Leprosy Mailing List – July 8, 2019
Ref.: (LML) Nerve transfers for the restoration of upper limb function in tetraplegia
From: Pieter AM Schreuder, Maastricht, the Netherlands
Dear colleagues,
Last week, I read an interesting piece in the Guardian, UK edition. In this they refer to an article in the Lancet medical journal.
Pioneering surgery brings movement back to paralysed hands by Sarah Boseley and Calla Wahlquist, The Guardian, July 5, 2019
Melbourne-based Natasha van Zyl has treated 13 young adults with nerve transfer surgery
Thirteen young adults who were paralysed in sporting or traffic accidents have had movement in their hands restored through pioneering nerve transfer surgery, enabling them to feed themselves, hold a drink, write and in some cases return to work.
Natasha van Zyl, the Melbourne-based surgeon who leads a research programme that has given some people their lives back, said the patients were able to use their hands and extend their arms from the elbow. "Extending your elbow allows you to push a wheelchair better, helps you to transfer in and out of a car, reach out and do something in space in front of you, shake someone's hand.
"It allows you to reach above your head, which you need to be able to do because the world is designed for standing-up people. So you can switch a light off, you can get something off a shelf. Hand function is everything you use your hand for. You would just need to tape your hands up for five minutes to experience how frustrating life would be without your hands, without your fingers."
The team at Austin Health in Melbourne, Australia, have been using combinations of tendon transfers, which result in greater strength for the muscle, and nerve transfers, which improve dexterity. Their findings from their work on 13 patients are reported reported in the Lancet medical journal. Van Zyl says she hopes they will encourage the thousands of people who become tetraplegic (also known as quadriplegic) by losing the function of all four limbs to seek surgery which could help them live more normal lives.
Expanding traditional tendon-based techniques with nerve transfers for the restoration of upper limb function in tetraplegia: a prospective case series. Natasha van Zyl, MBBS , Bridget Hill, PhD , Catherine Cooper, BAppSc, Jodie Hahn, BAppSc , Prof Mary P Galea, PhD. The Lancet: July 04, 2019 DOI:https://doi.org/10.1016/S0140-6736(19)31143-2
Summary
Background
Loss of upper extremity function after cervical spinal cord injury greatly affects independence, including social, vocational, and community engagement. Nerve transfer surgery offers an exciting new option for the reanimation of upper limb function in tetraplegia. The aim of this study was to evaluate the outcomes of nerve transfer surgery used for the reanimation of upper limb function in tetraplegia.
Methods
In this prospective case series, we consecutively recruited people of any age with early (<18 months post-injury) cervical spinal cord injury of motor level C5 and below, who had been referred to a single centre for upper extremity reanimation and were deemed suitable for nerve transfer. All participants underwent single or multiple nerve transfers in one or both upper limbs, sometimes combined with tendon transfers, for restoration of elbow extension, grasp, pinch, and hand opening. Participants were assessed at 12 months and 24 months post-surgery. Primary outcome measures were the action research arm test (ARAT), grasp release test (GRT), and spinal cord independence measure (SCIM).
Findings
Between April 14, 2014, and Nov 22, 2018, we recruited 16 participants (27 limbs) with traumatic spinal cord injury, among whom 59 nerve transfers were done. In ten participants (12 limbs), nerve transfers were combined with tendon transfers. 24-month follow-up data were unavailable for three patients (five limbs). At 24 months, significant improvements from baseline in median ARAT total score (34·0 [IQR 24·0–38·3] at 24 months vs 16·5 [12·0–22·0] at baseline, p<0·0001) and GRT total score (125·2 [65·1–154·4] vs 35·0 [21·0–52·3], p<0·0001) were observed. Mean total SCIM score and mobility in the room and toilet SCIM score improved by more than the minimal detectable change and the minimal clinically important difference, and the mean self-care SCIM score improved by more than the minimal detectable change between baseline and 24 months. Median Medical Research Council strength grades were 3 (IQR 2–3) for triceps and 4 (IQR 4–4) for digital extensor muscles after 24 months. Mean grasp strength at 24 months was 3·2 kg (SD 1·5) in participants who underwent distal nerve transfers (n=5), 2·8 kg (3·2) in those who had proximal nerve transfers (n=9), and 3·9 kg (2·4) in those who had tendon transfers (n=8). There were six adverse events related to the surgery, none of which had any ongoing functional consequences.
Interpretation
Early nerve transfer surgery is a safe and effective addition to surgical techniques for upper limb reanimation in tetraplegia. Nerve transfers can lead to significant functional improvement and can be successfully combined with tendon transfers to maximise functional benefits.
Request editors: If any of you reads an interesting article related to leprosy and you think it worthwhile to circulate in LML, please let us know.
Regards,
Pieter AM Schreuder
LML - S Deepak, B Naafs, S Noto and P Schreuder
LML blog link: http://leprosymailinglist.blogspot.it/
Contact: Dr Pieter Schreuder << editorlml@gmail.com
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