Optimizing the Timing of Peripheral Nerve Transfers for Functional Re-Animation in Cervical Spinal Cord Injury: A Conceptual Framework

Castanov, Valera; Berger, Michael; Ritsma, Benjamin; Trier, Jessica; Hendry, Joy

doi:10.1089/neu.2021.0247

Cited by 13 publications

(15 citation statements)

References 65 publications

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“…Our findings challenge the classic notion that delayed nerve transfers are not feasible, because outcomes of nerve transfers performed in chronic SCI (ie, ≥12 months) were comparable to early nerve transfers. 38 This finding suggests that with careful selection of healthy recipient nerves, motor function can be maximized in both subacute and chronic SCI. 39 Nerve transfers performed in upper limbs with a lower level of injuries (ICSHT groups 3-4), which often have intact wrist extension and forearm pronation, resulted in superior motor outcomes compared with higher-level injuries (ICSHT groups 0-2).…”

Section: Discussionmentioning

confidence: 99%

Upper Limb Nerve Transfer Surgery in Patients With Tetraplegia

et al. 2022

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ImportanceCervical spinal cord injury (SCI) causes devastating loss of upper extremity function and independence. Nerve transfers are a promising approach to reanimate upper limbs; however, there remains a paucity of high-quality evidence supporting a clinical benefit for patients with tetraplegia.ObjectiveTo evaluate the clinical utility of nerve transfers for reanimation of upper limb function in tetraplegia.Design, Setting, and ParticipantsIn this prospective case series, adults with cervical SCI and upper extremity paralysis whose recovery plateaued were enrolled between September 1, 2015, and January 31, 2019. Data analysis was performed from August 2021 to February 2022.InterventionsNerve transfers to reanimate upper extremity motor function with target reinnervation of elbow extension and hand grasp, pinch, and/or release.Main Outcomes and MeasuresThe primary outcome was motor strength measured by Medical Research Council (MRC) grades 0 to 5. Secondary outcomes included Sollerman Hand Function Test (SHFT); Michigan Hand Outcome Questionnaire (MHQ); Disabilities of Arm, Shoulder, and Hand (DASH); and 36-Item Short Form Health Survey (SF-36) physical component summary (PCS) and mental component summary (MCS) scores. Outcomes were assessed up to 48 months postoperatively.ResultsTwenty-two patients with tetraplegia (median age, 36 years [range, 18-76 years]; 21 male [95%]) underwent 60 nerve transfers on 35 upper limbs at a median time of 21 months (range, 6-142 months) after SCI. At final follow-up, upper limb motor strength improved significantly: median MRC grades were 3 (IQR, 2.5-4; P = .01) for triceps, with 70% of upper limbs gaining an MRC grade of 3 or higher for elbow extension; 4 (IQR, 2-4; P &lt; .001) for finger extensors, with 79% of hands gaining an MRC grade of 3 or higher for finger extension; and 2 (IQR, 1-3; P &lt; .001) for finger flexors, with 52% of hands gaining an MRC grade of 3 or higher for finger flexion. The secondary outcomes of SHFT, MHQ, DASH, and SF36-PCS scores improved beyond the established minimal clinically important difference. Both early (&lt;12 months) and delayed (≥12 months) nerve transfers after SCI achieved comparable motor outcomes. Continual improvement in motor strength was observed in the finger flexors and extensors across the entire duration of follow-up.Conclusions and RelevanceIn this prospective case series, nerve transfer surgery was associated with improvement of upper limb motor strength and functional independence in patients with tetraplegia. Nerve transfer is a promising intervention feasible in both subacute and chronic SCI.

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Section: Discussionmentioning

confidence: 99%

Upper Limb Nerve Transfer Surgery in Patients With Tetraplegia

et al. 2022

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“…5,43 There is a narrow window of opportunity for the timing of these surgeries, as permanent denervation and atrophy occurs in the muscles involved in the injured segment of the spinal cord. 7,44 However, it is important to consider that following tetraplegia, patients have significant potential for spontaneous recovery in the early phase of SCI. 15,45 Therefore, early surgery might obliterate the spontaneous natural recovery following SCI.…”

Section: Discussionmentioning

confidence: 99%

“…15,45 Therefore, early surgery might obliterate the spontaneous natural recovery following SCI. 7 This heterogeneity of clinical presentation complicates clinical decision-making regarding the appropriateness and timing of surgical intervention. This newly developed score after SCI may serve as a clinical decision support tool preventing unnecessary resource investment and irreversible reconstructive surgeries in patients with high probability of functional improvement.…”

Section: Discussionmentioning

confidence: 99%

“…5,6 However, reconstructive upper limb surgeries carry risk, and subsets of SCI patients have significant potential for spontaneous recovery without any intervention. 7 There are competing interests at play, whereby early surgery may impair spontaneous natural recovery, while late surgery may fail due to irreversible neuromuscular atrophy resulting in suboptimal outcomes. 7 Therefore, determining appropriate surgical candidates and surgical timing remains a major challenge and is foundational in maximizing outcomes.…”

Section: Introductionmentioning

confidence: 99%

“…7 There are competing interests at play, whereby early surgery may impair spontaneous natural recovery, while late surgery may fail due to irreversible neuromuscular atrophy resulting in suboptimal outcomes. 7 Therefore, determining appropriate surgical candidates and surgical timing remains a major challenge and is foundational in maximizing outcomes. Moreover, it remains a challenge to determine the inclusion of cervical SCI patients in acute clinical trials.…”

