Combined nerve and tendon transfer to restore elbow extension in tetraplegic patients: surgical technique and case report (original) (raw)
Related papers
Annals of rehabilitation medicine, 2016
In tetraplegia patients, activities of daily living are highly dependent on the remaining upper limb functions. In other countries, upper limb reconstruction surgery to improve function has been applied to diverse cases, but few cases have been reported in Korea. The current authors experienced a case of posterior deltoid-to-triceps tendon transfer and rehabilitation in a complete spinal cord injury with a C6 neurologic level, and we introduce the case-a 36-year-old man-with a literature review. The patient's muscle strength in C5 C6 muscles were normal, but C7 muscles were trace, and the Spinal Cord Independence Measure III (SCIM III) score was 24. The tendon of the posterior deltoid was transferred to the triceps brachii muscle, and then the patient received comprehensive rehabilitative treatment. His C7 muscle strength in the right upper extremity was enhanced from trace to fair, and his SCIM III score improved to 29.
The Journal of Hand Surgery, 2012
We undertook a brachialis to triceps nerve transfer to restore elbow extension in a 53-yearold man 5 months after he sustained a spine injury that resulted in a central cord syndrome. Within 3 months of surgery, the patient had recovered active elbow extension and had M3 level strength, which increased to M4 and 5 kg of strength by 12 months postoperatively. Despite transferring an antagonist nerve for triceps reinnervation, the patient had no problems controlling active elbow flexion-extension. Harvesting the brachialis nerve caused no permanent decrease in elbow flexion strength
Microsurgery, 2011
In spinal cord injuries at the C6 level, elbow extension is lost and needs reconstruction. Traditionally, elbow extension has been reconstructed by muscle transfers, which improve function only moderately. We have hypothesized that outcomes could be ameliorated by nerve transfers rather than muscle transfers. We anatomically investigated nerve branches to the teres minor and posterior deltoid as donors for transfer to triceps motor branches. In eight formalin-fixed cadavers, the axillary nerve, the teres minor branch, the posterior deltoid branch, the triceps long and upper medial head motor branches, and the thoracodorsal nerve were dissected bilaterally, their diameters measured and their myelinated fibers counted. To simulate surgery, using an axillary approach in two fresh cadavers, we transferred the teres minor or the posterior deltoid branch to the triceps long head and to the thoracodorsal nerve. The posterior division of the axillary nerve gave off the teres minor motor branch and then the branch to the posterior deltoid, terminating as the superior lateral brachial cutaneous nerve. The diameters of the teres minor motor branch, posterior deltoid, triceps long and upper medial head branches, and the thoracodorsal nerve all were 2 mm, with minimal variation. The nerves varied little in their numbers of myelinated fibers, being consistently about 1,000. Via an axillary approach, either the teres minor or the posterior deltoid branch could be transferred directly to the thoracodorsal nerve or to triceps branches without any tension.
Surgical Technique: Posterior Deltoid-to-Triceps Transfer in Tetraplegic Patients
The Journal of Hand Surgery, 2011
Several surgical techniques exist for restoring triceps function in tetraplegic patients. The goal is to establish a more synchronized, better controlled arm that allows increased self-sufficiency and further reconstructive surgery on the hand. To obtain the most secure fixation, adjust the tension, and allow early mobilization, the technique we prefer uses the central tendon of the triceps muscle and bony block fixation reinforced by the palmaris longus. (J Hand Surg 2011;36A:711-715. FIGURE 8: Preoperative photograph showing inability to extend elbow with gravity eliminated.
Transfer of the teres minor motor branch for triceps reinnervation in tetraplegia
Journal of Neurosurgery, 2011
In a case involving tetraplegia and paralysis of elbow extension, the authors transferred teres minor branches to the nerve of the triceps long head. Surgery was performed bilaterally 9 months after the patient sustained a spinal cord injury. Fourteen months postoperatively, elbow extension was complete (British Medical Research Council Score M4). Harvesting of the teres minor motor branch produced no deficits in shoulder function. In patients with tetraplegia, nerve transfer seems to be a promising new alternative for elbow extension reconstruction.
The Journal of Hand Surgery, 2013
A 39-year-old tetraplegic patient had paralysis of elbow, thumb, and finger extension and thumb and finger flexion. We transferred axillary nerve branches to the triceps long and upper medial head motor branches, supinator motor branches to the posterior interosseous nerve, and brachioradialis tendon to the flexor pollicis longus and flexor superficialis of the index finger. Surgery was performed bilaterally 18 months after spinal cord injury. At 12 months after surgery, we performed bilateral distal radioulnar arthrodesis percutaneously. By 22 months postoperatively, we observed triceps strength scoring M3 bilaterally and full metacarpophalangeal joint extension scoring M4 bilaterally. The thumb span was 53 and 66 mm from the proximal index phalanx on the right and left sides, respectively. Pinch strength measured 1.5 kg on the left side and 2.0 kg on the right. Before surgery, the patient was incapable of grasping; after surgery, a useful grasp had been restored bilaterally. (J Hand Surg 2013;xx:.
Nerve transfers in tetraplegia I: Background and technique
Surgical Neurology International, 2011
Background: The recovery of hand function is consistently rated as the highest priority for persons with tetraplegia. Recovering even partial arm and hand function can have an enormous impact on independence and quality of life of an individual. Currently, tendon transfers are the accepted modality for improving hand function. In this procedure, the distal end of a functional muscle is cut and reattached at the insertion site of a nonfunctional muscle. The tendon transfer sacrifices the function at a lesser location to provide function at a more important location. Nerve transfers are conceptually similar to tendon transfers and involve cutting and connecting a healthy but less critical nerve to a more important but paralyzed nerve to restore its function. Methods: We present a case of a 28-year-old patient with a C5-level ASIA B (international classification level 1) injury who underwent nerve transfers to restore arm and hand function. Intact peripheral innervation was confirmed in the paralyzed muscle groups corresponding to finger flexors and extensors, wrist flexors and extensors, and triceps bilaterally. Volitional control and good strength were present in the biceps and brachialis muscles, the deltoid, and the trapezius. The patient underwent nerve transfers to restore finger flexion and extension, wrist flexion and extension, and elbow extension. Intraoperative motor-evoked potentials and direct nerve stimulation were used to identify donor and recipient nerve branches. Results: The patient tolerated the procedure well, with a preserved function in both elbow flexion and shoulder abduction. Conclusions: Nerve transfers are a technically feasible means of restoring the upper extremity function in tetraplegia in cases that may not be amenable to tendon transfers.
Plastic and reconstructive surgery, 2018
Surgical strategy to treat incomplete brachial plexus injury with palsies of the shoulder and elbow by using proximal nerve graft/transfer or distal nerve transfer is still debated. The aim of this study was to compare both strategies with respect to the recovery of elbow flexion. One hundred forty-seven patients were enrolled: 76 patients underwent reconstruction using proximal nerve graft/transfer, and 71 patients underwent reconstruction using distal nerve transfer. All patients were evaluated preoperatively and postoperatively to assess the recovery rate and muscle strength of elbow flexion. Shoulder abduction and hand grip power were also recorded to assess any concomitant postoperative changes between the two methods. The best recovery rate for functional elbow flexion (p = 0.006) and the fastest recovery to M3 strength (p < 0.001) were found in the double fascicular transfer group. However, recovery of shoulder abduction with proximal nerve graft/transfer was significantly...