Editor's Choice| Volume 47, ISSUE 12, P1157-1165, December 2022

Quantifying Donor Deficits Following Nerve Transfer Surgery in Tetraplegia

Published:October 15, 2022DOI:


      Nerve transfer (NT) surgery can improve function in people with cervical spinal cord injury (SCI). However, the impact of donor nerve deficits remains unclear. The purpose of this study was to quantify donor deficits experienced by individuals with cervical SCI following NT.


      This prospective single-arm, comparative study included people with SCI undergoing upper extremity NTs. Myometry was used to assess muscle strength at baseline and follow-up. The Spinal Cord Independence Measure was used to measure the ability to perform activities of daily living.


      Ten individuals underwent 20 NTs to restore elbow extension (donor, posterior deltoid; n = 2), hand opening (donor, supinator; n = 7), and hand closing (donor, brachialis; n = 11). Shoulder abduction strength decreased (−5.6% at early and −4.5% late follow-up) in the elbow extension NT. Wrist extension strength decreased at early (−46.9% ± 30.3) and increased by late (76.4% ± 154.0) follow-up in the hand opening NT. No statistically significant change in elbow flexion strength was noted in the hand closing NT. Spinal Cord Independence Measure scores did not change significantly between baseline and early postoperative follow-up; they improved at late follow-up.


      Use of expendable donor nerves with redundant function to perform NT surgery has relatively little impact on strength or capacity to perform activities of daily living, even in the unique and highly vulnerable SCI population. Early, temporary loss in wrist extension strength can be seen after the supinator to posterior interosseous nerve transfer. This study offers quantitative data about possible diminution of donor function after NT, enabling hand surgeons to better counsel individuals contemplating upper extremity reconstruction.

      Type of study/Level of Evidence

      Prognostic I.

