Carina Reinholdt

A single-stage operation for reconstruction of hand flexion, extension, and intrinsic function in tetraplegia: the alphabet procedure.

Surgical reconstruction is an established method to restore grip and grasp function after traumatic cervical spinal cord injury and tetraplegia. It can offer the patient improved ability to perform activities of daily living. Traditionally, surgical reconstruction of hand function has required separate operations for flexors and extensors. Here, we present a combination of procedures that provides key pinch and finger flexion together with opening of hand as a 1-stage operation. This reconstruction includes 7 individual operations that are performed in the following order: (1) split flexor pollicis longus-extensor pollicis longus distal thumb tenodesis, (2) reconstruction of passive interossei, (3) thumb CMC arthrodesis (4) brachioradialis-flexor pollicis longus tendon transfer, (5) extensor carpi radialis longus-flexor digitorum profundus tendon transfer, (6) EPL tenodesis, and (7) extensor carpi ulnaris tenodesis. We have chosen to entitle this reconstruction the alphabet or ABCDEFG procedure, an abbreviation for Advanced Balanced Combined Digital Extensor Flexor Grip reconstruction. To reduce the risk of adhesions after this extensive surgery and to facilitate relearning the activation of transferred muscles with new functions, early active training is performed. It is concluded that this 1-stage combination of operations can reliably provide grip, grasp, and release function in persons with C6 tetraplegia, patient satisfaction is high, time and effort for patient and caregivers are less, and incidence of complications is comparable with other published treatment modalities.

Outcomes of single-stage grip-release reconstruction in tetraplegia.

PURPOSE To evaluate the outcomes of our technique for single-stage grip-release reconstruction and compare it with previous 1- and 2-stage grip reconstructions in tetraplegia. METHODS A total of 14 patients (16 hands) with tetraplegia underwent a single-stage combination of operations to provide pinch, grip, and release function. We compared the study group with a historical control group of 15 patients (18 hands) who had been treated with staged flexion-extension grip-release reconstructions. Both groups were classified as ocular cutaneous 4. Assessment parameters included grip and pinch strength, maximal opening of the first webspace, and Canadian Occupational Performance Measurement. Both groups were rehabilitated with early active mobilization beginning the first day after surgery. RESULTS Grip strength and opening of the first webspace were significantly greater in the single-stage group than in the comparative group. Pinch strength was not significantly different between groups. On the Canadian Occupational Performance Measurement score, patients belonging to the single-stage group were highly satisfied (increase of 3.7 points) and could perform several of their self-selected goals (3.5 points of improvement). CONCLUSIONS The single-stage grip-release reconstruction provides people who have spinal cord injuries and tetraplegia with improved and reliable grip function; active finger flexion, active thumb flexion, passive thumb extension, and passive interossei function can all be achieved through this procedure. Early active mobilization is particularly important in improving functional outcome after this combination of grip reconstruction procedures. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic III.

Upper extremity reconstruction in non-traumatic spinal cord injuries: An under-recognized opportunity.

OBJECTIVE This study reviews the usefulness of surgical improvement of arm and hand function in patients with non-traumatic spinal cord injury who differ significantly from individuals with post-traumatic tetraplegia with respect to age, injury pattern, gender and socio-economic factors. DESIGN Case series. Tests were conducted preoperatively and 12 months postoperatively. PATIENTS The results of 14 upper extremity reconstructions in 11 patients (7 women, 4 men) with spinal cord injury, mean age at injury 49 years (standard deviation (SD) 12), were reviewed. METHODS Key pinch strength, grip strength and first web space opening were recorded pre- and post-operatively in all patients, 5 patients (7 hands) were evaluated prospectively regarding manual dexterity. RESULTS All parameters were significantly improved. Strength of key pinch increased from 0.3 kg in 1 case and zero in 10 cases to a mean of 1.6 kg (SD 0.9). Mean grip strength increased from 0 to 3.2 kg (SD 4.5). Maximal distance between thumb and index increased from 2.1 cm (SD 4.1) to 6.4 cm (SD 4.4). Manual dexterity increased. CONCLUSION Individuals with stable non-traumatic tetraplegia benefit from surgical rehabilitation of their upper extremities. The number of non-traumatic spinal cord injuries is likely to increase as lifespan increases worldwide, and further research into the functional rehabilitation of this population will therefore become increasingly relevant.

Selective release of the digital extensor hood to reduce intrinsic tightness in tetraplegia

Abstract Patients with tetraplegia may have various degrees of spasticity in the hand ranging from a completely clenched fist to reduced control of grip at triggered spasticity. The objective of the present study was to evaluate the functional effect of the distal ulnar intrinsic release procedure to reduce intrinsic tightness. Seventeen patients with tetraplegia (37 fingers) and with prominent intrinsic tightness were operated on for distal intrinsic release with a modification of the procedure to include only the ulnar side of the proximal phalanx. All the patients had more pronounced tightness on the ulnar than on the radial side of the affected finger. Long fingers were consistently the most affected digits. The intrinsic tightness was released completely in all patients and the range of motion (ROM) was improved by 25%, and up to 45% in mild and severe cases, respectively. The good immediate effects of treatment as shown by increased ROM remained intact by 6 months postoperatively. These data suggest that the distal ulnar intrinsic release procedure is a simple and valuable way of reducing intrinsic tightness and improving hand function and grip for patients with intrinsic tightness. This procedure can be added to other procedures such as lengthening and transfer of tendons.

