Combining Nerve Transfers and Tendon Transfers in Tetraplegia: Proposal of a New Surgical Strategy
Bruno Battiston, MD, PhD; Paolo Titolo, MD; Alessandro Crosio, MD; Chiara Arrigoni, MD
UO di Microshirurgia Ricostruttiva, Hand Surg., Microsurg. Unit, Torino, Italy
The global incidence of spinal cord injury has been estimated between 10 and 80 new cases per million people annually .
More than 50% of all spinal cord injuries occur at cervical level resulting in tetraplegia.
The commonly used classification system in upper limb in tetraplegia was developed at the Second International Conference (Giens, France, 1984).
This classification organizes the most common patterns of presentation of the upper limb lesions in tetraplegia not on the specific level of cervical injury but on the number of functional muscles existing below the elbow and that aims surgeons to chose a reconstructive strategy mainly based on tendon transfer and tenodesis procedures. It focus on forearm and hand only and it doesn't include the elbow.
The main problem in this kind of disease is the paucity of adequate donor muscles available for transfer. Donor muscles are used to restore function following some priorities: first restore wrist extension than restore function of pinch, grasp, finger and thumb extension and intrinsic function.When transfer options are ended, remaining functions are reached using tenodesis and arthrodesis.
Recently we observed a progressive development of other surgical techniques based on nerve transfers.
Nerve transfers techniques are commonly used to restore motor function in the setting of brachial plexus nerve root avulsion injuries in which an end- to-end repair of the native motor nerve is physically impossible. They are also useful more distally in peripheral nerve injuries, where rapid restoration of function can to be accomplished by rerouting expendable donor nerves.
In the last few years some authors introduced nerve transfer in tetraplegia, reporting unexpected results that are impossible to reach with classical reconstruction.
Following these concepts, we propose a new strategy based on the previous system adding to classical reconstructive strategy the use of nerve transfer techniques. A frequent concern about nerve transfer is the loosing of secondary possibilities of "predictable" results with standard techniques for "unpredictable" results. The strategy proposed is designed to avoid these situation using, as a donor for nerve transfer, branches of common muscles used for tendon transfer as described on the previous classification; in this way, if the nerve transfer does not achieve the expected results it can be still performed a second stage surgery following the classical tendon transfers enodesis techniques.
Another innovation is that we included in our strategy solutions for elbow recovery.
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