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The outcome of tendon transfers for C6-spared quadriplegics
THE OUTCOME
OF T E N D O N T R A N S F E R S QUADRIPLEGICS
FOR C6-SPARED
I. K. Y. LO, R. TURNER, S. CONNOLLY, G. DELANEY and J. H. ROTH From the St Joseph's Health Centre and ParkwoodHospital, London, Ontario, Canada The purpose of this study was to review retrospectively and evaluate a uniform group of C6-spared quadriplegics who had similar surgical procedures. Eight patients undergoing 12 procedures were reviewed at an average of 3.8 years follow-up. There were three bilateral procedures. All patients had extensor carpi radialis longus to flexor digitorum profundus and brachioradialis to flexor pollicis longus transfers to improve grip strength and key pinch. All patients reported subjective improvements in quality of life, activities of daily living and patient-centred goals. There were six excellent and two good results. Objective improvements included mild improvements in key pinch and grip strength. Journal of Hand Surgery (British and European Volume, 1998) 23B: 2:156-161 Spinal cord trauma is a devastating injury with up to 60% involving injury to the cervical spine with varying degrees of quadriplegia (Lamb and Chan, 1983). The loss of a functional upper extremity is considered to be a major disability to quadriplegic patients. In 75% of quadriplegics, upper extremity disability has been ranked in importance above the loss of bowel and bladder control, sexual function and lower extremity function (Hanson and Franklin, 1976). Because almost all activities of daily living (ADLs) are affected by the quadriplegic's limited use of upper extremity function, the greatest potential improvement in independence and function lies in the proper rehabilitation of the upper extremity. Multiple operative procedures have been described in patients with a wide disparity of neurological deficits leading to difficulties in assessing surgical and rehabilitative outcomes (Ejeskar, 1988; Ejeskar and Dahllof, 1988; Freehafer et al, 1984; 1988; Hentz et al, 1983; 1988; Lamb and Chan, 1983; Moberg, 1978; 1990; Mohammed et al, 1992; Murphy and Chuinard, 1988; Vanden Berghe et al, 1991; Waters et al, 1985). The purpose of this study was to review retrospectively and evaluate subjectively and objectively a uniform group of C6-spared quadriplegic patients who all had similar operations done by one surgeon. The operative goal was to improve functional use of the extremity by providing key pinch and grip.
adequate passive and active range of motion in the entire upper extremity. If function of the upper extremity could be improved, a stretching and strengthening programme was developed to build strength, endurance and to achieve adequate active and passive range of motion. Goals, expectations and motivation were carefully assessed preoperatively. Patients were thoroughly informed about what was possible with surgery, what gains could be realistically expected, complications and the possible need for secondary procedures. Candidates for surgery were encouraged to meet previously treated patients. A retrospective chart review of muscle function and sensation made it possible to classify the preoperative status according to the International classification for surgery of the hand in tetraplegia (McDowell et al, 1979; 1986). Operative procedure All surgery was performed by the senior surgeon (JR). All patients underwent similar surgical procedures to improve both grip strength and lateral pinch. Operations were done with an above elbow pneumatic tourniquet and loupe magnification. Local infiltration of 1% lignocaine without adrenaline on the dorsal radial aspect of the left wrist provided adequate analgesia for the initial procedure. A dorsal longitudinal incision was made over the extensors of the wrist. The extensor carpi radialis longus (ECRL) and extensor carpi radialis brevis (ECRB) were exposed and umbilical tape was passed around each tendon. The patient was then asked to extend the wrist actively and the function of both the ECRL and ECRB was confirmed before proceeding with the operation. General anaesthesia was then induced. The dorsal radial incision was extended more proximally and the superficial radial nerve was exposed and protected. The ECRL tendon was detached from its distal insertion and was freed up to its musculotendinous junction to maximize excursion. The brachioradialis (BR) tendon was then identified and its distal insertion
PATIENTS AND M E T H O D S From 1988 to 1995, nine patients underwent multiple tendon transfers for C6-spared quadriplegia. All patients had suffered traumatic spinal cord injuries, most related to motor vehicle accidents or sports. Patients were not considered candidates for tendon transfers until at least 1 year after injury to ensure they had reached a plateau in neurological recovery. All patients were assessed, on several occasions, by a dedicated spinal cord injury team which included an upper limb surgeon (JR), a physical medicine and rehabilitation specialist (GD) and an occupational therapist (SC). The patient was assessed for 156
157
TENDON TRANSFERSIN QUADRIPLEGIA
Table 1 Rehabilitationprogramme Week post surgery
A ctive/passive goals and restrictions
Treatment
Week 1
Bulky dressing No AROM/PROM Cast applied Patient at home Cast removed PROM Wrist Ext 15° Wrist Flex 5° AROM Wrist Ext initiated Wrist Flex 0°
Assistance for most aspects of self care Power wheel chair for mobility Assistance for most aspects of self care
Weeks ~ 6 Week 7
Week 8
PROM Wrist Ext 20 30° Wrist Flex 10-15° AROM Wrist Ext 1550 °
Week 9
PROM Wrist Ext 35~40° AROM Wrist Ext 25 °
Weeks 10-11
PROM Wrist Ext 45 60° AROM Wrist Ext 30°
Week 12 and later
PROM Wrist Ext 65° AROM Wrist Ext 35°--+as tolerated
