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Upper limb surgery in tetraplegia
Review Article UPPER
LIMB
SURGERY
IN TETRAPLEGIA
D. W. LAMB Emeritus Consultant Orthopaedic Surgeon, Princess Margaret Rose Orthopaedic Hospital, Edinburgh
Traumatic tetraplegia is now the commonest cause of severe bilateral upper limb paralysis in the Western world and second only to leprosy throughout the world as a whole. The marvels pioneered during and after the Second World War in the successful management of the paraplegic have now also been achieved in the management of cervical injuries, so that the tetraplegic now has a very long life expectancy. The exact incidence of spinal cord injury every year in the United Kingdom is not known with certainty, but it can be estimated that there is approximately one new spinal cord injury per 100,000 population. As a result, some 500-600 new spinal cord injuries will occur every year in this country and now 60% of these are likely to be in the cervical region. Most of them result from flexion injuries of the neck occurring in young active adults at the height of their physical powers, usually from a vehicular accident but increasingly in sporting activities : diving, surfing, trampolining, skiing and collapsing of the strum at rugby football have been common causes in the last 15 or 20 years. As a result of the injury, these predominantly young people will be confined to a wheelchair for the remainder of their lives. There will be a varying amount of paralysis of the upper limbs, making it difficult to fend for themselves in everyday activities such as dressing and tmdressing, cleaning the teeth, shaving, brushing and combing the hair, applying make-up, writing, using a telephone and eating and drinking. Anything that can be done to improve the quality of life by surgical means must be considered very carefully. In the past, the upper limb has often been neglected in the overall consideration of the management of these patients. It has usually been accepted that much has to be done for the unfortunate individual by others and that the most that can be done to help the arms is by the provision of various gadgets and orthoses and in the higher levels of cervical cord injury by sophisticated equipment. Papers on the possible benefits of surgical treatment in these circumstances were few and far between until recent years. Wilson (1956) suggested a tenodesis of the flexor tendons to provide some automatic grasp. These procedures give a fixed hook deformity of the fingers; the functional benefits were limited and the hand ugly in appearance. The possible place of tendon transfers in improving function of the hand in tetraplegia was first proposed from the Mayo clinic (Lipscomb et al., 1958). As the increasing survival-rate from cervical spine injuries became apparent, the importance of Lipscomb’s paper VOL.
14-B No. 2 MAY
1989
was more appreciated in setting a standard which stimulated the interest of the reviewer, who had recently been appointed as orthopaedic surgeon to the new spinal injury unit in Edinburgh. In 1963, a symposium on spinal cord injuries was held at the Royal College of Surgeons of Edinburgh and Lamb presented a paper on the management of the upper limbs in cervical cord injuries. During the past twenty years, there has been an increasing interest in the subject by many hand surgeons, led by Moberg (1975) and the publication in 1978 of his book The upper limb in tetraplegia. Another important influence was Zancolli who in 1975 reviewed 25 years experience with the management of tetraplegics. There was strong opposition to surgery by many influential physicians in spinal injury units who had found that the results of surgery in some of their patients had been disappointing, but this was more due to a failure of the delicate techniques required than of the principles involved. The lessons learnt from tendon transfers in the management of poliomyelitis had to be re-appraised and techniques altered to meet the needs of the tetraplegic hand. One of the main indications now for tendon transfers in the upper limb and hand is in tetraplegia and the potential for this has not yet been fully realised by many hand surgeons. If the valuable lessons learnt by those who have pioneered this development and the advantageous results to the tetraplegic which have been reported (Beasley, 1983; De Benedetti, 1979; Freehafer, 1975; Hentz & Keoshian, 1979; Hentz et al., 1983; House et al., 1976; Lacey et al., 1986; Lamb and Chan, 1983; Moberg, 1975 and Zancolli, 1975) are to be fully realised, it is incumbent upon those who specialise in hand surgery to see that their expertise is put to the full benefit of this group who are so severely disabled. Many spinal injury services have been slow to realise the potential. Surgeons who are attached to these units may be interested mainly in the management of the vertebral injury or the problems of the bladder or pressure sores, but very few indeed have been trained in the skills necessary for upper limb reconstructive surgery. The victims of tetraplegia are only too aware of the problems resulting from the paralysis of the upper limbs. 100 young tetraplegics were asked what would be the one most important benefit to them from all their disabilities : 75% placed restoration of upper limb function as their main priority (Hanson and Franklin, 1976). Patients will go to great lengths to regain some improved upper limb function. They meet and talk at 143
D. W. LAMB
social and sporting occasions with others who have had reconstructive surgery and will make remarkable efforts to seek out those centres where surgery is available to restore active elbow extension and grasp in the hand. We must not over-emphasise to the patient the potential benefits of surgery. Nothing can restore sensation and even motor function will not be in any way comparable to the normal, but even a small measure of improvement to the person who is severely disabled will mean a lot. Three international meetings have now been held on this topic. The first was in Edinburgh in 1978 (Moberg and Lamb, 1980) and attended by a small select band of those interested. A second meeting at Giens, France, in 1984 (McDowall et al., 1986) attracted a wider range of representatives from around the world and the most recent conference in Gothenburg in 1988, to honour Eric Moberg, showed the extent to which this subject is attracting the attention of many experienced and skilled hand surgeons. A cross-section of the results obtained by Moberg and his colleagues in over 800 patients was seen at this recent meeting and there can be no doubts about the benefits. While it is important to encourage our colleagues to pvvide their expertise to our spinal injury units, it is equally important that great care be taken in the selection of patients suitable for operation and who have the necessary driving desire to make the best use of what is provided. Careful patient selection, attention to operative detail and, most essential, post-operative therapy services will prevent the development of complications such as contractures, resulting in a hand which is less useful than before operation.
