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Nerve Transfers to Restore Upper Extremity Function in Cervical Spinal Cord Injury: Update and Preliminary Outcomes

Fox, Ida K. M.D.; Davidge, Kristen M. M.D., M.S.; Novak, Christine B. Ph.D.; Hoben, Gwendolyn M.D., Ph.D.; Kahn, Lorna C. B.S.; Juknis, Neringa M.D.; Ruvinskaya, Rimma M.D.; Mackinnon, Susan E. M.D.

Plastic and Reconstructive Surgery: October 2015 - Volume 136 - Issue 4 - p 780–792
doi: 10.1097/PRS.0000000000001641
Hand/Peripheral Nerve: Original Articles

Background: Cervical spinal cord injury can result in profound loss of upper extremity function. Recent interest in the use of nerve transfers to restore volitional control is an exciting development in the care of these complex patients. In this article, the authors review preliminary results of nerve transfers in spinal cord injury.

Methods: Review of the literature and the authors’ cases series of 13 operations in nine spinal cord injury nerve transfer recipients was performed. Representative cases were reviewed to explore critical concepts and preliminary outcomes.

Results: The nerve transfers used expendable donors (e.g., teres minor, deltoid, supinator, and brachialis) innervated above the level of the spinal cord injury to restore volitional control of missing function such as elbow extension, wrist extension, and/or hand function (posterior interosseous nerve or anterior interosseous nerve/finger flexors reinnervated). Results from the literature and the authors’ patients (after a mean postsurgical follow-up of 12 months) indicate gains in function as assessed by both manual muscle testing and patients’ self-reported outcomes measures.

Conclusions: Nerve transfers can provide an alternative and consistent means of reestablishing volitional control of upper extremity function in people with cervical level spinal cord injury. Early outcomes provide evidence of substantial improvements in self-reported function despite relatively subtle objective gains in isolated muscle strength. Further work to investigate the optimal timing and combination of nerve transfer operations, the combination of these with traditional treatments (tendon transfer and functional electrical stimulation), and measurement of outcomes is imperative for determining the precise role of these operations.


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St. Louis, Mo.; and Toronto, Ontario, Canada

From the Division of Plastic and Reconstructive Surgery, Department of Surgery, the Division of Neurorehabilitation, Spinal Cord Injury Program, and the Department of Neurology, Washington University School of Medicine; the Milliken Hand Center of The Rehabilitation Institute of Saint Louis; and the Hand and Upper Extremity Program, Division of Plastic and Reconstructive Surgery, Hospital for Sick Children.

Received for publication November 25, 2014; accepted March 27, 2015.

This trial is registered under the name “Upper Extremity Surgery in Spinal Cord Injury,” identification number NCT01899664 (

Disclosure: The authors have no funding sources or other financial disclosures.

Supplemental digital content is available for this article. Direct URL citations appear in the text; simply type the URL address into any Web browser to access this content. Clickable links to the material are provided in the HTML text of this article on the Journal’s Web site (

Ida K. Fox, M.D., Division of Plastic Surgery, Washington University School of Medicine, Box 8238, 660 South Euclid Avenue, St. Louis, Mo. 63110-1010,

©2015American Society of Plastic Surgeons