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Optimizing Post-Surgical Nerve Transfer Motor Re-education in Tetraplegia
Kristen Davidge, MD1; Lorna Kahn, PT, CHT1; Christine B. Novak, PT, PhD2; Neringa Juknis, MD1; Rimma Ruvinkaya, MD1; Ida K. Fox, MD1
1Washington University, Saint Louis, MO; 2University of Toronto, Toronto, ON, Canada

Introduction: Hand therapy post nerve transfer surgery can be challenging when patient functional limitations such as tetraplegia exist. We present a case report to illustrate the time course and unique strategies used for rehabilitation after a combined nerve transfer to restore volitional prehension and wrist flexion in a patient 11 years following a cervical spinal cord injury (SCI) or tetraplegia.
Methods: A retrospective case review of time course of reinnervation, recovery, and therapeutic adaptations after nerve transfer in cervical SCI was done. Data were collected on pre and post-operative physical findings and the therapeutic modalities used to advance patient reeducation.
Results: Our patient is a 30 year old male who sustained cervical SCI 11 years prior to presentation. He was evaluated by our multi-disciplinary Upper Extremity Surgery in SCI team and in November 2012, he underwent nerve transfers of the brachialis to the anterior interosseous (AIN) and flexor carpi radialis (FCR).
Pre-op, the patient was evaluated and fitted for splints to maintain his existing passive range of motion (PROM). Immediately post-op, patient had absence of FCR spasticity; there was no appreciable loss of elbow flexion from a functional standpoint. Therapy was instituted including: patient education and donor muscle strengthening.
One month post-op, full baseline activity was resumed. A splint was made to position the wrist and fingers in an optimal recipient muscle length/tension relationship and resisted elbow flexion exercises were started.
At 5.5 months, a flicker of volitional FCR was identified. Co-contraction exercises elbow flexion and gravity-eliminated wrist flexion exercises were instituted with an emphasis on functionally driven activity. Adaptations for cortical re-education were also begun.
At 6.5 months, volitional index finger flexion was noted with co-contraction of the donor elbow flexors. Formal therapy was increased to capture and enhance this early motor recovery. This included active prehension and tool stimulator exercises.
At 8.5 months, AIN innervated index and long finger flexion continued to improve (grade 3-) and a flicker of thumb flexion appeared. Resistance putty exercises were initiated and additional co-contraction exercises, with elbow, wrist, thumb and finger combined flexion (not tenodesis), were instituted.

Conclusion: By use of an illustrative case example, we provide suggestions for improving our post-nerve transfer motor retraining strategies in a particularly challenging setting. These data will assist in providing comprehensive treatment protocols in the future as we gain more experience in this dynamic and rapidly developing field—nerve transfers in the setting of tetraplegia.

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