoration of upper limb function, because its posterior portion can be used to restore elbow extension. The aim of this clinical retrospective study was to describe and evaluate the techniques used to improve the quality of life in patients with spinal chord lesions at the C5 level.

MATERIAL AND METHODS

The group studied consisted of 15 patients (3 women and 12 men; average age, 34 years) with a spinal chord lesion at the C5 segment who had zero wrist extension or in whom wrist extensor muscle force was equal to the third degree of muscle strength or less. The procedures to restore active extension of the wrist involved the radiobrachialis muscle, the reconstruction of elbow extension was activated by the posterior portion of the deltoid muscle, and a fixed supination posture of the forearm was corrected by elongating the distal tendon of the biceps muscle which was derotated and attached to the proximal radius. The interval between injury and reconstructive surgery was 36 months on the average.

RESULTS

The reconstructive surgery described resulted in restoration of hand and wrist function with sufficient muscle strength in all patients, which had a favourable effect on many aspects of their daily lives. The average values of muscle strength were 4.1° (3° to 5°). for wrist extension and 3.3° (2° to 4°) for elbow extension. Key-pinch force was on average 1.2 kg (0.2 to 2.1). A failure of thumb carpometacarpal arthrodesis was the most frequent complication and occurred in two patients. On clinical evaluation, all patients reported satisfaction with the restored function of their upper extremities and expressed their willingness to undergo the same procedure again.

DISCUSSION

Reconstructive surgery of the upper extremity in tetraplegic patients has been performed with success in several countries, namely USA and Sweden, for many years. Since 2003 the results in the Czech Republic have also shown positive effects of reconstructive procedures on better quality of life in patients with cervical spinal chord injury at the lower levels, in whom the goal is to restore vital pinching and gripping abilities. A good outcome of surgical treatment requires good quality post-operative care provided by a team of physical therapists fully informed of the reconstructive procedures involved.

CONCLUSIONS

A restored function of the upper extremity in the patients with spinal chord injury at the C level plays a decisive role in the whole spectrum of the patient's daily activities, such as dressing, communication, etc., and thus improves their self- care. The restoration of active elbow extension has a positive effect on the patient's mobility.

[C1-C2 transarticular screw fixation of atlanto-axial instability with tetraparesis in rheumatoid patient--case report]

A case of a 50-year-old patient with C1-C2 subluxation and concomitant neurological deficits in the course of rheumatoid arthritis has been described. In the article the diagnostic and therapeutic procedures, consisting mainly of surgical treatment, have been presented. Indications for the surgery were: a rapid disease progression observed during the last six months, and tetraparesis. The authors propose the choice of applied surgical technique by taking into account difficulties consequential to the anatomy of this region, as well as additional complications regarding the chronic inflammation process. The use of transarticular screw fixation method, together with concurrent spinal cord decompression allowed the stabilization of C1-C2 subluxation and improvement of the neurological state of the patient.

Autologous bone marrow derived mononuclear cell therapy for spinal cord injury: A phase I/II clinical safety and primary efficacy data

OBJECTIVE

We sought to assess the safety and therapeutic efficacy of autologous human bone marrow derived mononuclear cell transplantation on spinal cord injury in a phase I/II, nonrandomized, open-label study, conducted on 297 patients.

MATERIALS AND METHODS

We transplanted unmanipulated bone marrow mononuclear cells through a lumbar puncture, and assessed the outcome using standard neurologic investigations and American Spinal Injury Association (ASIA) protocol, and with respect to safety, therapeutic time window, CD34-/+ cell count, and influence on sex and age.

RESULTS

No serious complications or adverse events were reported, except for minor reversible complaints. Sensory and motor improvements occurred in 32.6% of patients, and the time elapsed between the injury and the treatment considerably influenced the outcome of the therapy. The CD34-/+ cell count determined the state of improvement, or no improvement, but not the degree of improvement. No correlation was found between level of injury and improvement, and age and sex had no role in the outcome of the cellular therapy.

CONCLUSION

Transplant of autologous human bone marrow derived mononuclear cells through a lumbar puncture is safe, and one-third of spinal cord injury patients show perceptible improvements in the neurologic status. The time elapsed between injury and therapy and the number of CD34-/+ cells injected influenced the outcome of the therapy.

Pinch and elbow extension restoration in people with tetraplegia: a systematic review of the literature

PURPOSE

We conducted a systematic review of the literature to summarize the available data on reconstructive surgeries involving pinch reconstruction and elbow extension restoration in people with tetraplegia.

METHODS

English-language and French-language articles and abstracts published between 1966 and February 2007, identified through MEDLINE and EMBASE searches, bibliography review, and expert consultation, were reviewed for original reports of outcomes with pinch reconstruction and elbow extension restoration in tetraplegic patients after a spinal cord injury. Two reviewers independently extracted data on patient characteristics, surgical methods, and patient outcomes.

