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 results in many problems in daily living, particularly related to the preservation of independence (Welraeds et al. 2003). A study by Hanson and Franklin (1976) showed recovery of hand function was preferred to that of the bladder, bowel or even sexual function among persons with tetraplegia. In a survey of tetraplegia patients, 75% responded that hand function was very important for their independence in ADLs 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 wanted upper limb function restored and 44% of the surveyed individuals reported an interest in receiving upper extremity reconstructive surgery (Wagner et al. 2007). More recently, Rivers and colleagues (2018) conducted a health-related quality of life survey and found that loss of upper extremity function significantly affects measures of functional independence negatively in subjects with SCI.

Although many studies have argued that up to 75% of persons with tetraplegia could benefit from hand surgery (Moberg et al. 1975; Wangdell et al. 2018; Anderson et al. 2009; Curtin et al. 2005; Rothwell et al. 2003), it is not common practice in many spinal units. In the USA, it was found that only seven percent of appropriate surgical candidates actually received surgery (Curtin et al., 2005). Internationally, many barriers to reconstructive surgery exist resulting in an underutilization of surgery (Fox et al. 2015). Reasons for underutilization of reconstructive surgery have been identified including: 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 or physiatrists and negative physician bias toward reconstructive surgery (Curtin et al. 2005; Squitieri and Chung 2008). Several studies suggest only a small percentage of persons with tetraplegia benefit from hand surgery (Forner-Cordero et al. 2003; Guttmann et al. 1976; McSweeney et al. 1969; Bedbrook et al. 1969). Many of these studies argue that with proper rehabilitation, individuals are able to re-adjust to the function of their arm and hands. Despite underutilization of surgery, however, 70% of individuals that do receive upper extremity surgery report satisfaction with their results, and 68% report improvements in ADLs (Wuolle et al. 2003). These statistics are consistent with physician estimates of patient satisfaction, suggesting that both clients and medical professionals may view reconstructive surgery as beneficial and/or satisfying (Wagner et al. 2007).

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.

In order to obtain functional pinch and grasp use, multiple, individualized procedures are often necessary. The type of reconstruction performed is also dependent on what muscles/tendons are present and if they are strong enough for transfer (Kozin 2002). Dunn et al. (2012) completed a study that addressed client’s decision-making process for reconstructive upper limb surgery and it was found that that a client’s decision to have surgery was underpinned by 6 core influences: the overall outcome of surgery, current goals and priorities in life, potential for QOL improvement, a stable home environment, available social supports and assistance with care needs postsurgery and access to information on surgery. It was also found that these factors were individualized to each person and change with time.

Various types of reconstructive surgeries are performed to increase hand function in individuals with SCI. The type of reconstruction done and associated studies are presented below.