1. Introducing Nerve Transfers for Upper Limb Reanimation in Tetraplegia
Natasha van Zyl MBChB, FRACS
Plastic and Reconstructive Surgeon
The Upper Limb Program
Victorian Spinal Cord Service
Austin Health
Heidelberg, Victoria, Australia
Co-Authors:
Stephen Flood
Michael Weymouth
Catherine Cooper
Jodie Hahn
Andrew Nunn

2. Aim To reconstruct:- Elbow extension Grasp Release To do it:-
By using nerve transfers alone
With no/little morbidity from donor nerve harvest
While keeping the all the options for standard tendon transfer reconstruction available
The authors have recently introduced a nerve transnfer program for upper limb reanimation and a tertiary spinal hospital. Our aims were…

3. This presentation describes…
Background to the conception of this project
Therapeutic & investigational techniques involved
Logistics of delivery & assessment of safe nerve transfer reconstruction in tetraplegia

4. Background Inspiration: Success of nerve transfers in BPI & PNI
Reanimate the native muscle directly
Careful choice of donor nerves can preserve muscles used for tendon transfers
These muscles can be used to reconstruct distal functions e.g. opposition, intrinsic function
No more grafts, tendon tensioning, stretching or adhesion problems, no long immobilisations
Greater than 1:1 functional exchange

5. What is a motor nerve transfer?
Surgical reinnervation of a denervated muscle by transferring an expendable, intact donor nerve to the non-functional nerve of a paralysed muscle in order to reanimate that muscle with axonal ingrowth from the donor nerve

6. What is different in SCI?
Donor nerves
Use “obscure” muscles – difficult to be sure they are under voluntary control
Recipient nerves
May be LMN or UMN denervated or a combination of both so time to surgery is an issue

7. Where to start ?... The Team! 3 Surgeons 2 Specialist Tetraplegia OT’s
Spinal Rehabilitation Physicians
Spinal Physiotherapists and OT’s
Neurologist
Neuroscience technician
(Histopathologist)

8. Patient Selection SCI Adults, C5-C7 motor level of injury
Complete or incomplete
Seeking surgical improvement of upper limb function
No head, BPI or PNI
No pre-existing neurological condition
Able to comply with therapy pre and post op

9. Clinical Assessment Initial consult - 3/12
Routine motor and sensory examination
Upper limb AROM and PROM
Upper limb spasticity assessment
Examination of all potential donor nerve muscles
FES of recipient nerve’s muscles

10. Consent Details of operation Hospital stay
Immobilisation and upper limb therapy
Time till first reinnervation expected
Full maturity may take up to 12-18m
Expected outcomes nerve vs tendon transfer
Specific risks: motor or sensory disturbance, failure of transfer
Opportunity to meet previous patients

11. Baseline Outcome Measures
Measurement of pinch and grip strength
Modified pinch meter by Jaymar which allows testing of weak/little strength
Action Research Arm Test
Grasp Release Test
A timed test of lateral pinch and grasp which records how many objects can be picked up and released in a given time
Canadian Occupational Performance Measure
Spinal Cord Independence Measure

12. Electrodiagnostic Testing
Donor Muscles
Are they under voluntary control?
Is there evidence of any denervation?
Recipient muscles
Are they UMN or LMN denervated?
Or a combination of both?

13. Surgery – Equipment Needs
Microscope/microsurgery instruments
Nerve stimulator -Biphasic nerve/muscle stimulator with a range of stimulation control (Checkpoint® Stimulator/Locator, Cleveland, OH, USA)
Intraoperative Motor Evoked Potentials -Using trained multi pulse trans-cranial electrical stimulation of the motor cortex

14. The Triple Nerve Transfer
Elbow Extension
Teres Minor  Triceps Nerve(s)
(Bertelli, J. A., et al. (2011) J Neurosurg 114(5): )
Grasp
Brachialis  Anterior Interosseous Nerve
(Gu, Y., et al. (2004). Microsurgery 24(5): )
Release
Supinator  Posterior Interosseous Nerve
(Bertelli, J. A., et al. (2010). J Hand Surg Am 35(10): )

15. Intra Operative Data Collection

16. Post operative Management
Hospital stay 48hrs
Plaster changed to thermoplastic forearm splint and broad-arm sling
Outpatient hand therapy begins immediately
Surgical review 3 monthly for first year, then 6 monthly for second year
Outcome assessments at 12,18 and 24m

17. Post Operative Rehabilitation
Phase 1
Protect the transfer
Phase 2
Activate donor & watch for flicker in recipient muscle
Phase 3
Strengthen recipient muscle
Phase 4
Disassociate donor from recipient

18. Data Collection

19. Summary Relatively easy to expand the team & services needed
Learning curve:
– Patient selection
- Surgical techniques and timing of surgery
- Utility of NCS/EMG and MEPs
Development of protocols including:
- Pre op clinical evaluation
- Intra op data collection
- Post op nerve transfer therapy
- Timing of post op reviews/outcome assessments

20. Thank you