aticle & opinion

Expanding traditional tendon-based techniques with nerve transfers for the restoration of upper limb function in tetraplegia: a prospective case series – The Lancet

Expanding traditional tendon-based techniques with nerve transfers for the restoration of upper limb function in tetraplegia: a prospective case series – The Lancet



Loss of upper extremity function after cervical spinal cord injury greatly affects
independence, including social, vocational, and community engagement. Nerve transfer
surgery offers an exciting new option for the reanimation of upper limb function in
tetraplegia. The aim of this study was to evaluate the outcomes of nerve transfer
surgery used for the reanimation of upper limb function in tetraplegia.


In this prospective case series, we consecutively recruited people of any age with
early (<18 months post-injury) cervical spinal cord injury of motor level C5 and below, who had been referred to a single centre for upper extremity reanimation and were deemed suitable for nerve transfer. All participants underwent single or multiple nerve transfers in one or both upper limbs, sometimes combined with tendon transfers, for restoration of elbow extension, grasp, pinch, and hand opening. Participants were assessed at 12 months and 24 months post-surgery. Primary outcome measures were the action research arm test (ARAT), grasp release test (GRT), and spinal cord independence measure (SCIM).


Between April 14, 2014, and Nov 22, 2018, we recruited 16 participants (27 limbs)
with traumatic spinal cord injury, among whom 59 nerve transfers were done. In ten
participants (12 limbs), nerve transfers were combined with tendon transfers. 24-month
follow-up data were unavailable for three patients (five limbs). At 24 months, significant
improvements from baseline in median ARAT total score (34·0 [IQR 24·0–38·3] at 24
vs 16·5 [12·0–22·0] at baseline, p<0·0001) and GRT total score (125·2 [65·1–154·4] vs 35·0 [21·0–52·3], p<0·0001) were observed. Mean total SCIM score and mobility in the room and toilet SCIM score improved by more than the minimal detectable change and the minimal clinically important difference, and the mean self-care SCIM score improved by more than the minimal detectable change between baseline and 24 months. Median Medical Research Council strength grades were 3 (IQR 2–3) for triceps and 4 (IQR 4–4) for digital extensor muscles after 24 months. Mean grasp strength at 24 months was 3·2 kg (SD 1·5) in participants who underwent distal nerve transfers (n=5), 2·8 kg (3·2) in those who had proximal nerve transfers (n=9), and 3·9 kg (2·4) in those who had tendon transfers (n=8). There were six adverse events related to the surgery, none of which had any ongoing functional consequences.


Early nerve transfer surgery is a safe and effective addition to surgical techniques
for upper limb reanimation in tetraplegia. Nerve transfers can lead to significant
functional improvement and can be successfully combined with tendon transfers to maximise
functional benefits.


Institute for Safety, Compensation, and Recovery Research (Australia).

To read this article in full you will need to make a payment


  1. 1.
    • Bickenbach J
    • Officer A
    • Shakespeare T
    • von Groote P
    • et al.

    International perspectives on spinal cord injury.

    World Health Organization,
    Geneva; 2013

  2. 2.
    • Anderson KD

    Targeting recovery: priorities of the spinal cord-injured population.

    J Neurotrauma. 2004; 21: 1371-1373

  3. 3.
    • Hentz VR
    • Leclercq C

    Surgical rehabilitation of the upper limb in tetraplegia.

    New York; 2002

  4. 4.
    • Cain SA
    • Gohritz A
    • Fridén J
    • van Zyl N

    Review of upper extremity nerve transfer in cervical spinal cord injury.

    J Brachial Plex Peripher Nerve Inj. 2015; 10: e34-e42

  5. 5.
    • van Zyl N
    • Hahn JB
    • Cooper CA
    • Weymouth MD
    • Flood SJ
    • Galea MP

    Upper limb reinnervation in C6 tetraplegia using a triple nerve transfer: case report.

    J Hand Surg. 2014; 39: 1779-1783

  6. 6.
    • Agha RA
    • Borrelli MR
    • Farwana R
    • Koshy K
    • Fowler AJ
    • Orgill DP

    The PROCESS 2018 statement: updating consensus preferred reporting of case series in surgery (PROCESS) guidelines.

    Int J Surg. 2018; 60: 279-282

  7. 7.
    • Bertelli JA
    • Ghizoni MF
    • Tacca CP

    Transfer of the teres minor motor branch for triceps reinnervation in tetraplegia.

    J Neurosurg. 2011; 114: 1457-1460

  8. 8.
    • Bertelli JA
    • Ghizoni MF

    Transfer of supinator motor branches to the posterior interosseous nerve in C7-T1 brachial plexus palsy.

    J Neurosurg. 2010; 113: 129-132

  9. 9.
    • Bertelli JA

    Transfer of the radial nerve branch to the extensor carpi radialis brevis to the anterior interosseous nerve to reconstruct thumb and finger flexion.

    J Hand Surg. 2015; 40 (): 323

  10. 10.
    • Mackinnon SE
    • Yee A
    • Ray WZ

    Nerve transfers for the restoration of hand function after spinal cord injury: case report.