      Key words

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        • Domeshek L.F.
        • Novak C.B.
        • Patterson J.M.M.
        • et al.
        Nerve Transfers-a paradigm shift in the reconstructive ladder.
        Plast Reconstr Surg Glob Open. 2019; 7e2290
        • Moore A.M.
        Nerve transfers to restore upper extremity function: a paradigm shift.
        Front Neurol. 2014; 5: 40
        • Garg R.
        • Merrell G.A.
        • Hillstrom H.J.
        • Wolfe S.W.
        Comparison of nerve transfers and nerve grafting for traumatic upper plexus palsy: a systematic review and analysis.
        J Bone Joint Surg Am. May 4 2011; 93: 819-829
        • Morris M.
        • Brogan D.M.
        • Boyer M.I.
        • Dy C.J.
        Trends in nerve transfer procedures among board-eligible orthopedic hand surgeons.
        J Hand Surg Glob Online. 2021; 3: 24-29
        • Fox I.K.
        • Davidge K.M.
        • Novak C.B.
        • et al.
        Use of peripheral nerve transfers in tetraplegia: evaluation of feasibility and morbidity.
        Hand (N Y). 2015; 10: 60-67
        • Khalifeh J.M.
        • Dibble C.F.
        • Van Voorhis A.
        • et al.
        Nerve transfers in the upper extremity following cervical spinal cord injury. Part 1: systematic review of the literature.
        J Neurosurg Spine. 2019; 31: 629-640
        • Hinchcliff K.M.
        • Pulos N.
        • Shin A.Y.
        • Stutz C.
        Morbidity of nerve transfers for brachial plexus birth injury: a systematic review.
        J Pediatr Orthop. 2021; 41: e188-e198
        • Sammer D.M.
        • Kircher M.F.
        • Bishop A.T.
        • Spinner R.J.
        • Shin A.Y.
        Hemi-contralateral C7 transfer in traumatic brachial plexus injuries: outcomes and complications.
        JBJS J Bone Joint Surg Am. 2012; 94: 131-137
        • Anderson K.D.
        Targeting recovery: priorities of the spinal cord-injured population.
        J Neurotrauma. 2004; 21: 1371-1383
        • Dunn J.A.
        • Sinnott K.A.
        • Rothwell A.G.
        • Mohammed K.D.
        • Simcock J.W.
        Tendon transfer surgery for people with tetraplegia: an overview.
        Arch Phys Med Rehabil. 2016; 97: S75-S80
        • Hill E.J.R.
        • Fox I.K.
        Nerve transfers to restore upper limb function in tetraplegia.
        Lancet. 2019; 394: 543-544
        • van Zyl N.
        • Hill B.
        • Cooper C.
        • Hahn J.
        • Galea M.P.
        Expanding traditional tendon-based techniques with nerve transfers for the restoration of upper limb function in tetraplegia: a prospective case series.
        Lancet. 2019; 394: 565-575
        • Leclercq C.
        • Hentz V.R.
        Surgical restoration of the upper limb in cervical spinal cord injury patients.
        Hand Surg Rehabil. 2022; 41S: S148-S152
        • Bertelli J.A.
        • Tacca C.P.
        • Ghizoni M.F.
        • Kechele P.R.
        • Santos M.A.
        Transfer of supinator motor branches to the posterior interosseous nerve to reconstruct thumb and finger extension in tetraplegia: case report.
        J Hand Surg Am. 2010; 35: 1647-1651
        • van Zyl N.
        • Hahn J.B.
        • Cooper C.A.
        • Weymouth M.D.
        • Flood S.J.
        • Galea M.P.
        Upper limb reinnervation in C6 tetraplegia using a triple nerve transfer: case report.
        J Hand Surg Am. 2014; 39: 1779-1783
        • Bertelli J.A.
        • Ghizoni M.F.
        Nerve transfers for restoration of finger flexion in patients with tetraplegia.
        J Neurosurg Spine. 2017; 26: 55-61
        • Cain S.A.
        • 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
        • Khalifeh J.M.
        • Dibble C.F.
        • Van Voorhis A.
        • et al.
        Nerve transfers in the upper extremity following cervical spinal cord injury. Part 2: preliminary results of a prospective clinical trial.
        J Neurosurg Spine. 2019; 1–13
        • Hill E.J.R.
        • Fox I.K.
        current best peripheral nerve transfers for spinal cord injury.
        Plast Reconstr Surg. 2019; 143: 184e-198e
        • Fox I.K.
        • Novak C.B.
        • Krauss E.M.
        • et al.
        The use of nerve transfers to restore upper extremity function in cervical spinal cord injury.
        PM R. 2018; 10: 1173-1184.e1172
        • Jain N.S.
        • Hill E.J.R.
        • Zaidman C.M.
        • et al.
        Evaluation for late nerve transfer surgery in spinal cord injury: predicting the degree of lower motor neuron injury.
        J Hand Surg Am. 2020; 45: 95-103
        • Hill E.J.R.
        • El-Haj M.
        • Giles J.A.
        • Fox I.K.
        Using electrodiagnostics to define injury patterns amenable to nerve transfer surgery in tetraplegia: an illustrative case report.
        Spinal Cord Ser Cases. 2020; 6: 78
        • Fox I.K.
        • Novak C.B.
        • Kahn L.C.
        • Mackinnon S.E.
        • Ruvinskaya R.
        • Juknis N.
        Using nerve transfer to restore prehension and grasp 12 years following spinal cord injury: a case report.
        Spinal Cord Ser Cases. 2018; 4: 37
        • Fox I.K.
        Nerve transfers in tetraplegia.
        Hand Clin. 2016; 32: 227-242
        • Grinnon S.T.
        • Miller K.
        • Marler J.R.
        • et al.
        National Institute of Neurological Disorders and Stroke Common Data Element Project - approach and methods.
        Clin Trials. 2012; 9: 322-329
        • Kirshblum S.C.
        • Burns S.P.
        • Biering-Sorensen F.
        • et al.
        International standards for neurological classification of spinal cord injury (revised 2011).
        J Spinal Cord Med. 2011; 34: 535-546
        • Stark T.
        • Walker B.
        • Phillips J.K.
        • Fejer R.
        • Beck R.