RESULTS

Our search identified 765 articles, of which 37 met eligibility criteria (one article contained information on both elbow and pinch procedures). Results from 377 pinch reconstructions in 23 studies and 201 elbow extension restorations in 14 studies were summarized. The mean Medical Research Council score for elbow extension went from 0 to 3.3 after reconstruction. The overall mean postoperative strength measured after surgery for pinch reconstruction was 2 kg.

CONCLUSIONS

More than 500 patients having these procedures experienced a clinically important improvement for both procedures-one restoring elbow extension, and the other, pinch strength. Upper-limb surgeries markedly improved the hand function of people with tetraplegia.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

A multicriteria decision analysis of augmentative treatment of upper limbs in persons with tetraplegia

This study supported the evaluation by a rehabilitation team of the performance of two treatment options that improve the arm-hand function in subjects with sixth cervical vertebra (C6) level Motor Group 2 tetraplegia. The analytic hierarchy process, a technique for multicriteria decision analysis, was used by a rehabilitation team and potential recipients to quantitatively compare a new technology, Functional Elec trical Stimulation (FES), with conventional surgery. Perform-ance was measured by functional improvement, treatment load, risks, user-friendliness, and social outcomes. Functional improvement after FES was considered better than that after conventional surgery. However, the rehabilitation team's overall rating for conventional surgery was slightly higher than that for FES (57% vs 44%). Compared with the rehabilitation team, potential recipients gave greater weight to burden of treatment and less weight to functional improvement. This study shows that evaluation of new technology must be more comprehensive than the evaluation of functional improvement alone, and that patient preferences may differ from those of the rehabilitation team.

Demyelinating plaque imitates an intramedullary tumour

An isolated spinal demyelinating lesion is very rare and almost always associated with multiple sclerosis. There are only a few reports of biopsy or resection of MS-associated lesions. Sometimes the radiological and the histopathological findings can lead to a false diagnosis of a tumour. A 15-year-old girl presented with a progressive spastic tetraparesis and various associated clinical symptoms. Magnetic resonance imaging (MRI) suggested a possible intramedullary tumour extending from C4 to C7 and the need for surgical intervention. There was no previous neurological or other history and the brain MRI was normal. The performing surgeons based their procedures on oncological criteria. The extracted lesion was finally diagnosed as a demyelinating plaque. The postoperative course was uneventful without deterioration of the neurological status and the young patient improved completely after 4-months of rehabilitation. After an 8-year follow-up, the patient remains in remission and free of neurological defects. Apart from the radiological findings, the CSF exam as well as the evoked potentials does not suggest a diagnosis of MS. A demyelinating plaque in the cervical spinal cord can occasionally imitate a cervical intramedullary tumour leading to an operation. Such lesions underscore the sensitivity of present-day lesion detection procedures. An addition of a MS work up could be beneficial in some cases of intramedullary tumours without a typical history, although in the case presented this type of workup was negative.

Ersatzoperationen bei Ausfall motorischer Funktionen an der Hand

Nerve injuries in the upper extremity can result in severe disability. In the last three decades, progress in microsurgical techniques has improved the outcome for nerve injuries and if the prognosis is reasonably good, nerve repair should usually be performed prior to tendon transfer procedures. However, above all proximal lesions of peripheral nerves such as high radial nerve palsy still often yield unsatisfactory results, despite a technically well-executed nerve repair. Prognosis further depends on the time interval since the injury and also on the age of the patient, as the regenerative process is delayed in older patients. The indication for tendon transfers strongly depends on the personal and professional profiles of the individual patient. Tendon transfer procedures alleviate the suffering from functional hand impairment providing a superior alternative to permanent external splints. Tendon transfers are usually secondary procedures for replacing function after evaluation of the functional motor loss. Numerous transfer procedures have been described for every nerve trunk of the upper extremity, their prognosis depending mainly on the extent and pattern of nerve loss, local effects of the trauma (e.g. involvement of soft tissues, joints), and the physiological characteristics of the transferred muscle. Even if the results of the tendon transfers may finally be less satisfactory in cases of complex nerve damage than in isolated motor nerve lesions, they offer a valuable functional benefit, often being the only possibility to restore hand function. Although regrettably underused, tendon transfer improve upper extremity function in more than 70% of patients with cervical spinal cord injury. Reconstruction of key elements such as wrist extension, key grip between the thumb and the index finger, or digital flexion and extension leads to highly improved use of the tetraplegic hand and thus provides new mobility and independence from the help of others. This article presents an overview of the most common procedures to restore hand function in peripheral nerve injuries and tetraplegia in order to provide a systematic approach for decision making.

Quadriparesis and spinal cord stimulation: case report

STUDY DESIGN

Case report.

OBJECTIVE

To report the occurrence of a rare complication following revision of a spinal cord stimulator.

SUMMARY OF BACKGROUND DATA

Puncture of the dura with placement of an electrode within the spinal cord has not been reported as a complication of spinal cord stimulation.