Scar massage +/- ultrasound C-bar splint for thumb positioning and web space Gentle PROM initiate pinch activities with no resistance Tenodesis activities (cones, foam balls, tubing) Self feeding with rubazote tubing Light grooming tasks (brushing teeth, hair, washing face etc.) introduce light resistive pinch exercises Theraputty to strengthen thumb Continue to develop tenodesis function Wrist extension on wedge building repetitions and number of sets Increase ADLs, writing and computer skills initiated Introduce weights for wrist extension Continue with tenodesis activities at higher planes (above shoulder) Continue resistive pinch Increase ADLs including dressing Aggressive PROM if ranges becoming difficult to achieve Splints as necessary Increase weights for wrist extension Increase shoulder activities Begin self catheterizations Begin gradual weight bearing activities through the wrist Short distance manual wheelchair Continue to refine skills and strength
AROM = active range of motion. PROM = passive range of motion. Ext = extension. Flex = flexion. on to the r a d i u s was e x p o s e d a n d detached. T h e B R t e n d o n a n d muscle unit was then freed to the p r o x i m a l o n e - t h i r d o f the f o r e a r m to m a x i m i z e excursion. A second p a l m a r incision was m a d e from the p a l m a r wrist crease, extending longitudinally on the p a l m a r u l n a r aspect o f the distal forearm. T h e m e d i a n nerve a n d its p a l m a r c u t a n e o u s b r a n c h was exposed a n d protected. T h e u l n a r artery a n d vein were also identified a n d protected. T h e flexor d i g i t o r u m p r o f u n d u s ( F D P ) t e n d o n s to the index, long, r i n g a n d small fingers were t h e n identified as was the flexor pollicis longus ( F P L ) . T h e p r o n a t o r q u a d ratus a n d the interosseous m e m b r a n e p r o x i m a l to it were exposed. A l o n g i t u d i n a l incision was m a d e in the interosseous m e m b r a n e , j u s t p r o x i m a l to the p r o n a t o r quadratus. T h e E C R L t e n d o n was p a s s e d t h r o u g h this to the p a l m a r a s p e c t o f the distal forearm. T h e E C R L tend o n was t r a n s f e r r e d to the F D P o f the index, long, ring a n d small fingers a n d sutured using 2/0 E t h i b o n d using a P u l v e r t a f t weave technique. Tension was a d j u s t e d so t h a t with the wrist in extension, the tips o f the index, long, ring a n d small fingers t o u c h e d the palm. T h e B R was then t r a n s f e r r e d s u b c u t a n e o u s l y a r o u n d the r a d i a l b o r d e r o f the r a d i u s a n d s u t u r e d to the F P L t e n d o n u n d e r t e n s i o n such that w i t h the wrist in extension the i n t e r p h a l a n g e a l j o i n t o f the t h u m b was in flexion. This was also s u t u r e d with 2/0 E t h i b o n d .
T h e t o u r n i q u e t was released a n d h a e m o s t a s i s was achieved. T h e w o u n d was closed a n d a bulky dressing applied.
Postoperative rehabilitation A l l patients u n d e r w e n t intensive r e h a b i l i t a t i o n p r o grammes. T h e t r e a t m e n t p r o t o c o l is s u m m a r i z e d in Table 1. Once surgery was c o m p l e t e d patients r e m a i n e d in h o s p i t a l for 1 to 5 days for m e d i c a l a n d nursing m o n i t o r i n g for c o m p l i c a t i o n s such as a u t o n o m i c dysreflexia a n d infection. Patients were then p l a c e d in a fibreglass cast for 6 weeks. F o l l o w i n g r e m o v a l o f the cast, patients were r e - a d m i t t e d to the r e h a b i l i t a t i o n unit for intensive h a n d a n d o c c u p a t i o n a l therapy. Patients spent up to 3 h o u r s p e r d a y at therapy. Significant gains were usually realized within 3 weeks o f cast removal. Once patients b e g a n to use the h a n d in daily t a s k s they were d i s c h a r g e d a n d c o n t i n u e d o u t - p a t i e n t therapy.
Follow-up The follow-up e v a l u a t i o n consisted o f using b o t h subjective a n d objective assessments. A s t a n d a r d i z e d questionnaire was answered, key p i n c h a n d grip strength
158
THE JOURNAL OF HAND SURGERY VOL. 23B No. 2 APRIL 1998
Table 2 Subjective questionnaire and responses
Activity
Number of responses Much Worse Worse
Unchanged
Improved
Greatly Improved
Mobility Raise yourself in seat Propel wheelchair on level ground Propel up and down gentle slope Transfer from wheelchair to bed Drive a car
0 0 0 0 0
0 0 0 0 0
4 6 3 6 3
4 t 4 2 4
0 1 1 0 1
0 0
0 0
1 2
5 5
2 1
0 0 0
0 0 0
1 1 1
5 4 5
2 3 2
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
4 0 2 2 0 2 5 5
4 6 4 3 3 3 1 2
0 2 2 3 5 3 2 1
0 0 0
0 0 0
0 2 1
3 4 4
5 2 3
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
2 2 0 1 1 2 1 2 6 0 0 3 0
4 3 6 3 6 2 3 3 1 1 1 4 3
2 3 2 4 1 4 4 3 1 7 7 ! 5
Dressing Upper garments Lower garments
Communications Using a telephone Writing or typing Handling money
Washing and toileting Getting in and out of shower/bath Washing and drying upper limbs Washing and drying lower limbs Cleaning teeth Shaving or applying cosmetics Brushing hair Bladder use of urodome or catheter Bowel: inserting suppositories and cleaning after bowel action
Feeding and drinking Use of cutlery Cutting meat Holding a cup or glass
Miscellaneous Making a meal or snack Reaching a shelf above Opening and closing drawers Operating buttons Turning pages in book/newspapers Picking up things from the floor Using a key Putting a plug into a point Have your educational/vocational options changed? Were your overall expectations met? Have you become more independent? Has your self confidence changed? Has surgery changed your quality of life?
Points M u c h worse = 0, Worse = 1, U n c h a n g e d = 2 Improved = 3, Greatly improved = 4
Results Poor 0 69 Fair 70-84
Good 85-101 Excellent 1 0 ~ 1 3 6
measurements were recorded, and the Minnesota rate of manipulation and Carroll upper extremity functional tests were done.
addition, patients were asked to name the five most important goals or activities they wished to improve with surgery and asked how surgery had affected each goal.
