Supinator to Posterior Interosseous Nerve Transfer for Recovery of Hand Opening in the Tetraplegic Patient: A Case Series

Abstract

BACKGROUND AND OBJECTIVES: Cervical spinal cord injury results in devastating loss of function. Nerve transfers can restore functional use of the hand, the highest priority function in this population to gain independence. Transfer of radial nerve branches innervating the supinator to the posterior interosseous nerve (SUP-PIN) has become a primary intervention for the recovery of hand opening, but few outcome reports exist to date. We report single-surgeon outcomes for this procedure. METHODS: The SUP-PIN transfer was performed on adults with traumatic spinal cord injury resulting in hand paralysis. Outcome measures include Medical Research Council strength grade for extension of each digit, and angles representing critical apertures: the first web space opening of the thumb, and metacarpophalangeal angle of the remaining fingers. Factors affecting these measurements, including preserved tone and spasticity of related muscles, were also assessed. RESULTS: Twenty-three adult patients with a C5–7 motor level underwent SUP-PIN transfers on 36 limbs (median age 31 years, interquartile range [21.5, 41]). The median interval from injury to surgery was 10.5 (8.2, 6.5) months, with 9 (7.5, 11) months for the acute injuries and 50 (32, 66) months for the chronic (>18 months) injuries. Outcomes were observed at a mean follow-up of 22 (14, 32.5) months. 30 (83.3%) hands recovered at least antigravity extension of the thumb and 34 (94.4%) demonstrated successful antigravity strength for the finger extensors, providing adequate opening for a functional grasp. Chronic patients (>18 months after injury) showed similar outcomes to those who had earlier surgery. Supination remained strong (at least M4) in all but a single patient and no complications were observed. CONCLUSION: SUP-PIN is a reliable procedure for recovery of finger extension. Chronic patients remain good candidates, provided innervation of target muscles is preserved. Higher C5 injuries were more likely to have poor outcomes.