Nerve and Tendon Transfer Surgery in Cervical Spinal Cord Injury: Individualized Choices to Optimize Function

Abstract

Background: Recent adaption of nerve transfer surgery to improve upper extremity function in cervical spinal cord injury (SCI) is an exciting development. Tendon transfer procedures are well established, reliable, and can significantly improve function. Despite this, few eligible surgical candidates in the United States undergo these restorative surgeries. Evidence Acquisition: The literature on these procedures was reviewed. Results: Options to improve function include surgery to restore elbow extension, wrist extension, and hand opening and closing function. Tendon transfers are reliable and well tolerated but require weeks of immobilization and limits on extremity use. The role of nerve transfers is still being established. Early results indicate variable return of meaningful function with less immobilization but longer periods (up to years) required to gain appreciable function. Conclusion: Nerve and tendon transfer surgery sacrifice an expendable donor to restore a missing and more critical function. These procedures are well described in hand surgery; are reliable, well tolerated, and covered by insurance; and should be part of the SCI rehabilitation discussion.

Keywords: nerve transfer; spinal cord injury; tendon transfer; tetraplegia; upper extremity.

Figure 1.

This illustration depicts the underlying physiology of nerve transfer surgery in the setting of cervical spinal cord injury. (A) In this SCI scenario, the lower motor neuron (LMN) is intact and the peripheral nerve transfer procedure can work to re-route expendable donors under volitional control to nonfunctional recipients. (B) If there is a more extensive LMN zone of injury, the nerve transfer must be done soon (<1 year post SCI) to restore both volitional control and LMN integrity. © 2014 Washington University in St. Louis, nervesurgery.wustl.edu. Used with permission.

Figure 2.

Tendon transfer surgery photo that depicts the freeing up of a donor tendon. Note that an extensive zone of dissection is required to free up the tendon and attach sutures to it. The donor tendon is subsequently sewn to the recipient.

Figure 3.

Nerve transfer surgery photos. (A) The dissection to identify the donor and recipient nerve branches. (B) The donor and recipient nerve branches have been coapted without tendon. © 2014 Washington University in St. Louis, nervesurgery.wustl.edu. Used with permission.

Figure 4.

This schematic depicts the characteristics of nerve and tendon transfer and factors that might influence individual preferences for one procedure over another. On the left hand side of the schematic are nerve transfers and on the right are tendon transfers. The choice of one procedure over the other will depend on the individual's priorities and preferences, the findings of the clinical evaluation, and a discussion of goals.