Subjective assessment
Objective assessment
We used a questionnaire similar to the one previously described by Mohammed et al (1992) which was based on that described by Lamb and Chan (1983) (Table 2). It consists of a list of 36 questions based on six major topics. In
Objective assessment was obtained using physical examination and grading on the Medical Research Council (1975) rating system for strength. Lateral key pinch strength was measured using a Preston pinch meter
TENDON TRANSFERS IN QUADRIPLEGIA
159 Table 3 Patients' responses to the five most important goals they wished to improve.
Patients' goals Improve independence in self-care Holding/grasping Writing/typing Dressing Driving Eating Transfering Wheelchair Fine finger dexterity Others
Number of responses 8 7 5 4 3 3 2 2 2 4
Subjective results Fig 1 Patient completing the displacement portion of the Minnesota rate of manipulation test.
(European Bissel Healthcare Ltd, Winchester, England) and hook grip strength was measured using a vigorimeter (Martin, Germany). In addition, the Minnesota rate of manipulation test (American Guidance Service, 1969) was used and the Carroll upper extremity functional test (Carroll, 1965) was used to evaluate function. The displacing test portion of the Minnesota rate of manipulation test was used. This is a timed exercise requiring patients to move circular blocks, one by one, on a holed board (Fig 1). Comparisons may be made with the opposite unoperated extremity and also between normal controls. The Carroll (1965) upper extremity functional test is a simple semi-quantitative test of upper extremity function. This evaluation consists of 33 tasks which require the patient to move objects to a shelf, place them over a peg, place the hand to the head, neck and mouth, write their name, and pour water from a pitcher or glass. The objects are of different shapes and weight and are designed to test grasp, pinch, grip, arm extension/elevation, placing, pronation/supination and strength. Scores may be compared against normal individuals. A higher score denotes higher function. RESULTS Nine patients underwent 12 procedures from 1988 to 1995. Three patients had bilateral procedures, one simultaneously. Eight of nine patients were available for subjective assessment or 11/12 transfers. Seven of nine patients were available for objective assessment or 10/12 transfers. The mean age at first operation was 26.1 years (range, 2 3 4 0 years). The mean follow-up was 3.8 years (range, 1.5-7.5 years). The mean time from injury to reconstruction was 4.5 years (range, 1.5 16 years).
Overall, all reported good to excellent results with six excellent and two good according to the scoring system of Mohammed et al (1992). There were no poor or fair results. In the patients with bilateral procedures, two had excellent results and one had a good result. Results of the questionnaire evaluation are summarized in Table 2. All patients reported they would have surgery again. Two said they would not consider surgery on the other side. One had a previous elbow fusion, and the other a malunited distal radius fracture. Both felt that improvements in function on that side would be minimal. Patients' responses to the five most important goals they wished to obtain with surgery are listed in Table 3. No patient described worsening of these activities. Six patients achieved improvements in five out of five of their goals, one patient in 4/5 and one patient in 2/5 goals.
Objective results Key pinch strength measured 1.2 (1.1) kg (mean (SD)) in operatively treated limbs. In non-operatively treated limbs the key pinch strength was 1.0 (1.3)kg. Grip strength was measured with either the thumb in or out depending on whichever the patient found most comfortable. The mean grip strength was 24.0 (41.6) m m H g for operatively treated limbs and 21.5 (13.7) mmHg for nonoperatively treated limbs. The Minnesota rate of manipulation was 2 minutes 56 seconds (1 minute 56 seconds) for operatively treated limbs and 1 minute 29 seconds (15 seconds) for nonoperatively treated limbs. However, three patients were unable to complete the task in the non-operated extremity and were not included in the mean times. For patients who were able to complete the task bilaterally, nonoperatively treated limbs tended towards quicker times. However, they were noted to use grip "tricks" and not use key pinch to move blocks. These times lie within the 1st percentile of normal control patients. The Carroll upper extremity functional test (Fig 2) revealed a mean score of 72.5 (18.0) in the operated extremity. The mean
160
Fig 2
THE JOURNAL OF HAND SURGERY VOL. 23B No. 2 APRIL 1998
Patient demonstrating key pinch during the Carroll upper extremity function test.
score for the nonoperated extremity was 52.4 (25.1). When scoring these patients to standardized scores one patient scored trace function, three very poor, three poor and one patient partial function. They required substantially greater effort to complete the task with the contralateral arm or needed to use "tricks" to complete the task.
Complications There were no infections, haematomas, skin sloughs, or failures of fixation. Two patients experienced autonomic dysreflexia in the immediate postoperative period and were treated accordingly. One patient required a second operative procedure for retensioning of the BR to FPL transfer, which was done 10 months postoperatively. Following this satisfactory thumb flexion was obtained. The same patient failed to comply with rehabilitation instructions and accidentally struck the fingers against an object and suffered hyperextension injury to the FDP tendons. The tendon to the left ring finger ruptured. However the patient was not significantly disabled and did not require revision surgery. DISCUSSION The quadriplegic's level of functional independence relies heavily on the ability to use the upper extremities in activities of daily living. Activities such as dressing, bathing, feeding, transfers and wheelchair mobility require the ability to use the arm and hand in purposeful and precise movements. The goals of tendon transfer surgery are to provide a strong grasp and a more precise and useful lateral pinch between the thumb and side of the index finger. The level of independence in self care, productivity and leisure can be dramatically enhanced. The assessment of surgical outcome following tendon transfers is difficult. There is a wide range of neurological loss and possible surgical procedures. Most reports involve multiple surgeons, different procedures and diverse populations (Ejeskar, 1988; Ejeskar and Dahllof,
1988; Freehafer et al, 1984; 1988; Hentz et al, 1983; 1988; Lamb and Chan, 1983; Moberg, 1978; 1990; Mohammed et al, 1992; Murphy and Chuinard, 1988; Vanden Berghe et al, 1991; Waters et al, 1985). In addition, objective assessment of lateral pinch and grip strength may not correlate with improvements in ADLs and quality of life. We examined a group of patients who had the same procedure. Improvements in independence and ADLs were obtained in all patients. It is also important to note that no patient was made worse in any ADL evaluated. All patients were in general satisfied with their surgery. All patients were rated as good or excellent using the Mohammed et al (1992) scoring system. This is similar to the experience of Lamb and Chan (1983) and Mohammed et al (1992) who reported results of 83% and 75% good or excellent results, respectively. To obtain the best results, the importance of a team approach throughout all stages of management cannot be overemphasized. Patient, surgeon, rehabilitation physiatrist, and therapist must all be intimately involved in the decision making process and postoperative rehabilitation. A high level of personal commitment and motivation from the patient is also a prerequisite to a successful result. Objective evaluation of the transfers is in general similar to that reported in the literature. The Carroll upper extremity functional test evaluates grasp, grip, pinch, placing, arm extension, supination, pronation, forward flexion and abduction. However, during testing none of these activities is isolated and almost all activities performed in the test bring into action the whole upper extremity and trunk. For this reason, poor scores are expected in quadriplegic patients. It was noted that some patients had limited function due to absence of a functional triceps mechanism, especially during tests involving placing. Only one patient had triceps function above MRC grade 2 and therefore most suffered in scoring. Brys and Waters (1987) reported that the absence of triceps function decreased the effectiveness of the brachioradialis as a tendon transfer. This is because brachioradialis gains its origin from the supracondylar ridge of the humerus and therefore acts as an elbow flexor. For the optimal use of the brachioradialis as a motor for tendon transfer, function in the triceps may improve motor control. All patients were offered secondary posterior deltoid transfers but they refused because they were satisfied and not interested in a second extended rehabilitation programme. The traditional view is that restoration of triceps function is required before distal transfers (Moberg, 1978). However, the absence of triceps function may not preclude a useful result. Although patients scored low in grip strength and key pinch this is similar to previous reports in the literature (Ejeskar and Dahllof, 1988; Mohammed et al, 1992; Vanden Berghe, 1991). When compared with controls, patients scored poorly in the Carroll upper extremity function and the Minnesota rate of manipulation tests.
