Nerve transfers in the upper extremity following cervical spinal cord injury. Part 1: Systematic review of the literature

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OBJECTIVE

Patients with cervical spinal cord injury (SCI)/tetraplegia consistently rank restoring arm and hand function as their top functional priority to improve quality of life. Motor nerve transfers traditionally used to treat peripheral nerve injuries are increasingly being used to treat patients with cervical SCIs. In this study, the authors performed a systematic review summarizing the published literature on nerve transfers to restore upper-extremity function in tetraplegia.

METHODS

A systematic literature search was conducted using Ovid MEDLINE 1946–, Embase 1947–, Scopus 1960–, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and clinicaltrials.gov to identify relevant literature published through January 2019. The authors included studies that provided original patient-level data and extracted information on clinical characteristics, operative details, and strength outcomes after nerve transfer procedures. Critical review and synthesis of the articles were performed.

RESULTS

Twenty-two unique studies, reporting on 158 nerve transfers in 118 upper limbs of 92 patients (87 males, 94.6%) were included in the systematic review. The mean duration from SCI to nerve transfer surgery was 18.7 months (range 4 months–13 years) and mean postoperative follow-up duration was 19.5 months (range 1 month–4 years). The main goals of reinnervation were the restoration of thumb and finger flexion, elbow extension, and wrist and finger extension. Significant heterogeneity in transfer strategy and postoperative outcomes were noted among the reports. All but one case report demonstrated recovery of at least Medical Research Council grade 3/5 strength in recipient muscle groups; however, there was greater variation in the results of larger case series. The best, most consistent outcomes were demonstrated for restoration of wrist/finger extension and elbow extension.

CONCLUSIONS

Motor nerve transfers are a promising treatment option to restore upper-extremity function after SCI. Flexor reinnervation strategies show variable treatment effect sizes; however, extensor reinnervation may provide more consistent, meaningful recovery. Despite numerous published case reports describing good patient outcomes with nerve transfers, there remains a paucity in the literature regarding optimal timing and long-term clinical outcomes with these procedures.

ABBREVIATIONS AIN = anterior interosseous nerve; ASIA = American Spinal Injury Association; ECRB = extensor carpi radialis brevis; EDC = extensor digitorum communis; EPL = extensor pollicis longus; FCR = flexor carpi radialis; FDP = flexor digitorum profundus; FDS = flexor digitorum superficialis; FPL = flexor pollicis longus; ICSHT = International Classification for Surgery of the Hand in Tetraplegia; MRC = Medical Research Council; PIN = posterior interosseous nerve; SCI = spinal cord injury.

Article Information

Correspondence Wilson Z. Ray: Washington University School of Medicine, St. Louis, MO. rayz@wustl.edu.

INCLUDE WHEN CITING Published online July 12, 2019; DOI: 10.3171/2019.4.SPINE19173.

Disclosures Dr. Mahan: consultant for AxoGen, joimax, and Gecko Biomedical. Dr. Ray: consultant for Globus and DePuy Synthes and patent holder with Acera.

© AANS, except where prohibited by US copyright law.

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Figures

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    PRISMA flow diagram outlining the systematic review process. Data added to the PRISMA template. From Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 6(7):e1000097, under the terms of the Creative Commons Attribution License. Figure is available in color online only.

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