Surgical restoration of hand function in tetraplegia

Surgical Neurology International, 2011

Background: The recovery of hand function is consistently rated as the highest priority for persons with tetraplegia. Recovering even partial arm and hand function can have an enormous impact on independence and quality of life of an individual. Currently, tendon transfers are the accepted modality for improving hand function. In this procedure, the distal end of a functional muscle is cut and reattached at the insertion site of a nonfunctional muscle. The tendon transfer sacrifices the function at a lesser location to provide function at a more important location. Nerve transfers are conceptually similar to tendon transfers and involve cutting and connecting a healthy but less critical nerve to a more important but paralyzed nerve to restore its function. Methods: We present a case of a 28-year-old patient with a C5-level ASIA B (international classification level 1) injury who underwent nerve transfers to restore arm and hand function. Intact peripheral innervation was confirmed in the paralyzed muscle groups corresponding to finger flexors and extensors, wrist flexors and extensors, and triceps bilaterally. Volitional control and good strength were present in the biceps and brachialis muscles, the deltoid, and the trapezius. The patient underwent nerve transfers to restore finger flexion and extension, wrist flexion and extension, and elbow extension. Intraoperative motor-evoked potentials and direct nerve stimulation were used to identify donor and recipient nerve branches. Results: The patient tolerated the procedure well, with a preserved function in both elbow flexion and shoulder abduction. Conclusions: Nerve transfers are a technically feasible means of restoring the upper extremity function in tetraplegia in cases that may not be amenable to tendon transfers.

Plastic and Aesthetic Research , 2020

Nerve transfers were used, originally, to restore shoulder and elbow function in brachial plexus lesions. This concept has been developed over the years and applied to distal nerve injuries in which lower functionality was expected because of the gap between the injury site and the target muscle. The aim of this review is to describe nerve transfers in the distal forearm and hand for isolated lesions of the median, ulnar and radial nerves. The different advantages achieved by transposition of a functional nerve stump near the effector muscle have opened up new options for the management of nerve lesions. Some of these alternatives have only been recently reported and a few are exclusively case reports.

The Journal of Hand Surgery, 2017

Purpose In high median nerve repairs, thenar muscle reinnervation is impossible because of the long distances over which axons must regenerate. To overcome this obstacle, we propose transferring the abductor digiti quinti motor branch (ADQMB) to the thenar branch of the median nerve (TBMN). Methods We used 10 embalmed hands for anatomical and histological studies. Thereafter, 5 patients with a high median nerve injury underwent surgical reconstruction within 8 months of their accident and were followed for at least 10 months after surgery (mean, 13.2 months). We transferred the ADQMB to the TBMN. The median nerve was grafted in 4 patients and the motor branch of the extensor carpi radialis brevis was transferred to the anterior interosseous nerve in 3. Patients had pre-and postoperative evaluations of thumb range of motion and strength. Results In cadaveric hands, the ADQMB was the first branch of the ulnar nerve to arise near the pisiform bone. The TBMN arose from the anterior surface of the median nerve, underneath the flexor retinaculum. Retrograde dissection of the TBMN allowed tension-free coaptation with the ADQMB. Both branches contained approximately 650 myelinated fibers. After surgery, all our patients improved thumb pronation, thenar eminence bulk, and abductor pollicis brevis British Medical Research Council score. They recovered approximately 75% of their normal-side grasp and pinch strength. No patient lost little finger abduction. Conclusions Transfer of the ADQMB to the TBMN reinnervated the thenar muscles, which improved thumb range of motion and strength.

Brain Sciences, 2016

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.

Biomedical Journal of Scientific & Technical Research, 2021

The aim of our work is to propose a systematic approach in the management of the upper limb rehabilitation in tetraplegic patients, focused on the preoperative rehabilitation aspects that must be tailored to the specific therapeutic path, in order to assure the best conditions both before the intervention or the conservative management, and optimize the results. Methods: Evaluation criteria, surgical and rehabilitation timing with reference to the recent literature are reported. Timing and objectives of upper limb rehabilitation in tetraplegic patients are discussed, focusing on obstacles in the management of patients that can be overcome with a multidisciplinary approach. Results and Discussion: The upper limb diagnostic-therapeutic path of tetraplegic patients is developed point by point, starting from the evaluation, the indications, therapeutic options, surgical timing and focusing on the role of pre-operative rehabilitation. At present, there is consensus regarding the need for physiotherapy aimed to maintain flexible joints if surgery is planned or learning compensatory mechanisms for candidates to a conservative management. The application timing of rehabilitation protocols in relation to the different surgical strategies is of great importance, as the choice to perform the classic tendon transfers or the most innovative nerve transfers influences the entire therapeutic path. Conclusion: The management of the tetraplegic patient requires a coordinated and multidisciplinary approach, which can be intended to implement residual functions, or prepare for surgery. Preoperative physiotherapy must take into account both the best personalized protocol and the timing dictated by the type of surgical choice.

Plastic and Aesthetic Research, 2015

Nerve transfer surgery, also referred to neurotization, developed in the mid 1800s with the use of animal models, and was later applied in the treatment of brachial plexus injuries. Neurotization is based on the concept that following a proximal nerve lesion with a poor prognosis, expendable motor or sensory nerves can be re-directed in proximity of a specific target, whether a muscle or skin territory, in order to obtain faster re-innervation. Thanks to the contribution of several authors including Oberlin, MacKinnon and many others, the field of nerve transfer surgery has expanded in treatment of not only the brachial plexus, but also the arm, forearm and hand. This article reviews the recent literature regarding current concepts in nerve transfer surgery, including similarities to and differences from tendon transfer surgery. Moreover, indications and surgical techniques are illustrated for different types of nerve injury affecting the extrinsic and intrinsic musculature of the hand as well as sensory function.