TENDON TRANSFERS IN QUADRIPLEGIA
However, the goal of upper extremity reconstruction is not to return a patient to normal, but to regain some use of a previously nonfunctional extremity. As Bunnell has emphasized, "If you have nothing, a little is a lot" (Moberg, 1990). Although the operated limb required longer to perform the Minnesota manipulation test than the unoperated limb, it was noted that numerous trick motions were substituted for the pinch grasp used on the operated limb. Although pinching was less efficient for this particular test, the ability to pinch results in greater overall function as indicated by the questionnaires and the Carroll test. Reconstructive surgery for the upper extremity quadriplegic patient remains a demanding yet rewarding experience. The ECRL to FDP and BR to FPL transfers provide adequate upper extremity function to provide improvements in quality of life and ADLs. Transfer for active elbow extension does not necessarily need to be performed before distal transfers. References American Guidance Service. Minnesota rate of manipulation test: Examiner's manual. AGS, Circle Pines, Minnesota 1969: 1-22. Brys D, Waters R L (1987). Effect of triceps function on the brachioradialis transfer in quadriplegia. Journal of Hand Surgery, 12A: 237-239. Carroll D (1965). A quantitative test of upper extremity function. Journal of Chronic Diseases, 18: 479491. Ejeskar A (1988). Upper limb surgical rehabilitation in high-level tetraplegia. Hand Clinics, 4:585 599. Ejeskar A, Dahllof A (1988). Results of reconstructive surgery in the upper limb of tetraplegic patients. Paraplegia, 26: 204-208. Freehafer AA, Kelly CM, Peckham PH (1984). Tendon transfer for the restoration of upper limb function after a cervical spinal cord injury. Journal of Hand Surgery, 9A: 887 893. Freehafer AA, Peckham PH, Keith MW (1988). New concepts on treatment of the upper limb in the tetraplegie. Hand Clinics, 4: 563-574.
161 Hanson RW, Franklin MR (1976). Sexual loss in relation to other functional losses for spinal cord injuried males. Archives of Physical Medicine and Rehabilitation, 57:291 293. Hentz VR, Brown M, Keoshian LA (1983). Upper limb reconstruction in quadriplegia: functional assessment and proposed treatment modifications. Journal of Hand Surgery, 8:119-131. Hentz VR, Hamlin C, Keoshian LA (1988). Surgical reconstruction in tetraplegia. Hand Clinics, 4: 60I 607. Lamb DW, Chan KM (1983). Surgical reconstruction of the upper limb in traumatic tetraplegia. A review of 41 patients. Journal of Bone and Joint Surgery, 6~B: 291 298. McDowell CL, Moberg EA, Smith AG (1979). International conference on surgical rehabilitation of the upper limb in tetraplegia. Journal of Hand Surgery, 4: 387-390. McDowell CL, Moberg EA, House JH (1986). The second international conference on surgical rehabilitation of the upper limb in tetraplegia (quadriplegia). Journal of Hand Surgery, 1IA: 604 608. Medical Research Council. Aids to the investigation of peripheral nerve injuries', War Memorandum No. 7, 2nd edn., revised. London, Her Majesty's Stationary Office, 1975. Moberg E. The upper limb in tetraplegia. Stuttgart, George Thieme, 1978. Moberg E. Upper limb surgical rehabilitation in tetraplegia. In Evarts CM (Ed.): Surgery of the museuloskeletal system, 2nd edn. New York, ChurchilI Livingstone, 1990, Vol. l: 915. Mohammed KD, Rothwell AG, Sinclair SW, Willems SM, Bean AR (1992). Upper-limb sm'gery for tetraplegia. Journal of Bone and Joint Surgery, 74B: 873-879. Murphy CP, Chuinard RG (1988). Management of the upper extremity in traumatic tetraplegia. Hand Clinics, 4: 201509. Vanden Berghe A, Van Laere M, Hellings S, Vercauteren M (1991). Reconstruction of the upper extremity in tetraplegia: functional assessment, surgical procedures and rehabilitation. Paraplegia, 29: 103-112. Waters R, Moore KR, Graboff ST, Paris K (1985). Brachioradialis to flexor pollicis longus tendon transfer for active lateral pinch in the tetraplegic. Journal of Hand Surgery, 10A: 385 39I.
