Epidemiology
Nearly 2/3 cervical level injury survivors have C6 root level function
- biceps and wrist extension function
Function
C5
- active elbow flexion
- dependant for transfer and bed position
C6
- shoulder stability (RC)
- wrist extension
- can give them a tenodesis grip
C7
- triceps
- can roll over and transfer
- eat independently
C8-T1
- independent
Walking
- > grade 3 hip flexion on one side
- > grade 3 knee extension on other side
Requirements
1. Transfer / Triceps
2. Object manipulation
- grip
- key grip / self catheterisation
Timing
Consider > 18/12
Allows
- serial evaluation
- psychological adjustment
Delayed if evidence of neurological recovery
Principles
1. Start on side with most function / or dominant limb
2. If 2 point discrimination > 10mm
- operate on only one limb, as patient uses visual cues
3. Keep treatment simple
4. Restore elbow extension first if C6
- Moberg Deltoid - Triceps
- aids transfer
5. Perform only one operation at time
6. Don't transfer spastic muscles
- ? dynamic EMG
7. Remember the principles of tendon transfer
Classification
Neurologic level
- lowest level with normal motor & sensory function bilaterally
- level of bony fracture doesn't exactly correspond with level of cord injury
Frankel Grade
A Complete neurological deficit
B Sensory only below injury level
C Motor < 3 below level
D Motor < 5 below level
E Normal
Transfer summary
C5
- Moberg deltoid to triceps transfer
C6
- Moberg deltoid to triceps transfer
- FPL tenodesis
C7
- BR to EDC / EPL for finger extension
- ECRL to FDP for finger flexion
C8
- Zancolli FDS tendodesis to prevent intrinsic plus
C5 Quadriplegia
Intact
- deltoid / supraspinatus / biceps
Require
- elbow extension / Moberg deltoid to triceps
- forearm pronation / Zancolli Biceps tendon re-routing
A. Deltoid to Triceps transfer - Moberg
Indications
- Triceps < Grade 3
Benefits
- helps stabilisation in wheelchair
- helps transfers
- improves control of self-help devices
Procedure
- posterior 1/3 of deltoid isolated
- dissect up till see AXN entering posterior deltoid & stop
- preserve as much of its tendinous insertion
- tendon grafts obtained / EDL or T anterior
- tendon grafts interlaced between distal deltoid belly & triceps aponeurosis
Post op
- elbow immobilised in extension for 6/52 with GHJ adducted
- then slowly flex 10° per week
- avoid transfer for 3/12
B. Zancolli Biceps Tendon Rerouting
C5 level patients lack ability to place hand in working position
Procedure
1. Obtain passive pronation first
- removal of interosseous membrane + DRUJ
2. Biceps tendon exposed
- Z Plasty
- distal 1/2 rerouted around neck of radius
- sutured to a tension to obtain full pronation & yet allow extension
C6 Quadriplegia
Intact
- wrist extension - BR, ECRL, ECRB
- pronation
Require
- elbow extension / Moberg biceps to triceps transfer
- stronger wrist extension / BR to ECRB
- Key pinch / BR to FPL / Moberg FPL tenodesis
A. Moberg FPL Tenodesis
Indication
- strong wrist extensors with no finger flexors i.e. C6 lesion
- inability to key pinch
Mechanism
- tenodesis of FPL to provide flexion with wrist extension
Procedure
Release of A1 pulley of thumb
- permits bowstringing
- increases mechanical advantage
FPL tenodesis to volar radius
- exposed in forearm
- divided 6 cm proximal to wrist
- tenodesed to volar radius by passing through hole in radius & sutured to itself
Dorsal tenodesis of extensor hood of thumb MCPJ
- stops MCPJ hyperflexion
- hood sutured to dorsum of MC through drillholes
Fusion of IPJ of Thumb
- at zero degrees
- via longitundinal K wire
Post op
- thumb spica for 4/52
B. BR to FPL
Indications
- strong ECRL or ECRB
C. BR to ECRB
Indications
- strong BR with weak ECRB/ ERCL
Advantage
- allows wrist extension for tenodesis effect of finger flexors
- gives grasp
C7 Quadriplegia
Intact
- triceps
- EDC
Require
- finger & thumb flexion
Criteria
Many SCI patients can be helped with hand surgery - 75%
Suitable criteria
- 2 point discrimination < 10mm
- plateau of neurology 12-18/12
- grade 4 MRC power of transfer (lose minimum 1 grade)
- no uncontrolled spasticity
- no excessive pain in hand
- psychologically stable
Zancolli 2 Stage procedure
Stage I / Finger & thumb extensors
- BR to EPL / EDC
- use CMCJ thumb
- thumb MCPJ volar plate capsuloplasty / suture plate to MC neck / stop hyperextension
- transfer BR to EPL & ED via long radial incision
- immobilize for 4/42
Stage II / Grasp
- 6/12 later
- ECRL to FDP
Options to power FPL
1. TT to ECR Tertius if present
2. Side to side suture to ECRB
3. Passive tenodesis (Moberg)
C8 Quadriplegia
Intact
- FDP/FDS
Require
- prevent MCPJ hyperextension
Zancolli FDS Lasso tenodesis
Technique
- divide FDS slips at A2 level
- pass proximal slips under A1
- suture slips to FDS above A1
- effectively suture FDS to A1