Introduction

Quadriplegia (tetraplegia) as a result of severe cervical spinal cord injury belongs to the most profound dysfunction of the locomotor system. Similar cord injuries on lower level, in spite of paralysis of both legs and trunk - don’t cause severe grade of disability. They left over the chances for quite good performed everyday - life activity, self- service and ability to use the wheelchair. The degree of disability is dependent from the degree of hand insufficiency. Function of the hand for patient with cord injury in the cervical spine has got very important role. Such person spends most of the day - time in bad or on the wheelchair, is lucking of performing any, even simplest every - day activities, is totally dependent from surrounding society, which is usually unable to secure persistent, full - time care. The importance of hand functioning for such patients is stressed in clinical material taken from Hanson and Franklin [1]. They have been checking in anonymous questionnaire what human function seems to be the most important. About 76% of hole randomized group pointed out function of the hand. That’s why analysis of functional abilities of the hand so performed [2-4] and undertaking every possible method directed to regain and enhance hand functioning [5-9] has got so important meaning in treatment of patients after cervical cord lesions.

Materials and Methods

The material of 285 clinical cases has been analysed. All of them were treated after cervical cord injuries and were admitted to hospital (Metropolitan Rehabilitation Centre in Konstancin, near Warsaw) with symptoms of quadriplegia. In Table 1 is visualized the relation between neurologic deficit and level of spine injury. The level of damaged spine has been determined using standard X-ray and in doubtful cases CT or MRJ examination. The level of neurologic deficit has been defined accordingly to evaluation of superficial feeling loss level. Spine injure in most cases, dealt with spaces C5 - C6 and C6 - C7 (totally over 43% of all cases), and all together injuries between C5 - C7 made 80% of analysed group. Neurologic deficit mostly dealt with C6 segment (38%). Usually, it is accepted, that cervical cord lesion is one segment lower than the level of spine damage.
In analysed material we usually found neurologic deficit on the level of bony metamere lesion or little above (65% of cases). This is probably because of fact, that primary examination was performed early - after couple or several hours after the accident had happened, when the posttraumatic oedema of the cord could cause certain elevation of neurologic deficit level. Important is the fact though, that neurologic deficit level seems to be higher in intervertebral damage, connected with luxation of vertebral bodies, not in vertebral body fracture, where the level of spinal cord compression is relatively lower.

The Relation Between Cord Injury and Function of the Hand

Many factors have influence on the range of hand function in patients after cervical spine injury. They are: severity of cord lesion, mechanism and force of trauma, duration of cord compression, undertaken treatment, age of patient, cooperation with the patient during rehabilitation process and others. The most important factor though, seems to be the level and degree of the cord lesion [2,3,8]. This is clearly illustrated in the Table 2, where we can see the relation between upper extremity function notified in primary examination and the level of cord injury. As an active muscle complex has been assumed dynamic group of muscles with strength of more than 2 according to Lovett scale. Primarily - at the admission it has been notified just the activity of elbow flexors (41% of cases), with accompanying activity of deltoid muscles only. A smaller was group of better prognosis, with additionally active extensors of the wrist (28% of cases).

There was numerous though group of patients with total plegia of the upper extremity (23% of cases). The level of cord injury is in high correlation with dynamic complexes of upper limb, which work quite properly. The cord lesion on the level of C5 is usually accompanied with functional paralysis of the limb (87% of cases). The symptoms of lesion on the C6 level is the peripheral paralysis of extremity with left preserved activity of elbow flexors (96%). The lesion on the C7 level secures fair activity of flexors and extensors of the wrist (85% of cases). This creates the chance to regain at least the simple hand - grip activity by the use of “trick” mechanism (this means that active, strong extension of fingers in the way of tensed finger flexors tendons). At the group of patients with lower cervical cord injuries we meet sometimes individuals with good fingers activity, though with the level of C8 lesion more common is group of patients with active only wrist extensors (56%).

Function of the Hand after Hospital Treatment

During treatment, the area of oedema and blood supply abnormalities got diminished, what usually decreases the level of neurological deficit and sometimes regains activity in primarily muscles [4,6]. Early undertaken of hand rehabilitation process and functional hand therapy in many cases allow full or at least partial recovery of hand function. In Table 3 it has been presented handgrip abilities regained in final stage of hospital treatment in correlation with activity of main dynamic complexes extremity notified during admission to the hospital. Overall, in 58% of analysed group different level of hand functioning has been regained. Of course, regarding primary neurological and functional state in analysed group of patients - regaining precise and accurate hand function we have met relatively rarely (only about 10% of cases) and usually during low level of cord injury (C8 - D1).

Unfortunately, quite large group of treated patients (42%) didn’t regain functional activity of hand, and quite numerous is also group of patients, who be able to use the hand only into specific everyday - life situations, minding limited hand - grip functioning (“Trick Grip”). The relation between hand function and the balance of upper extremity dynamic complexes, notified during primary examination is clear. If the paralysis of the extremity during primary examination is total, the hand usually stays functionally useless (88% of patients). Also in the group, where we had primarily preserved only activity of elbow flexors - the hand often stays functionally useless (53%), and in none case from that group we didn’t regain precise function of the hand. Definitely better results have been noted in patients with active, during primary examination, extensors of the wrist. In most patients (55%) hand has been useful during every day - life activities, and in 10% of treated individuals good, precise function of the hand was regained. When during primary examination, flexors and extensors of finger were present - nearly in all of patients (87%) precise efficiency was recovered.

Conclusion

Based on the facts set out above, function of the hand, even not precise, but useful in everyday - life activities are extremely important for the patients with quadriplegia. At high grade it is deciding about quality of life. Properly undertaken treatment, early rehabilitation process, functional hand therapy in many cases allow recovering its function - assuring self - service. In the group of patients treated restoration of the hand functioning, in different level has been regained in 58%. Precisely performed manoeuvres was however rare (about 10% cases), and quite numerous (26%) where the hand function was very weak, enabling only simple tasks. In such cases it is worth consider special orthopaedic equipment to use, what could improve functioning of the hand [6-8] or on the way of surgical procedures [9-11]. But the indication into surgical procedures are not stated too often.

The results of transmitting active tendons, but usually weakened muscles into paralyzed ones are uncertain. This refers particularly to spastic hand, when the operational indications should be stated very cautiously. The biggest problem makes patients who in spite of therapeutic efforts have got totally functionally useless hand (42% of analysed group). There are different trials performed to improve functioning of the quadriplegic around the word, using special systems of robot - manipulators [8], functional electrostimulation of nerves, muscles (Figure 1) [12-14] and preferred in our Centre transmitting of musculo- cutaneous nerve into median nerve (Figure 2) [6,15,16]. The results of such procedures are not fully satisfactory, but even regaining simple hand - grip allows the patient to grab big thing like apple, sandwich, cutlery with bold handle, enables limited independent activity, self - service and improves positive thinking.

Figure 1: A patient with hybrid orthosis (using nerve stimulation) - enabling the function of the paralyzed tetraplegic hand.

Figure 2: Connection of the median nerve and the musculocutaneous nerve to restore simple function of the paralyzed hand.

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