Lecture 10: Surgical Rehabilitation after Quadriplegia

Question 1

How many cervical spinal cord segments and cervical vertebrae are there?

Answer 1

7 vertebrae
8 cervical segments

roots exit above the vertebrae for which they share the same name except C8! which goes below C7

Question 2

What do C3-T1 innervate?

Answer 2

C3-T1 innervate the muscles of and receive sensation from the
upper extremity

Question 3

Define: tetraplegia

Answer 3

• aka quadriplegia
• Injury/Illness resulting in partial or total loss of voluntary use of all four limbs, torso and some pelvic organs.
• Usually occurs due to damage of cervical spinal cord.
• Does NOT include injuries to the brachial plexus or to peripheral nerves

Question 4

Define: tetraparesis

Answer 4

• Muscle weakness affecting all 4 limbs

Question 5

Define: neurological level

Answer 5

• the most caudal segment of the spinal cord with normal sensory and motor
  function on both sides of the body. (remember how this differs from the definition of physiotherapists)
• The segments at which normal function is preserved can differ by side of body
  and in sensory vs. motor testing. In cases when up to 4 different segments may
  be identified in determining the neurological level (i.e., R-sensory, L-sensory, R-
  motor, L-motor), a “single level” should not be used, as this could be misleading.

Question 6

Define: sensory level and motor level

Answer 6

the most caudal segment of the spinal cord
with normal sensory function on both sides of the body.

The “Motor Level” is similarly defined with respect to motor function.

Question 7

Describe the innervation status of a muscle if their location of the motonueron cell bodies that supply a muscle are
1. above the level of SCI
2. at the level of SCI (dead band)
3. below the level of SCI

Answer 7

1. innervated and under voluntary control
2. possibly denervated - damaged. motoneurons may die!
3. paralyzed (disconnected from brain) but usually remain innervated. muscle will atrophy.

Question 8

define: injured metamere

Answer 8

the AREA of injured spinal cord. (Not necessarily just a single level)

Question 9

Describe muscle power grades

Answer 9

0 - complete paralysis
1 - flicker of contraction possible
2 - movement possible if gravity eliminated
3 - movement against gravity but not resistance
4 - movement possible against some resistance
5 - power normal

Question 10

Describe ASIA classification

Replicate decision tree

Answer 10

1. Determine the sensory level on RIGHT and LEFT sides
2. Determine the motor level on RIGHT and LEFT sides
3. Determine the neurological level of injury (most caudal
   segment with normal sensory and motor function on
   both sides)
4. Determine if the injury is complete or incomplete

ASIA A = complete No voluntary anal contraction, No anal sensation;

ASIA B = incomplete
Sensory but not motor function is preserved below the neurological level and includes sacral segments S4-S5.
ASIA C = incomplete
Motor function is preserved below the neurological level, and more than half of key muscles below the neurological level have a muscle grade less than 3.
ASIA D = incomplete Motor function is preserved below the neurological level, and at least half of key muscles below the neurological level have a muscle grade greater than or equal to 3.
ASIA E = normal Sensory function and motor function are normal.

Question 11

Describe the upper limb myotomes that are clinically tested by manual muscle examination. What muscles are being tested?

Answer 11

C5 elbow flexors (biceps, brachialis)
C6 wrist extensors (extensor carpi radialis longus and brevis)
C7 elbow extensors (triceps)
C8 finger flexors (fl. digitorum profundus to middle finger)
T1 small finger abductors (abductor digiti minimi)

Question 12

What can be presumed about C1-C4 myotomes

Answer 12

the motor level is presumed to be the same as the sensory level.

Question 13

What are some rehabilitative goals for restoring hand function after cervical injury?

Answer 13

1. Ambulation
   - Transfer in & out of chair, bed - requires triceps (C7), rotator cuff, deltoid strength
   - Use wheelchair - triceps (C7), rotator cuff, deltoid
2. Activities of daily living
   - Feeding - biceps (C5), grip (C8)
   - Toileting - complex
3. Human Contact
   - Being able to shake hands, interact with others
4. Specific Patient Focus/Desire?

Question 14

Describe the steps and requirements for picking up an object

Answer 14

1. Position the arm in space
   (shoulder, triceps/biceps)
2. Move hand into correct
   position (pronation, wrist
   extension)
3. Grasp the object
   (finger/thumb flexion) (C8)
4. Release functions (Finger extension)

• list the myotomes required too

Question 15

What are some operative interventions for cervical SCI?

