Department of Neurological Surgery, Washington University, St Louis, Missouri.
Department of Neurological Surgery, Johns Hopkins University, Baltimore, Maryland.
JAMA Netw Open. 2022 Nov 1;5(11):e2243890. doi: 10.1001/jamanetworkopen.2022.43890.
Cervical spinal cord injury (SCI) causes devastating loss of upper extremity function and independence. Nerve transfers are a promising approach to reanimate upper limbs; however, there remains a paucity of high-quality evidence supporting a clinical benefit for patients with tetraplegia.
To evaluate the clinical utility of nerve transfers for reanimation of upper limb function in tetraplegia.
DESIGN, SETTING, AND PARTICIPANTS: In this prospective case series, adults with cervical SCI and upper extremity paralysis whose recovery plateaued were enrolled between September 1, 2015, and January 31, 2019. Data analysis was performed from August 2021 to February 2022.
Nerve transfers to reanimate upper extremity motor function with target reinnervation of elbow extension and hand grasp, pinch, and/or release.
The primary outcome was motor strength measured by Medical Research Council (MRC) grades 0 to 5. Secondary outcomes included Sollerman Hand Function Test (SHFT); Michigan Hand Outcome Questionnaire (MHQ); Disabilities of Arm, Shoulder, and Hand (DASH); and 36-Item Short Form Health Survey (SF-36) physical component summary (PCS) and mental component summary (MCS) scores. Outcomes were assessed up to 48 months postoperatively.
Twenty-two patients with tetraplegia (median age, 36 years [range, 18-76 years]; 21 male [95%]) underwent 60 nerve transfers on 35 upper limbs at a median time of 21 months (range, 6-142 months) after SCI. At final follow-up, upper limb motor strength improved significantly: median MRC grades were 3 (IQR, 2.5-4; P = .01) for triceps, with 70% of upper limbs gaining an MRC grade of 3 or higher for elbow extension; 4 (IQR, 2-4; P < .001) for finger extensors, with 79% of hands gaining an MRC grade of 3 or higher for finger extension; and 2 (IQR, 1-3; P < .001) for finger flexors, with 52% of hands gaining an MRC grade of 3 or higher for finger flexion. The secondary outcomes of SHFT, MHQ, DASH, and SF36-PCS scores improved beyond the established minimal clinically important difference. Both early (<12 months) and delayed (≥12 months) nerve transfers after SCI achieved comparable motor outcomes. Continual improvement in motor strength was observed in the finger flexors and extensors across the entire duration of follow-up.
In this prospective case series, nerve transfer surgery was associated with improvement of upper limb motor strength and functional independence in patients with tetraplegia. Nerve transfer is a promising intervention feasible in both subacute and chronic SCI.
颈椎脊髓损伤 (SCI) 导致上肢功能和独立性的毁灭性丧失。神经转移是一种有前途的重新激活上肢的方法；然而，仍然缺乏高质量的证据支持四肢瘫痪患者的临床获益。
评估神经转移在四肢瘫痪患者上肢功能再激活中的临床应用。
设计、地点和参与者：在这项前瞻性病例系列研究中，纳入了 2015 年 9 月 1 日至 2019 年 1 月 31 日期间 SCI 并上肢瘫痪且康复停滞的成年患者。数据分析于 2021 年 8 月至 2022 年 2 月进行。
神经转移以重新激活上肢运动功能，目标是重新支配肘部伸展和手抓、捏和/或释放。
主要结果是通过 Medical Research Council (MRC) 等级 0 到 5 测量的运动力量。次要结果包括 Sollerman 手部功能测试 (SHFT)；密歇根手部结果问卷 (MHQ)；手臂、肩部和手部残疾 (DASH)；以及 36-Item 短格式健康调查 (SF-36) 身体成分综合评分 (PCS) 和心理成分综合评分 (MCS) 分数。结果在术后最长 48 个月进行评估。
22 例四肢瘫痪患者（中位数年龄 36 岁[范围 18-76 岁]；21 名男性[95%]）在 SCI 后 21 个月（范围 6-142 个月）中位数时间内接受了 35 个上肢的 60 个神经转移。在最终随访时，上肢运动力量显著改善：三头肌的中位数 MRC 等级为 3（IQR，2.5-4；P = .01），70%的上肢获得了 MRC 等级 3 或更高的肘部伸展；手指伸肌为 4（IQR，2-4；P < .001），79%的手获得了 MRC 等级 3 或更高的手指伸展；手指屈肌为 2（IQR，1-3；P < .001），52%的手获得了 MRC 等级 3 或更高的手指弯曲。SHFT、MHQ、DASH 和 SF36-PCS 评分的次要结果均超过了既定的最小临床重要差异。SCI 后早期（<12 个月）和晚期（≥12 个月）神经转移均获得了可比的运动结果。在整个随访期间，手指屈肌和伸肌的运动力量持续改善。
在这项前瞻性病例系列研究中，神经转移手术与四肢瘫痪患者上肢运动力量和功能独立性的改善相关。神经转移是一种有前途的干预措施，在亚急性和慢性 SCI 中均可行。