De BENEDETTI, M. (1979). Restoration of elbow extension power in the tetraplegic patient using the Moberg technique. Journal of Hand Surgery, 4: 1: 86-89. FREEHAFER, A. A. (1975). Tendon transfer to improve grasp in patients with cervical spinal cord injury. Paraplegia, 13 : 15-21. HANSON, R. W. and FRANKLIN, M. R. (1976). Sexual loss in relation toother functional losses for spinal cord injured patients. Archives of Physical Medicine and Rehabilitation. 57: 291-293. HENTZ, V. R. andKEOSHIAN,L. A. (1979). Changing Perspectivesin Surgical Hand Rehabilitation in Quadriplegic Patients. Plastic and Reconstructive Surgery, 64: 4: 509-515. HENTZ, V. R., BROWN, M. and KEOSHIAN, L. A. (1983). Upper limb reconstruction in auadriuleeia: Functional assessment and orouosed treatment modificationk Journal-of Hand Surgery, 8: 2: 119-130.& I HOUSE, J. H., GWATHMEY, L. W. and LUNDSGAARD, D. K. (1976). Restoration of strong grasp and lateral pinch in tetraplegia due to cervical spinal cord injury. Journal of Hand Surgery, 1: 2: 152-159. LACEY, S. H., WILBER, R. G., PECKHAM, P. H. and FREEHAFER, A. A. (1986). The posterior deltoid to triceps transfer: A clinical and biomechanical assessment, Journal of Hand Surgery, 11A: 4: 542-547. LAMB, D. W. The management of upper limbs in cervical cord injuries. In Proceedings ofsymposium at the Royal College of Surgeonsof Edinburgh. Morrison & Gibb. Edinbureh. 1963. LAMB, D. W. and &AN, K.-hi. (1983). Surgical reconstruction of the upper limb in traumatic tetraplegia. Journal of Bone and Joint Surgery, 65B: 3 : 291-298. LIPSCOMB, P. R., ELKINS, E. C. and HENDERSON, E. D. (1958). Tendon Transfers to Restore Function of Hands in Tetraplegia, Especially after Fracture-Dislocation of the Sixth Cervical Vertebra on the Seventh. Journal of Bone and Joint Surgery, 40A: 5 : 1071&1080. MCDOWELL, C. L., MOBERG, E. A. and HOUSE, J. H. (1986). The Second International Conference on Surgical Rehabilitation of the Upper Limb in Tetraplegia (Quadriplegia). Journal of Hand Surgery, 11A: 4: 604-608. MOBERG, E. The Upper Limb in Tetraplegia. Thieme, Stuttgart, 1978. MOBERG, E. and LAMB, D. W. (1980). Surgical rehabilitation of the upper limb in tetraplegia. Proceedings of the International Conference in Edinburgh. The Hand, 12: 2: 209-213. MOBERG, E. (1975). Surgical Treatment for Absent Single-Hand Grip and Elbow Extension in Quadriplegia. Journal of Bone and Joint Surgery, S7A: 2: 196-206. WILSON, J. N. (1956). Providing Automatic Grasp byFlexor Tenodesis. Journal ofBone and Joint Surgery, 38A: 5: 1019-1024. ZANCOLLI, E. (1975). Surgery for the Quadriplegic Hand With Active, Strong Wrist Extension Preserved. Clinical Orthopaedics and Related Research, 112: 101-113.
References BEASLEY, R. W. (1983). Surgical Treatment of Hands for C5-C6 Tetraplegia. Orthopedic Clinics of North America, 14: 4: 893-904.
