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Restoring Prehension/Wrist Flexion and Decreasing Spasticity 11 years Following Spinal Cord Injury: a Case Study of Use of the Brachialis Nerve Transfer
Kristen Davidge, MD1, Lorna Kahn, PT, CHT1, Christine B. Novak, PT, PhD2, Neringa Juknis, MD3, Rimma Ruvinskaya, MD3 and Ida K. Fox, MD4
1Division of Plastic and Reconstructive Surgery, Washington University, Saint Louis, MO, 2University of Toronto, Toronto, ON, Canada, 3Physical Medicine and Rehabilitation, Washington University, Saint Louis, MO, 4Division of Plastic Surgery, Washington University, Saint Louis, MO
Purpose: Nerve transfers are a novel technique to restore function in patients with spinal cord injury (SCI). The purpose of this study was to systematically review the evaluation, management and preliminary outcome of the brachialis-to-anterior interosseous nerve (AIN) transfer for restoration of prehension in cervical SCI. Methods: A case study was performed of a patient undergoing brachialis-to-AIN and brachialis-to-flexor carpi radialis (FCR) nerve transfers11 years following an incomplete C4-level SCI. Donor morbidity and functional outcome were evaluated at 6 weeks and then every three months post-operatively using quantitative (manual muscle testing; Graded Redefined Assessment of Strength, Sensibility and Prehension (GRASSP)) and self-report measures (Spinal Cord Independence Measure (SCIM), Patient-Specific Functional Scale (PSFS)). The pre-operative clinical and electrodiagnostic assessments, as well as intraoperative histology, were reviewed in relation to functional outcome. Results: This 30 year old male patient with C4 ASIA C class SCI presented with normal deltoid, biceps and brachialis function; wrist extension (MRC 4-) and pronation (MRC 3) on his right side. Hand function was achieved through the tenodesis effect and was complicated by significant spasticity of the wrist and finger flexors. Pre-operative electrodiagnostic evaluation suggested no superimposed lower motor neuron injury at the C8-T1 level. Brachialis-to-AIN and brachialis-to-FCR nerve transfers were performed 9 cm proximal to the antecubital fossa. Intraoperatively, both donor and recipient nerves demonstrated excellent motor response to nerve stimulation indicating continuity of the neuromuscular junction. Operative time was 162 minutes, and length of hospitalization was 1 day. There were no complications; elbow flexion remained at MRC 5 and wrist flexion spasticity significantly decreased. Activation of the muscles innervated via the nerve transfers was first noted at 6 months post-operatively. Active flexion of FCR, then flexor digitorum profundus, was followed by active flexion of flexor pollicis longus. Examination at 9 months post-operatively demonstrated volitional control over wrist, thumb, index and middle finger flexion. GRASSP and PSFS scores increased postoperatively from baseline. Conclusion: With appropriate patient selection, the brachialis-to-AIN transfer can successfully restore volitional hand and other function and may play a role in managing dysfunctional spasticity even more than 10 years following SCI. In so doing, such nerve transfers have the potential to significantly improve independence in performing daily tasks, such as feeding, as well as quality of life, while having minimal donor morbidity and little post-operative down-time for patients with cervical SCI.
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