Tendon transfer procedures have been done for decades and applied in spinal cord injury (SCI) since the 1950s – though Shepherd Center is one of only a handful of facilities that offer the procedure for people with SCI.
In the past several decades, techniques and protocols have been greatly improved through research. In fact, Shepherd Center's Upper Extremity Clinic has conducted some of this research and presented it at international meetings and published it in journals and books.
Upper-extremity surgical procedures can improve the quality of life in people with spinal cord injury - specifically tetraplegia..
Among the options are tendon transfer surgery, which can restore function in hands, wrists and arms for people with tetraplegia.
Allan Peljovich, M.D.,MPH, is here to discuss upper-extremity surgical procedures.
Selected Podcast
Upper-Extremity Surgical Options for People with Spinal Cord Injury
Featured Speaker:
Allan Peljovich, M.D., MPH
Dr. Peljovich, of the Hand & Upper Extremity Center of Georgia, is a consulting orthopedist at Shepherd Center, where he specializes in hand and upper-extremity surgery. Transcription:
Upper-Extremity Surgical Options for People with Spinal Cord Injury
Melanie Cole (Host): Upper extremity surgical procedures can improve the quality of life in people with spinal cord injury. The upper extremity rehabilitation clinic at Shepherd Center offers a comprehensive therapy and treatment program to improve upper extremity function for individuals with catastrophic injuries who have limited function in their arms, wrists, and/or hands. My guest today is Dr. Allan Peljovich. He’s a board-certified orthopedic surgeon with a specialty in hand and upper extremity surgery. Welcome to the show, Dr. Peljovich. Tell us a little bit about what upper extremity problems and issues people with spinal cord injury might experience.
Dr. Allan Peljovich (Guest): Well, thanks for having me. I think the main thing that these folks will experience is dysfunction, inability to use their arms for simple activities that they need. For example, just to help mobilize, to help transfer from one location to another, to eat, to use their technology that helps them to manipulate their environment. That’s probably the most common that are difficulties that they encounter.
Melanie: Is this problem that goes from the shoulder, elbow, and wrist? Is it more localized in one area? Can they just not use their fingers, hands? I know it’s different with every patient, but generally, does it include the whole arm?
Dr. Peljovich: Yes, really it’s a little bit different because I think most people think of tetraplegia or quadriplegia as being one thing, meaning an inability to use our arms, but the truth is, it’s really more than that. Most people, the average person who has this sort of an injury has good use of their shoulder, some ability to bend their elbow and maybe even the ability to straighten out their wrist, and then that’s about it. They can’t always straighten out their elbows, they can’t move their fingers, and that’s usually the difficulty that they have. What they really have trouble with is the inability to use their fingers to grip and manipulate objects.
Melanie: What’s the first thing you do with them? Does this start with physical therapy before it goes to a surgical intervention? What happens at the beginning?
Dr. Peljovich: At the beginning for anybody who has sustained this injury, there’s a huge period of adjustment. Hopefully, they’re doing this at a Model Care Spinal Cord System that’s used to taking care of individuals who are going through this really very dramatic transition in their life. It starts with rehabilitating every part of them, not just their arms, but their legs to the extent that they can, their psyche, any other injury that they may have sustained. The focus on the arms starts really at the beginning. It’s about keeping everything mobile and not allowing stiffness to set in, about sponging them, about strengthening the parts that have function and protecting them from injury as they start transitioning and adjusting to their new life. Then we wait. We wait because most people who have this injury are going to regain some degree of function that the spinal cord has some capacity to heal very limited. We want to wait until they have finished going through that healing process so that we really have a good expectation of what their arms and hands are going to be like for the rest of their life, and that can take six months to a year sometimes.
Melanie: Once you’ve determined what their level of recovery is going to be after that six months or a year, which must be a very frustrating waiting period for the patient, then how do you help them? What types of surgical interventions are offered? Tell us a little bit about this tendon transfer surgery.
Dr. Peljovich: The idea is to try to build function that they are lacking, and we have a fairly algorithmic approach to doing that. For example, one of our priorities is to want to make sure that if someone doesn’t have the ability to straighten out their elbow with strength, that we might be able to do something to provide that for them because that could mean the ability to reach out above them and manipulate a greater part of the world around them, and they can if they can do anything above their shoulder level and it might even mean the ability for them to transfer themselves in and out of a wheelchair or in and out of bed and things like that.