144
0 1989 The British Sow&y for Surgery of the Hand 0266-76X1/89/0014-0143/$10.00
THE
JOURNAL
OF HAND
SURGERY
LIMB
SURGERY
IN TETRAPLEGIA
D. W. LAMB Emeritus Consultant Orthopaedic Surgeon, Princess Margaret Rose Orthopaedic Hospital, Edinburgh
Traumatic tetraplegia is now the commonest cause of severe bilateral upper limb paralysis in the Western world and second only to leprosy throughout the world as a whole. The marvels pioneered during and after the Second World War in the successful management of the paraplegic have now also been achieved in the management of cervical injuries, so that the tetraplegic now has a very long life expectancy. The exact incidence of spinal cord injury every year in the United Kingdom is not known with certainty, but it can be estimated that there is approximately one new spinal cord injury per 100,000 population. As a result, some 500-600 new spinal cord injuries will occur every year in this country and now 60% of these are likely to be in the cervical region. Most of them result from flexion injuries of the neck occurring in young active adults at the height of their physical powers, usually from a vehicular accident but increasingly in sporting activities : diving, surfing, trampolining, skiing and collapsing of the strum at rugby football have been common causes in the last 15 or 20 years. As a result of the injury, these predominantly young people will be confined to a wheelchair for the remainder of their lives. There will be a varying amount of paralysis of the upper limbs, making it difficult to fend for themselves in everyday activities such as dressing and tmdressing, cleaning the teeth, shaving, brushing and combing the hair, applying make-up, writing, using a telephone and eating and drinking. Anything that can be done to improve the quality of life by surgical means must be considered very carefully. In the past, the upper limb has often been neglected in the overall consideration of the management of these patients. It has usually been accepted that much has to be done for the unfortunate individual by others and that the most that can be done to help the arms is by the provision of various gadgets and orthoses and in the higher levels of cervical cord injury by sophisticated equipment. Papers on the possible benefits of surgical treatment in these circumstances were few and far between until recent years. Wilson (1956) suggested a tenodesis of the flexor tendons to provide some automatic grasp. These procedures give a fixed hook deformity of the fingers; the functional benefits were limited and the hand ugly in appearance. The possible place of tendon transfers in improving function of the hand in tetraplegia was first proposed from the Mayo clinic (Lipscomb et al., 1958). As the increasing survival-rate from cervical spine injuries became apparent, the importance of Lipscomb’s paper VOL.
14-B No. 2 MAY
1989
was more appreciated in setting a standard which stimulated the interest of the reviewer, who had recently been appointed as orthopaedic surgeon to the new spinal injury unit in Edinburgh. In 1963, a symposium on spinal cord injuries was held at the Royal College of Surgeons of Edinburgh and Lamb presented a paper on the management of the upper limbs in cervical cord injuries. During the past twenty years, there has been an increasing interest in the subject by many hand surgeons, led by Moberg (1975) and the publication in 1978 of his book The upper limb in tetraplegia. Another important influence was Zancolli who in 1975 reviewed 25 years experience with the management of tetraplegics. There was strong opposition to surgery by many influential physicians in spinal injury units who had found that the results of surgery in some of their patients had been disappointing, but this was more due to a failure of the delicate techniques required than of the principles involved. The lessons learnt from tendon transfers in the management of poliomyelitis had to be re-appraised and techniques altered to meet the needs of the tetraplegic hand. One of the main indications now for tendon transfers in the upper limb and hand is in tetraplegia and the potential for this has not yet been fully realised by many hand surgeons. If the valuable lessons learnt by those who have pioneered this development and the advantageous results to the tetraplegic which have been reported (Beasley, 1983; De Benedetti, 1979; Freehafer, 1975; Hentz & Keoshian, 1979; Hentz et al., 1983; House et al., 1976; Lacey et al., 1986; Lamb and Chan, 1983; Moberg, 1975 and Zancolli, 1975) are to be fully realised, it is incumbent upon those who specialise in hand surgery to see that their expertise is put to the full benefit of this group who are so severely disabled. Many spinal injury services have been slow to realise the potential. Surgeons who are attached to these units may be interested mainly in the management of the vertebral injury or the problems of the bladder or pressure sores, but very few indeed have been trained in the skills necessary for upper limb reconstructive surgery. The victims of tetraplegia are only too aware of the problems resulting from the paralysis of the upper limbs. 100 young tetraplegics were asked what would be the one most important benefit to them from all their disabilities : 75% placed restoration of upper limb function as their main priority (Hanson and Franklin, 1976). Patients will go to great lengths to regain some improved upper limb function. They meet and talk at 143
D. W. LAMB
social and sporting occasions with others who have had reconstructive surgery and will make remarkable efforts to seek out those centres where surgery is available to restore active elbow extension and grasp in the hand. We must not over-emphasise to the patient the potential benefits of surgery. Nothing can restore sensation and even motor function will not be in any way comparable to the normal, but even a small measure of improvement to the person who is severely disabled will mean a lot. Three international meetings have now been held on this topic. The first was in Edinburgh in 1978 (Moberg and Lamb, 1980) and attended by a small select band of those interested. A second meeting at Giens, France, in 1984 (McDowall et al., 1986) attracted a wider range of representatives from around the world and the most recent conference in Gothenburg in 1988, to honour Eric Moberg, showed the extent to which this subject is attracting the attention of many experienced and skilled hand surgeons. A cross-section of the results obtained by Moberg and his colleagues in over 800 patients was seen at this recent meeting and there can be no doubts about the benefits. While it is important to encourage our colleagues to pvvide their expertise to our spinal injury units, it is equally important that great care be taken in the selection of patients suitable for operation and who have the necessary driving desire to make the best use of what is provided. Careful patient selection, attention to operative detail and, most essential, post-operative therapy services will prevent the development of complications such as contractures, resulting in a hand which is less useful than before operation.
