Reconstructive upper limb surgery in patients with cervical spinal cord injury. Evaluation of postoperative treatments and examination of applicability of the Klein-Bell ADL Scale

Abstract

Aims: Studies I & II: To describe and evaluate postoperative deltoid-triceps protection of tendon elongation and long-term clinical follow-up after tenodesis to the IP joint of the thumb. Study III: To examine and explore the applicability of the Klein-Bell ADL Scale (KB Scale) in patients with cervical spinal cord injury in terms of daily activities and the association between basic ADL and upper extremity function. Method: Studies I & II data were collected retrospectively. Eleven patients were included in study I. The patients were divided postoperatively into two groups; patients using their manual wheelchair without a special armrest and patients using an electric power driven wheelchair with a special armrest. Stainless steel sutures (markers) were placed proximally and distally of the tendon-to-tendon attachment sites. The distances between markers were measured via upper extremity x-ray to evaluate tendon elongations. Thirtythree patients were included in study II. Extension, flexion and range of motion were measured to evaluate how the tenodesis of the IP joint of the thumb influenced the different movement modalities of the IP joint of the thumb. Study III: Data were collected prospectively. Fifty-five patients were included in the study. Assessments of the patients’ independence were made according to the K-B Scale. Three more analyses were performed; the first analysis was made to examine whether assistive devices and car and house adaptations could influence the patient’s independence. The last two analyses included investigations of whether arm and different grip functions and different grip phases could be detected in the items’ operational criteria. Results: In study I the total distances between markers after reconstruction of deltoid to triceps were significantly lower in the patients using an electric power driven wheelchair with special armrest compared to those without the armrest. The largest difference in tendon elongation between the groups occurred in the proximal tendon transfer. Elbow extension deficit was decreased in the group using the electric power wheelchair with an armrest, although not significantly as compared to those without the armrest. In study II treatment with a thumb splint after tenodesis to the IP joint of the thumb gave a pliable and well balanced IP joint with comparable results in extension, flexion and ROM at six months and 12 months postoperatively. In study III only the raw sum score and not the weight scheme in the K-B scale discriminated the patient’s independence in daily activities (ADL). Assistive devices and car and house adaptations made the patients more independent. Lack of grip function decreased the patient’s ability to become independent. Conclusion: The use of an electric power driven chair with a special armrest and thumb splint has shown that relatively simple adjuncts can positively influence the effectiveness of operations performed. The cooperation between the hand surgeons and the therapist to develop these treatments has been important for improved results in these studies. The K-B Scale can be used to assess basic ADL and can discriminate between cervical SCI patients’ independence in ADL. To become a useful tool, the K-B Scale’s structural properties in conjunction with arm and grip function must be further investigated.