ABC of spinal cord injury. Later management and complications--II.
Authors: D Grundy, J Russell
Journal: BMJ (1986)

Psychological factorsThe initial psychological adjustment to a spinal cord injury has already been discussed, but long term support may also be required.The frustrations associated with the physical limitations of such a severe injury Factors are compounded by the fact that most patients are young and before injury * Acute stage -sensory deprivation, led active lives, often expressing themselves mainly through physical most noticeable in high lesions activities.The sudden inability to continue in this manner and the need to -swings in mood: fear, anger, lead a more ordered life can mean a very difficult and prolonged period of depression, euphoria, adjustment.Failure to recognise that this process can continue for as long as frustration two or three years may damage the process ofrehabilitation and the * Later stages-long period of patient's ultimate resettlement.The patient needs time to come to terms adjustment required (2-3 years with his or her new status and to make decisions about the future without -continuing support necessary undue pressure.Continuing support will be needed after discharge from hospital, both from community services and from outpatient visits, and the problems and fears of the able bodied partner or close relatives must also be remembered. The hand in tetraplegiaAims * To restore active elbow extension * To provide a functional grip Most tetraplegics give priority to restoring function in their arms.In selected patients with injuries below the fifth cervical segment surgery may be helpful, the main aims being to restore active elbow extension and provide a functional hand grip.An important factor in selection is motivation, as treatment will be prolonged, requiring perseverance and cooperation from the patient.Surgery is particularly indicated in complete lesions, the muscle chart having shown no change for at least six months, and there being adequate sensation in the hand.There should be no spasticity in the limb, and any contracture must be previously corrected by physiotherapy or splintage.Restoring elbow extension by transferring the posterior third of the deltoid muscle into the triceps tendon enables a patient to reach overhead and facilitates wheelchair transfers and lifting to relieve pressure.Good results from surgery have been achieved in 80% ofpatients.To provide a functional hand grip active finger flexion must be restored.Ifwrist extension is normal the extensor carpi radialis longus can be transferred into the flexor digitorum profundus and independent thumb flexion made possible by transferring the brachioradialis into the flexor pollicis longus.An alternative approach, probably the most generally useful, is that described by Moberg, in which a strong key pinch grip is provided by tenodesis of the flexor pollicis longus to the lower end of the radius with stabilisation of the interphalangeal joint of the thumb in a straight position.With the wrist extended the thumb will then oppose the radial side of the index finger.This procedure can also be combined with transfer of the extensor carpi radialis longus to the flexor digitorum profundus to restore active finger flexion.There is an almost 70% success rate after surgery to restore a functional hand grip provided the muscles used for transfer are normally innervated.Key pinch grip, achieved by using the Moberg technique.Factors in selection for surgery * Neurological level below C5 * No change in muscle power for at least 6 months * Adequate sensation in hand * No spasticity or contracture * Well motivated