SURGICAL MANAGEMENT PROTOCOL FOR MIDDLE LEVEL TRAUMATIC TETRAPLEGIA: A case for “Surgical Internalisation” of External Splints

Abstract

In most places the surgical and rehabilitative management of tetraplegic patients is done on an ad hoc basis. We believe that the best interests of these unfortunate patients can only be served by a comprehensive surgical and rehabilitative management protocol through a dedicated team of professionals. The surgical protocol should be a basic standard programme known to the whole team. Depending on the patient's basic needs, variations to this basic surgical programme could be worked out. We propose a basic surgical programme for the mid-cervical tetraplegic patient in order to get rid of cumbersome external splints during the rehabilitative period. Substituting surgical procedures for external splints has become known as “internalisation of splints”. These include: 1. Motorising elbow extension using an improved bone-to-bone posterior deltoid to triceps tendon transfer. 2. Motorising forearm pronation by rerouting biceps tendon around radius. 3. Motorising thumb and finger extension, using M. brachioradialis. 4. Metacarpophalangcal finger flexion, using flexor digitorum superficialis tendon Zancolli lasso procedure (tenodesis effect). 5. Motorising distal interphalangeal finger joint flexion, using extensor carpi radialis longus transfer. 6. Thumb pinch/adduction against the fingers, rerouting flexor pollicis longus tendon to extensor carpi radialis brevis tendon, end-to-side. 7. Thumb stabilisation procedures on any one or two thumb joints. The above procedures contribute greatly to the independent function of the patient. Careful preoperative assessment and prerequisites include the patient’s needs, patient’s motivation, muscle power and endurance and important “trick movements”.