Khalifeh Jawad M, Dibble Christopher F, Van Voorhis Anna, Doering Michelle, Boyer Martin I, Mahan Mark A, Wilson Thomas J, Midha Rajiv, Yang Lynda J S, Ray Wilson Z
1Department of Neurological Surgery.
2Milliken Hand Rehabilitation Center, Program in Occupational Therapy.
J Neurosurg Spine. 2019 Jul 12;31(5):629-640. doi: 10.3171/2019.4.SPINE19173. Print 2019 Nov 1.
Patients with cervical spinal cord injury (SCI)/tetraplegia consistently rank restoring arm and hand function as their top functional priority to improve quality of life. Motor nerve transfers traditionally used to treat peripheral nerve injuries are increasingly being used to treat patients with cervical SCIs. In this study, the authors performed a systematic review summarizing the published literature on nerve transfers to restore upper-extremity function in tetraplegia.
A systematic literature search was conducted using Ovid MEDLINE 1946-, Embase 1947-, Scopus 1960-, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and clinicaltrials.gov to identify relevant literature published through January 2019. The authors included studies that provided original patient-level data and extracted information on clinical characteristics, operative details, and strength outcomes after nerve transfer procedures. Critical review and synthesis of the articles were performed.
Twenty-two unique studies, reporting on 158 nerve transfers in 118 upper limbs of 92 patients (87 males, 94.6%) were included in the systematic review. The mean duration from SCI to nerve transfer surgery was 18.7 months (range 4 months-13 years) and mean postoperative follow-up duration was 19.5 months (range 1 month-4 years). The main goals of reinnervation were the restoration of thumb and finger flexion, elbow extension, and wrist and finger extension. Significant heterogeneity in transfer strategy and postoperative outcomes were noted among the reports. All but one case report demonstrated recovery of at least Medical Research Council grade 3/5 strength in recipient muscle groups; however, there was greater variation in the results of larger case series. The best, most consistent outcomes were demonstrated for restoration of wrist/finger extension and elbow extension.
Motor nerve transfers are a promising treatment option to restore upper-extremity function after SCI. Flexor reinnervation strategies show variable treatment effect sizes; however, extensor reinnervation may provide more consistent, meaningful recovery. Despite numerous published case reports describing good patient outcomes with nerve transfers, there remains a paucity in the literature regarding optimal timing and long-term clinical outcomes with these procedures.
颈脊髓损伤（SCI）/四肢瘫痪患者一直将恢复手臂和手部功能列为改善生活质量的首要功能目标。传统上用于治疗周围神经损伤的运动神经移植越来越多地用于治疗颈脊髓损伤患者。在本研究中，作者进行了一项系统综述，总结了已发表的关于神经移植以恢复四肢瘫痪患者上肢功能的文献。
使用Ovid MEDLINE 1946年起、Embase 1947年起、Scopus 1960年起、Cochrane对照试验中央登记册、Cochrane系统评价数据库和clinicaltrials.gov进行系统文献检索，以识别截至2019年1月发表的相关文献。作者纳入了提供原始患者水平数据的研究，并提取了神经移植手术后的临床特征、手术细节和肌力结果等信息。对文章进行了严格的评审和综合分析。
系统综述纳入了22项独特的研究，报告了92例患者（87例男性，占94.6%）118条上肢的158次神经移植。从脊髓损伤到神经移植手术的平均时间为18.7个月（范围4个月至13年），术后平均随访时间为19.5个月（范围1个月至4年）。再支配的主要目标是恢复拇指和手指屈曲、肘部伸展以及腕部和手指伸展。各报告之间在移植策略和术后结果方面存在显著异质性。除一份病例报告外，所有报告均显示受者肌肉群至少恢复到医学研究委员会3/5级肌力；然而，较大病例系列的结果差异更大。腕部/手指伸展和肘部伸展的恢复显示出最佳、最一致的结果。
运动神经移植是脊髓损伤后恢复上肢功能的一种有前景的治疗选择。屈肌再支配策略显示出不同的治疗效果大小；然而，伸肌再支配可能提供更一致、更有意义的恢复。尽管有大量已发表的病例报告描述了神经移植取得的良好患者结果，但关于这些手术的最佳时机和长期临床结果的文献仍然匮乏。
