Prevalence of Concomitant Distal Suprascapular Nerve Injury in Patients with Root-level Brachial Plexus Palsy: A Clinical Anatomic Study of Injury Pattern.

BACKGROUND: Root-level suprascapular nerve palsy is commonly reconstructed via spinal accessory nerve transfer in brachial plexus injury, yet some patients fail to recover. We hypothesize that this relates to concomitant undetected lesions distal to the nerve transfer coaptation. METHODS: 67 patients with plexus injury and C5/6 root involvement were included in this prospective study between March 2021 and October 2022. During spinal accessory to suprascapular nerve transfer the entire suprascapular nerve was explored, via cresenteric clavicular osteotomy, and anatomic variations and injury patterns categorized. RESULTS: Proximal root involvement was C5-C6 (n=8), C5-C7 (n=13), C5-C8 (n=17), C5-T1(29). Mean time from injury to surgery was 5.6 months. The suprascapular nerve was found to be injured in 16/67 cases (24%). In 9 cases (13%) the lesion was proximal to the suprascapular fossa. In 3 cases (4%) the suprascapular nerve was injured both proximally and within the fossa, and in 4 cases (6%) in the fossa or distal to it. Therefore, in 7 cases (10%), a traditional suprascapular nerve transfer would not successfully bypass the zone of injury of the suprascapular nerve in the fossa. Of the 16 cases of concomitant suprascapular nerve injury, 1/8 in occurred in C5-C6 root injury, 4/13 of C5-C7 root injury, 5/17 of C5-C8 root injury and 6/39 in total paralysis. CONCLUSIONS: Concomitant distal suprascapular nerve injury in brachial plexus stretch palsy occurred in 24% of the cases. This warrants attention from the surgeon to identify distal lesions and to perform the nerve transfer beyond any secondary lesions.

Decompression with Brachioradialis Tenotomy Improves Pain and Quality of Life in Patients with Radial Sensory Nerve Compression.

BACKGROUND: Decompression of the superficial sensory branch of the radial nerve (SBRN) with complete brachioradialis tenotomy may treat pain in both simple and complex cases of SBRN compression neuropathy. METHODS: A retrospective chart review was performed of consecutive patients undergoing this procedure between 2008 and 2020 including postoperative outcomes within 90 days. Data were collected and analyzed, including patient and injury demographics, pain descriptors, and patient-reported pain questionnaire, including reported pain severity and impact on quality of life using visual analogue scale (VAS) instruments. Within-group presurgical and postsurgical analyses and between-group statistical analyses were performed. RESULTS: Thirty-three of 58 patients met inclusion criteria. Median time from symptom onset to surgery was 300 days, and median postoperative follow-up time was 37 days. Twenty-five percent of patients ( n = 8) underwent isolated SBRN decompression. The remainder had concomitant decompression of another radial [ n = 16 (48%) or peripheral [ n = 12 (36%)] entrapment point. Ten of 33 patients (30%) had resolution of pain at final follow-up ( P = 0.004). Median change in worst pain over the previous week was -4 ( P < 0.001), and average pain over the last month was -2.75 ( P < 0.001) on the VAS. The impact of pain on quality of life showed a median change of -3 ( P < 0.001) on the VAS. CONCLUSION: Decompression of the sensory branch of the radial nerve including a complete brachioradialis tenotomy improves pain and quality-of-life VAS scores in patients with both simple compression neuropathy syndrome and complex nerve compression syndrome. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

What is Operative? Conceptualizing Neuralgia: Neuroma, Compression Neuropathy, Painful Hyperalgesia, and Phantom Nerve Pain.

Neuralgia, or nerve pain, is a common presenting complaint for the hand surgeon. When the nerve at play is easily localized, and the cause of the pain is clear (eg, carpal tunnel syndrome), the patient may be easily treated with excellent results. However, in more complex cases, the underlying pathophysiology and cause of neuralgia can be more difficult to interpret; if incorrectly managed, this leads to frustration for both the patient and surgeon. Here we offer a way to conceptualize neuralgia into 4 categories-compression neuropathy, neuroma, painful hyperalgesia, and phantom nerve pain-and offer an illustrative clinical vignette and strategies for optimal management of each. Further, we delineate the reasons why compression neuropathy and neuroma are amenable to surgery, while painful hyperalgesia and phantom nerve pain are not.

