upper-limb surgery in tetraplegia upper-limb surgery in tetraplegia upper-limb surgery in tetraplegia includes a number of surgical interventions that can help improve the quality of life of a patient with tetraplegia. upper-limb surgery in tetraplegiaspecialtyneurosurgeon loss of upper-limb function in patients with following a spinal cord injury is a major barrier to regain autonomy. the functional abilities of a tetraplegic patient increase substantially for instance if the patient can extend the elbow. this can increase the workspace and give a better use of a manual wheelchair. to be able to hold objects a patient needs to have a functional pinch grip, this can be useful for performing daily living activities. a large survey in patients with tetraplegia demonstrated that these patients give preference to improving upper extremity function above other lost functions like being able to walk or sexual function. surgical procedures do exist to improve the function of the tetraplegic patient's arms, but these procedures are performed in fewer than 10% of the tetraplegic patients. each tetraplegic patient is unique, and therefore surgical indication should be based on the remaining physical abilities, wishes and expectations of the patient. in 2007 a resolution was presented and accepted at the world congress in reconstructive hand surgery and rehabilitation in tetraplegia, that stated that every patient with tetraplegia should be examined and informed about the options for reconstructive surgery of the tetraplegic arms and hands. this resolution demonstrates mostly the necessity to increase the awareness on this subject amongst physicians. history reconstructive surgery of the upper limb in tetraplegic patients began during the mid-20th century. the first attempts at regaining gripping function of the hand probably took place in europe at the end of the 1920s with the construction of flexor-hinge splints. in the early 1940s, a surgeon called sterling bunnell (1882–1957) was probably one of the first to refer to the reconstruction of gripping function for the tetraplegic hand. he described surgeries of combining tenodeses and tendon transfers to restore hand function. he also advocated transferring the m. brachioradialis to the wrist extensors when these muscles are paralyzed. in the 1950s, understanding of the tenodesis effect (see tenodesis grasp) influenced the development of surgical techniques such as the static flexor tenodesis. these procedures provided the basic functions of grasp and pinch. tendon transfers were developed to accomplish both digital release and gripping functions in two surgical stages. the originators of these procedures were lipscomb et al. , zancolli, house et al. house et al. contributed important clinical investigations while showing the value of different surgical procedures. according to zancolli, transfer of the m. brachioradialis to the m. extensor carpi radialis tendons was proposed by vulpius and stoffel in 1920. in tetraplegia, this was first proposed by wilson. and first described fully by freehafer. in 1967, alvin freehafer of cleveland, ohio, contributed valuable ideas towards achieving independence in the arms of tetraplegic patients. he and his team published the results of six patients who underwent transfer of the m. brachioradialis to restore active wrist extension. in 1974, freehafer et al. recommended opposition transfers and finger-flexion transfers. in 1971, surgery of the tetraplegic upper limb experienced a revival after moberg’s clinical investigations. his main contributions were (1) to restore elbow extension through transfer of the posterior deltoid to triceps (the initial procedure); and (2) to reconstruct a key pinch. moberg’s idea of posterior deltoid transfer to restore elbow extension has been used extensively by many surgeons, such as bryan and debenedetti. in 1983, douglas lamb of edinburgh, scotland, gave great headway to surgery of the tetraplegic upper extremity when lamb and chan recommended reconstruction of elbow extension by transferring the posterior deltoid to the triceps according to moberg’s technique, which was published in 1975. a publication by friedenberg was the starting point for future indications of biceps-to-triceps transfers, including those of zancolli, hentz et al., kuts et al., allieu et al. and revol et al. another major change was the change to one-step procedures, reconstructiong opening and closing phases at the same time. especially jan friden, from gothenburg, with major experience in this area championed this thought, partially driven by the transport problems in sweden during winter, it saved the patients an operation and minimized hospital stay. the development of hand surgery for tetraplegia has received important contributions through published reports and by the international conferences initiated with the influence of erik moberg from goteborg, sweden. conferences have been of great interest because of the convergences of hand surgeons interested in the field, promoting discussion and comparison of different surgical methods and experiences. goals for surgery a common goal of surgical reconstruction of the arms in patients with tetraplegia is to restore elbow extension, key pinch and palmar grip. restoration of these functions, results in increasing a patient's independence. palmar gripelbow extension is an important part of upper limb surgical reconstruction in patients with tetraplegia. although gravity can extend the arm, active elbow extension is needed to maintain a stable arm while extended in space. this is needed to reach for something or replace an object. other functional gains include: increasing available workspace, performing pressure relief maneuvers, propelling a manual wheelchair, enhancing self-care and leisure activities, and promoting independent transfer. elbow extension against gravity further enhances these activities above the shoulder level and reachable workspace. the key pinch is a simple grasp in which the thumb applies force to an object to hold it against the lateral side of the index finger. restoring this function allows a patient to hold objects such as a fork or pen that are necessary for activities of daily living such as eating, self-grooming and self-catheterization. palmar grip allows the patient to grasp objects in the palm of the hand and secure the object by flexing the fingers at the metacarpal joint. this gives the patient the possibility to hold objects such as a cup and also permits use of the hand for wheelchair propulsion. a social aspect of regaining the palmar grip is that the patient is able to give a handshake. classification of the injury spinal cord injuries