Upper-limb surgery in tetraplegia includes a number of surgical interventions that can help improve the quality of life of a patient with tetraplegia.
Loss of upper-limb function in patients with following a spinal cord injury is a major barrier to regain autonomy. The functional abilities of a tetraplegic patient increase substantially for instance if the patient can extend the elbow. This can increase the workspace and give a better use of a manual wheelchair. To be able to hold objects a patient needs to have a functional pinch grip, this can be useful for performing daily living activities.Pinch and elbow extension restoration in people with tetraplegia: a systematic review of the literature; Cynthia Hamou, et al., JHS vol 34A April 2009 A large survey in patients with tetraplegia demonstrated that these patients give preference to improving upper extremity function above other lost functions like being able to walk or sexual function.
Surgical procedures do exist to improve the function of the tetraplegic patient's arms, but these procedures are performed in fewer than 10% of the tetraplegic patients.Opinions on the treatment of people with tetraplegia: Contrasting perceptions of physiatrists and hand surgeons; Catherine M. Curtin et al., J Spinal Cord Med. 2007;30:256–262 Each tetraplegic patient is unique, and therefore surgical indication should be based on the remaining physical abilities, wishes and expectations of the patient.General indications for functional surgery of the hand in tetraplegic patients; Yves Allieu, Hand Clin 18 (2002) 413–421
In 2007 a resolution was presented and accepted at the world congress in reconstructive hand surgery and rehabilitation in tetraplegia, that stated that every patient with tetraplegia should be examined and informed about the options for reconstructive surgery of the tetraplegic arms and hands. This resolution demonstrates mostly the necessity to increase the awareness on this subject amongst physicians.Current concepts in reconstruction of hand function in tetraplegia; J Friden, C Reinholdt, Scandinavian journal of surgery 97:341–346, 2008
History Reconstructive surgery of the upper limb in tetraplegic patients began during the mid-20th century. The first attempts at regaining gripping function of the hand probably took place in Europe at the end of the 1920sThe upper limb in tetraplegia: a new approach to surgical rehabilitation. Moberg E., Stuttgart, Germany: George Thieme; 1978. with the construction of flexor-hinge splints.Development of useful function in the severely paralyzed hand. Nickel VL, Perry J, Garret A., J Bone Joint Surg 1963;45:933–52.
In the early 1940s, a surgeon called Sterling Bunnell (1882–1957) was probably one of the first to refer to the reconstruction of gripping function for the tetraplegic hand. He described surgeries of combining tenodeses and tendon transfers to restore hand function. He also advocated transferring the m. brachioradialis to the wrist extensors when these muscles are paralyzed.
In the 1950s, understanding of the tenodesis effect (See Tenodesis grasp) influenced the development of surgical techniques such as the static flexor tenodesis. These procedures provided the basic functions of grasp and pinch.Providing automatic grasp by flexor tenodesis. Wilson JN., J Bone Joint Surg Am 1956;38:1019–24.Restoration of finger function by poliomyelitis. Irwin CE, Wray JC., J Bone Joint Surg Am 1957;19:716.Finger flexor tenodesis. Street DM, Stambaugh HD., Clin Orthop 1959;13:155–63. Tendon transfers were developed to accomplish both digital release and gripping functions in two surgical stages. The originators of these procedures were Lipscomb et al. , Zancolli,Structural and dynamic bases of hand surgery, 2nd ed. Zancolli EA., Philadelphia: JB Lippincott; 1979Structural and dynamic bases of hand surgery, 1st ed. Zancolli EA., Philadelphia: Lippincott; 1968.Surgery of the quadriplegic hand with active strong wrist extension preserved. Zancolli EA., A study of 97 cases. Clin Orthop 1975;12:101–13. House et al.Restoration of strong grasp and lateral pinch in the tetraplegic due to cervical spinal cord injury. House JH, Gwathmey FW, Lundsgaard DK., J Bone Joint Surg Am 1976;1:152–9.Two-stage reconstruction of the tetraplegic hand in master techniques in orthopaedic surgery. House JH, Walsh T., In: Strickland JW, editor. The hand. Philadelphia: Lippincott-Raven; 1998. House et al. contributed important clinical investigations while showing the value of different surgical procedures.
According to Zancolli, transfer of the m. brachioradialis to the m. extensor carpi radialis tendons was proposed by Vulpius and Stoffel in 1920. In tetraplegia, this was first proposed by Wilson. and first described fully by Freehafer.
In 1967, Alvin Freehafer of Cleveland, Ohio, contributed valuable ideas towards achieving independence in the arms of tetraplegic patients. He and his team published the results of six patients who underwent transfer of the m. brachioradialis to restore active wrist extension.Transfer of the brachio radialis to improve wrist extension in high spinal cord injury. Freehafer AA, Mast WA., J Bone Joint Sur Am. 1967;49:648–52. In 1974, Freehafer et al.Tendons transfers to improve grasp after injuries of the cervical spinal cord.Freehafer AA, Vonhaam E, Allen V., J Bone Joint Surg Am. 1974;56:951–9. recommended opposition transfers and finger-flexion transfers.