The next thing we look at is if they can already straighten out their wrist, to try to provide them with some pinch, the ability to take their thumb, their index finger, and bring that together with strength, with at least enough strength to be able to pick up anything, whether it’s a pen or a phone or eating utensils or even a catheter that they need to use to catheterize themselves, any objects that they will be given on a regular basis. Then after that, we look at grasp, the ability to close their fingers and make a fist so that they can manipulate a larger object like a cup or a bottle or a glass. The most common way that we do this is with tendon transfers. A tendon transfer is a surgical procedure where we take a muscle that is already working for them, that is strong and that is under their own voluntary control, and we reorient it. Instead of doing a function that they were designed to do, it does something new. That’s the most common way to do it. For example, we can take one of three muscles that bend an individual’s elbow and turn that muscle into a thumb pincher simply by reorienting where the muscle attaches to. Another way that we can do it, but we don’t use it too often because there are not clear reasons to do it regularly yet, is to shift some nerves around, to take a nerve that’s working or a part of a nerve that’s working and plug it into a nerve that’s not working and sort of achieve the same thing.
Melanie: In the tendon transfer, what is that surgery like as far as recovery? How soon will they know if that works and then also take that into the brachial plexus surgery? Nerves take a long time to heal. When would you know if that one worked?
Dr. Peljovich: Yes, so that’s the thing. There are two nice things about tendon transfers. One is that we have a lot of experience with them. These procedures have been done and these techniques have been sort of honed and developed over the course of decades now, so we really have gotten pretty good and pretty reliable with our results. The nice thing is that it takes about three weeks for the tendon to start healing strongly to its new position. Usually by about two to three months postoperative, people are using it. That process has begun. So it’s a fairly quick process where they have function, and if they stick with it and they’re motivated over the course of the next six months to a year, these functions which are a little bit clumsy initially because they’re having to relearn certain muscles, become second nature. Now, they have a new arm, new hand they didn’t have before.
With the nerve surgery, that takes a lot longer. Nerves do heal very slowly, and the quote we always give people is about a millimeter a day. You’re looking at three to four inches of nerve healing, that’s four to five months before a nerve ever makes it to the target, and then about six months to a year before it strengthens. It’s more like a long-term investment. While I think there’s a lot of promise with nerve transfers in tetraplegia, it’s not yet really become a tried-and-true technique that we can count on with the same reliability than with tendon transfers. I think the features are probably going to be hybrid where we’re doing a combination of tendon transfers and nerve procedures that will really potentially create even more elegant function than we’re able to do now.
Melanie: Along the research line, Dr. Peljovich, what else is going on that’s exciting for upper extremity issues with spinal cord injury?
Dr. Peljovich: One of the really exciting issues in terms of hand and arms is electrical stimulation. It always has been. There’s an ability to stimulate these paralyzed muscles because the problem is not the muscle, and in fact, the problem is not even the nerve that feeds the muscle. The problem is in the spinal cord. These nerves are still alive and the muscles are still alive. They just miss that signal from the brain to contract, but you can put tiny little electrodes on the various muscles and using very elegant computer programming to coordinate grasp and pinch and opening of the fingers and motion at the elbow. These techniques were actually commercially available over a decade ago, no longer available but the research really does continue in that vein, and the ability to control it becomes even more elegant in trying to use brain signals in order to control these devices. I think that’s something very exciting on the forefront that may be available eventually and then, of course, any research that’s devoted to potentially improving the outcome of the spinal cord injury from the beginning to minimize the impact. There’s a lot of work there and hopefully progress eventually.
Melanie: In just the last minute or so, Dr. Peljovich, give listeners your best advice about having a loved one suffering from spinal cord injury and the upper extremity options that are available to them and why they should come to Shepherd Center for their care.
Dr. Peljovich: The advice that I would give anybody who’s dealt with this injury or is dealing with this injury is that the time to consider these things is when someone realizes that they need more out of their arms, more out of their life than they’re able to get. There’s no such thing as the injuries have been around too long for someone to get benefit from at least a consultation or this operation. We’ve done these procedures early on in someone’s recovery to years later with similar results. I think the reason why places like Shepherd Center, and certainly Shepherd Center, has an advantage and other models to your spinal systems where there are set programs is because we have just tremendous experience. We’ve been doing this for a long time. We are focused on taking care of people with spinal cord injury, and that is a unique and distinct injury that is not so easily understood or appreciated at centers that don’t do this very often. There’s lots to coordinating a patient’s care that have nothing to do with the operation but has everything to do with their disability and the particulars of that disability, so we just take some things like that.