Satisfaction with upper limb reconstructive surgery in individuals with tetraplegia: the development and reliability of a Swedish self-reported satisfaction questionnaire

Study design:A questionnaire-based survey.Objectives:To assess satisfaction after upper limb reconstructive surgery in individuals with tetraplegia and to determine the reliability of a Swedish satisfaction questionnaire.Setting:A center for advanced reconstruction of extremities, Gothenburg, Sweden.Methods:Seventy-eight individuals with tetraplegia were invited to participate in the survey assessing satisfaction with the result of surgery across various domains. Measures of reliability included stability and internal consistency of domains consisting questions regarding global satisfaction, activities and occupation/schooling.Results:Fifty-eight individuals (76%) participated, among whom 47 (82%) completed the questionnaire twice for repeatability assessment. The responses in the domains relating to global satisfaction, activities and occupation/schooling were positive in 83%, 72% and 31% of participants, respectively. Ninety-five percent felt they had benefited from the surgery, and 86% felt that the surgery had made a positive impact on their life. The psychometric testing indicated that the questionnaire yields scores that are reliable by both test–retest and internal consistency, with the exception of the domain occupation/schooling that had a high prevalence of missing and neutral responses and seemingly represents separate and distinct entities.Conclusion:Surgical rehabilitation of the upper limb in tetraplegia is highly beneficial and rewarding from a patient perspective, leading to satisfactory gains in activities of daily living as well as enhanced quality of life. The questionnaire is a reliable instrument for measuring satisfaction after surgery. However, occupationally and educationally related aspects of the surgical outcome should constitute separate domains, and further modifications of the questionnaire are thus recommended.

Simultaneous powering of forearm pronation and key pinch in tetraplegia using a single muscle-tendon unit.

This study clinically assessed the concept that both thumb flexion and forearm pronation can be restored by brachioradialis (BR)-to-flexor pollicis longus (FPL) tendon transfer if the BR is passed dorsal to the radius. Six patients [two women and four men, mean age 32.3 years (SD 4.9, range 23–56)] underwent BR-to-FPL transfer dorsal to the radius and through the interosseous membrane (IOM). Lateral key pinch strength and pronation range of motion (ROM) were measured 1 year after surgery. A group of six patients [two women and four men, mean age 31.2 years (SD 5.0, range 19–52)] who underwent traditional palmar BR-to-FPL was included for comparison. Postoperative active pronation was significantly greater in the dorsal transfer group compared to the palmar group [149 (SD 6) and 75 (SD 3), respectively] and pinch strength was similar in the two groups [1.28 (SD 0.16) kg and 1.20 (SD0.21) kg, respectively]. We conclude that it is feasible to reconstruct lateral key pinch and forearm pronation simultaneously using only the BR motor.

The extensor pollicis longus-loop-knot (ELK) procedure for dynamic balance of the paralyzed thumb interphalangeal joint.

Hyperflexion of the thumb interphalangeal (IP) joint interferes significantly with pinching between the thumb and the index finger in a paralyzed hand. The extensor pollicis longus-loop-knot (ELK) procedure was used successfully in 7 tetraplegic patients to balance the IP joint between strong restored flexor function and lacking or weak antagonism of the thumb extensors. A V-shaped incision was made over the extensor hood at the level of the IP joint, the extensor pollicis longus (EPL) tendon was elevated, a loop was formed, secured by sutures, and then turned proximally onto the EPL tendon itself and fixed on both sides. The operation reliably limited the maximum range of IP flexion at 20 to 30 degrees from neutral. Postoperative problems did not occur. The ELK procedure is easy and quick and secures the optimal setting of IP flexion with limited flexibility, which is advantageous compared with rigid bony arthrodesis. It also avoids certain disadvantages of the commonly used flexor pollicis longus split tenodesis and is therefore a valuable alternative for the correction of Froment’s sign due to intrinsic or extrinsic paralysis of the thumb.

Rebalancing the tetraplegic wrist using extensor carpi ulnaris-tenodesis

Patients with cervical spinal cord injury and tetraplegia often present with a radial deviation deformity of the wrist owing to impaired active wrist flexion and extension. Tenodesis of the extensor carpi ulnaris can help optimize grip strength. The purpose of the study was to compare reconstruction of the grip with and without extensor carpi ulnaris-tenodesis, as well as evaluating the outcome of the procedure. The grip strength of the group with tenodesis of the extensor carpi ulnaris was twice as strong as of the group without the tenodesis and with similar wrist joint flexion–extension range of motion. Correction of the wrist deformity enables a more ergonomic use of the hand. This may also help prevent shoulder pain, which is common among patients with tetraplegia.

Activity gains after upper limb surgery for spasticity in patients with spinal cord injury

Spasticity is a common and increasingly prevalent secondary complication of spinal cord injury. The aim of the study was to evaluate patient-experienced gains in prioritized activities after surgery to reduce the effects of spasticity in upper limbs in tetraplegia. The study includes evaluation of 30 operations for 27 patients performed on hypertonic tetraplegic hands during 2007–2015 using the Canadian Occupational Performance Measure. Activity performance increased at both 6 months and 12 months by a mean of 3.0 and 2.9 points, respectively. Satisfaction increased by 3.3 and 3.4, respectively. All types of activities improved, with wheelchair manoeuvring as one of the highest rated. The intervention increased prioritized activity performance and persisted at least 12 months after surgery. Patients with mild upper limb impairment showed greater improvement after surgery. After operation, patients were able to perform 71% of their prioritized activities, which they could not perform before. Patients’ satisfaction with the performance was high. Level of evidence: IV