The Era of Nerve Transfers in Tetraplegic Patients: Our Multidisciplinary Experience

Abstract

The aim of our work is to propose a systematic approach in the management of the upper limb rehabilitation in tetraplegic patients, focused on the preoperative rehabilitation aspects that must be tailored to the specific therapeutic path, in order to assure the best conditions both before the intervention or the conservative management, and optimize the results.Methods: Evaluation criteria, surgical and rehabilitation timing with reference to the recent literature are reported. Timing and objectives of upper limb rehabilitation in tetraplegic patients are discussed, focusing on obstacles in the management of patients that can be overcome with a multidisciplinary approach.Results and Discussion: The upper limb diagnostic-therapeutic path of tetraplegic patients is developed point by point, starting from the evaluation, the indications, therapeutic options, surgical timing and focusing on the role of pre-operative rehabilitation. At present, there is consensus regarding the need for physiotherapy aimed to maintain flexible joints if surgery is planned or learning compensatory mechanisms for candidates to a conservative management. The application timing of rehabilitation protocols in relation to the different surgical strategies is of great importance, as the choice to perform the classic tendon transfers or the most innovative nerve transfers influences the entire therapeutic path. Conclusion:The management of the tetraplegic patient requires a coordinated and multidisciplinary approach, which can be intended to implement residual functions, or prepare for surgery. Preoperative physiotherapy must take into account both the best personalized protocol and the timing dictated by the type of surgical choice.

Nerve transfers in a patient with asymmetrical neurological deficit following traumatic cervical spinal cord injury: simultaneous bilateral restoration of pinch grip and elbow extension. Illustrative case

“…Planning reconstruction with NTs of the most prioritized motor functions of the upper extremity is a challenging task because of the asymmetry of the neurological deficit following cervical SCI. 2 , 5 , 6 The mixture of injury patterns, 2 , 5 , 11 , 15 , 22 both of longitudinal 2 , 22 and segmental 2 , 22 origins, poses two main challenges for successful NT: (1) identification of IM and ILSs in regard to the long-term preservation of viability of target muscles 5 , 15 and (2) identification of donor nerves with preserved functionality, located close enough to the target muscle, in regard to the potential mixture of the injury pattern within one SLS.…”

“…8–10 Nowadays, surgical techniques aimed at restoring most prioritized functions of the upper extremity in the event of cervical SCI include tendon transfers, arthrodesis, tenodesis procedures, 1 and, most recently, nerve transfers (NTs). 1 , 2 , 11 Potential donor nerves in the event of cervical SCI can be found at the level of SLS: upper and lower motoneurons are intact, and corresponding muscles are under volitional control. 1 , 2 …”

“… 13 , 14 Myotomes that adhere to ILS in the event of cervical SCI are deprived of the time-dependence factor: 5 , 15 the myotomes preserve their connection with lower motoneurons and maintain tissue integrity and potential for recovery during a long period after the initial injury. 5 , 11 , 15 …”

“…Because most SCI injuries present with a mixed, complex injury pattern, 11 positive clinical results could be achieved if NT were performed shortly after SCI. 18 Relatively early NT helps to reduce the time sensitivity of the muscles related to IM, whereas electrodiagnostic studies serve only as a robust confirmation of the preserved nerve function in SLSs, which can potentially become donors.…”

“… 18 Relatively early NT helps to reduce the time sensitivity of the muscles related to IM, whereas electrodiagnostic studies serve only as a robust confirmation of the preserved nerve function in SLSs, which can potentially become donors. 5 , 11 , 15 , 18 …”