The goal of the investigators work is to establish how nerve transfers can be best used to
improve upper extremity function in patients with cervical level spinal cord injury (SCI).
The investigators' hypothesis is that nerve transfers are safe and effective and will
improve function and quality of life in patients with loss of upper function due to spinal
cord injury. The investigators plan on looking at upper limb function, and health-related
quality of life in patients before and after surgery to better understand how patients
benefit from these treatments.
A nerve transfer procedure can be used to rewire the system to make some muscles work again
following SCI. The nerve transfer procedure (which is done in the arm and not at the level
of the spinal cord) can be used to bypass the damaged area and to deliver a signal from the
brain to a muscle that became disconnected following that injury. A donor nerve is taken
from another muscle whose use is not essential and then transferred to help in providing
more a more critical function.
For example, one type of nerve transfer is done to restore the lost ability to pinch or
grasp small objects between the fingers that occurs in many patients with cervical SCI. In
this surgery, a donor nerve that normally helps flex the elbow. This nerve can be used
because the biceps muscle is also working to flex the elbow. This donor nerve is cut and
re-attached to the nerve going to muscles in the forearm that provide pinch by bending the
tips of the thumb and index finger.
Because the nerve transfer procedure involves cutting and reattaching nerve and muscle
tissues, time is required to regenerate working connections between the nerves and muscle as
well as to allow the brain to relearn how to use and strengthen that muscle.
Cervical spinal cord injury (SCI) is a life altering injury that results in profound loss of
upper limb function. Nerve transfer surgery has transformed the field of peripheral nerve
injury surgery, allowing remarkable restoration of upper limb motor function. The
investigators expanded use of nerve transfer surgery to cervical SCI patients and are the
first center to successfully restore volitional hand function in a patient with a C7 motor
level injury (now 3 years post-surgery). Results in 7 more patients show early functional
gains at 3-6 months post-surgery (most gains are expected at 12 months and these patients
are still early in their course). The proposed study will obtain formative outcomes data
from a pilot investigation of nerve transfer surgery to restore upper extremity function in
patients with cervical SCI.
Upper extremity and hand function is essential to basic activities of daily living and
independence; patients with cervical SCI rate this as more important than walking and sexual
performance. Restoration of critical upper extremity and hand function requires the unique
expertise and technical skill of hand surgeons; traditionally tendon transfer/tenodesis are
used. Although studies report reasonable outcomes in SCI patients for this procedure, use is
limited particularly in the US.
Nerve transfers offer an alternative and promising approach. In peripheral nerve injury,
nerve transfers are well-established, safe and are often the treatment of choice. A nerve
transfer uses an expendable donor nerve and coapts this to a nonfunctional recipient nerve
to restore volitional motor function. Since a nerve transfer reinnervates the
musculotendinous unit responsible for the absent but desired function, this procedure: 1)
does not have the biomechanical limitations of tendon transfers; 2) can use expendable donor
nerves whose muscles cannot be used for tendon transfer (i.e. the brachialis); and 3) a
single donor nerve can provide more than one function via reinnervation of multiple muscles.
Most importantly for SCI patient acceptability, nerve transfers do not require prolonged
periods of immobilization; early resumption of activity is encouraged.
Case reports offer early evidence that this novel application of nerve transfers may be a
better alternative to tendon transfers in SCI. Based on our extensive experience with nerve
transfers in peripheral nerve injury, we expect this approach will have a profound impact on
improving function, independence and health-related quality of life (QoL).
The purpose of this study is to provide evidence on the feasibility, safety, and outcomes of
nerve transfers in SCI patients via systematically collected data and to evaluate patients'
perspective of the benefits and disadvantages of nerve transfers. These data are vital for
patient selection, patient and surgeon education, and adaptation of this well-established
technique to this unique and traditionally underserved patient population.
Hypothesis and Approach:
Hypothesis: Nerve transfers are safe, effective procedures that have a role in the treatment
armamentarium of cervical SCI associated upper extremity dysfunction.
Aim 1: To document the safety, time course and improvement (potential for nerve transfers to
improve functional outcomes) by assessing pre and post-operative function.
Aim 2: To evaluate the feasibility and suitability of nerve transfers through
multidisciplinary evaluation, electrodiagnostic testing, ultrasound, and nerve specimen
examination and correlation with the clinical outcome.
Aim 3: To assess patient satisfaction with and acceptability for this treatment by use of
semi-structured patient interviews.
- clinical diagnosis of cervical level spinal cord injury
- some upper extremity dysfunction (ex: lack of wrist extension or hand function)
- greater then 6 months post-injury or with stable neurologic function for at least 6
- good access to and ability to pay for hand and physical therapy
- ability to comply and participate in rigorous post-surgical therapy regimen
- severe autonomic dysreflexia
- open pressure sores or other wounds
- respiratory insufficiency
- untreated urinary tract infections
- lack of access to physical therapy