But also the one nice thing that we have is we have all the specialists available to us as we need to evaluate people. That includes the therapist and the radiologist and, whenever needed, to see a podiatrist and even the neurologist. We have a whole cascade of specialists, all geared and focused on providing the very best care in a very comprehensive manner. I think that always works better for people, just makes things easier, more efficient, safer, better outcome.
Melanie: That’s great information. Thank you so much. You are listening to Shepherd Center Radio. For more information, you can go to shepherd.org. That’s shepherd.org. This is Melanie Cole. Thanks so much for listening.
Upper-Extremity Surgical Options for People with Spinal Cord Injury
Melanie Cole (Host): Upper extremity surgical procedures can improve the quality of life in people with spinal cord injury. The upper extremity rehabilitation clinic at Shepherd Center offers a comprehensive therapy and treatment program to improve upper extremity function for individuals with catastrophic injuries who have limited function in their arms, wrists, and/or hands. My guest today is Dr. Allan Peljovich. He’s a board-certified orthopedic surgeon with a specialty in hand and upper extremity surgery. Welcome to the show, Dr. Peljovich. Tell us a little bit about what upper extremity problems and issues people with spinal cord injury might experience.
Dr. Allan Peljovich (Guest): Well, thanks for having me. I think the main thing that these folks will experience is dysfunction, inability to use their arms for simple activities that they need. For example, just to help mobilize, to help transfer from one location to another, to eat, to use their technology that helps them to manipulate their environment. That’s probably the most common that are difficulties that they encounter.
Melanie: Is this problem that goes from the shoulder, elbow, and wrist? Is it more localized in one area? Can they just not use their fingers, hands? I know it’s different with every patient, but generally, does it include the whole arm?
Dr. Peljovich: Yes, really it’s a little bit different because I think most people think of tetraplegia or quadriplegia as being one thing, meaning an inability to use our arms, but the truth is, it’s really more than that. Most people, the average person who has this sort of an injury has good use of their shoulder, some ability to bend their elbow and maybe even the ability to straighten out their wrist, and then that’s about it. They can’t always straighten out their elbows, they can’t move their fingers, and that’s usually the difficulty that they have. What they really have trouble with is the inability to use their fingers to grip and manipulate objects.
Melanie: What’s the first thing you do with them? Does this start with physical therapy before it goes to a surgical intervention? What happens at the beginning?
Dr. Peljovich: At the beginning for anybody who has sustained this injury, there’s a huge period of adjustment. Hopefully, they’re doing this at a Model Care Spinal Cord System that’s used to taking care of individuals who are going through this really very dramatic transition in their life. It starts with rehabilitating every part of them, not just their arms, but their legs to the extent that they can, their psyche, any other injury that they may have sustained. The focus on the arms starts really at the beginning. It’s about keeping everything mobile and not allowing stiffness to set in, about sponging them, about strengthening the parts that have function and protecting them from injury as they start transitioning and adjusting to their new life. Then we wait. We wait because most people who have this injury are going to regain some degree of function that the spinal cord has some capacity to heal very limited. We want to wait until they have finished going through that healing process so that we really have a good expectation of what their arms and hands are going to be like for the rest of their life, and that can take six months to a year sometimes.
Melanie: Once you’ve determined what their level of recovery is going to be after that six months or a year, which must be a very frustrating waiting period for the patient, then how do you help them? What types of surgical interventions are offered? Tell us a little bit about this tendon transfer surgery.
Dr. Peljovich: The idea is to try to build function that they are lacking, and we have a fairly algorithmic approach to doing that. For example, one of our priorities is to want to make sure that if someone doesn’t have the ability to straighten out their elbow with strength, that we might be able to do something to provide that for them because that could mean the ability to reach out above them and manipulate a greater part of the world around them, and they can if they can do anything above their shoulder level and it might even mean the ability for them to transfer themselves in and out of a wheelchair or in and out of bed and things like that.
The next thing we look at is if they can already straighten out their wrist, to try to provide them with some pinch, the ability to take their thumb, their index finger, and bring that together with strength, with at least enough strength to be able to pick up anything, whether it’s a pen or a phone or eating utensils or even a catheter that they need to use to catheterize themselves, any objects that they will be given on a regular basis. Then after that, we look at grasp, the ability to close their fingers and make a fist so that they can manipulate a larger object like a cup or a bottle or a glass. The most common way that we do this is with tendon transfers. A tendon transfer is a surgical procedure where we take a muscle that is already working for them, that is strong and that is under their own voluntary control, and we reorient it. Instead of doing a function that they were designed to do, it does something new. That’s the most common way to do it. For example, we can take one of three muscles that bend an individual’s elbow and turn that muscle into a thumb pincher simply by reorienting where the muscle attaches to. Another way that we can do it, but we don’t use it too often because there are not clear reasons to do it regularly yet, is to shift some nerves around, to take a nerve that’s working or a part of a nerve that’s working and plug it into a nerve that’s not working and sort of achieve the same thing.