Bilateral Ulnar Nerve Injury in the Wrist: Comparison of First Webspace Muscle Reconstruction by Opponens Nerve Transfer in the Right Hand Versus Direct Ulnar Nerve Repair in the Left Hand.

We report a case of a bilateral glass injury to the wrist with transection of flexor tendons and the ulnar nerve and artery in a 60-year-old male patient. Two days after his accident, we repaired all divided structures, and on the right hand, we added the transfer of the opponens motor branch to the deep terminal division of the ulnar nerve aimed at first dorsal interosseous and adductor pollicis muscle reinnervation. After surgery, the patient was followed over 24 months. Postoperative dynamometry of the hand, which included grasping, key-pinch, subterminal-key-pinch, pinch-to-zoom, and first dorsal interosseous muscle strength, indicated recovery only in the nerve transfer side.

The Cutaneous Branches of the Median and Ulnar Nerves in the Palm.

PURPOSE: The dermatomal distributions of the ulnar and median nerves on the palmar skin of the hand have been studied thoroughly. However, the anatomic course of the median and ulnar cutaneous nerve branches and how they supply the skin of the palm is not well understood. METHODS: The cutaneous branches of the median and ulnar nerves were dissected bilaterally in 9 fresh cadavers injected arterially with green latex. RESULTS: We observed 3 groups of cutaneous nerve branches in the palm of the hand: a proximal row group consisting of long branches that originated proximal to the superficial palmar arch and reached the distal palm, first web space, or hypothenar region; a distal row group consisting of branches originating between the superficial palmar arch and the transverse fibers of the palmar aponeurosis (these nerves had a longitudinal trajectory and were shorter than the branches originating proximal to the palmar arch); and a metacarpophalangeal group, composed of short perpendicular branches originating on the palmar surface of the proper palmar digital nerves at the web space. The radial and ulnar borders of the hand distal to the palmar arch were innervated by short transverse branches arising from the proper digital nerves of the index and little finger. Nerve branches did not perforate the palmar aponeurosis in 16 of 18 cases. CONCLUSIONS: The palm of the hand was consistently innervated by 20-35 mm long cutaneous branches originating proximal to the palmar arch and shorter branches originating distal to the palmar arch. These distal branches were either perpendicular or parallel to the proper palmar digital nerves. CLINICAL RELEVANCE: Transfer of long proximal row branches may present an opportunity to restore sensibility in nerve injuries.

Living With Cervical Spinal Cord Injury During the COVID-19 Pandemic: A Qualitative Study.

Objective: To understand how COVID-19 has affected the daily lives of people living with cervical spinal cord injury (SCI). Design: Cross sectional qualitative study. Setting: Academic medical center in the Midwestern United States. Participants: Ten community-dwelling individuals (8 men, 2 women), average 11.6 years post-mid-cervical level SCI (N=10). Interventions: Not applicable. Main Outcome Measures: Semistructured interviews were completed by phone. The research team used thematic analysis and inductive strategies to analyze the data in this exploratory investigation. Results: People with cervical SCI living in the United States during the spring of 2020 experienced changes to their daily lives. Participants described how interactions with caregivers for activities of daily living were complicated by fear about contracting and/or transmitting COVID-19. The pandemic limited this population's access to medical care and adversely affected their mental and physical health. Telemedicine was seen as a helpful alternative to in-person visits. Some participants felt that their previous life-altering experience (SCI) better prepared them to cope with the pandemic and "roll with things." Conclusions: Learning about how people with SCI cope, persevere, and survive to overcome adversity during the pandemic should inform future research to support those with SCI. Improving telemedicine and rewarding and recognizing caregivers for their role in maintaining health are important first steps. We must continue to be creative about improving our health care systems and access for people with disabilities, particularly during this and future public health crises.

Outcome Analysis of Medial Triceps Motor Nerve Transfer to Axillary Nerve in Isolated and Brachial Plexus-Associated Axillary Nerve Palsy.

