Upper limb surgery for tetraplegia: assessment of a 10-point strategy

Palliative motor surgery of the tetraplegic upper limb is well-defined, with relatively precise indications that however vary somewhat from team to team. Our personal indications originated mainly from Zancolli, and were applied by the same surgeon in two independent rehabilitation centers. The goals of this study were to assess the application of these indications with time.

Our retrospective study included three parts: summarization of our initial indications into a 10-point reference strategy; gathering the medical records related to all of the tetraplegic upper limb operations from 1989 to 2006, except for those related to complications and/or salvage procedures. For each patient, collected data corresponded to the 10 strategic points (SP); comparison of the collected data with the reference strategy, upper limb by upper limb, point by point, in order to identify and document any deviations.

We assessed the use of the reference strategy in 272 consecutive operations (139 upper limbs, 96 patients). Overall nonconformity rate with the use of the 10-point strategy was 27% (38/139). Except for one very atypical case, all of the exceptions from the reference strategy were due to specific anatomical or physiological conditions.

Our reference strategy has remained noticeably stable over time. However, three important evolutionary modifications occurred: systematic choice of biceps instead of deltoid to restore elbow extension; addition of the split distal flexor pollicis longus tenodesis procedure; and removal of extensor carpi radialis brevis from the list of potential flexor pollicis longus motors. Two issues, dealing with the systematic use of lassos and with brachio radialis to extensor digitorum communis transfer, are likely to be revisited in the future.