A Prospective Case Series Evaluating Long-term Outcomes Following Nerve Transfers in Tetraplegia
Noah Oiknine, MD1, Charlotte Jaloux, MD, PhD2, Catherine Dansereau, PT3,4, Philippe Ménard, PT3,4, Josée Dubois, OT3,4, Véronique Maes, OT3,4, Géraldine Jacquemin, MD, MPH, FRCPC3, Dominique Tremblay, MD, OT, FRCSC3,5 and Elie Boghossian, MD, MSc, FRCSC3,5, 1Université de Montréal, Faculté de Médecine, Montreal, QC, Canada, 2Department of Hand Surgery, Plastic and Reconstructive Surgery of the Limbs - La Timone University Hospital - Assistance Publique Hôpitaux de Marseille, Marseille, France, 3CIUSSS du Centre-Sud-de-l'Ile-de-Montréal, Institut de Réadaptation Gingras-Lindsay de Montréal, Montreal, QC, Canada, 4Centre de Recherche Interdisciplinaire en Réadaptation du Montréal Métropolitain, Montreal, QC, Canada, 5Division of Plastic Surgery, Department of Surgery, Université de Montréal, Hôpital Maisonneuve-Rosemont, Montreal, QC, Canada
Introduction: Spinal cord injury (SCI) leads to devastating loss of functional independence. For tetraplegic patients, regaining upper extremity function is consistently rated as a top priority. Upper extremity reconstruction among this patient population has traditionally been accomplished via tendon transfers. More recently, studies have shown promising results with nerve transfers; however, published data remains scarce. The goal of this study was to evaluate the long-term functional outcomes of nerve transfer surgery in tetraplegia.
Methods: Tetraplegic patients who were admitted to our rehabilitation center and deemed candidates for nerve transfer were included. Motor nerve transfers were performed to restore elbow extension, pinch/grasp, and hand opening. Participants were prospectively assessed at baseline, 6, 12, and 24 months postoperatively. Motor function (i.e., MRC grades, webspace opening, pinch/grasp strength), Canadian Occupational Performance Measure (COPM), Spinal Cord Independence Measure (SCIM), and Toronto Rehabilitation Institute-Hand Function Test (TRI-HFT) scores were measured. The Wilcoxon signed-rank test was used for statistical analysis.
Results: Eight consecutive patients were included. Thirty-four nerve transfers were performed on 15 limbs at a mean of 8.7 ± 2.0 months post-SCI. Median MRC grades for elbow extension and finger extension were 2 (IQR 2 – 2) and 4 (IQR 2.5 – 4), respectively, at 24 months. Overall, the median MRC grade for finger flexion was 4 (IQR 2.25 – 4.75) at 24 months, with better outcomes seen in distal nerve transfers as compared to proximal nerve transfers (5 [IQR 4 –5] vs. 3 [IQR 2 – 3.5]). At 24 months, the mean grasp strength for distal nerve transfers (n=7) and proximal nerve transfers (n=7) were 3.3 ± 1.9 kg and 1.6 ± 1.3 kg, respectively. A significant improvement in webspace opening was seen at 24 months (median 103.0 mm [IQR 86.3 – 111.5], p<0.001). Statistically significant improvements were seen between baseline and 24-month COPM (performance, p=0.012; satisfaction, p=0.012), SCIM (total score, p=0.012) and TRI-HFT (object manipulation, p=0.006) scores. Two adverse events related to surgery were observed (hematoma in an anticoagulated patient, sensory loss in the median nerve territory after brachialis to AIN transfer).
Conclusions: Motor nerve transfers are an effective treatment option that can be used to restore upper extremity function in tetraplegic patients. Improvements in motor strength for elbow extension, pinch/grasp, and hand opening were seen at long-term follow-up, translating to meaningful improvements in functional independence. In our experience, there appears to be better motor recovery for finger flexion with distal nerve transfers.
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