        Hand-held dynamometry correlation with the gold standard isokinetic dynamometry: a systematic review.
        PM R. 2011; 3: 472-479
        • Herbison G.J.
        • Isaac Z.
        • Cohen M.E.
        • Ditunno Jr., J.F.
        Strength post-spinal cord injury: myometer vs manual muscle test.
        Spinal Cord. 1996; 34: 543-548
        • Ackerman P.
        • Morrison S.A.
        • McDowell S.
        • Vazquez L.
        Using the Spinal Cord Independence Measure III to measure functional recovery in a post-acute spinal cord injury program.
        Spinal Cord. 2010; 48: 380-387
        • Anderson K.D.
        • Acuff M.E.
        • Arp B.G.
        • et al.
        United States (US) multi-center study to assess the validity and reliability of the Spinal Cord Independence Measure (SCIM III).
        Spinal Cord. 2011; 49: 880-885
        • Catz A.
        • Itzkovich M.
        Spinal Cord Independence Measure: comprehensive ability rating scale for the spinal cord lesion patient.
        J Rehabil Res Dev. 2007; 44: 65-68
        • Itzkovich M.
        • Gelernter I.
        • Biering-Sorensen F.
        • et al.
        The Spinal Cord Independence Measure (SCIM) version III: reliability and validity in a multi-center international study.
        Disabil Rehabil. 2007; 29: 1926-1933
        • Rudhe C.
        • van Hedel H.J.
        Upper extremity function in persons with tetraplegia: relationships between strength, capacity, and the spinal cord independence measure.
        Neurorehabil Neural Repair. 2009; 23: 413-421
        • Bluvshtein V.
        • Front L.
        • Itzkovich M.
        • et al.
        SCIM III is reliable and valid in a separate analysis for traumatic spinal cord lesions.
        Spinal Cord. 2011; 49: 292-296
        • Fekete C.
        • Eriks-Hoogland I.
        • Baumberger M.
        • et al.
        Development and validation of a self-report version of the Spinal Cord Independence Measure (SCIM III).
        Spinal Cord. 2013; 51: 40-47
        • Benassy J.
        Transposition of the musculo-cutaneous nerve upon the median nerve.
        Case report. Med Serv J Can. 1966; 22: 695-697
        • Brown J.M.
        Nerve transfers in tetraplegia I: background and technique.
        Surg Neurol Int. 2011; 2: 121
        • Mackinnon S.E.
        • Yee A.
        • Ray W.Z.
        Nerve transfers for the restoration of hand function after spinal cord injury.
        J Neurosurg. 2012; 117: 176-185
        • Bertelli J.A.
        • Ghizoni M.F.
        Single-stage surgery combining nerve and tendon transfers for bilateral upper limb reconstruction in a tetraplegic patient: case report.
        J Hand Surg Am. 2013; 38: 1366-1369
        • Hawasli A.H.
        • Chang J.
        • Reynolds M.R.
        • Ray W.Z.
        Transfer of the brachialis to the anterior interosseous nerve as a treatment strategy for cervical spinal cord injury: technical note.
        Global Spine J. 2015; 5: 110-117
        • Emamhadi M.
        • Andalib S.
        Double nerve transfer for restoration of hand grasp and release in C7 tetraplegia following complete cervical spinal cord injury.
        Acta Neurochir (Wien). 2018; 160: 2219-2224
        • Fox I.K.
        • Davidge K.M.
        • Novak C.B.
        • et al.
        Nerve transfers to restore upper extremity function in cervical spinal cord injury: update and preliminary outcomes.
        Plast Reconstr Surg. 2015; 136: 780-792
        • Sananpanich K.
        • Kraisarin J.
        • Siriwittayakorn W.
        • Tongprasert S.
        • Suwansirikul S.
        Double motor nerve transfer for all finger flexion in cervical spinal cord injury: an anatomical study and a clinical report.
        J Hand Surg Am. 2018; 43: 920-926
        • Huynh K.A.
        • Cho H.E.
        • Yue M.
        • Wang L.
        • Chung K.C.
        • Waljee J.F.
        Patterns of upper extremity reconstruction for patients with tetraplegia across the united states: a retrospective study.
        J Hand Surg Am. 2021; 46: 952-962.e24
        • Squitieri L.
        • Chung K.C.
        Current utilization of reconstructive upper limb surgery in tetraplegia.
        Hand Clin. 2008; 24: 169-173
        • Curtin C.M.
        • Gater D.R.
        • Chung K.C.
        Upper extremity reconstruction in the tetraplegic population, a national epidemiologic study.
        J Hand Surg Am. 2005; 30: 94-99
        • Punj V.
        • Curtin C.
        Understanding and Overcoming barriers to upper limb surgical reconstruction after tetraplegia: the need for interdisciplinary collaboration.
        Arch Phys Med Rehabil. 2016; 97: S81-S87
        • Fox P.M.
        • Suarez P.
        • Hentz V.R.
        • Curtin C.M.
        Access to surgical upper extremity care for people with tetraplegia: an international perspective.
        Spinal Cord. 2015; 53: 302-305
        • Yeung C.
        • Salim S.
        • Fox I.K.
        • Novak C.B.
        • Dengler J.
        Identifying barriers to upper extremity reconstruction in tetraplegia: a systematic scoping review.
        Spinal Cord. 2021; 59: 1088-1095
        • Ray W.Z.
        • Yarbrough C.K.
        • Yee A.
        • Mackinnon S.E.
        Clinical outcomes following brachialis to anterior interosseous nerve transfers.
        J Neurosurg. 2012; 117: 604-960
        • Bertelli J.A.
        • Ghizoni M.F.
        Nerve transfers for elbow and finger extension reconstruction in midcervical spinal cord injuries.
        J Neurosurg. 2015; 122: 121-127
        • Knepler C.
        • Bohannon R.W.
        Subjectivity of forces associated with manual-muscle test grades of 3+, 4-, and 4.
        Percept Mot Skills. 1998; 87: 1123-1128
        • 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 Rehabil. 2016; 97: S160-S168