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Hand

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The loss of upper limb function especially the use of the hand is one of the most significant and devastating losses an individual can experience. Tetraplegia is responsible for many problems in daily living, mostly related to the recovery and/or preservation of independence for the tetraplegic individual (Welraeds et al. 2003). The study by Hanson and Franklin (1976) showed recovery of hand function was preferred to that of the bladder, bowel or even sexual function among tetraplegics. In a survey of tetraplegic patients, 75% responded that hand function was very important for their independence in activities of daily living (ADL) and to increase their quality of life (Snoek et al. 2004). In another study conducted in the United States with a sample of individuals with tetraplegia, 42% of the individuals viewed upper limb function as their top restoration priority (the function they wanted restored first) and 44% of the surveyed individuals reported an interest in receiving upper extremity reconstructive surgery (Wagner et al. 2007).

Reconstructive surgery is one option to attempt to improve the function of the hand and upper limb in persons with tetraplegia. Functionally, the benefit of reconstructive surgery may be evident as improved ability to write, complete catheterizations, dress, self-feed, drive, lift objects, button, turn dials, propel their wheelchair, catch objects overhead, turn in bed and swim are only some of the activities that become possible after surgery (Rabischong et al. 1993). Surgery has been reported to improve quality of life for those people who had little or no upper limb function (Freehafer et al. 1984).

Despite the many reported studies, over 40 documented studies, hand reconstructive surgery is not common practice in many spinal units and its importance in improving hand function still remains controversial (Forner-Cordero et al. 2003). Guttmann (1976), McSweeney (1969) and Bedbrook (1969) believed that only a small percentage of tetraplegics (5%) benefit from hand surgery because they re-adjust the function of their arm and hands if properly rehabilitated, while other authors like Moberg (1975) state that 75% of tetraplegics can obtain benefit from hand surgery. A recent review of epidemiologic data from the 1988 to 2000 in the USA found that only 7% of appropriate surgical candidates actually received surgery (Curtin et al. 2005). In a study completed by Wuolle et al. (2003), they surveyed individuals with tetraplegia who received upper extremity surgery, 70% of the individuals were satisfied with their results and 68% reported improvement in activities of daily living (ADLs). These statistics are consistent with another study that surveyed physicians who estimated that there was 75% client satisfaction, suggesting that both the client and caregiver (physician and/or surgeon) view reconstructive surgery to be beneficial and satisfying (Wagner et al. 2007). Studies by Curtin et al. (2005) and Squitieri and Chung (2008) explored the reason for underutilization of reconstructive surgery in the tetraplegic population. Issues identified were; lack of clarity in the literature about the value of reconstructive procedures, lack of access to centres that perform reconstructive surgeries, lack of qualified and experienced hand surgeons and physiatrists who have an interest in this area of surgery and negative physician bias toward reconstructive surgery. Curtin et al. (2005) identified that it is important that there is good relationships between spinal cord specialists and surgeons (surgeons were 13.1 times more likely to perform surgery; physiatrists were 2.8 times more likely to refer clients for surgery).

Reconstructive surgery and tendon transfers are generally performed following an identifiable pattern based on the level of injury and results depend on the patient’s residual motor and sensory function as identified in each group (Freehafer et al. 1984). In 1978, the International Classification for Surgery of the Hand in Tetraplegia was developed at the International Conference held in Edinburgh and modified in 1984. The classification takes into account the residual motor strength below the elbow, considering that only the muscles graded 4 or 5 according to the Medical Research Council Scale (MRCS) are adequate for muscle transfer, as well as the sensibility in thumb and index. The sensibility was evaluated by the two-point discrimination test in the thumb and the index. If it is lower than 10mm the classification belongs to the group Cutaneous (Cu-) and if it is higher than 10mm and the patient needs visual help it is classified in the group Ocular (O-).