De BENEDETTI, M. (1979). Restoration of elbow extension power in the tetraplegic patient using the Moberg technique. Journal of Hand Surgery, 4: 1: 86-89. FREEHAFER, A. A. (1975). Tendon transfer to improve grasp in patients with cervical spinal cord injury. Paraplegia, 13 : 15-21. HANSON, R. W. and FRANKLIN, M. R. (1976). Sexual loss in relation toother functional losses for spinal cord injured patients. Archives of Physical Medicine and Rehabilitation. 57: 291-293. HENTZ, V. R. andKEOSHIAN,L. A. (1979). Changing Perspectivesin Surgical Hand Rehabilitation in Quadriplegic Patients. Plastic and Reconstructive Surgery, 64: 4: 509-515. HENTZ, V. R., BROWN, M. and KEOSHIAN, L. A. (1983). Upper limb reconstruction in auadriuleeia: Functional assessment and orouosed treatment modificationk Journal-of Hand Surgery, 8: 2: 119-130.& I HOUSE, J. H., GWATHMEY, L. W. and LUNDSGAARD, D. K. (1976). Restoration of strong grasp and lateral pinch in tetraplegia due to cervical spinal cord injury. Journal of Hand Surgery, 1: 2: 152-159. LACEY, S. H., WILBER, R. G., PECKHAM, P. H. and FREEHAFER, A. A. (1986). The posterior deltoid to triceps transfer: A clinical and biomechanical assessment, Journal of Hand Surgery, 11A: 4: 542-547. LAMB, D. W. The management of upper limbs in cervical cord injuries. In Proceedings ofsymposium at the Royal College of Surgeonsof Edinburgh. Morrison & Gibb. Edinbureh. 1963. LAMB, D. W. and &AN, K.-hi. (1983). Surgical reconstruction of the upper limb in traumatic tetraplegia. Journal of Bone and Joint Surgery, 65B: 3 : 291-298. LIPSCOMB, P. R., ELKINS, E. C. and HENDERSON, E. D. (1958). Tendon Transfers to Restore Function of Hands in Tetraplegia, Especially after Fracture-Dislocation of the Sixth Cervical Vertebra on the Seventh. Journal of Bone and Joint Surgery, 40A: 5 : 1071&1080. MCDOWELL, C. L., MOBERG, E. A. and HOUSE, J. H. (1986). The Second International Conference on Surgical Rehabilitation of the Upper Limb in Tetraplegia (Quadriplegia). Journal of Hand Surgery, 11A: 4: 604-608. MOBERG, E. The Upper Limb in Tetraplegia. Thieme, Stuttgart, 1978. MOBERG, E. and LAMB, D. W. (1980). Surgical rehabilitation of the upper limb in tetraplegia. Proceedings of the International Conference in Edinburgh. The Hand, 12: 2: 209-213. MOBERG, E. (1975). Surgical Treatment for Absent Single-Hand Grip and Elbow Extension in Quadriplegia. Journal of Bone and Joint Surgery, S7A: 2: 196-206. WILSON, J. N. (1956). Providing Automatic Grasp byFlexor Tenodesis. Journal ofBone and Joint Surgery, 38A: 5: 1019-1024. ZANCOLLI, E. (1975). Surgery for the Quadriplegic Hand With Active, Strong Wrist Extension Preserved. Clinical Orthopaedics and Related Research, 112: 101-113.
References BEASLEY, R. W. (1983). Surgical Treatment of Hands for C5-C6 Tetraplegia. Orthopedic Clinics of North America, 14: 4: 893-904.
144
0 1989 The British Sow&y for Surgery of the Hand 0266-76X1/89/0014-0143/$10.00
THE
JOURNAL
OF HAND
SURGERY