Nerve transfers for the restoration of hand function after spinal cord injury

Case report

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Spinal cord injury (SCI) remains a significant public health problem. Despite advances in understanding of the pathophysiological processes of acute and chronic SCI, corresponding advances in translational applications have lagged behind. Nerve transfers using an expendable nearby motor nerve to reinnervate a denervated nerve have resulted in more rapid and improved functional recovery than traditional nerve graft reconstructions following a peripheral nerve injury. The authors present a single case of restoration of some hand function following a complete cervical SCI utilizing nerve transfers.

Abbreviations used in this paper:AIN = anterior interosseous nerve; ASIA = American Spinal Injury Association; ICSHT = International Classification for Surgery of the Hand in Tetraplegia; MRC = Medical Research Council; SCI = spinal cord injury.

Article Information

Address correspondence to: Wilson Z. Ray, M.D., Department of Neurological Surgery, Washington University School of Medicine, 660 South Euclid Avenue, St. Louis, Missouri 63110. email:

Please include this information when citing this paper: published online May 15, 2012; DOI: 10.3171/2012.3.JNS12328.

© AANS, except where prohibited by US copyright law.



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    Preoperative physical examination of the left and right upper extremities. A–E: Left upper extremity. The patient exhibited strong elbow flexion (A), strong pronation (B), strong wrist flexion (C), strong wrist extension (D), but no finger or thumb movement (E). F–J: Right upper extremity. The patient exhibited strong elbow flexion (F) and his pronation was near normal in strength (slight weakness)(G). He was able to flex his wrist, but not against resistance specifically testing flexor carpi radialis (H). His wrist extension was strong with slight weakness in wrist extension (I). He exhibited no finger or thumb movement (J).

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    Musculocutaneous and median nerve anatomy relevant to the brachialis nerve to AIN transfer in C-7 SCI. A: The donor brachialis branch divides from the musculocutaneous nerve on its medial aspect. After this branch point, the musculocutaneous nerve becomes the lateral antebrachial cutaneous nerve. B: The recipient AIN branches from the median nerve in the forearm on its lateral aspect, but courses proximally into the arm on its posterior/medial aspect. The donor brachialis nerve is transferred into the anterior interosseous fascicle in the arm. C: The AIN fascicle in the arm is located on the posterior/medial aspect of the median nerve, between the palmaris longus/flexor digitorum superficialis/flexor carpi radialis fascicle and the sensory component of the median nerve. The fascicular group to the pronator teres is located in the anterior portion of the median nerve, while the sensory fibers are lateral and the motor fibers medial. A = anterior; L = lateral; M = medial; N = nerve; P = posterior; R = radial; U = ulnar.

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    Intraoperative electrical stimulation of the nonintact nerves. A: Stimulation of the right anterior interosseous fascicle with the hand at rest and contraction of the flexor pollicis longus and median nerve–innervated flexor digitorum profundus. B: Stimulation of the right ulnar nerve with the hand at rest and contraction of the intrinsic muscles, more apparent on the lateral aspect. C: Stimulation of the left anterior interosseous fascicle with the hand at rest and contraction. The blue arrows indicate change from the nonstimulated to the stimulated condition.

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    Qualitative histological assessment of the brachialis nerve and AIN in the right extremity. Upper: A small fascicle of the brachialis nerve reveals normal myelinated nerve fibers. This fascicle is not representative of the brachialis branch used as the donor nerve for transfer. Lower: Assessment of the nonintact AIN reveals sporadic myelinated fibers. Original magnification × 100.

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    Brachialis nerve–AIN transfer in the left upper extremity. A: The anterior interosseous fascicle was separated from the median nerve on its posterior/medial aspect. B: The distal branches of the brachialis nerve were identified. C: The brachialis nerve was transected distally and the anterior interosseous fascicle was separated proximally for transection. D: The donor brachialis nerve was transferred to the recipient anterior interosseous fascicle. LABC = lateral antebrachial cutaneous.

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    Brachialis nerve–AIN transfer in the right extremity. A: The AIN was identified distally and followed proximally to identify its fascicular component. B: The distal branches of the brachialis nerve were identified. C: The brachialis nerve was transected distally and the anterior interosseous fascicle was separated proximally. D: The donor brachialis nerve was transferred to the recipient anterior interosseous fascicle.

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    Postoperative examination of the left and right hands following brachialis nerve–AIN transfer. A and B: Left and right hands in resting position. C and D: Left and right hands performing AIN function through pinch with simultaneous activation of the donor brachialis nerve through elbow flexion. E and F: Functional recovery included the ability to grasp small objects such as a ball. G and H: The patient has recovered the ability to feed himself.

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    Mirror therapy utilizing the left hand to rehabilitate the weaker right hand. Left: The patient used the left hand, with its recovered AIN function, to visualize the mirror image as the right hand during cocontraction. Right: The right hand within the mirror box.


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