Neurosurgical focus, 2017

A successful nerve transfer surgery can provide a wealth of benefits to a patient with cervical spinal cord injury. The process of surgical decision making ideally uses all pertinent information to produce the best functional outcome. Reliance on clinical examination and imaging studies alone can miss valuable information on the state of spinal cord health. In this regard, neurophysiological evaluation has the potential to effectively gauge the neurological status of even select pools of anterior horn cells and their axons to small nerve branches in question to determine the potential efficacy of their use in a transfer. If available preoperatively, knowledge gained from such an evaluation could significantly alter the reconstructive surgical plan and avoid poor results. The authors describe their institution's approach to the assessment of patients with cervical spinal cord injury who are being considered for nerve transfer surgery in both the acute and chronic setting and broa...

2022

Introduction: Nerve transfers are the only surgical option for reconstruction of directly irreparable injuries of the brachial plexus. In the recent years, there has been a trend toward the increased use of nerve transfers, with the introduction of new methods and novel indications. Patients with total brachial plexus palsy generally have poor outcomes due to the limited number of donor nerves. On the contrary, patients with partial injuries involving the C5, C6, and sometimes C7 spinal nerves have favorable outcomes in a large majority of cases. In both situations, restoration of elbow flexion and shoulder functions are the main priorities. The purpose of this review article to characterize the advantages, problems and controversies of nerve transfers. Methods: PubMed/Medline database was searched for English-language original research and series of adult patients who received nerve transfers for functional restoration of the upper arm, performed within one year after injury and with minimum follow-up of one year. Literature search for outcome analysis was limited to articles published after 1990, amounting to 45 systematic reviews / meta-analyses of the most common nerve transfers (intercostal, spinal accessory, fascicular, and collateral branches of the brachial plexus). Analysis of clinical outcomes was based on Medical Research Council (MRC) grading system for muscle strength, and grades M3 or more were considered as useful functional recovery. Results: A total of 70 articles were included. Generally, intraplexal nerve transfers resulted in a higher rate and better quality of recovery compared to extraspinal transfers. Grades M3 or higher were obtained in 72% of the intercostal and 73% of the spinal accessory nerve transfers for restoration of elbow flexion, and in 56% vs. 98% of transfers for restoration of shoulder function. Among intraplexal nerve transfers, elbow flexion was restored in 84% to 91% of the medial pectoral, 100% of the thoracodorsal, and 94% to 100% of the single or double fascicular nerve transfers. Shoulder function was restored in 81,8% of the medial pectoral, 86% to 93% of the thoracodorsal, and 100% of the triceps branch nerve transfers. Dual nerve transfer (simultaneous reinnervation of the suprascapular and axillary nerves), resulted in 100% rate of recovery. Conclusion: Double fascicular transfer for restoration of elbow flexion and dual nerve transfer for restoration of shoulder function resulted in the most favorable results relative to other transfers, especially regarding quality of recovery. Medial pectoral and thoracodorsal nerve transfers were reasonable alternatives for restoration of both functions.

The Journal of Hand Surgery, 2020

Purpose With nerve or tendon surgery, the results of thumb reconstruction to treat radial nerve paralysis are suboptimal. The goals of this study were to describe the anatomy of the deep branch of the posterior interosseous nerve (PIN) to the thumb extensor muscles (DBPIN), and to report the clinical results of transferring the distal anterior interosseous nerve (DAIN) to the DBPIN. Methods The PIN was dissected in 12 fresh upper limbs. Myelinated nerve fibers in the DBPIN and DAIN were counted. Five patients with radial nerve paralysis underwent transfer of the motor branch to the flexor carpi radialis to the PIN and a motor branch of the pronator teres to the extensor carpi radialis brevis. In addition, these patients had selective reconstruction of thumb motion by transferring the DAIN to the DBPIN, through either a combined volar and dorsal approach (n ¼ 2) or a single dorsal approach (n ¼ 3) with division of the interosseous membrane. Results At the origin of the abductor pollicis longus, the DBPIN divided into a lateral branch that innervated the abductor pollicis longus and extensor pollicis brevis, and a medial branch that innervated the extensor pollicis longus and extensor index proprius. The number of myelinated nerve fibers in the DAIN corresponded to 65% of that of the DBPIN. In each of the 5 patients, full thumb motion at the trapeziometacarpal joint was restored with no, or minimal, extension lag at the metacarpophalangeal (MCP) joint. Conclusions The anatomy of the DBPIN is predictable. Transferring the DAIN to the DBPIN is feasible through a single dorsal approach, allowing full recovery of thumb motion.

Neurosurgical FOCUS, 2009

Peripheral nerve injuries can result in devastating numbness and paralysis. Surgical repair strategies have historically focused on restoring the original anatomy with interposition grafts. Distal nerve transfers are becoming a more common strategy in the repair of nerve deficits as these interventions can restore function in months as opposed to more than a year with nerve grafts. The changes that take place over time in the cell body, distal nerve, and target organ after axotomy can compromise the results of traditional graft placement and may at times be better addressed with the use of distal nerve transfers. A carefully devised nerve transfer offers restoration of function with minimal (if any) detectable deficits at the donor site. A new understanding of cortical plasticity along with patient reeducation allow for good return of strength and function after nerve transfer.