are classified as complete and incomplete by the american spinal injury association (asia) classification. the asia scale grades patients based on their functional impairment as a result of the injury, grading a patient from a to d. this has considerable consequences for surgical planning and therapy. more information on classification of tetraplegia can be found on the tetraplegia page. pre-operative assessment a group of hand surgeons realized in the 1970s that the level of injury did not predict the number of available muscles in the upper limb very well. therefore, the international classification was established in 1979, at the edinburgh meeting. it was called “the international classification (ic) of hand surgery in tetraplegic patients” (table 2) and it describes the number of possible transferable muscles. to measure and evaluate hand strength each muscle is tested and all muscles with a bmrc grade of m4 or more are recorded. table 2: international classification of hand surgery in tetraplegic patients groupm4 (bmrc) muscles ic 0no muscle below the elbow high-level tetraplegia ic 1m. brachioradialis ic 2m. extensor carpi radialis longus mid-level tetraplegia ic 3m. extensor carpi radialis brevis ic 4m. pronator teres ic 5m. flexor carpi radialis low-level tetraplegia ic 6finger extensors ic 7thumb extensor ic 8partial digital flexors ic 9lack only intrinsics ic xexceptions a muscle not included in the international classification, but of great importance, is the triceps muscle. when assessing a patient pre-operatively the triceps strength must also be recorded. an active triceps means a patient can reach in space, and the elbow can be stabilized against gravity and against other muscles to be transferred. (see further) furthermore, to classify patients it is essential to record sensation in at least the thumb and index pulpa. patients with a two point discrimination of less than 10mm are classified as cutaneous sensation (ocu) and patients with a two-point discrimination of more than 10mm are classified as ocular sensation (o) (meaning that control of the to be operated limb cannot be performed by normal sensation, but is controlled visually). therefore, patients are classified as: o or ocu, ic gr(0-x), triceps + or – for example: a patient has sensation of 8 mm in thumb and index pulpa, and has a good brachioradialis, extensor carpi radialis longus and brevis and a pronator teres (all of m4) but no triceps. this patient is classified as ocu 4, tr -. patient oriented goals the pre-operative assessment of patients has turned more patient-goal oriented. this means that the patients are asked to define their goals before surgery. in order to evaluate this the canadian occupational performance measure (copm) was developed. this test is based on the world health organisation's framework of measuring health and disability: the international classification of function(icf): this framework measures health and disability by means of two lists: a list of body functions and structure, and a list of domains of activity and participation. functional deficits can be measured according to the level of loss of structure and function, the level of activity limitations, and the level of restriction in social participation. reaching or gripping represents the integration of strength, sensation and range of motion, and therefore occur at the individual level rather than at the organ system level. for this reason, reaching and gripping are on the icf level of activities. however, this level includes a broad range of activities, from basic activities (for example grasping and moving objects) to complex activities (such as dressing, grooming). it is useful to make a distinction between basic activities and complex activities. copm as mentioned above, the canadian occupational performance measure (copm) is used to measure a tetraplegic patient's performance and satisfaction before and after upper limb surgery. this is done by identifying important goals of hand surgery and evaluating patient-perceived performance and satisfaction of hand surgery for these goals. goals are identified through an interview between the therapist and the patient based on past experience. published reports are provided about the expected outcomes of elbow extension transfers on strength and function of patients with a spinal cord injury. for each goal, the subject rated performance and satisfaction using a 10-point likert scale, in which 1 was negative (“cannot perform,” “not satisfied”) and 10 was positive (“performs very well,” “very satisfied”). after surgery, performance and satisfaction are rated again for each goal. a positive change is seen in patient-perceived performance and satisfaction with self-identified goals after tendon transfers. a good example of the use of the copm can be found in a report published by scott kozin, thirty-three goals for surgery were established. following the biceps-to-triceps transfer, improvement in at least one goal was seen in all patients. performance and satisfaction were greatly improved (an improvement of at least 4 points) in certain activities of daily living, including reaching for objects, recreational activities, wheelchair propulsion, and transfers. although improvement was seen in most goals, a reduction was reported in 2 goals (one pertaining to dressing and the other to transfer). after tendon transfers, the total mean score statistically increased from 2.6 to 5.6 for performance (p .001) and from 1.8 to 5.7 for satisfaction (p .001). criteria for surgery general indications for functional surgery of the hand and arm in tetraplegic patients: there are different views on optimal timing of surgery after a spinal cord injury. the general consensus is to operate the patient when he or she is neurologically stable. some surgeons try to operate a patient as early as possible. the advantages of this are that the patient can take advantage of the new functional possibilities before new adjustments and adaptations develop. other surgeons operate when it becomes feasible. this is usually 12–18 months after injury (can be shortened to 6–7 months) and only after stabilization of motor function. important spasticity (see further) and neurovegetative complications (i.e. bladder function, bowel function, pulmonary function and pressure sores) must have been treated already. the patient must be able to sit in a wheelchair so that he/she can move the arm against gravity. usually a compromise is found between the patient’s wishes and the surgeon when timing the surgery. an indication for biceps-to-triceps surgery is when the patient plateaud for more than 3 months in their motor recovery. it is usually the