Melanie: In the tendon transfer, what is that surgery like as far as recovery? How soon will they know if that works and then also take that into the brachial plexus surgery? Nerves take a long time to heal. When would you know if that one worked?
Dr. Peljovich: Yes, so that’s the thing. There are two nice things about tendon transfers. One is that we have a lot of experience with them. These procedures have been done and these techniques have been sort of honed and developed over the course of decades now, so we really have gotten pretty good and pretty reliable with our results. The nice thing is that it takes about three weeks for the tendon to start healing strongly to its new position. Usually by about two to three months postoperative, people are using it. That process has begun. So it’s a fairly quick process where they have function, and if they stick with it and they’re motivated over the course of the next six months to a year, these functions which are a little bit clumsy initially because they’re having to relearn certain muscles, become second nature. Now, they have a new arm, new hand they didn’t have before.
With the nerve surgery, that takes a lot longer. Nerves do heal very slowly, and the quote we always give people is about a millimeter a day. You’re looking at three to four inches of nerve healing, that’s four to five months before a nerve ever makes it to the target, and then about six months to a year before it strengthens. It’s more like a long-term investment. While I think there’s a lot of promise with nerve transfers in tetraplegia, it’s not yet really become a tried-and-true technique that we can count on with the same reliability than with tendon transfers. I think the features are probably going to be hybrid where we’re doing a combination of tendon transfers and nerve procedures that will really potentially create even more elegant function than we’re able to do now.
Melanie: Along the research line, Dr. Peljovich, what else is going on that’s exciting for upper extremity issues with spinal cord injury?
Dr. Peljovich: One of the really exciting issues in terms of hand and arms is electrical stimulation. It always has been. There’s an ability to stimulate these paralyzed muscles because the problem is not the muscle, and in fact, the problem is not even the nerve that feeds the muscle. The problem is in the spinal cord. These nerves are still alive and the muscles are still alive. They just miss that signal from the brain to contract, but you can put tiny little electrodes on the various muscles and using very elegant computer programming to coordinate grasp and pinch and opening of the fingers and motion at the elbow. These techniques were actually commercially available over a decade ago, no longer available but the research really does continue in that vein, and the ability to control it becomes even more elegant in trying to use brain signals in order to control these devices. I think that’s something very exciting on the forefront that may be available eventually and then, of course, any research that’s devoted to potentially improving the outcome of the spinal cord injury from the beginning to minimize the impact. There’s a lot of work there and hopefully progress eventually.
Melanie: In just the last minute or so, Dr. Peljovich, give listeners your best advice about having a loved one suffering from spinal cord injury and the upper extremity options that are available to them and why they should come to Shepherd Center for their care.
Dr. Peljovich: The advice that I would give anybody who’s dealt with this injury or is dealing with this injury is that the time to consider these things is when someone realizes that they need more out of their arms, more out of their life than they’re able to get. There’s no such thing as the injuries have been around too long for someone to get benefit from at least a consultation or this operation. We’ve done these procedures early on in someone’s recovery to years later with similar results. I think the reason why places like Shepherd Center, and certainly Shepherd Center, has an advantage and other models to your spinal systems where there are set programs is because we have just tremendous experience. We’ve been doing this for a long time. We are focused on taking care of people with spinal cord injury, and that is a unique and distinct injury that is not so easily understood or appreciated at centers that don’t do this very often. There’s lots to coordinating a patient’s care that have nothing to do with the operation but has everything to do with their disability and the particulars of that disability, so we just take some things like that.
But also the one nice thing that we have is we have all the specialists available to us as we need to evaluate people. That includes the therapist and the radiologist and, whenever needed, to see a podiatrist and even the neurologist. We have a whole cascade of specialists, all geared and focused on providing the very best care in a very comprehensive manner. I think that always works better for people, just makes things easier, more efficient, safer, better outcome.
Melanie: That’s great information. Thank you so much. You are listening to Shepherd Center Radio. For more information, you can go to shepherd.org. That’s shepherd.org. This is Melanie Cole. Thanks so much for listening.