tendon-transfer-stabilize-quads-thumb-restore-pinch-grasp-function
A tendon transfer can stabilize a quad’s thumb (A) and help restore pinch and grasp function (B).

If you are one of the thousands of people with limited hand and arm function as the result of a cervical spinal cord injury, would you be surprised to know that there is a proven road to increased function and independence that doesn’t involve a cure?

For over 40 years, orthopedic surgeons have been helping individuals with SCI regain pinch, grasp, finger flexion, triceps use and more by transferring tendons to connect enervated muscles (below the level of injury) with muscles patients can control. As surgeons have refined the procedures and studied the outcomes, immobilization times have decreased and results have improved. Most surgeons report nearly universal happiness with the outcomes and promise no noticeable impact, should a cure arrive. Yet only a small percentage of those eligible for the surgery take advantage of it, and many quads don’t even know it is an option, raising the question: why?

Drs. Scott Kozin and Dan Zlotolow, orthopedic surgeons at the Philadelphia Shriners Hospital and published experts on tendon transfers, say the answer is complicated and are working to address its many roots.

“It’s an uphill battle for us,” says Zlotolow. “There’s a bias among physiatrists in particular, who don’t see the results of these surgeries so they don’t believe in them and think it’s just a bunch of surgeons operating willy-nilly — they don’t really see that there is any benefit to them. They generally tend to discourage patients from having anything done. … It’s very frustrating.”

Additionally, Zlotolow says the surgeries are “underused” because of the relatively small number of surgical centers where doctors specialize in transfers and because of fears that transfers could impede an eventual cure. His response to concerns about the impact on a cure has the polished sound of a line that has been delivered many times. “Tendon transfers do not get in the way of a cure,” he says. “The day we have a cure is the day you will be cured, whether you’ve had tendon transfer or not. You can think of the tendon transfers as a way to make you as functional as possible until the cure comes.”

As little as 10-15 years ago, lengthy immobilization times and rehab periods also discouraged potential beneficiaries, but new techniques and a better understanding of how best to rehab tendon transfers have all but eliminated those excuses.

A biceps-to-triceps transfer to give a C5 or C6 quad the ability to extend his/her elbow and use the biceps to function like triceps formerly required up to six weeks in a motion-restricted cast before rehab could begin. Now recipients are mobilized as quickly as one-week post-surgery. For wrist and grip transfers, immobilization can be as little as one day. “We’ve got pretty good data that shows that biceps-triceps does better with less post-operative immobilization and is not as hard to relearn,” says Kozin.

Kozin and Zlotolow described their target audience as “the person who has a little bit of function in their arm, but not enough to be independent.”

“Because most of the time, if you have a little bit of function in your arm we can get you independent,” says Zlotolow.

As an example, he described how tendon transfers might benefit a C7 quad with some grasp, a weak pinch and decent triceps. “You can take that person and give them a strong pinch and a stronger grasp, and usually you can give them opposition [control of the thumb],” he explains. “The difference between somebody who has no pinch and no grasp and you give them pinch and grasp — that’s huge.”

Both doctors said transfers can benefit someone as low as C8, but acknowledged that the farther down the injury, the less the benefit.

Kozin encouraged interested quads to reach out directly to a surgeon who is known for doing transfers or an SCI center that can help connect you with one. While there may not be a multitude of surgeons specializing in tendon transfers, Zlotolow believes the patient-pleasing surgery has attracted a uniquely loyal brand of doctor. “People who do this surgery do it because they really care about it,” he says. “Nobody does it just to make money. People who are doing it are very committed to people who have spinal cord injuries.” Shriners Hospitals in Philadelphia, Chicago and Sacramento, Calif., all offer transfer options for minors, and the doctors there can help connect adults too.

Once connected, one of those individuals should be able to put you in contact with someone with a similar level of injury who has had whatever transfer you are interested in. “We’ve found that personal connections are the most effective way to educate and help people learn [about potential benefits],” says Kozin.

Resources

  • For more detailed information on tendon transfers and what is involved, check out this helpful overview prepared by the American Society for Surgery of the Hand: www.assh.org/Public/HandConditions/Pages/Tendon-TransferSurgery.aspx.
  • The three Shriners hospitals that specialize in spinal cord injury are located in Sacramento, Philadelphia and Chicago, for eligibility questions call 800.237.5055.
  • To find out more about nerve transfers, call the Peripheral Nerve Center at UC San Diego Health System, 858.246.0674.

Nerve Transfers

If tendon transfers aren’t your thing, but you’re still interested in options to regain arm and hand function, Dr. Justin Brown thinks he may have the ticket. Dr. Brown, the Director of the Neurosurgery Peripheral Nerve Program and Co-Director of the Center for Neurophysiology and Restorative Neurology for the UC San Diego Health System, is one of the leading advocates and practitioners of nerve transfers for people with SCI.

Surgeons have transferred nerves to help people with nerve injuries for many years, but only in the last four to five years have they begun connecting nerves to restore function below the level of injury for people with spinal cord injury. Conceptually, imagine tendon transfers with nerves replacing tendons. The potential benefits can surpass tendon transfers according to Brown.

“For a muscle tendon to move you can only gain one movement on the other side, so if you take a wrist extensor and you put it into finger flexors, you’re going to tie it into all the finger flexors and they’re all going to pull as a single unit,” he explains. “When you do the corresponding nerve transfer, you plug the nerve into the recipient nerve and there is the potential in some folks to have independent movement of individual fingers.”

A shorter, simpler operation and the absence of immobilization post-op are among other reasons Brown is excited about the transfers potential for SCI, though he noted that recipients must wait up to a year for the transferred nerve to grow and connect before seeing results.