Table: Modified International Classification for Surgery of the Hand in Tetraplegia

Candidates for reconstructive surgery are carefully selected and are followed by a rehabilitation team that includes an orthopedic surgeon, rehabilitation physiatrist, and therapist over a significant period of time. The identified criteria for selection are as follows: at least one year post-injury, completed a comprehensive rehabilitation program, neurologically stable, and psychologically adjusted to their injury.

The measure of outcomes following reconstructive surgery continues to be debated in the literature. Many of the reported studies on surgical outcomes are older, are case series evaluations and lack the rigor of randomized controlled trials, and have subjective outcomes based on reported client satisfaction. In addition, there is little consensus in the literature on the assessment instruments and tools to be used in this population as their reliability, validity and responsiveness have not been adequately proven. The methodology appears to be a major failing of the various scales and the absence of clear conceptual models forming the basis of their scales. Also, the scales or instruments have been deemed to be too insensitive to document the small but meaningful functional gains made by those with tetraplegia after functional surgery (Fattal 2004). Many authors state that comparing the post-surgical condition is the best way to evaluate results (Freehafer et al. 1984). There have been several articles published that discuss the use of the ICF conceptual framework as a way to interpret hand function outcomes following tendon transfer surgery for tetraplegia (Bryden et al. 2005; Sinnott et al. 2004).

The reconstructions of upper limb to obtain functions of pinch and grasp often require multiple procedure and are also individualized to each person. The reconstructions performed are also dependent on what motor muscles/tendons are present and strong enough for transfer (Kozin 2002). Dunn et al. (2012) completed a study that addressed client’s decision making process for reconstructive UL surgery and it was found that that a client’s decision to have surgery were underpinned by 6 core influences. These influences were the overall outcome of surgery, the client’s current goals and priorities in their life, the hope that their overall quality of life (QOL) would be improved, a stable home environment, available social supports and assistance for assisting with increased care needs post-surgery and access to information on surgery. It was also found that these factors were individualized to each person and is dependent on any number of issues at one time and can change in its priority over time. The most commonly performed surgeries for reconstructive pinch are:

Key-Pinch Grip – Brachioradialis to Extensor Carpi Radialis Longus, Flexor Pollicis Longus split tenodesis. The IP joint of the thumb may need to be stabilized to prevent excessive IP flexion.

Key-Pinch Grip with or without Hook Grip – Brachioradialis to Flexor Pollicis Longus with or without Flexor Digitorum Profundus tenodesis or Brachioradialis to Extensor Carpi Radialis Longus.

Key-Pinch Grip and Hook Grip – Brachioradialis or Pronator Teres to Flexor Pollicis Longus and Brachioradialist or Extensor Carpi Radialis Longus to Flexor Digitorum Profundus.

Additional procedures to increase thumb pinch and thumb opposition may also be completed.

Table: Reconstructive Surgery Pinch Studies

Summary Table: Pinch Studies

Pinch and Grasp (Key-Pinch and Hook Grip)

The most commonly performed surgeries to obtain key-pinch and hook grip are:

Wrist Extension – If the person does not have adequate wrist extension, Brachioradialis (BR) to Extensor Carpi Radialis Brevis (ECRB) is performed prior to any surgery for pinch reconstruction.

Key-Pinch and Hook Grip – Extensor Carpi Radialis Longus (ECRL) to Flexor Digitorum Profundus (FDP). This is a synergistic transfer in which dorsiflexion of the wrist potentiates the effects of the transfer. The amplitude of excursion provides strong flexion of the fingers into the palm. Brachioradialis (BR) is also transferred to Flexor Pollicis Longus (FPL).

The aim of these transfers is to provide mass finger flexion for grasp and independent thumb flexion for key-pinch against the side of the middle phalanx of the index finger. Adjustment of tension in these transfers is also completed (Lamb & Chan 1983).

Table: Reconstructive Surgery Pinch and Grip Studies

Summary Table: Pinch and Grip Studies