2024-01-01 23:54:13
The Institut Guttmann, in Badalona, is a pioneer in Spain in performing nerve transfers in quadriplegic patients and the use of the 3D model in osteoma resections.
When an injury affects the cervical spinal cord, paralysis of the upper extremities occurs as well as the lower extremities. The function of the hand, wrist, elbow and even the shoulder will be paralyzed depending on the cervical level injured in the trauma, so that the higher the neurological injury, the more severe the associated physical limitation. Tendon transposition is the surgical intervention performed to improve the mobility of the upper extremities and promote the autonomy of the patient with tetraplegia. This technique involves the disinsertion of muscles with active mobility and their subsequent insertion in another location, with the aim of performing the function of another muscle that was paralyzed by not receiving nervous stimulation after the spinal cord injury.
Álex del Arco, neuroorthopedic surgeon at the Guttmann Institute, explains that this surgery is performed in very few centers in Spain, and that it requires a multidisciplinary team that includes not only the team of orthopedic surgeons but also rehabilitation doctors, physiotherapists and occupational therapists. “The Institut Guttmann is at the forefront in Spain, with more than 100 tendon transpositions performed since 1990,” he emphasizes. In addition, two years ago he pioneered a promising intervention: nerve transfer. Its origin arises from the need to respond to patients with high cervical injuries where there are no functional muscles that can be transferred, and in which a healthy nerve is connected to an affected one to recover the transmission of nerve impulses and, therefore , the function of the paralyzed muscle.
Osteoma intervention at the Institut Guttmann with a 3D model of the patient’s bones and blood vessels.
Advantages and disadvantages
The main advantage of nerve transfer is that it offers a more ambitious result, being able to recover the function of more muscles and achieve more precise movement. “The tendon transposition provides greater strength when gripping an instrument, like a glass, for example, but it is not as fine as the nerve transfer, which could allow, perhaps, typing on a computer,” he points out. Another advantage is that it is less “mutilating” compared to tendon transposition, since it does not alter the patient’s anatomy. Furthermore, after the intervention it is not necessary to immobilize the limb with an orthosis.
One of the drawbacks associated with nerve transfer is its prolonged recovery process. “With tendon transposition, the patient begins to notice changes from the first weeks after surgery. However, with nerve transfer, the paralyzed nerve needs to be reinnervated and does so at a rate of one millimeter per day. This means that the patient has to wait approximately a year to notice the effects of the operation,” he explains. On the other hand, the outcome of nerve transfer is less predictable. In the last two years, 12 patients have had nerve transpositions operated on at the Institut Guttmann, some of them combined with tendon transpositions.
The Institut Guttmann stands out for the complexity and pioneering nature of the interventions it carries out in the field of neuroorthopedics, both in spinal cord injuries and in other neurological injuries. This is the case of multilevel surgery, introduced in the hospital more than a decade ago by the team led by traumatologist and neuroorthopedist Frederic Dachs, a technique that addresses the problem of children with spasticity (muscle contractures secondary to a brain injury that prevent walking autonomously). Classically, the child was subjected to successive interventions that could involve two years of coming and going from the hospital. With multilevel surgery, the intervention is planned based on the results obtained in the hospital’s gait laboratory and, using a team of four surgeons, up to nine surgical procedures are performed simultaneously and bilaterally. Thus the entire surgical treatment is carried out in a single session.
Another example is the 60 interventions in patients with neurological injuries, focused on the extraction of osteomas or heterotopic calcifications that grow around the joints, mostly in the hip, blocking it and causing pain and serious mobility limitations. These surgeries carry a high risk of vascular injuries, so they are performed in collaboration with a vascular surgeon. In these interventions, the Institut Guttmann uses 3D models of the area to be operated on, based on CT angiography images. Thanks to them, the surgery team has an exact model of the patient’s bones and blood vessels in the operating room, which allows better planning of the operation and a safer approach when intervening, which reduces the risk of causing injury. Laura Clavijo
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