Received: 12 February 1997 Accepted after revision:30 June 1997 J. H. Roth MD FRCSC, St Joseph's Health Centre, 268 Grosvenor Street, London, Ontario, Canada N6A 4L6. © 1998The British Societyfor Surgeryof the Hand
OF T E N D O N T R A N S F E R S QUADRIPLEGICS
FOR C6-SPARED
I. K. Y. LO, R. TURNER, S. CONNOLLY, G. DELANEY and J. H. ROTH From the St Joseph's Health Centre and ParkwoodHospital, London, Ontario, Canada The purpose of this study was to review retrospectively and evaluate a uniform group of C6-spared quadriplegics who had similar surgical procedures. Eight patients undergoing 12 procedures were reviewed at an average of 3.8 years follow-up. There were three bilateral procedures. All patients had extensor carpi radialis longus to flexor digitorum profundus and brachioradialis to flexor pollicis longus transfers to improve grip strength and key pinch. All patients reported subjective improvements in quality of life, activities of daily living and patient-centred goals. There were six excellent and two good results. Objective improvements included mild improvements in key pinch and grip strength. Journal of Hand Surgery (British and European Volume, 1998) 23B: 2:156-161 Spinal cord trauma is a devastating injury with up to 60% involving injury to the cervical spine with varying degrees of quadriplegia (Lamb and Chan, 1983). The loss of a functional upper extremity is considered to be a major disability to quadriplegic patients. In 75% of quadriplegics, upper extremity disability has been ranked in importance above the loss of bowel and bladder control, sexual function and lower extremity function (Hanson and Franklin, 1976). Because almost all activities of daily living (ADLs) are affected by the quadriplegic's limited use of upper extremity function, the greatest potential improvement in independence and function lies in the proper rehabilitation of the upper extremity. Multiple operative procedures have been described in patients with a wide disparity of neurological deficits leading to difficulties in assessing surgical and rehabilitative outcomes (Ejeskar, 1988; Ejeskar and Dahllof, 1988; Freehafer et al, 1984; 1988; Hentz et al, 1983; 1988; Lamb and Chan, 1983; Moberg, 1978; 1990; Mohammed et al, 1992; Murphy and Chuinard, 1988; Vanden Berghe et al, 1991; Waters et al, 1985). The purpose of this study was to review retrospectively and evaluate subjectively and objectively a uniform group of C6-spared quadriplegic patients who all had similar operations done by one surgeon. The operative goal was to improve functional use of the extremity by providing key pinch and grip.
adequate passive and active range of motion in the entire upper extremity. If function of the upper extremity could be improved, a stretching and strengthening programme was developed to build strength, endurance and to achieve adequate active and passive range of motion. Goals, expectations and motivation were carefully assessed preoperatively. Patients were thoroughly informed about what was possible with surgery, what gains could be realistically expected, complications and the possible need for secondary procedures. Candidates for surgery were encouraged to meet previously treated patients. A retrospective chart review of muscle function and sensation made it possible to classify the preoperative status according to the International classification for surgery of the hand in tetraplegia (McDowell et al, 1979; 1986). Operative procedure All surgery was performed by the senior surgeon (JR). All patients underwent similar surgical procedures to improve both grip strength and lateral pinch. Operations were done with an above elbow pneumatic tourniquet and loupe magnification. Local infiltration of 1% lignocaine without adrenaline on the dorsal radial aspect of the left wrist provided adequate analgesia for the initial procedure. A dorsal longitudinal incision was made over the extensors of the wrist. The extensor carpi radialis longus (ECRL) and extensor carpi radialis brevis (ECRB) were exposed and umbilical tape was passed around each tendon. The patient was then asked to extend the wrist actively and the function of both the ECRL and ECRB was confirmed before proceeding with the operation. General anaesthesia was then induced. The dorsal radial incision was extended more proximally and the superficial radial nerve was exposed and protected. The ECRL tendon was detached from its distal insertion and was freed up to its musculotendinous junction to maximize excursion. The brachioradialis (BR) tendon was then identified and its distal insertion
PATIENTS AND M E T H O D S From 1988 to 1995, nine patients underwent multiple tendon transfers for C6-spared quadriplegia. All patients had suffered traumatic spinal cord injuries, most related to motor vehicle accidents or sports. Patients were not considered candidates for tendon transfers until at least 1 year after injury to ensure they had reached a plateau in neurological recovery. All patients were assessed, on several occasions, by a dedicated spinal cord injury team which included an upper limb surgeon (JR), a physical medicine and rehabilitation specialist (GD) and an occupational therapist (SC). The patient was assessed for 156
157
TENDON TRANSFERSIN QUADRIPLEGIA
Table 1 Rehabilitationprogramme Week post surgery
A ctive/passive goals and restrictions
Treatment
Week 1
Bulky dressing No AROM/PROM Cast applied Patient at home Cast removed PROM Wrist Ext 15° Wrist Flex 5° AROM Wrist Ext initiated Wrist Flex 0°
Assistance for most aspects of self care Power wheel chair for mobility Assistance for most aspects of self care
Weeks ~ 6 Week 7
Week 8
PROM Wrist Ext 20 30° Wrist Flex 10-15° AROM Wrist Ext 1550 °
Week 9
PROM Wrist Ext 35~40° AROM Wrist Ext 25 °
Weeks 10-11
PROM Wrist Ext 45 60° AROM Wrist Ext 30°
Week 12 and later
PROM Wrist Ext 65° AROM Wrist Ext 35°--+as tolerated
Scar massage +/- ultrasound C-bar splint for thumb positioning and web space Gentle PROM initiate pinch activities with no resistance Tenodesis activities (cones, foam balls, tubing) Self feeding with rubazote tubing Light grooming tasks (brushing teeth, hair, washing face etc.) introduce light resistive pinch exercises Theraputty to strengthen thumb Continue to develop tenodesis function Wrist extension on wedge building repetitions and number of sets Increase ADLs, writing and computer skills initiated Introduce weights for wrist extension Continue with tenodesis activities at higher planes (above shoulder) Continue resistive pinch Increase ADLs including dressing Aggressive PROM if ranges becoming difficult to achieve Splints as necessary Increase weights for wrist extension Increase shoulder activities Begin self catheterizations Begin gradual weight bearing activities through the wrist Short distance manual wheelchair Continue to refine skills and strength