In 1971, surgery of the tetraplegic upper limb experienced a revival after Moberg's clinical investigations. His main contributions were (1) to restore elbow extension through transfer of the posterior deltoid to triceps (the initial procedure); and (2) to reconstruct a key pinch.The physiological method of tendon transplantation. I. Historical: Anatomy and physiology of tendon., Mayer L. Surg Gynecol Obstet 1916;22:182–97. Moberg's idea of posterior deltoid transfer to restore elbow extension has been used extensively by many surgeons, such as BryanThe Moberg deltoid-triceps replacement and key-pinch operations in quadriplegia: preliminary report experiences., Bryan RS. Hand 1977;9:207–14. and DeBenedetti.Restoration of elbow extension power in the tetraplegic patient using the Moberg technique., DeBenedetti M. J Hand Surg 1979;4:86–9.
In 1983, Douglas Lamb of Edinburgh, Scotland, gave great headway to surgery of the tetraplegic upper extremity when Lamb and Chan recommended reconstruction of elbow extension by transferring the posterior deltoid to the triceps according to Moberg's technique, which was published in 1975.Surgical treatment for absent single-hand grip and elbow extension in quadriplegia. Principles and preliminary experience. Moberg E. J Bone, Joint Surg 1975;57A:196–206.
A publication by FriedenbergTransposition of the biceps brachii for triceps weakness., Friedenberg ZB. J Bone Joint Surgery Am. 1954;36:656–8. was the starting point for future indications of biceps-to-triceps transfers, including those of Zancolli,Structural and dynamic bases of hand surgery, 2nd ed. Zancolli EA., Philadelphia: JB Lippincott; 1979. Hentz et al., Kuts et al., Allieu et al. and Revol et al.
Another major change was the change to one-step procedures, reconstructing opening and closing phases at the same time. Especially Jan Friden, from Gothenburg, with major experience in this area championed this thought, partially driven by the transport problems in Sweden during winter, it saved the patients an operation and minimized hospital stay.
The development of hand surgery for tetraplegia has received important contributions through published reports and by the international conferences initiated with the influence of Erik Moberg from Goteborg, Sweden. Conferences have been of great interest because of the convergences of hand surgeons interested in the field, promoting discussion and comparison of different surgical methods and experiences.History of surgery in the rehabilitation of the tertaplegic hand; Eduardo A Zancolli, Hand Clinics 18 (2002) 369–376
Goals for surgery A common goal of surgical reconstruction of the arms in patients with tetraplegia is to restore elbow extension, key pinch and palmar grip. Restoration of these functions, results in increasing a patient's independence.Use of intrinsic thumb muscles may help to improve lateral pinch function restored by tendon transfer; Joseph D. Towles et al., Clinical Biomechanics 23 (2008) 387–394
Elbow extension is an important part of upper limb surgical reconstruction in patients with tetraplegia. Although gravity can extend the arm, active elbow extension is needed to maintain a stable arm while extended in space. This is needed to reach for something or replace an object.Biceps-to-Triceps Transfer Technique; Ryan D Endress and Vincent R Hentz, J Hand Surg Am 2011 vol. 36 (4) pp. 716-721 Other functional gains include: increasing available workspace, performing pressure relief maneuvers, propelling a manual wheelchair, enhancing self-care and leisure activities, and promoting independent transfer. Elbow extension against gravity further enhances these activities above the shoulder level and reachable workspace.
The key pinch is a simple grasp in which the thumb applies force to an object to hold it against the lateral side of the index finger. Restoring this function allows a patient to hold objects such as a fork or pen that are necessary for activities of daily living such as eating, self-grooming and self-catheterization.
Palmar grip allows the patient to grasp objects in the palm of the hand and secure the object by flexing the fingers at the metacarpal joint. This gives the patient the possibility to hold objects such as a cup and also permits use of the hand for wheelchair propulsion. A social aspect of regaining the palmar grip is that the patient is able to give a handshake.
Classification of the injury Spinal cord injuries are classified as complete and incomplete by the American Spinal Injury Association (ASIA) classification. The ASIA scale grades patients based on their functional impairment as a result of the injury, grading a patient from A to D. This has considerable consequences for surgical planning and therapy.
More information on classification of tetraplegia can be found on the tetraplegia page.
Pre-operative assessment A group of hand surgeons realized in the 1970s that the level of injury did not predict the number of available muscles in the upper limb very well. Therefore, the international classification was established in 1979, at the Edinburgh meeting. It was called "The international classification (IC) of hand surgery in tetraplegic patients" (table 2) and it describes the number of possible transferable muscles. To measure and evaluate hand strength each muscle is tested and all muscles with a BMRC grade of M4 or more are recorded.
Table 2: International Classification of Hand surgery in Tetraplegic Patients Group M4 (BMRC) Muscles IC 0 No muscle below the elbow High-level Tetraplegia IC 1 m. brachioradialis IC 2 m. extensor carpi radialis longus Mid-level tetraplegia IC 3 m. extensor carpi radialis brevis IC 4 m. pronator teres IC 5 m. flexor carpi radialis Low-level tetraplegia IC 6 finger extensors IC 7 thumb extensor IC 8 partial digital flexors IC 9 lack only intrinsics IC X exceptions
A muscle not included in the International Classification, but of great importance, is the triceps muscle. When assessing a patient pre-operatively the triceps strength must also be recorded. An active triceps means a patient can reach in space, and the elbow can be stabilized against gravity and against other muscles to be transferred. (see further)