Answer 15

tendon transfer: repurpose tendon from muscle that is under voluntary control but not a primary mover. tendon that sits close to muscle that is paralyzed.

arthrodesis: refers to surgical immobilization of a joint by fusion of the adjacent bones. It is often performed to reduce joint pain, or to reduce the number of joints powered by a transferred tendon.

tenodesis: refers to surgical fixation of a tendon. A tendon may be transferred from its initial point of origin to a new origin in order to restore muscle balance to stabilize a joint, to restore lost function, or to increase active power of joint motion. simplify limb control. change lever arm

nerve transfer: nerve of a muscle that is still under voluntary control may be deliberately cut and redirected to grow into a muscle that is no longer under voluntary control but is still a key muscle

Question 16

What can tendon transfer help with for patients with cervical SCI

Answer 16

help restore critical capabilities necessary
for self-care and increased independence:
The ability to extend and flex the elbow
The ability to extend and flex the wrist
The ability to grip with the fingers and hand

Question 17

Why are tendon transfers better suited for tetraplegics than individuals with peripheral lesions

Answer 17

Tendon transfers are often more effective in tetraplegics than in individuals with peripheral lesions. Tetraplegics can have more suitable intact muscles available for tendon transfer.
- person with a peripheral lesion will have lost control of muscles that are next to each other. now you can’t transfer since both are denervated.

Question 18

Describe an upper extremity tendon transfer/tendon graft placement

• Who is an ideal candidate?
• Why is this surgery useful
• What muscle is often used?
• Explain the process
• Explain post op procedures
• What is the trade off

Answer 18

• A person with a C5 spinal injury level who has good shoulder control and strong elbow flexion, but lacks active elbow extension (C7)
• The ability to straighten the elbow adds greatly to a person’s independence, so this is often the first surgery to be performed.
• In most cases the deltoid muscle is used to provide elbow extension.
• The posterior portion of deltoid is brought down toward the elbow. If the deltoid is not long enough, a tendon graft is taken from an upper leg muscle (fascia lata).
• After the surgery the arm is immobilized in a slightly bent position for up to 4 wks. When cast is removed, a hinged brace is used for gradual stretching and strengthening of the muscles. Initially the brace is worn night and day. Once the person can fully extend the arm, the brace is worn only at night.
• lose some shoulder motion but you gain elbow extension which is very useful (push wheelchair, push self up from lying down,

Question 19

What procedure did Moberg create?

Answer 19

Moberg Key Grip Procedure to restore lateral pinch in C5-C6 SCI subjects who lost thumb flexion but retain control of wrist extension.

brings thumb in when wrist is extended. helpful to restore full grip

Question 20

Describe the passive tenodesis test of normal tendon function

Answer 20

When the wrist joint is extended the digits
are synergistically flexed

This is called tenodesis. Its a natural synergy of wrist extensors and finger flexors

Question 21

Describe the steps for Moberg Procedure to restore lateral pinch “key grip”

Answer 21

• Arthrodesis: a bone screw is placed to fix the distal
  phalanx of the thumb
• Tenodesis: the FPL tendon is
  cut from its muscle and
  attached to the radius
• Tenodesis: The EPL/EPB are
  anchored to the insertion of
  the APB to stabilize the thumb.

With the Moberg procedure when
the wrist is extended the thumb
is passively adducted, to provide a
lateral pinch or “key grip.”

FPL flexor pollicis longus

EPL and EPB - Extensor Pollicis
Longus and Brevis

APB abductor pollicis brevis

fuck polite language (FPL) real (Radius) energetic people leave egotistical people broken (extensor pollicis longus; extensor pollicis brevis) and permanently broken (abdductor pollicis brevis)

Question 22

Describe restoration of active lateral pinch
* who is the ideal candidate
* compare this to the restoration of passive lateral pinch

Answer 22

Tendon Transfer Surgery

A person with an C6 spinal injury (affecting FPL)

• brachioradialis tendon to tendon of flexor pollicis longus
• Since there are 3 elbow extensors, brachioradialis can be spared.
• This procedure is more complex but provides independent control of the thumb flexion w/o wrist extension

Question 23

Decsribe tendon Transfer Surgery to provide Active Wrist Extension

Answer 23

Brachioradialis is used as a donor and sutured to extensor carpi radialis brevis and longus

Question 24

Compare Tendon Transfer vs. Nerve Transfer Procedures to restore same function

Answer 24

• can take months for full recovery as it takes time for axon to grow back (10cm = 100 days = 3 months). but better mechanics. original muscle belly and tendon

A tendon transfer involves inserting a functioning muscle with intact nerve supply into a different tendon and muscle that has lost its function. Nerve transfer involves surgically removing a health nerve to insert on a denervated muscle to treat paralysis and restore function. Patients recover faster with a tendon transfer but often have less dexterity after recovery. Patients with a nerve transfer recover much more slowly but have greater potential for return to almost normal dexterity. Tendon transfers rely on having a suitable muscle with adequate strength and excursion. You must also be willing to sacrifice the original function of that muscle tendon complex .