AROM = active range of motion. PROM = passive range of motion. Ext = extension. Flex = flexion. on to the r a d i u s was e x p o s e d a n d detached. T h e B R t e n d o n a n d muscle unit was then freed to the p r o x i m a l o n e - t h i r d o f the f o r e a r m to m a x i m i z e excursion. A second p a l m a r incision was m a d e from the p a l m a r wrist crease, extending longitudinally on the p a l m a r u l n a r aspect o f the distal forearm. T h e m e d i a n nerve a n d its p a l m a r c u t a n e o u s b r a n c h was exposed a n d protected. T h e u l n a r artery a n d vein were also identified a n d protected. T h e flexor d i g i t o r u m p r o f u n d u s ( F D P ) t e n d o n s to the index, long, r i n g a n d small fingers were t h e n identified as was the flexor pollicis longus ( F P L ) . T h e p r o n a t o r q u a d ratus a n d the interosseous m e m b r a n e p r o x i m a l to it were exposed. A l o n g i t u d i n a l incision was m a d e in the interosseous m e m b r a n e , j u s t p r o x i m a l to the p r o n a t o r quadratus. T h e E C R L t e n d o n was p a s s e d t h r o u g h this to the p a l m a r a s p e c t o f the distal forearm. T h e E C R L tend o n was t r a n s f e r r e d to the F D P o f the index, long, ring a n d small fingers a n d sutured using 2/0 E t h i b o n d using a P u l v e r t a f t weave technique. Tension was a d j u s t e d so t h a t with the wrist in extension, the tips o f the index, long, ring a n d small fingers t o u c h e d the palm. T h e B R was then t r a n s f e r r e d s u b c u t a n e o u s l y a r o u n d the r a d i a l b o r d e r o f the r a d i u s a n d s u t u r e d to the F P L t e n d o n u n d e r t e n s i o n such that w i t h the wrist in extension the i n t e r p h a l a n g e a l j o i n t o f the t h u m b was in flexion. This was also s u t u r e d with 2/0 E t h i b o n d .
T h e t o u r n i q u e t was released a n d h a e m o s t a s i s was achieved. T h e w o u n d was closed a n d a bulky dressing applied.
Postoperative rehabilitation A l l patients u n d e r w e n t intensive r e h a b i l i t a t i o n p r o grammes. T h e t r e a t m e n t p r o t o c o l is s u m m a r i z e d in Table 1. Once surgery was c o m p l e t e d patients r e m a i n e d in h o s p i t a l for 1 to 5 days for m e d i c a l a n d nursing m o n i t o r i n g for c o m p l i c a t i o n s such as a u t o n o m i c dysreflexia a n d infection. Patients were then p l a c e d in a fibreglass cast for 6 weeks. F o l l o w i n g r e m o v a l o f the cast, patients were r e - a d m i t t e d to the r e h a b i l i t a t i o n unit for intensive h a n d a n d o c c u p a t i o n a l therapy. Patients spent up to 3 h o u r s p e r d a y at therapy. Significant gains were usually realized within 3 weeks o f cast removal. Once patients b e g a n to use the h a n d in daily t a s k s they were d i s c h a r g e d a n d c o n t i n u e d o u t - p a t i e n t therapy.
Follow-up The follow-up e v a l u a t i o n consisted o f using b o t h subjective a n d objective assessments. A s t a n d a r d i z e d questionnaire was answered, key p i n c h a n d grip strength
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Table 2 Subjective questionnaire and responses
Activity
Number of responses Much Worse Worse
Unchanged
Improved
Greatly Improved
Mobility Raise yourself in seat Propel wheelchair on level ground Propel up and down gentle slope Transfer from wheelchair to bed Drive a car
0 0 0 0 0
0 0 0 0 0
4 6 3 6 3
4 t 4 2 4
0 1 1 0 1
0 0
0 0
1 2
5 5
2 1
0 0 0
0 0 0
1 1 1
5 4 5
2 3 2
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
4 0 2 2 0 2 5 5
4 6 4 3 3 3 1 2
0 2 2 3 5 3 2 1
0 0 0
0 0 0
0 2 1
3 4 4
5 2 3
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
2 2 0 1 1 2 1 2 6 0 0 3 0
4 3 6 3 6 2 3 3 1 1 1 4 3
2 3 2 4 1 4 4 3 1 7 7 ! 5
Dressing Upper garments Lower garments
Communications Using a telephone Writing or typing Handling money
Washing and toileting Getting in and out of shower/bath Washing and drying upper limbs Washing and drying lower limbs Cleaning teeth Shaving or applying cosmetics Brushing hair Bladder use of urodome or catheter Bowel: inserting suppositories and cleaning after bowel action
Feeding and drinking Use of cutlery Cutting meat Holding a cup or glass
Miscellaneous Making a meal or snack Reaching a shelf above Opening and closing drawers Operating buttons Turning pages in book/newspapers Picking up things from the floor Using a key Putting a plug into a point Have your educational/vocational options changed? Were your overall expectations met? Have you become more independent? Has your self confidence changed? Has surgery changed your quality of life?
Points M u c h worse = 0, Worse = 1, U n c h a n g e d = 2 Improved = 3, Greatly improved = 4
Results Poor 0 69 Fair 70-84
Good 85-101 Excellent 1 0 ~ 1 3 6
measurements were recorded, and the Minnesota rate of manipulation and Carroll upper extremity functional tests were done.
addition, patients were asked to name the five most important goals or activities they wished to improve with surgery and asked how surgery had affected each goal.
Subjective assessment
Objective assessment
We used a questionnaire similar to the one previously described by Mohammed et al (1992) which was based on that described by Lamb and Chan (1983) (Table 2). It consists of a list of 36 questions based on six major topics. In
Objective assessment was obtained using physical examination and grading on the Medical Research Council (1975) rating system for strength. Lateral key pinch strength was measured using a Preston pinch meter
TENDON TRANSFERS IN QUADRIPLEGIA
159 Table 3 Patients' responses to the five most important goals they wished to improve.
Patients' goals Improve independence in self-care Holding/grasping Writing/typing Dressing Driving Eating Transfering Wheelchair Fine finger dexterity Others
Number of responses 8 7 5 4 3 3 2 2 2 4
Subjective results Fig 1 Patient completing the displacement portion of the Minnesota rate of manipulation test.
