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Peripheral Nerve Transfer for Spinal Cord Injury: Lower Motoneuron Solutions for Upper Motoneuron Problems
Andrew S Jack, MD, MSc, FRCSC1; Line G Jacques, MD, MSc, FRCSC2; Michael J. Morhart, MD3; Jaret Olson, MD, FRCSC4; Ming Chan, MB ChB, FRCPC4
1University of Alberta, Edmonton, AB, Canada; 2UCSF, San Francisco, CA; 3Department of Plastic and Reconstructive Surgery, University of Alberta, Edmonton, AB, Canada; 4Plastic and Reconstructive Surgery, University of Alberta, Edmonton, AB, Canada

Introduction: Traumatic spinal cord injuries (tSCI) are unfortunately common, often leaving patients irreparably debilitated. Therefore, novel strategies for mitigating secondary SCI damage and improving patient rehabilitation are needed. Of these, nerve transfers (NTs) have been recognized as a promising strategy. Although different tSCI NT options have been previously detailed, little is known about the epidemiological and injury-related aspects of this patient population. Here, we report such characteristics to better identify and understand the number and types of tSCI patients who may benefit from this treatment.
Materials and Methods: All tSCI patients presenting to our local institution were identified through a prospectively collected tSCI data registry since its inception. Inclusion criteria consisted of: i) admission with cervical tSCI (C1-T1) between 2005-2019, ii) ≥18-years-old, iii) documented tSCI severity using the ASIA Impairment Scale (AIS). Two peripheral nerve (PN) experts independently evaluated each patientís suitability for NT (nerve donor with MRC strength ≥4/5 and recipient £2/5). Demographic, traumatic injury-related, and neurological injury-related variables were collected and analyzed.
Results: A total of 709 tSCI patients were identified with 224 (32%) being selected for based on their tSCI level (C1-T1). After initial review, there was 94% agreement between the PN experts. Details of the remaining discordant cases were discussed individually before reaching a final consensus. From the total sample of 709 patients, 108 (15% of all tSCIs and 48% of all cervical tSCIs) were deemed to be appropriate NT candidates. Their average age was 43-years-old and the majority were male (82/108, 76%). The range of tSCI severity included: 54 (50%) patients being AIS A, 17 (16%) AIS B, 34 (31%) AIS C, and 3 (3%) AIS D. The AIS motor level ranged from C4 to C8 with 7 (6%) C4, 40 (37%) C5, 22 (20%) C6 patients, 38 (35%) C7 patients, and 1 (1%) C8 patient. Six initial NT candidate patients no longer qualified by their last follow-up and 19 patients not initially considered NT candidates then become candidates by their last follow-up (due to SCI recovery).
Conclusion: To our knowledge, this is the first study to detail the number of tSCI patients that may qualify for NT from a large prospective database. We found that a large proportion of patients with cervical tSCI could potentially benefit from this. Better characterizing the epidemiological and injury patterns of this patient population will form an important first step to increase awareness and inform tSCI NT candidate identification


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