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.

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.

Using nerve transfer to restore prehension and grasp 12 years following spinal cord injury: a case report.

INTRODUCTION: Nerve transfers are used routinely for reconstruction of hand function following lower motor neuron lesions. In people with cervical spinal cord injury (SCI), this novel and alternate reconstruction option may be useful to restore prehension and grasp, and improve hand function. CASE PRESENTATION: A 34-year-old male presented 12 years post-mid-cervical SCI. Pre-operative electrodiagnostic studies revealed intact lower motor neurons below the SCI level. He elected to undergo nerve transfer surgery to restore hand function. Intraoperative evaluation led to the transfer of a brachialis nerve to several median nerve recipient branches. Post surgery, he was discharged home and resumed activities of daily living. He achieved independent thumb and finger flexion function and continued to exhibit functional improvement at 4 years post surgery. DISCUSSION: These results should prompt referral for consideration of nerve transfer surgery-an exciting alternative to tendon transfer and neuroprostheses.

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 Transfers to Restore Upper Extremity Function in Cervical Spinal Cord Injury: Update and Preliminary Outcomes.

BACKGROUND: Cervical spinal cord injury can result in profound loss of upper extremity function. Recent interest in the use of nerve transfers to restore volitional control is an exciting development in the care of these complex patients. In this article, the authors review preliminary results of nerve transfers in spinal cord injury. METHODS: Review of the literature and the authors' cases series of 13 operations in nine spinal cord injury nerve transfer recipients was performed. Representative cases were reviewed to explore critical concepts and preliminary outcomes. RESULTS: The nerve transfers used expendable donors (e.g., teres minor, deltoid, supinator, and brachialis) innervated above the level of the spinal cord injury to restore volitional control of missing function such as elbow extension, wrist extension, and/or hand function (posterior interosseous nerve or anterior interosseous nerve/finger flexors reinnervated). Results from the literature and the authors' patients (after a mean postsurgical follow-up of 12 months) indicate gains in function as assessed by both manual muscle testing and patients' self-reported outcomes measures. CONCLUSIONS: Nerve transfers can provide an alternative and consistent means of reestablishing volitional control of upper extremity function in people with cervical level spinal cord injury. Early outcomes provide evidence of substantial improvements in self-reported function despite relatively subtle objective gains in isolated muscle strength. Further work to investigate the optimal timing and combination of nerve transfer operations, the combination of these with traditional treatments (tendon transfer and functional electrical stimulation), and measurement of outcomes is imperative for determining the precise role of these operations. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Use of peripheral nerve transfers in tetraplegia: evaluation of feasibility and morbidity.

BACKGROUND: Peripheral nerve transfers are being used to improve upper extremity function in cervical spinal cord injury (SCI) patients. The purpose of this study was to evaluate feasibility and perioperative complications following these procedures. METHODS: Eligible SCI patients with upper extremity dysfunction were assessed and followed for a minimum of 3 months after surgery. Data regarding demographics, medical history, physical examination, electrodiagnostic testing, intraoperative nerve stimulation, recipient nerve histomorphometry, surgical procedure, and complications were collected. RESULTS: Seven patients had surgery on eight limbs, mean age of 28 ± 9.9 years and mean time from SCI injury of 5.1 ± 5.2 years. All patients had volitional elbow flexion and no volitional hand function. The nerve to the brachialis muscle was used as the expendable donor, and the recipients included the anterior interosseous nerve (AIN) (for volitional prehension), nerve branches to the flexor carpi radialis, and flexor digitorum superficialis. Two patients underwent additional nerve transfers: (1) supinator to extensor carpi ulnaris or (2) deltoid to triceps. No patients had any loss of baseline upper extremity function, seven of eight AIN nerve specimens had preserved micro-architecture, and all intraoperative stimulation of recipient neuromuscular units was successful further supporting feasibility. Four patients had perioperative complications; all resolved or improved (paresthesias). CONCLUSION: Nerve transfers can be used to reestablish volitional control of hand function in SCI. This surgery does not downgrade existing function, uses expendable donor nerve, and has no postoperative immobilization, which might make it a more viable option than traditional tendon transfer and other procedures.