(European Bissel Healthcare Ltd, Winchester, England) and hook grip strength was measured using a vigorimeter (Martin, Germany). In addition, the Minnesota rate of manipulation test (American Guidance Service, 1969) was used and the Carroll upper extremity functional test (Carroll, 1965) was used to evaluate function. The displacing test portion of the Minnesota rate of manipulation test was used. This is a timed exercise requiring patients to move circular blocks, one by one, on a holed board (Fig 1). Comparisons may be made with the opposite unoperated extremity and also between normal controls. The Carroll (1965) upper extremity functional test is a simple semi-quantitative test of upper extremity function. This evaluation consists of 33 tasks which require the patient to move objects to a shelf, place them over a peg, place the hand to the head, neck and mouth, write their name, and pour water from a pitcher or glass. The objects are of different shapes and weight and are designed to test grasp, pinch, grip, arm extension/elevation, placing, pronation/supination and strength. Scores may be compared against normal individuals. A higher score denotes higher function. RESULTS Nine patients underwent 12 procedures from 1988 to 1995. Three patients had bilateral procedures, one simultaneously. Eight of nine patients were available for subjective assessment or 11/12 transfers. Seven of nine patients were available for objective assessment or 10/12 transfers. The mean age at first operation was 26.1 years (range, 2 3 4 0 years). The mean follow-up was 3.8 years (range, 1.5-7.5 years). The mean time from injury to reconstruction was 4.5 years (range, 1.5 16 years).
Overall, all reported good to excellent results with six excellent and two good according to the scoring system of Mohammed et al (1992). There were no poor or fair results. In the patients with bilateral procedures, two had excellent results and one had a good result. Results of the questionnaire evaluation are summarized in Table 2. All patients reported they would have surgery again. Two said they would not consider surgery on the other side. One had a previous elbow fusion, and the other a malunited distal radius fracture. Both felt that improvements in function on that side would be minimal. Patients' responses to the five most important goals they wished to obtain with surgery are listed in Table 3. No patient described worsening of these activities. Six patients achieved improvements in five out of five of their goals, one patient in 4/5 and one patient in 2/5 goals.
Objective results Key pinch strength measured 1.2 (1.1) kg (mean (SD)) in operatively treated limbs. In non-operatively treated limbs the key pinch strength was 1.0 (1.3)kg. Grip strength was measured with either the thumb in or out depending on whichever the patient found most comfortable. The mean grip strength was 24.0 (41.6) m m H g for operatively treated limbs and 21.5 (13.7) mmHg for nonoperatively treated limbs. The Minnesota rate of manipulation was 2 minutes 56 seconds (1 minute 56 seconds) for operatively treated limbs and 1 minute 29 seconds (15 seconds) for nonoperatively treated limbs. However, three patients were unable to complete the task in the non-operated extremity and were not included in the mean times. For patients who were able to complete the task bilaterally, nonoperatively treated limbs tended towards quicker times. However, they were noted to use grip "tricks" and not use key pinch to move blocks. These times lie within the 1st percentile of normal control patients. The Carroll upper extremity functional test (Fig 2) revealed a mean score of 72.5 (18.0) in the operated extremity. The mean
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Fig 2
THE JOURNAL OF HAND SURGERY VOL. 23B No. 2 APRIL 1998
Patient demonstrating key pinch during the Carroll upper extremity function test.
score for the nonoperated extremity was 52.4 (25.1). When scoring these patients to standardized scores one patient scored trace function, three very poor, three poor and one patient partial function. They required substantially greater effort to complete the task with the contralateral arm or needed to use "tricks" to complete the task.
Complications There were no infections, haematomas, skin sloughs, or failures of fixation. Two patients experienced autonomic dysreflexia in the immediate postoperative period and were treated accordingly. One patient required a second operative procedure for retensioning of the BR to FPL transfer, which was done 10 months postoperatively. Following this satisfactory thumb flexion was obtained. The same patient failed to comply with rehabilitation instructions and accidentally struck the fingers against an object and suffered hyperextension injury to the FDP tendons. The tendon to the left ring finger ruptured. However the patient was not significantly disabled and did not require revision surgery. DISCUSSION The quadriplegic's level of functional independence relies heavily on the ability to use the upper extremities in activities of daily living. Activities such as dressing, bathing, feeding, transfers and wheelchair mobility require the ability to use the arm and hand in purposeful and precise movements. The goals of tendon transfer surgery are to provide a strong grasp and a more precise and useful lateral pinch between the thumb and side of the index finger. The level of independence in self care, productivity and leisure can be dramatically enhanced. The assessment of surgical outcome following tendon transfers is difficult. There is a wide range of neurological loss and possible surgical procedures. Most reports involve multiple surgeons, different procedures and diverse populations (Ejeskar, 1988; Ejeskar and Dahllof,
1988; Freehafer et al, 1984; 1988; Hentz et al, 1983; 1988; Lamb and Chan, 1983; Moberg, 1978; 1990; Mohammed et al, 1992; Murphy and Chuinard, 1988; Vanden Berghe et al, 1991; Waters et al, 1985). In addition, objective assessment of lateral pinch and grip strength may not correlate with improvements in ADLs and quality of life. We examined a group of patients who had the same procedure. Improvements in independence and ADLs were obtained in all patients. It is also important to note that no patient was made worse in any ADL evaluated. All patients were in general satisfied with their surgery. All patients were rated as good or excellent using the Mohammed et al (1992) scoring system. This is similar to the experience of Lamb and Chan (1983) and Mohammed et al (1992) who reported results of 83% and 75% good or excellent results, respectively. To obtain the best results, the importance of a team approach throughout all stages of management cannot be overemphasized. Patient, surgeon, rehabilitation physiatrist, and therapist must all be intimately involved in the decision making process and postoperative rehabilitation. A high level of personal commitment and motivation from the patient is also a prerequisite to a successful result. Objective evaluation of the transfers is in general similar to that reported in the literature. The Carroll upper extremity functional test evaluates grasp, grip, pinch, placing, arm extension, supination, pronation, forward flexion and abduction. However, during testing none of these activities is isolated and almost all activities performed in the test bring into action the whole upper extremity and trunk. For this reason, poor scores are expected in quadriplegic patients. It was noted that some patients had limited function due to absence of a functional triceps mechanism, especially during tests involving placing. Only one patient had triceps function above MRC grade 2 and therefore most suffered in scoring. Brys and Waters (1987) reported that the absence of triceps function decreased the effectiveness of the brachioradialis as a tendon transfer. This is because brachioradialis gains its origin from the supracondylar ridge of the humerus and therefore acts as an elbow flexor. For the optimal use of the brachioradialis as a motor for tendon transfer, function in the triceps may improve motor control. All patients were offered secondary posterior deltoid transfers but they refused because they were satisfied and not interested in a second extended rehabilitation programme. The traditional view is that restoration of triceps function is required before distal transfers (Moberg, 1978). However, the absence of triceps function may not preclude a useful result. Although patients scored low in grip strength and key pinch this is similar to previous reports in the literature (Ejeskar and Dahllof, 1988; Mohammed et al, 1992; Vanden Berghe, 1991). When compared with controls, patients scored poorly in the Carroll upper extremity function and the Minnesota rate of manipulation tests.