BACKGROUND: Since 2007, the authors have performed the triceps-to-axillary nerve transfer using the medial triceps branch to reconstruct axillary nerve function in brachial plexus and isolated axillary nerve palsies. METHODS: A retrospective chart review was undertaken of patients reconstructed with this transfer, recording patient and injury demographics and time to surgery. Preoperative and postoperative function was graded using the Medical Research Council scale and the Disabilities of the Arm, Shoulder, and Hand questionnaire. RESULTS: Postoperatively, 31 patients (64.6 percent) reached Medical Research Council grade 3 or higher at final follow-up. The median Disabilities of the Arm, Shoulder, and Hand score was 59.9 (interquartile range, 38.8 to 70.5) preoperatively and 25.0 (interquartile range, 11.3 to 61.4) at final follow-up. Sixteen patients (33 percent) had isolated axillary nerve injury; the median Medical Research Council grade was 4.25 (interquartile range, 3 to 4.25), with 14 patients (87.6 percent) achieving grade 3 or higher. Thirty-two patients (77 percent) had brachial plexus-associated injury; median Medical Research Council grade was 3 (interquartile range, 2 to 3), with 17 patients (53.1 percent) achieving grade 3 or higher. CONCLUSION: Medial triceps nerve branch is a strong donor for triceps-to-axillary nerve transfer; however, injury factors may limit the motor recovery in this complex patient population, particularly in axillary nerve palsy associated with brachial plexus injury. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Donor activation focused rehabilitation approach to hand closing nerve transfer surgery in individuals with cervical level spinal cord injury.

STUDY DESIGN: Case Series. OBJECTIVES: To describe the donor activation focused rehabilitation approach (DAFRA) in the setting of the hand closing nerve transfers in cervical spinal cord injury (SCI) so that therapists may apply it to treatment of individuals undergoing this procedure. SETTING: United States of America-Academic Level 1 Trauma Center. METHODS: We reviewed the records of individuals with cervical SCI who underwent nerve transfer to restore hand closing and post-surgery DAFRA therapy at our institution. The three post-surgery phases of DAFRA included (1) early phase (0-12 months) education, limb preparation, and donor activation exercises, (2) middle phase (12-24 months) volitional recipient muscle activation and (3) late phase (18 + months) strengthening and incorporation of motion in activities of daily living. RESULTS: Subtle gains in hand closing were first observed at a mean of 8.4 months after hand closing nerve transfer surgery. Remarkable improvements including discontinuation of assistive devices, independence with feeding and urinary function, and measurable grip were observed. Function continued to improve slowly for one to two more years. CONCLUSIONS: A deliberate, slow-paced (monthly for >2 years post-surgery) and incremental therapy program-DAFRA-can be used to improve outcomes after nerve transfer to restore hand closing in cervical SCI. SPONSORSHIP: This work was made possible by funding from the Craig H. Neilsen Foundation Spinal Cord Injury Research on the Translation Spectrum (SCIRTS) Grant: Nerve Transfers to Restore Hand Function in Cervical Spinal Cord Injury (PI: Ida Fox).

Using the modified frailty index to predict negative outcomes in free-flap breast reconstruction: A National Surgical Quality Improvement Project-based study.

BACKGROUND: Post-mastectomy free-flap breast reconstruction is becoming increasingly common in the United States. However, predicting which patients may suffer complications remains challenging. We sought to apply the validated modified frailty index (mFI) to free-flap breast reconstruction in breast cancer patients and determine its utility in predicting negative outcomes. METHODS: We conducted a retrospective study using National Surgical Quality Improvement Project (NSQIP). All patients who had a CPT code of 19364, indicative of free tissue transfer for breast cancer reconstruction, were included. Data on preoperative characteristics and postoperative outcomes were collected. Patients were separated based on the number of mFI factors present into three categories: 0, 1, and > 2 factors. Preoperative demographics, clinical status, and other comorbidities were also studied. Negative outcomes were compared using multivariate logistic regression. RESULTS: 11,852 patients (mean age 50.9 ± 9.5) were found; 24.2% had complications, comparable to previous literature. mFI is predictive of all types of negative outcomes. 22.5% of all patients with 0 mFI, 27.7% of patients with 1 mFI and 34.2% of patients with at least two mFI had a negative outcome. The most common factors contributing to the mFI were history of hypertension (24.8%) and diabetes (6.1%). mFI was found to be an isolated risk factor for negative outcomes, along with steroid use, American Society of Anesthesiology (ASA) classification, body mass index, and immediate, and bilateral operations. CONCLUSIONS: This NSQIP-based study for patients undergoing free flap breast reconstruction shows that the mFI holds predictive value regarding negative outcomes. This provides more information to properly counsel patients before free flap breast reconstruction surgery.

