Range Of Motor Recovery And Functional Independence In Cervical-level Spinal Cord Injury: Implications For Peripheral Nerve Transfer Surgery To Restore Upper Limb Function
Jana Dengler, MD1, Munish Mehra, PhD2, Carie Kennedy, BSN, RN3, Armin Curt, MD4, Catherine Curtin, MD5, Doug Ota, MD5, Katherine Stenson, MD6, Christine Novak, PhD7, John Steeves, PhD8, Ida K. Fox, MD3.
1Sunnybrook Health Sciences Centre, Toronto, ON, Canada, 2Quantum Change Group LLC, Gaithersburg, MD, USA, 3Washington University in St. Louis, St Louis, MO, USA, 4University of Zurich Spinal Cord Injury Center, Research Balgrist University Hospital, Zurich, Switzerland, 5Palo Alto Veterans Healthcare System, Palo Alto, CA, USA, 6VA St. Louis Healthcare System, St Louis, MO, USA, 7Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada, 8ICORD, University of British Columbia, Vancouver, BC, Canada.
Functional gains can occur for years post spinal cord injury (SCI), but candidacy for nerve transfers can be time sensitive due to axon and muscle degeneration after injury. To identify eligibility criteria and allow for optimal timing of restorative surgical treatment for cervical SCI, more precise information is needed on spontaneous motor recovery and independence in activities of daily living within the first year after injury. This study evaluated the improvement in upper limb motor strength and functional independence with no surgical intervention at differing levels of cervical SCI.
Using the comprehensive European Multi-center Study about Spinal Cord Injury data set, analysis was undertaken of individuals with traumatic SCI, motor level C5-C8. Recovery of motor function between 6 and 12 months after injury was ascertained. Data on feeding, bladder management and transfers (bed to wheelchair) were also compared at 6 months and 12 months. Subgroup analyses of symmetric and asymmetric SCI, and between complete and incomplete SCI were performed. The impact of age and gender on functional independence was ascertained.
From 6 to 12 months post-SCI, few patients recovered additional strong (MRC 4-5) function below the motor level. The majority of recovery occurred at the level immediately below the motor level. Specifically, analysis of 402 limbs showed that 3% of individuals with strong proximal cervical level function (C5 +/- C6 intact) and no elbow extension (C7 function) at 6 months gained strong (MRC 4-5) and 8% gained antigravity (MRC 3) elbow extension by 12 months. With respect to recovery of C8 function (finger flexion), of those with intact proximal level function at 6 months (n = 519 limbs), 3% gained strong finger flexion at 12 months. Participants with incomplete SCI injury (AIS C or D) had significantly greater recovery than those with complete SCI (AIS A or B).At 6 months post injury, data on feeding, bladder management and transfers were available for participants with symmetric (n = 204) and asymmetric (n = 95) SCI. There was no significant increase in independence between 6 and 12 months for any activity of daily living. Feeding with assistive devices was reported for nearly all with strong wrist extension (C6). Independence in feeding and bladder management was noted with strong finger flexion (C8). Elbow extension (C7) did not uniformly result in the ability to transfer independently, whereas finger flexion (C8) did.
There are no significant gains in motor strength or functional independence between 6 and 12 months post SCI. Thus, if individuals are interested in nerve transfers to gain function, evaluation for eligibility at 6 months post SCI is appropriate. The expected functional range from this study will guide expectations for independent self-care.
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