METHODS

A patient presented with upper and lower extremity weakness following inadvertent placement of an electrode into the spinal cord. The clinical case is presented as well as review of the literature.

RESULTS

The patient had the electrode successfully removed; however, her neurologic status deteriorated.

CONCLUSION

Revision of spinal cord stimulators is usually a safe procedure. However, placement of an electrode within the spinal cord during the revision process is a potential complication resulting in severe neurologic injury.

Decision for reconstructive interventions of the upper limb in individuals with tetraplegia: the effect of treatment characteristics

STUDY DESIGN

Survey.

OBJECTIVE

To determine the effect of treatment characteristics on the decision for reconstructive interventions for the upper extremities (UE) in subjects with tetraplegia.

SETTING

Seven specialized spinal cord injury centres in the Netherlands.

METHOD

Treatment characteristics for UE reconstructive interventions were determined. Conjoint analysis (CA) was used to determine the contribution and the relative importance of the treatment characteristics on the decision for therapy. Therefore, a number of different treatment scenarios using these characteristics were established. Different pairs of scenarios were presented to subjects who were asked to choose the preferred scenario of each set.

RESULTS

Forty-nine subjects with tetraplegia with a stable C5, C6 or C7 lesion were selected. All treatment characteristics significantly influenced the choice for treatment. Relative importance of treatment characteristics were intervention type (surgery or surgery with functional electrical stimulation implant) 13%, number of operations 15%, in-patient rehabilitation period 22%, ambulant rehabilitation period 9%, complication rate 15%, improvement of elbow function 10%, improvement of hand function 15%. In deciding for therapy, 40% of the subjects focused on one characteristic.

CONCLUSION

CA is applicable in Spinal Cord Injury medicine to study the effect of health outcomes and non-health outcomes on the decision for treatment. Non-health outcomes, which relate to the intensity of treatment, are equally important or even more important than functional outcome in the decision for reconstructive UE surgery in subjects with tetraplegia.

Tetraparesis secondary to cervical ossification of the posterior longitudinal ligament: case report

Ossification of the posterior longitudinal ligament (OPLL) is a rare cause of myelopathy in non-Oriental populations and relatively unrecognized by general practitioners. A case of an Afro-Brazilian 54-years-old woman presenting with tetraparesis due to cervical OPLL is presented. Emphasis is made for the inclusion of OPLL in the differential diagnosis of compressive cervical myelopathy.

Cervical neurapraxia in elite athletes: evaluation and surgical treatment

Object

Neurapraxia, transient posttraumatic paralysis of the motor and/or sensory tracts in the spinal cord, may be a career-ending event in an athlete. Management, rehabilitation, and return-to-play decisions remain controversial.

Methods

Five elite football players were evaluated after experiencing episodes of neurapraxia. All patients experienced bilateral paresthesias—three in all four extremities and two in the upper extremities—lasting a few minutes to more than 24 hours. Transient motor deficits occurred in two individuals but caused no permanent sequelae. Neuroimaging confirmed the presence of herniated discs, focal cord compression, and no parenchymal changes in all cases.

All patients underwent anterior cervical microdiscectomy and fusion, and cervical plates were placed in four. After aggressive rehabilitation and confirmation of fusion ranging from 9 weeks to 8 months postoperatively, the players were allowed to return to active play. Two of the players developed recurrent career-ending disc herniations, one above and the other below the fusion level. One player required repeated spinal cord decompression.

Conclusions

Neurologically intact athletes with focal cord compression due to a single-level herniated disc may safely return to football after undergoing decompressive surgery and confirmation of fusion. It appears, however, that there may be an increased chance of repeated herniation above or below a fused level.

Perceptions of people with tetraplegia regarding surgery to improve upper-extremity function

PURPOSE

In the United States, more than 100,000 Americans live with the disability of tetraplegia. These individuals must struggle through long and complicated rehabilitations. Upper-extremity reconstructive surgery can improve use of the upper limb for appropriate candidates; however, a prior national study showed that these procedures rarely are performed. This cross-sectional survey identified the attitudes and beliefs of people with tetraplegia that may dissuade potential candidates from receiving these procedures.

METHODS

An oral survey was designed to determine priorities of reconstruction in individuals with tetraplegia. This survey was administered to 50 people with tetraplegia.

RESULTS

Among those surveyed, 13 (26%) had never heard of upper-extremity reconstructive surgery, but 22 (44%) were interested in upper-extremity reconstruction. People with tetraplegia who had a negative first impression of these procedures were far less likely to want reconstruction 0 (0%) vs. 11 (45%). Of patients who learned about these procedures from their physicians, 10 (67%) had a negative first impression after the physician consultation.

CONCLUSIONS

Although many people with tetraplegia understand the benefits of upper-extremity reconstruction, a large number of them are unaware of or have unfavorable attitudes toward these procedures. These negative attitudes may account for the marked underuse of upper-extremity reconstructive procedures in the United States.