Nerve transfer to partially restore upper limb function in tetraplegia

Evidence-based recommendations on nerve transfer to partially restore upper limb function in people with tetraplegia. This involves connecting an undamaged, functioning, but non-essential nerve near the injury to the damaged essential nerve.

# Recommendations
The evidence on efficacy of nerve transfer to partially restore upper limb function in tetraplegia is limited in quantity. There are no major safety concerns. Therefore, this procedure should only be used with special arrangements for clinical governance, consent, and audit or research. Find out what special arrangements mean on the NICE interventional procedures guidance page.
Clinicians wishing to do nerve transfer to partially restore upper limb function in tetraplegia should:
Inform the clinical governance leads in their NHS trusts.
Ensure that patients understand the uncertainty about the procedure's safety and efficacy, and provide them with clear written information to support shared decision-making. In addition, the use of NICE's information for the public is recommended.
Audit and review clinical outcomes of all patients having nerve transfer to partially restore upper limb function in tetraplegia. NICE has identified relevant audit criteria and has developed NICE's interventional procedure outcomes audit tool.
Patient selection and treatment should be done by a multidisciplinary team with expertise in managing spinal cord injury, and nerve and tendon transfers. This team should typically include a surgeon with experience in the surgical management of tetraplegia and nerve transfer, an occupational therapist, a physiotherapist with experience in spinal injury rehabilitation, a spinal injuries consultant and a neurophysiologist.
NICE may update the guidance on publication of further evidence.# The condition, current treatments and procedure

# The condition
Tetraplegia is typically caused by cervical spinal cord injuries, with associated complete or incomplete loss of muscle strength in all 4 extremities. The exact symptoms depend on the location and extent of injury. The most common neurological level of injury is the fifth cervical vertebra. This results in loss of upper limb function and the inability to carry out activities of daily living.

# Current treatments
Restoring upper limb function is an important rehabilitation aim in people with tetraplegia. Conservative treatment options include a comprehensive program of physical and occupational therapy, including orthoses and functional electrical stimulation. Surgical techniques to restore function of the upper limb (elbow, thumb and finger extension, wrist movement, hand opening and closing, and pinch and grip) include neuroprostheses, tendon transfer, nerve transfers, reconstructive surgeries or a combination of these procedures.

# The procedure
In this procedure, the nearest functional undamaged and non-essential nerve is used as the donor nerve.
Under general anaesthesia, with the patient in a supine position and with their arms on a board, the non-functioning nerve is exposed and the degree of paralysis is defined neurophysiologically. The closest functional donor nerve is identified. It is then isolated, divided, transferred and joined to the selected damaged nerve while avoiding tension in the donor nerve. The aim is to reinnervate the target muscles and improve limb function.
Post-operatively, the patient needs nerve and muscle rehabilitation training to recover the strength of the reinnervated muscles and improve activities of daily living.
Nerve transfers may sometimes be combined with tendon transfers.