TENDON TRANSFERS IN QUADRIPLEGIA
However, the goal of upper extremity reconstruction is not to return a patient to normal, but to regain some use of a previously nonfunctional extremity. As Bunnell has emphasized, "If you have nothing, a little is a lot" (Moberg, 1990). Although the operated limb required longer to perform the Minnesota manipulation test than the unoperated limb, it was noted that numerous trick motions were substituted for the pinch grasp used on the operated limb. Although pinching was less efficient for this particular test, the ability to pinch results in greater overall function as indicated by the questionnaires and the Carroll test. Reconstructive surgery for the upper extremity quadriplegic patient remains a demanding yet rewarding experience. The ECRL to FDP and BR to FPL transfers provide adequate upper extremity function to provide improvements in quality of life and ADLs. Transfer for active elbow extension does not necessarily need to be performed before distal transfers. References American Guidance Service. Minnesota rate of manipulation test: Examiner's manual. AGS, Circle Pines, Minnesota 1969: 1-22. Brys D, Waters R L (1987). Effect of triceps function on the brachioradialis transfer in quadriplegia. Journal of Hand Surgery, 12A: 237-239. Carroll D (1965). A quantitative test of upper extremity function. Journal of Chronic Diseases, 18: 479491. Ejeskar A (1988). Upper limb surgical rehabilitation in high-level tetraplegia. Hand Clinics, 4:585 599. Ejeskar A, Dahllof A (1988). Results of reconstructive surgery in the upper limb of tetraplegic patients. Paraplegia, 26: 204-208. Freehafer AA, Kelly CM, Peckham PH (1984). Tendon transfer for the restoration of upper limb function after a cervical spinal cord injury. Journal of Hand Surgery, 9A: 887 893. Freehafer AA, Peckham PH, Keith MW (1988). New concepts on treatment of the upper limb in the tetraplegie. Hand Clinics, 4: 563-574.
161 Hanson RW, Franklin MR (1976). Sexual loss in relation to other functional losses for spinal cord injuried males. Archives of Physical Medicine and Rehabilitation, 57:291 293. Hentz VR, Brown M, Keoshian LA (1983). Upper limb reconstruction in quadriplegia: functional assessment and proposed treatment modifications. Journal of Hand Surgery, 8:119-131. Hentz VR, Hamlin C, Keoshian LA (1988). Surgical reconstruction in tetraplegia. Hand Clinics, 4: 60I 607. Lamb DW, Chan KM (1983). Surgical reconstruction of the upper limb in traumatic tetraplegia. A review of 41 patients. Journal of Bone and Joint Surgery, 6~B: 291 298. McDowell CL, Moberg EA, Smith AG (1979). International conference on surgical rehabilitation of the upper limb in tetraplegia. Journal of Hand Surgery, 4: 387-390. McDowell CL, Moberg EA, House JH (1986). The second international conference on surgical rehabilitation of the upper limb in tetraplegia (quadriplegia). Journal of Hand Surgery, 1IA: 604 608. Medical Research Council. Aids to the investigation of peripheral nerve injuries', War Memorandum No. 7, 2nd edn., revised. London, Her Majesty's Stationary Office, 1975. Moberg E. The upper limb in tetraplegia. Stuttgart, George Thieme, 1978. Moberg E. Upper limb surgical rehabilitation in tetraplegia. In Evarts CM (Ed.): Surgery of the museuloskeletal system, 2nd edn. New York, ChurchilI Livingstone, 1990, Vol. l: 915. Mohammed KD, Rothwell AG, Sinclair SW, Willems SM, Bean AR (1992). Upper-limb sm'gery for tetraplegia. Journal of Bone and Joint Surgery, 74B: 873-879. Murphy CP, Chuinard RG (1988). Management of the upper extremity in traumatic tetraplegia. Hand Clinics, 4: 201509. Vanden Berghe A, Van Laere M, Hellings S, Vercauteren M (1991). Reconstruction of the upper extremity in tetraplegia: functional assessment, surgical procedures and rehabilitation. Paraplegia, 29: 103-112. Waters R, Moore KR, Graboff ST, Paris K (1985). Brachioradialis to flexor pollicis longus tendon transfer for active lateral pinch in the tetraplegic. Journal of Hand Surgery, 10A: 385 39I.
Received: 12 February 1997 Accepted after revision:30 June 1997 J. H. Roth MD FRCSC, St Joseph's Health Centre, 268 Grosvenor Street, London, Ontario, Canada N6A 4L6. © 1998The British Societyfor Surgeryof the Hand