Adductor magnus muscle transfer to restore knee extension: Anatomical studies and clinical applications.

BACKGROUND: Loss of knee extension causes significant impairment. Though nerve-based reconstruction is preferable in cases of femoral nerve palsy or injury, these surgeries are not always appropriate if the pathology involves the quadriceps muscles or presentation too late for muscle reinnervation. Muscle transfers are another option that has been underutilized in the lower extremity. We describe the successful restoration of knee extension by adductor magnus muscle transfer without functional donor morbidity, along with anatomical considerations. METHODS: Ten fresh frozen cadaveric lower limbs were dissected at the groin and thigh. In addition, three patients presented with femoral nerve palsy for which nerve-based reconstruction was not appropriate because of late presentation. In these patients, adductor magnus muscle transfers were performed, along with sartorius, gracilis, and tensor fasciae latae transfers if available and healthy. RESULTS: In cadavers, the pedicle for the adductor magnus is at the level of the gracilis and adequate for muscle transfer, with sufficient weavable tendon length. The only major structure at risk is the femoral neurovascular bundle, which is in a reliable anatomic position. Two patients recovered 4/5 active knee extension and ambulation without assistive devices. A third required reoperation for a loosened tendon weave, after which the noted improved stability and strength with ambulation but did not regain strong active knee extension and continued to require a cane. CONCLUSIONS: We present a novel reconstructive approach for loss of quadriceps function in patients, which yields good clinical outcomes, with anatomic and technical details to demonstrate the utility of this technique. Ongoing evaluation of optimal technique and rehabilitation to maximize functional outcomes is still needed.

Video-based Learning in Surgery: Establishing Surgeon Engagement and Utilization of Variable-duration Videos.

OBJECTIVE: To measure surgeon engagement and preferred video duration in a video-based learning program for nerve surgery. BACKGROUND: Educational videos can improve, standardize, and democratize best practices in surgery. To improve care internationally, educators must optimize their videos for learning. However, surgeon engagement and optimal video duration remain undefined. METHODS: A YouTube channel and a video-based learning website, PASSIO Education (passioeducation.com), were examined from 2011 to 2017. We assessed views, geographic location, audience engagement (average percent of video watched), audience retention (percent of viewers at each timepoint), and usage of short (median 7.4, range 4.1-20.3 min) and long (median 17.2, range 6.1-47.7 min) video formats for the same procedures. A survey of PASSIO Education membership examined preferred video duration. RESULTS: Our 117 nerve surgery videos attained over 3 million views with 69% originating outside of the United States. While YouTube achieved more international exposure, PASSIO Education attained a greater mean engagement of 48.4% (14.3% absolute increase, P < 0.0001). Surveyed surgeons (n = 304) preferred longer videos when preparing for infrequent or difficult cases compared with routine cases (P < 0.0001). Engagement declined with video duration, but audience retention between short and long video formats was correlated (τB = 0.52, P < 0.0001). CONCLUSIONS: For effective spread of best practices, we propose the joint use of YouTube for audience outreach and a surgeon-focused platform to maximize educational value. Optimal video duration is surgeon- and case-dependent and can be addressed through offering multiple video durations and interactive viewing options.

Reconstruction of Severe Palm Injury with Sensate Medial Plantar Artery Flap and Nerve Grafting.

A 28-year-old, healthy man presented with an abrasion injury of the left palm, including a full-thickness glabrous skin defect, an open injury of the carpal tunnel with 50% transection of the median nerve, and a multilevel traction/avulsion injury of the thenar motor branch. He underwent repair with a free medial plantar artery flap, nerve transfer of the palmar cutaneous nerve to the medial plantar cutaneous nerve, grafting of the median nerve, and direct neurotization of the thenar muscles via an end-to-side nerve graft from the median nerve. At 8 months postoperative, both donor and recipient areas had healed completely, and the patient had regained meaningful 2-point discrimination of the palm and fingers, achieved innervation of the thenar muscles, and returned to work as a cook.