    J Neurosurg. 2012; 117: 176-185

  11. 11.
    • Tang JB

    Re: levels of experience of surgeons in clinical studies.

    J Hand Surg Eur Vol. 2009; 34: 137-138

  12. 12.
    • Hahn J
    • Cooper C
    • Flood S
    • Weymouth M
    • van Zyl N

    Rehabilitation of supinator nerve to posterior interosseous nerve transfer in individuals with tetraplegia.

    Arch Phys Med Rehab. 2016; 97: S160-S168

  13. 13.
    • Kirshblum SC
    • Burns SP
    • Biering-Sorensen F
    • et al.

    International standards for neurological classification of spinal cord injury (revised 2011).

    J Spinal Cord Med. 2011; 34: 535-546

  14. 14.
    • McDowell CL
    • Moberg EA
    • House JH

    The second international conference on surgical rehabilitation of the upper limb in tetraplegia (quadriplegia).

    J Hand Surg. 1986; 11: 604-608

  15. 15.
    • Seddon HJ

    Peripheral nerve injuries. Medical Research Council special report series no 282.

    Her Majesty’s Stationery Office,
    London; 1954

  16. 16.
    • Weinstein S

    Fifty years of somatosensory research: from the Semmes-Weinstein monofilaments to the Weinstein Enhanced Sensory Test.

    J Hand Ther. 1993; 6: 11-22

  17. 17.
    • Bickley LS
    • Szilagyi PG

    Bates’ guide to physical examination and history taking.

    Lippincott, Williams & Wilkins,
    Philadelphia; 2007

  18. 18.
    • Bryce TN
    • Biering-Sørensen F
    • Finnerup NB
    • et al.

    International spinal cord injury pain classification: part I. Background and description.

    Spinal Cord. 2012; 50: 413-417

  19. 19.
    • Lyle RC

    A performance test for assessment of upper limb function in physical rehabilitation treatment and research.

    Int J Rehabil Res. 1981; 4: 483-492

  20. 20.
    • Wuolle KS
    • Van Doren CL
    • Thrope GB
    • Keith MW
    • Peckham PH

    Development of a quantitative hand grasp and release test for patients with tetraplegia using a hand neuroprosthesis.

    J Hand Surg. 1994; 19: 209-218

  21. 21.
    • Catz A
    • Itzkovich M
    • Agranov E
    • Ring H
    • Tamir A

    SCIM—spinal cord independence measure: a new disability scale for patients with spinal cord lesions.

    Spinal Cord. 1997; 35: 850-856

  22. 22.
    • Law M
    • Baptiste S
    • McColl M
    • Opzoomer A
    • Polatajko H
    • Pollock N

    The Canadian Occupational Performance Measure: an outcome measure for occupational therapy.

    Can J Occup Ther. 1990; 57: 82-87

  23. 23.
    • Cohen J

    Statistical power analysis for the behavioral sciences.

    2nd edn. Lawrence Erlbaum Associates,
    Hillsdale, NJ; 1988

  24. 24.
    • Scivoletto G
    • Tamburella F
    • Laurenza L
    • Molinari M

    The spinal cord independence measure: how much change is clinically significant for spinal cord injury subjects.

    Disabil Rehabil. 2013; 35: 1808-1813

  25. 25.
    • Carswell A
    • McColl MA
    • Baptiste S
    • Law M
    • Polatajko H
    • Pollock N

    The Canadian Occupational Performance Measure: a research and clinical literature review.

    Can J Occup Ther. 2004; 71: 210-222

  26. 26.
    • Hamou C
    • Shah NR
    • DiPonio L
    • Curtin CM

    Pinch and elbow extension restoration in people with tetraplegia: a systematic review of the literature.

    J Hand Surg. 2009; 34: 692-699

  27. 27.
    • Reinholdt C
    • Fridén J

    Outcomes of single-stage grip-release reconstruction in tetraplegia.

    J Hand Surg. 2013; 38: 1137-1144

  28. 28.
    • Bertelli JA
    • Ghizoni MF

    Nerve transfers for restoration of finger flexion in patients with tetraplegia.

    J Neurosurg Spine. 2017; 26: 55-61

  29. 29.
    • Wangdell J
    • Fridén J

    Satisfaction and performance in patient selected goals after grip reconstruction in tetraplegia.

    J Hand Surg Eur Vol. 2010; 35: 563-568

  30. 30.
    • Pascoe GC

    Patient satisfaction in primary health care: a literature review and analysis.

    Eval Prog Plan. 1983; 6: 185-210

Article Info

Publication History




© 2019 Elsevier Ltd. All rights reserved.


Access this article on ScienceDirect

Linked Articles

Read More

Related posts

Bladder cancer ‘attacked and killed by common cold virus’ – Biorports News

admin2 admin2

Letter to Nigerian governors

Admin2 Admin

Scientists say they found a cure for HIV in some mice; humans could be next – INFORUM

admin2 admin2

Leave a Reply