Section: Introductionmentioning

confidence: 99%

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Derivation and Validation of a Clinical Prediction Rule for Upper Limb Functional Outcomes After Traumatic Cervical Spinal Cord Injury

et al. 2022

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ImportanceTraumatic cervical spinal cord injury (SCI) can result in debilitating paralysis. Following cervical SCI, accurate early prediction of upper limb recovery can serve an important role in guiding the appropriateness and timing of reconstructive therapies.ObjectiveTo develop a clinical prediction rule to prognosticate upper limb functional recovery after cervical SCI.Design, Setting, and ParticipantsThis prognostic study was a retrospective review of a longitudinal cohort study including patients enrolled in the National SCI model systems (SCIMS) database in US. Eligible patients were 15 years or older with tetraplegia (neurological level of injury C1-C8, American Spinal Cord Injury Association [ASIA] impairment scale [AIS] A-D), with early (within 1 month of SCI) and late (1-year follow-up) clinical examinations from 2011 to 2016. The data analysis was conducted from September 2021 to June 2022.Main Outcomes and MeasuresThe primary outcome was a composite of dependency in eating, bladder management, transfers, and locomotion domains of functional independence measure at 1-year follow-up. Each domain ranges from 1 to 7 with a lower score indicating greater functional dependence. Composite dependency was defined as a score of 4 or higher in at least 3 chosen domains. Multivariable logistic regression was used to predict the outcome based on early neurological variables. Discrimination was quantified using C statistics, and model performance was internally validated with bootstrapping and 10-fold cross-validation. The performance of the prediction score was compared with AIS grading. Data were split into derivation (2011-2014) and temporal-validation (2015-2016) cohorts.ResultsAmong 2373 patients with traumatic cervical SCI, 940 had complete 1-year outcome data (237 patients [25%] aged 60 years or older; 753 men [80%]). The primary outcome was present in 118 patients (13%), which included 92 men (78%), 83 (70%) patients who were younger than 60 years, and 73 (62%) patients experiencing AIS grade A SCI. The variables significantly associated with the outcome were age (age 60 years or older: OR, 2.31; 95% CI, 1.26-4.19), sex (men: OR, 0.60; 95% CI, 0.31-1.17), light-touch sensation at C5 (OR, 0.44; 95% CI, 0.44-1.01) and C8 (OR, 036; 95% CI, 0.24-0.53) dermatomes, and motor scores of the elbow flexors (C5) (OR, 0.74; 95% CI, 0.60-0.89) and wrist extensors (C6) (OR, 0.61; 95% CI, 0.49-0.75). A multivariable model including these variables had excellent discrimination in distinguishing dependent from independent patients in the temporal-validation cohort (C statistic, 0.90; 95% CI, 0.88-0.93). A clinical prediction score (range, 0 to 45 points) was developed based on these measures, with higher scores increasing the probability of dependency. The discrimination of the prediction score was significantly higher than from AIS grading (change in AUC, 0.14; 95% CI, 0.10-0.18; P &lt; .001).Conclusions and RelevanceThe findings of this study suggest that this prediction rule may help prognosticate upper limb function following cervical SCI. This tool can be used to set patient expectations, rehabilitation goals, and aid decision-making regarding the appropriateness and timing for upper limb reconstructive surgeries.

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Segmental infralesional pathological spontaneous activity in subacute traumatic spinal cord injury

Berger,

Adewuyi,

Doherty

et al. 2024

Muscle and Nerve

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Introduction/AimsThere is a dearth of knowledge regarding the status of infralesional lower motor neurons (LMNs) in individuals with traumatic cervical spinal cord injury (SCI), yet there is a growing need to understand how the spinal lesion impacts LMNs caudal to the lesion epicenter, especially in the context of nerve transfer surgery to restore several key upper limb functions. Our objective was to determine the frequency of pathological spontaneous activity (PSA) at, and below, the level of spinal injury, to gain an understanding of LMN health below the spinal lesion.MethodsNinety‐one limbs in 57 individuals (53 males, mean age = 44.4 ± 16.9 years, mean duration from injury = 3.4 ± 1.4 months, 32 with motor complete injuries), were analyzed. Analysis was stratified by injury level as (1) C4 and above, (2) C5, and (3) C6‐7. Needle electromyography was performed on representative muscles innervated by the C5‐6, C6‐7, C7‐8, and C8‐T1 nerve roots. PSA was dichotomized as present or absent. Data were pooled for the most caudal infralesional segment (C8‐T1).ResultsA high frequency of PSA was seen in all infralesional segments. The pooled frequency of PSA for all injury levels at C8‐T1 was 68.7% of the limbs tested. There was also evidence of PSA at the rostral border of the neurological level of injury, with 58.3% of C5‐6 muscles in those with C5‐level injuries.DiscussionThese data support a high prevalence of infralesional LMN abnormalities following SCI, which has implications to nerve transfer candidacy, timing of the intervention, and donor nerve options.

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Optimizing the Timing of Peripheral Nerve Transfers for Functional Re-Animation in Cervical Spinal Cord Injury: A Conceptual Framework

Cited by 13 publications

References 65 publications

Upper Limb Nerve Transfer Surgery in Patients With Tetraplegia

Upper Limb Nerve Transfer Surgery in Patients With Tetraplegia

Derivation and Validation of a Clinical Prediction Rule for Upper Limb Functional Outcomes After Traumatic Cervical Spinal Cord Injury

Segmental infralesional pathological spontaneous activity in subacute traumatic spinal cord injury

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