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Nerve Transfers to Improve Upper Extremity Function in Tetraplegia – Anatomical Feasibility and Clinical Case
Andreas Gohritz, MD
Plastic, Hand and Reconstructive Surgery, Medical School Hanover, Hanover, Germany
Introduction: Nerve transfers have been successful in peripheral nerve surgery, yet only rarely in spinal cord injury (SCI) - although they might be equally or even more useful in these individuals.
Objective: This paper provides a review of innovative techniques in PNI illustrated by own anatomical dissections to initiate a discussion how they could also improve function in tetraplegic patients.
Results: The following nerve transfers available in patients with intact C6 level were studied anatomically:
1. Brachialis nerve branch (C5/6) to the muscle branch to the ECRL of the radial nerve
2. Axillary nerve (C5/6) to posterior deltoid or teres minor or coracobrachialis branch of musculocutaneous nerve (C5/6) to triceps branch(es) of radial nerve (C7)
3. Supinator nerve branches (C6) to posterior or anterior interosseus nerve for thumb and finger function (C7-Th1)
4. Spinal accessory nerve from dorsal approach for shoulder or arm function
5. Lateral antebrachii cutaneous nerve (C5/6) for sensory restoration of the median nerve (1st web space) in patients categorized as 0 (ocular control)
All nerve transfer proved anatomically feasible and met the requirements of redundant donors with low morbidity, high motor axon density, good calibre match between donor and recipient and short regeneration distance.
Theoretically, nerve transfers in SCI may even be more effective compared to PNI:
1. Recipient muscles with intact lower motoneuron preserve reflex arcs and do not become refractory to reinnervation / external stimulation after 18-24 months as after peripheral palsy, 2. axon transfer to the intact donor nerve may allow highly selective neurotization by intraoperative fascicle stimulation of the intact recipient nerve, 3. this may minimize the distance between donor and recipient and regeneration time.
As a clinical example, a patient with no transferable muscles below the elbow 12 months after spinal cord injury underwent Brachialis-to-ECRL selective transfer and regained wrist extension against gravity (M3+) 6 months postoperatively and is now able to receive passive key grip reconstruction.
Conclusion: Nerve transfers could improve key muscle functions and sensory protection after SCI, especially in groups with very limited resources (such as IC groups 0-3). Further research should be directed at combining traditional algorithms with these new approaches.
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