Optimizing nerve transfer surgery in tetraplegia: clinical decision making based on innervation patterns in spinal cord injury

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  • 1 Departments of Neurological Surgery, and
  • | 2 Physical Medicine and Rehabilitation, Washington University, St. Louis, Missouri;
  • | 3 Department of Neurological Surgery, Johns Hopkins University, Baltimore, Maryland;
  • | 4 Department of Clinical Neurosciences, University of Calgary, Alberta, Canada; and
  • | 5 Department of Neurological Surgery, University of Michigan School of Medicine, Ann Arbor, Michigan
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OBJECTIVE

Nerve transfers are increasingly being utilized in the treatment of chronic tetraplegia, with increasing literature describing significant improvements in sensorimotor function up to years after injury. However, despite technical advances, clinical outcomes remain heterogenous. Preoperative electrodiagnostic testing is the most direct measure of nerve health and may provide prognostic information that can optimize preoperative patient selection. The objective of this study in patients with spinal cord injury (SCI) was to determine various zones of injury (ZOIs) via electrodiagnostic assessment (EDX) to predict motor outcomes after nerve transfers in tetraplegia.

METHODS

This retrospective review of prospectively collected data included all patients with tetraplegia from cervical SCI who underwent nerve transfer at the authors’ institution between 2013 and 2020. Preoperative demographic data, results of EDX, operative details, and postoperative motor outcomes were extracted. EDX was standardized into grades that describe donor and recipient nerves. Five zones of SCI were defined. Motor outcomes were then compared based on various zones of innervation.

RESULTS

Nineteen tetraplegic patients were identified who underwent 52 nerve transfers targeting hand function, and 75% of these nerve transfers were performed more than 1 year postinjury, with a median interval to surgery following SCI of 24 (range 8–142) months. Normal recipient compound muscle action potential and isolated upper motor neuron injury on electromyography (EMG) were associated with greater motor recovery. When nerve transfers were stratified based on donor EMG, greater motor gains were associated with normal than with abnormal donor EMG motor unit recruitment patterns. When nerve transfers were separated based on donor and recipient nerves, normal flexor donors were more crucial than normal extensor donors in powering their respective flexor recipients.

CONCLUSIONS

This study elucidates the relationship of the preoperative innervation zones in SCI patients to final motor outcomes. EDX studies can be used to tailor surgical therapies for nerve transfers in patients with tetraplegia. The authors propose an algorithm for optimizing nerve transfer strategies in tetraplegia, whereby understanding the ZOI and grade of the donor/recipient nerve is critical to predicting motor outcomes.

ABBREVIATIONS

AIN = anterior interosseus nerve; AIS = American Spinal Injury Association (ASIA) Impairment Scale; APB = abductor pollicis brevis; CMAP = compound muscle action potential; EDC = extensor digitorum communis; EDX = electrodiagnostic assessment; EIP = extensor indicis proprius; EMG = electromyography; EPB = extensor pollicis brevis; 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; IP-AMUNE = interference pattern–average motor unit number estimate; LMN = lower motor neuron; MRC = Medical Research Council; MUP = motor unit potential; NCS = nerve conduction study; PIN = posterior interosseus nerve; SA = spinal accessory; SCI = spinal cord injury; UMN = upper motor neuron; ZOI = zone of injury.

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