History of surgery in the rehabilitation of the tetraplegic upper limb

Reconstructive surgery of the upper limb in patients with tetraplegia has a relatively short existence. It began during the mid-20th century, undoubtedly influenced by the development of modern hand surgery and by the importance of restoring function to the tetraplegic hand. The traumatic tetraplegic patient who has suffered a complete and irreversible lesion of the cervical spine, must recover some function of his or her upper limbs to obtain the necessary autonomy to move with the assistance of a wheelchair and to perform activities of daily life. Because of these needs, surgical rehabilitation of the upper limb in tetraplegia is an ongoing challenge for the hand surgeon. The first attempts at producing some gripping function of the hand probably took place in Europe [11 at the end of the 1920s with the construction of flexor-hinge splints. Continuing interest in the use of hand splints in the years that followed resulted in the Rancho Splint developed by Nickel et al. [2]. In an excellent paper, these authors demonstrated that improvement of digital function in a severely paralyzed hand by using splints was increasingly successful as clinicians gained knowledge and experience. In the 1950s, further understanding of the tenodesis effect (ie, the automatic digital movements of extension and flexion produced by active movements of the wrist) influenced the development of surgical techniques such as the static flexor tenodesis. These procedures provided the basic functions of grasp and pinch for patients who lacked sufficient muscle motors for conventional transfers but in whom active wrist dorsillexion was present [3-5]. In 1963, Nickel et al [2] called the hands that resulted from these operations "finger-driven surgical flexor-hinge hands." . Based on the normal automatic synergistic mechanisms of the hand, tendon transfers were developed to obtain both digital release and gripping functions in two surgical stages. The originators of these procedures were Lipscomb et al [6], Zancolli [7-9], House et al [ 10, 11]. The development of hand surgery for tetraplegia has received important contributions through reports published by the Spinal Cord Injuries Committee of the International Federation of Societies for Surgery of the Hand and by the international conferences initiated with the influence of Erik Moberg from Goteborg, Sweden. The first international conference was convened at Princess Margaret Rose Orthopaedic Hospital in Edinburgh, Scotland, in June 1978 by Douglas Lamb. To date, seven conferences on tetraplegia have been organized, with the last one being held in Bologna, Italy, in June-2001 by Antonio Landi. These conferences have been of great interest because of the convergence of hand surgeons interested in the field, fostering discussion and comparison of different surgical methods and experiences. During the second irtternational meeting held. in October 1984 in Giens, France, at Renee-Sabran Hospital, an International Classification for Surgery of the Hand in Tetraplegia was detailed (Table 1). This was a modification of the initial classification discussed in Edinburgh in 1978 [121, the international classification was based on the sensibility of the hand, the remnant active muscles, and functions of the upper limb. Additionally, it was considered to be of great interest for surgical planning, dictating that the muscles should have a strength of at least grade 4 to be used as transfers. It was established that determinig the strength of the extensor carpi radialis brevis tendon, however, was not possible at the time without surgical exposure. Since then, a great number of surgeons have added their expertise, producing the current knowledge of rehabilitation of the tetraplegic upper limb.