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A new technique in which working nerves are rerouted to paralyzed sites in patients with spinal cord injury provides patients with significant functional improvement in upper limb function and hands, and is described as a Thu".
A series of prospective cases of 16 patients undergoing this nerve transfer operation in an Australian hospital showed significant improvements in elbow extension and grasping and pinching functions of the hand.
In some cases, nerve transfer surgery has been successfully associated with tendon transfers to maximize functional benefits.
This report – the largest series of cases of consecutive prospective nerve transfers carried out in a single center of the quadriplegic population – was published online July 4 in the Lancet.
"Our results show that nerve transfer gives particularly good results for hand function, including grasping and pinching, as well as the position of the open hand needed to use a computer or smartphone. new reign of independence, "senior author Natasha van Zyl, MBBS, Austin Health, Melbourne, Australia, said Medscape Medical News.
"The improvements in manual function we achieved with nerve transfer enabled patients to heal themselves, manage their money, eat with ordinary utensils, have a drink or drink, drink alone and going to the toilet themselves.Using their hands for functions like this is what spinal cord injury patients want most – more than walking, "she added.
Nerves "consumables"
Van Zyl explained that the procedure involves taking a nerve that works but that it's time to consume (it provides a muscle also supported by other nerves that work) and reorient it to a paralyzed muscle.
"Many patients with spinal cord injuries still have the ability to move their shoulders, bend their elbows and extend their wrists – that means we have the nerves of those muscles at our disposal," she declared.
"It's like unplugging the power supply from the toaster and plugging it into the kettle's place."
She explained that nerve transfer is not a new concept. "We have been doing this for many years for peripheral nerve and brachial plexus lesions, but its use for spinal cord injury has only recently begun and, before this publication, only one case has been reported . "
Van Zyl has been a pioneer in this field.
"I was doing a lot of nerve transfer surgery on the brachial plexus and I thought it might work in the spinal cord lesions, so we started to do it and we had good results, here we report a series of cases with a careful documentation of methodology and results so that others Surgeons can learn about the techniques that work best, "she said.
She notes that tendon transfer is already an established technique for patients with spinal cord injury, but that nerve transfer has different benefits.
"The tendon transfer usually gives more strength to a muscle, but the nerve transfer gives more natural and subtle movements better for fine motor control," Van Zyl said.
Both techniques can be complementary and are sometimes practiced in opposite members.
"We often perform a tendon transfer in one arm and a nerve transfer in the other, so the patient has a strong hand and another one more suited to the complex actions needed for everyday life," Van Zyl explained. "If they have to pick up something on the ground, patients say that they would use their tendon transfer hand to hold the steering wheel and stabilize their wheelchair and their nerve transfer hand to grab the wheelchair." object."
Nerve transfer can also extend the elbow so that patients can perform tasks such as propelling their wheelchairs, turning off lights, or washing their hair, Van Zyl said.
"It is very important that people in wheelchairs can access a world designed for people standing," she said.
The authors note that cervical spine injuries are devastating injuries that affect the lives of 250,000 to 500,000 people each year worldwide, and that more than 50% of these injuries result in quadriplegia.
They point out that nerve transfers are an attractive option: the procedure can resuscitate more than one muscle at a time and multiple nerve transfers can be performed simultaneously. The procedure also requires a smaller operative incision and shorter recovery than tendon transfer.
The lancet The article describes a series of cases of 16 patients with early cervical spinal cord injury (less than 18 months post-injury) of less than or equal to C5 and having undergone single or multiple nerve transfers in the US. One of the upper limbs, sometimes combined with tendon transfers, for restoration purposes. elbow extension, grasping, pinching and opening of the hand. A total of 59 nerve transfers were performed in 27 members.
The results at 24 months showed clinically significant improvements over the initial values of the median total score of the medial action arm (16.5 to 34.0) and the Grasp release test (35.0 to 125, 2). Measuring the average independence of the spinal cord (SCIM) has also shown clinically significant improvements.
"There is no measure for an open hand action but it's actually there that I think the maximum benefit must be obtained," Van Zyl said.
A "huge" advantage
In an accompanying commentary, Elspeth JR Hill, MBChB, and Ida K. Fox, MD, surgeons from the Washington University of St. Louis, Missouri, who also perform this procedure, note that nerve transfers "represent a huge step forward in reconstructing to restore hand function after spinal cord injury."
"Nervous transfers are an economical way of harnessing the innate ability of the body to reestablish movement in a paralyzed limb," they write.
Referred for comments, Fox called the results of the report "phenomenal for patients".
"They are able to no longer use their hands at all to be able to perform daily tasks requiring precise motor control, such as having a drink, holding a cup, using a computer keyboard, a smartphone and a TV remote control. . " a real game changer, "she said Medscape Medical News.
Fox said the current article was "groundbreaking" as it "diligently documents the benefits, which can take several years to become obvious".
"The nerves take time to re-innervate the target muscles, but it also takes time for motor rehabilitation and cortical remodeling.The brain must find ways to use the rewired muscles again.
"This document documents the largest series and the longest follow-up reported so far, and I think this publication will make a difference and this option will now be considered more widely.
"Too often, desperate patients pay for unproven procedures, but this approach now relies on good data. It's a compelling job – people can clearly see that it works and has a good success rate, "Fox said.
However, she added, it is important to select the right patients, the right surgeon, the right nerves to transfer, and to ensure that the patient receives appropriate care – with dedicated physiotherapy, a crucial part of process. "
Not all patients are candidates
Van Zyl pointed out that the technique does not apply to all patients with a spinal cord injury.
"The patients we are describing here had C5 or C6 injuries, which probably would not work for those with higher wounds – there is no shoulder movement, the Nerves that work will not be available.But C5 and C6 are the most common type of spinal cord lesions. "
"Patients must have a nerve function to fly," said Fox.
As for the timing of the surgery, Van Zyl said earlier that it's probably better.
"About six months after the injury, it is thought to be optimal, but I have patients for whom this technique has been successful for several years after the injury," she said. "If the muscle can be stimulated by an electrode, the nerve junction with the muscle still works and we can perform a transfer into it."
This technique is only available in a few centers around the world. The Van Zyl team has been doing it for the longest time. She advises surgeons who are considering it to begin by redirecting the nerve supplying the supinator muscle of the posterior interosseous nerve to restore the opening of the hand. "We have achieved incredible results with this procedure and opening with the hand can not be achieved with tendon transfer.Some centers only offer this procedure."
Van Zyl said she hoped the study would encourage more surgeons to perform these procedures and raise awareness of the entire field of nerve and tendon transfer.
"Many people think that there is nothing that can be done to improve the manual function of patients with quadriplegia," she said, "but these techniques make it possible to obtain excellent results. "
This study was funded by the Institute for Research on Safety, Compensation and Recovery, based in Melbourne, Australia. The authors did not reveal any relevant financial relationship.
The lancet. Posted online July 4, 2019. Abstract, Editorial
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