Restoring upper-limb function following cervical spinal cord injury: Current practice in the United Kingdom

Introduction

Cervical spinal cord injury (CSCI) is a devastating consequence of trauma that afflicts 1 in every 29 adult major trauma patients^[1] resulting in disabling loss of upper- and lower-limb function. Those affected endure reduced life expectancy, altered quality of life, significant morbidity, and long-term dependency.^[2],[3] In the United Kingdom (UK) and Republic of Ireland (EIRE), rehabilitation is undertaken within designated spinal cord injury centres (SCICs) where patients receive intensive multidisciplinary rehabilitation led by spinal injury physicians. Rehabilitation aims to transition patients to the greatest practicable level of independent living and minimize long-term care needs.

One of the most effective ways to optimize a patient's independence is to maximize their upper-limb function. The importance of upper-limb function is recognized by patients who rate it above control of sexual, bladder, bowel function, spasticity, and pain.^[4],[5],[6] Historically, the International Classification for Surgery of the Hand in Tetraplegia^[7] has guided the use of tendon transfer, tenodesis, and arthrodesis procedures to restore upper-limb function. However, increasingly, nerve transfers are advocated. Proponents argue that they present greater opportunities for functional gain over tendon transfer with restoration of prehensile grip, less postoperative morbidity, and limited or no sacrifice of donor function.^[8] Selective nerve fascicle transfer has been undertaken by a number of surgeons internationally^{[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23]} and represents a promising adjunct.

As UK-based upper-limb surgeons with peripheral nerve expertise, we wish to develop upper-limb services for CSCI patients but recognize provision faces a number of challenges. These include lack of geographically co-located services (hand surgery and spinal rehabilitation), limited surgical expertise nationally (particularly for nerve transfer), poor awareness of current expertise, and historic professional distance. To address some of these factors and inform future service developments, we undertook a postal survey of designated SCICs within the UK and EIRE. We hypothesised that access to reconstructive upper-limb services, particularly nerve transfer surgery, was limited to specialist centers and varied according to the region.

Materials and Methods

A postal questionnaire was distributed to the clinical lead of each UK and EIRE SCIC [Figure - 1] in early 2015. Respondents were asked to detail the number of new traumatic SCI patients managed between January 1 and December 31, 2014, according to the level of injury, outline the local provision of SCIC upper-limb services, detail surgical interventions undertaken for functional reconstruction locally (including outcomes), and outline local availability of nerve transfer for CSCI [Figure - 2]. Before survey distribution each SCIC was contacted to explain the questionnaire rationale. SCICs that did not respond to the survey were re-contacted with the same questions formulated as a freedom of information (FOI) request.

Figure 1: The United Kingdom spinal cord injury centers. (1) Glasgow (Queen Elizabeth National Spinal Injuries Unit). (2) Belfast (Musgrave Park Hospital). (3) Dublin, EIRE (National Medical Rehabilitation Centre). (4) Southport (Northwest Regional Spinal Injuries Centre). (5) Oswestry (Midlands Centre for Spinal Injuries). (6) Cardiff (Welsh Spinal Injuries and Neurological Rehabilitation Centre). (7) Middlesbrough (Golden Jubilee Regional Spinal Cord Injury Centre). (8) Wakefield (New Pinderfields Regional Spinal Injuries Centre). (9) Sheffield (Princess Royal Spinal Injuries Centre). (10) Aylesbury (The National Spinal Injuries Centre). (11) Stanmore (Spinal Cord Injuries Centre). (12) Salisbury (Duke of Cornwall Spinal Treatment Centre). Taken from http://www.apparelyzed.com/spinalunits.html (Website now defunct)

Figure 2: Survey questions

Results

Three SCICs responded to the postal questionnaire survey, and further eight SCICs subsequently responded to the FOI requests. No response was received from one centre despite follow-up communication.

Spinal cord injury centre admissions

For the study period, the mean number of any-level SCI and any-level tetraplegic admissions was 85.1 (range: 3–140, 11 centers) and 49.6 (range: 27–84, 9 centers), respectively, per SCIC. The mean number of admissions with a CSCI above C5, at C5/6, and below C6 was 27.9 (range: 10–63, 8 centers), 18 (range: 7–27, 7 centers), and 6.5 (range: 1–17, 7 centers), respectively [Figure - 3]. The American Spinal Injury Association Impairment Scale categories for CSCI patients at admission and discharge are presented in [Figure - 4]. The mean age of CSCI admissions (any-level) was 56.5 years (range: 52–63, 6 centers).

Figure 4: American Spinal Injury Association Impairment Scale categories at admission and discharge

Upper-limb services for cervical spinal cord injury patients

Six SCICs reported holding local clinics or referring CSCI patients to specialist upper-limb or hand surgery services. Three SCICs stated that they did not routinely or ever refer CSCI patients and two SCICs did not answer the questions posed [Figure - 5]. Four SCICs reported their outcomes for patients referred to specialist upper-limb or hand surgery services [Figure - 6].

Figure 5: Availability of upper-limb services for cervical spinal cord injury patients

Figure 6: Outcomes for patients referred to specialist upper-limb or hand surgery services by spinal cord injury centers over a 3-year period

Outcome measures

Six SCICs employed outcome measures to assess surgical outcomes [Figure - 7].

Figure 7: Outcome measures employed by spinal cord injury centers following surgery

Discussion

We find that CSCI accounts for nearly 60% of all admissions to the UK SCICs, with 50% of admissions representing C5–C8 level injuries. Comparative data relating to UK SCI incidence is difficult to obtain with no published national data currently available. This may change with the advent of the UK National Spinal Cord Injury Database (www.spinalcordinjury.nhs.uk). The high response rate (91.7%) of our survey means a snapshot assessment of annual CSCI workload can be extrapolated based on centre-reported response. We calculate annually that 596 patients within the UK and EIRE sustain an any-level CSCI and reach a SCIC including 294 C5–C8 injuries with varying levels of upper-limb function.

