Introduction

The most common causes of spinal cord injury (SCI) are road accidents and falls from a height, with a prevalence for male patients between 16 and 30 years old ( ) and an incidence between 10 and 80 new cases per millions of people annually worldwide ( ).

More than 50% of all spinal cord injuries involve cervical spine leading tetraplegia as main clinical feature, with loss of effective upper-limb function.

The lack of hand function is the sequela which mostly affected the quality of life in patients with tetraplegia and always requires support in their daily-life activities and mobility from other people ( ; ; ). Furthermore, it is reported as more desired than bowel, bladder and sexual function, standing and pain control ( ; ). In this scenario, tendon transposition is a reliable surgical technique able to restore active movement and strength of a damaged anatomical segment; however, the shortage of functional muscles above the segment lesion available for transfer is the main problem treating cervical SCI ( ). Similarly, nerve transfer required the adjustment of a healthy donor nerve to a denervated anatomical district to restore function nerve-target, but this means to sacrifice a potential useful nervous structure ( ).

In our review, we are going to illustrate the current available techniques of tendon and nervous transfer in order to restore hand and forearm function combining nerve and tendon transfer in patients with tetraplegia.

Classifications

The most useful and accepted classification for upper-limb lesion in tetraplegia is the:

The Classification for Surgery of the Hand in Tetraplegia (ICSHT), where, the most common patterns of injuries are classified following the number of functional muscles existing below the elbow.

A functional muscle is described as muscle graded 4 or more according to the Muscle Grading System ( ) ( Table 1 ), and the ICSHT principles are reported in the literature as the “gold standard” to choose the most appropriate reconstructive technique mainly based on tendon transfer and tenodesis procedure ( Table 2 ).

It’s important to select the most appropriate donor muscle in order to preserve function of anatomical region without creating another functional deficit after tendon transfer which can be used alone or in combination with tenodesis and arthrodesis showing interesting and reproducible results ( ).

According to function importance, a priority order to choose the correct sequence of donor muscles ( ; ) is well established:

• (1)
  

  wrist extension recovery,

  
  
• (2)
  

  pinch recovery,

  
  
• (3)
  

  grasp recovery,

  
  
• (4)
  

  finger and thumb extension recovery,

  
  
• (5)
  

  intrinsic muscles function recovery.

When transfer options are ended, the remaining functions are reached using tenodesis and arthrodesis ( ).

In the setting of arm dysfunction, nerve transfer is also a successful surgical procedure approaching proximal brachial plexus injury with avulsion of nerve roots or more peripheral nerve injuries. Nerve transfers are commonly used where anatomic repair of original motor nerve is not possible as well as where it’s possible to rapidly restore function by rerouting expendable donor nerves ( ). Recently, some Authors introduced nerve transfers in tetraplegia, reporting interesting outcomes ( ; ). According to our previous work ( ), the current authors propose a new surgical strategy based on classical tendon transfer surgery combined with nerve transfer techniques ( Table 3 ). The use of both surgical approaches allows avoiding a frequent concern about the use of nerve transfer in reconstructive surgery: the risk of using sources of “predictable” results for “unpredictable” results.

Table 3

Combining Nerve and Tendon Strategy in tetraplegia.

Group 0
Primary procedure	Positive outcome?	Secondary procedure
• Teres minor to triceps nerve transfer • Brachialis to ECRL nerve transfer	NO	Posterior deltoid to triceps tendon transfer
	YES	Flexor pollicis longus tenodesis + Moberg key pinch procedure
Group 1 (BR ➔ M 4)
Primary procedure	Positive outcome?	Secondary procedure
• Teres minor to triceps nerve transfer	NO	Posterior deltoid to triceps tendon transfer
• Brachialis to AIN/FDS nerve transfer	YES	Extensor digitorum communis tenodesis + Extensor pollicis longus tenodesis
	NO	Flexor pollicis longus tenodesis + Moberg key pinch procedure
• BR to ECRB tendon transfer
Group 2 (ERCL ➔ M 4)
Primary procedure	Positive outcome?	Secondary procedure
• Teres minor to triceps nerve transfer	NO	Posterior deltoid to triceps tendon transfer
• Supinator to PIN nerve transfer	NO	Extensor digitorum communis tenodesis + Extensor pollicis longus tenodesis
• Brachialis to AIN/FDS nerve transfer	YES	BR to opposition
	NO	BR to FPL tendon transfer
Group 3 (ECRB ➔ M 4)
Primary procedure	Positive outcome?	Secondary procedure
• Teres minor to triceps nerve transfer	NO	Posterior deltoid to triceps tendon transfer
• Supinator to PIN nerve transfer	NO	Extensor digitorum communis tenodesis + Extensor pollicis longus tenodesis
• Brachialis to AIN/FDS nerve transfer	YES	BR to opposition
	NO	BR to FPL tendon transfer + Tenodesis FDP 2° to FDP 3°-4°-5°
• ECRL to FDP (3°-4°-5° finger) tendon transfer
Group 4 (PT ➔ M 4)
Primary procedure	Positive outcome?	Secondary procedure
• Supinator to PIN nerve transfer	NO	Extensor digitorum communis tenodesis + Extensor pollicis longus tenodesis
• Brachialis to AIN/FDS nerve transfer	YES	BR to opposition
	NO	BR to FPL tendon transfer + Tenodesis FDP 2° to FDP 3°-4°-5°
• ECRL to FDP (3°-4°-5° finger) tendon transfer
Group 5 (FRC ➔ M 4)
Primary procedure	Positive outcome?	Secondary procedure
• Supinator to PIN nerve transfer	NO	Extensor digitorum communis tenodesis + Extensor pollicis longus tenodesis
• Brachialis to AIN/FDS nerve transfer	YES	BR to opposition
	NO	BR to FPL tendon transfer + Tenodesis FDP 2° to FDP 3°-4°-5°
• ECRL to FDP (3°-4°-5° finger) tendon transfer
Group 6 (EDC ➔ M 4)
Primary procedure	Positive outcome?	Secondary procedure
• Brachialis to AIN/FDS nerve transfer	YES	BR to opposition
	NO	BR to FPL tendon transfer + Tenodesis FDP 2° to FDP 3°-4°-5°
• ECRL to FDP (3°-4°-5° finger) tendon transfer
• EPL tenodesis
Group 7 (EPL ➔ M 4)
Primary procedure	Positive outcome?	Secondary procedure
• Brachialis to AIN/FDS nerve transfer	YES	EDM to APB or EIP to APB
	NO	BR to FPL tendon transfer + Tenodesis FDP 2° to FDP 3°-4°-5° + EDM to APB or EIP to APB
• ECRL to FDP (3°-4°-5° finger) tendon transfer
Group 8 (partial finger flexion)
Primary procedure	Positive outcome?	Secondary procedure
• ECRB to AIN nerve transfer	YES	EPI/EDM to opposition
	NO	BR to FPL tendon transfer + Tenodesis FDP 2° to FDP 3°-4°-5° + EPI/EDM to opposition
Group 9 (intrinsic deficit)
Primary procedure	Positive outcomes	Secondary procedure
• Intrinsic reconstruction (Zancolli lasso/house intrinsic procedure) • Opponensplasty	YES	None
	NO

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