Nerve Transfer for Restoration of Upper Limb Function in Traumatic Cervical Spinal Cord Injury

Abstract

Introduction: Cervical spinal cord injury (CSCI) is a devastating consequence of trauma that results in disabling loss of upper limb function. Surgical restoration can improve quality of life, reduce long-term care needs, and is highly rated by patients. Historically, expert opinion has recommended tendon transfer procedures, but there is now a renaissance of interest in selective nerve fascicle transfer to restore prehensile grip, maintain donor muscle function, and better serve patients. Due to a long-standing geographical and professional disconnect between spinal injury professionals and reconstructive hand surgeons, limited information exists regarding the number of CSCI patients eligible for nerve transfer surgery, extent of current service provision, and contemporaneous surgical practices. Objectives: (1) Conduct a survey of UK spinal cord injury centres (SCICs) to understand the number of CSCI patients eligible for nerve transfer surgery annually. (2) Survey UK health care professionals to understand the current provision of services and range of surgical interventions performed. Methodology: SCIC Questionnaire—This was distributed to the clinical leads of each UK and Éire SCIC between February and May 2015. Information was requested on the local CSCI caseload, referrals to upper limb services, and surgical procedures undertaken locally during January to December 2014. Nonresponders were followed up with freedom of information requests. Clinician Questionnaire—This was distributed to 18 spinal injury rehabilitation consultants and upper limb surgeons identified as having a relevant professional interest through a specialist interest meeting at the British Society for Surgery of the Hand Spring Meeting (BSSH) Spring Meeting 2015 and the SCIC questionnaire. The questionnaire requested information on clinician caseload, previous training, local multidisciplinary team (MDT) support, functional gains prioritized, and surgical interventions undertaken. Results: SCIC Questionnaire—In all, 11/12 SCICs responded (response rate [RR] 92%) with a mean of 49.6, any-level CSCI patients admitted annually (>C5: 27.9 patients, C5/6: 18 patients, <C6: 6.5 patients). No SCIC reported referring CSCI patients for nerve transfer or awareness of any peripheral nerve service. In all, 5/11 SCICs stated that they referred CSCI patients for surgery to restore upper limb function. Clinician Questionnaire—Seven surgeons and 1 rehabilitation consultant responded (RR: 44%). Each surgeon assessed a mean of 5.7 patients annually with ~60% of patients proceeding to surgery. Achieving elbow extension, wrist extension, and key pinch were the most frequently prioritized functional gains. These were pursued through deltoid to triceps transfer, tenodesis surgery, and brachioradialis to flexor pollicis longus (FPL) transfer, respectively. No surgeons reported undertaking nerve transfer but three-quarters expressed a willingness to do so. Conclusions: Surgery to restore upper limb function following CSCI is a developing area of hand surgery that will revolutionize functional outcomes for this small but important patient group. Clinical expertise is currently limited to only a handful of surgeons. Provision of services is sparse, uncoordinated, and regionally serendipitous. Most surgeons predominantly pursue tendon transfer strategies but recognize nerve transfer surgery represents a paradigm shift in the outcomes that may be achieved. It is clear that there is a willingness among surgeons to pursue nerve transfer with appropriate support. Awareness must be raised within the professional and patient spinal injury communities regarding this important treatment option.