Following a CSCI, it is essential that every patient should have a detailed functional assessment of their upper limb by a specialist upper-limb surgeon; our survey shows that this does not currently occur. Upper-limb examination post-CSCI should not be an isolated event and should be repeated regularly by specialist physiotherapists during inpatient and outpatient follow-up. We strongly recommend that repeated documented clinical examination of the upper limb in CSCI should be integrated into the NHS commissioning criteria for SCICs. This change would improve rehabilitative practice by documenting the course of upper-limb recovery, elucidating surgical candidates, and focusing finite clinical resources on this important functional area. Mandating assessment by an upper-limb surgeon also provides scope for any appropriate surgical strategies (nerve transfers, tendon transfers, etc.) to be explored, discussed and considered by patients.

Our survey suggests that access to upper-limb surgery services following CSCI varies significantly with 25% of SCICs not offering any access – a concerning health-care inequality. Larger SCICs provide greater availability and hold specialist consultant-led clinics but this is very much dependent on a motivated surgeon locally. Confirmatory evidence is available from a recent British Society for Surgery of the Hand survey that identified only ten self-reporting hand surgeons undertaking upper-limb reconstruction for CSCI patients with only two having undertaken more than five cases annually.^[24] Just four SCICs reported outcomes for patients who underwent reconstructive upper-limb surgery with tendon-related procedures mainly transfers being the mainstay intervention. No centres reported undertaking nerve transfer procedures – an unsurprising finding when expertise in peripheral nerve surgery is concentrated in specialist centres.

In light of the low number of patients and few SCICs that reported referral outcomes, it is difficult to draw conclusions regarding national practices, but it is clear that procedures performed varied between centers. The survey did not elucidate data on how patients were selected for surgery and the functional gains prioritized, but the recent publication of the International Federation of Societies for Surgery of the Hand Scientific Committee on Nerve–Spinal Cord Injury Report – “Update on Hand Surgery in Tetraplegia”^[25] – represents a useful guide for clinical assessment of CSCI patients. The document assists in surgical planning and goal prioritization making recommendations for interventional procedures (but excludes nerve transfer). We recommend that any surgeons asked to assess CSCI patients use this document to formulate treatment recommendations while being conscious of nerve transfer options. Those surgeons with an interest in nerve transfer should seek specialist training to increase exposure in addition to the current hand surgery curriculum.

Surgical uptake varied from 13% to 100% between centres. This is likely to represent variation in service access, surgical expertise, and depth and degree of counseling provided to patients regarding risks and gains of surgery. The decision for any CSCI patient to undergo reconstructive upper-limb surgery is highly influenced by how information is framed by health-care professionals. In similarity to the US, UK health professionals have intrinsic biases. At least one US questionnaire survey has documented discordance between professional groups (surgeons and physicians) on the utility of surgery. When asked whether “functional gains were worth the risk of surgery,” 73% of spinal rehabilitation professionals agreed or strongly agreed compared to 94% of surgeons.^[26] When asked whether they “would want upper-extremity surgery,” 93% of spinal rehabilitation consultants agreed compared to 96% of surgeons. Pertinently, the study showed that spinal rehabilitation professionals were much more likely to favor reconstructive upper-limb surgery making 2.8-times more referrals with 13.1 more reconstructions undertaken where good relationships with their local hand surgeon existed.^[27],[28] This clearly demonstrates the importance of delivering reconstructive upper-limb surgery for CSCI within the confines of a spinal injury multidisciplinary team (MDT) and good working relationships.

Conclusions

There is a scope for the development of reconstructive upper-limb surgery services, particularly nerve transfer within the UK, and it is hoped that this will act as a blueprint for service developments internationally. It is evident that upper-limb surgeons and spinal rehabilitation professionals need to work together and ensure that access does not vary geographically. This should aim to ensure that every CSCI patient receives an assessment of upper-limb function by an upper-limb surgeon working within a spinal injury MDT. Due to the limited number of upper-limb surgeons with expertise in peripheral nerve surgery, it is not pragmatic for all CSCI patients to be assessed by a peripheral nerve surgeon. Nonetheless, where such surgery may be beneficial, suitable patients should be referred for further assessment. We would encourage all hand surgeons to work with their local SCIC to raise awareness of the potential for reconstructive upper-limb surgery, in particular nerve transfer, for this small but very deserving patient group so that opportunities to improve functional outcomes are not missed.

Recommendations

1. All CSCI patients should have a detailed clinical examination of their upper-limb function by a specialist upper-limb surgeon within a year of injury
2. Clinical examination of the upper limb in CSCI patients should be integrated into the commissioning criteria for SCICs and regularly repeated
3. All SCICs should offer CSCI patients access to upper-limb services that can perform tendon or nerve transfer procedures
4. Upper-limb surgeons with an interest in nerve transfer should seek specialist training in CSCI to supplement the current hand surgery curriculum
5. All upper-limb surgery following CSCI should be undertaken within the confines of a spinal injury. Patients should be counseled carefully, honestly, and with equipoise.

Ethical consideration

Ethical approval not sought.

Acknowledgment

We acknowledge administrative support provided by Sarah Wilson.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Authors' contributions

DMP and JAW conceived the study. JAW drafted the questionnaire and collected and analyzed the data generated. JAW wrote and revised the manuscript in conjunction with DMP. DMP and JAW both agreed the final manuscript. All authors have critically reviewed and approved the final draft and are responsible for the content and similarity index of the manuscript.