Using electrodiagnostics to define injury patterns amenable to nerve transfer surgery in tetraplegia: an illustrative case report.

INTRODUCTION: Spinal cord injury is a devastating condition affecting a person's independence and quality of life. Nerve transfers are increasingly used to restore critical upper extremity function. Electrodiagnostic studies guide operative planning but the implications for clinical outcomes is not well defined. This case study delineates how clinical examination and electrodiagnostics can define the varying patterns of neuronal injury to guide timing and strategy for optimal outcomes in nerve transfers. CASE PRESENTATION: We discuss a 20-year-old man with a C6-7 spinal cord injury (SCI). We illustrate how history, physical examination, and electrodiagnostic studies predicted patterns of upper and lower motor neuron injury, confirmed intraoperatively via direct nerve stimulation. We undertook brachialis nerve transfer to the median fascicles supplying flexor digitorum superficialis and anterior interosseous nerve (to restore digit flexion), and supinator nerve transfer to posterior interosseous nerve (to restore digit extension). Preoperative electrodiagnostics of the right upper extremity demonstrated a pure upper motor neuron injury to median innervated muscles, and mixed upper and lower motor neuron injury to radial innervated muscles. These findings were confirmed via intraoperative direct neuromuscular stimulation. The preoperative studies provided important information regarding the anatomic basis and time sensitivity of the proposed nerve transfers. At 2 years post operatively the reconstructed digit flexion and extension resulted in improved hand function and independence. DISCUSSION: Upper and lower motor neuron injuries can coexist in individuals with SCI. This example provides proof-of-concept that preoperative electrodiagnostic studies predict LMN injury, and surgery can achieve positive outcomes if completed soon after SCI.

The Effect of Surgical Video on Resident Performance of Carpal Tunnel Release: A Cadaveric Simulation-Based, Prospective, Randomized, Blinded Pilot Study.

BACKGROUND: Surgical videos are increasingly common, although their role in residency curricula remains unclear. The aim of this study was to evaluate the impact of an educational surgical video on resident performance of an open carpal tunnel release through an Objective Structured Assessment of Technical Skills and serial questionnaires. METHODS: Twenty-two residents representing six postgraduate years were randomized to receive text-based materials with or without a surgical video before performing a carpal tunnel release on human cadavers. Procedures were video recorded, anonymized, and independently evaluated by three hand surgeons using the Objective Structured Assessment of Technical Skills global rating scale, a procedure-specific technical rating scale, a record of operative errors, and pass/fail designation. Residents completed questionnaires before and after the procedure to track confidence in their technical skills. RESULTS: Residents in their first and second postgraduate years (n = 10) who watched the surgical video committed fewer operative errors (median, 4 versus 1.3; p = 0.043) and were more confident in their abilities following the procedure (median, 75 versus 32; p = 0.043) than those receiving text resources alone. There were no significant differences in Objective Structured Assessment of Technical Skills performance or questionnaire responses among more senior residents (n = 12). The technical rating scale was internally consistent (Cronbach α = 0.95; 95 percent CI, 0.91 to 0.98), reliable (intraclass correlation coefficient, 0.73; 95 percent CI, 0.40 to 0.88), and correlated with surgical experience (Spearman ρ = 0.57; p = 0.006). CONCLUSION: Watching an educational surgical video to prepare for a cadaveric procedure significantly reduced operative errors and improved confidence among junior trainees performing a carpal tunnel release.

Cross-Palm Nerve Grafts to Enhance Sensory Recovery in Severe Ulnar Neuropathy.

Background: Intrinsic atrophy and debilitating sensory loss are prominent features of severe ulnar neuropathy with limited surgical options to reliably improve recovery. Restoration of sensation is important to provide protection for the vulnerable ulnar border of the hand. Here, we report our experience with side-to-side sensory nerve grafting from the median to ulnar nerve in the palm to enhance ulnar sensory recovery. Methods: A retrospective chart review identified patients with severe ulnar neuropathy who underwent cross-palm nerve grafting. Included patients had objective loss of protective sensation in the ulnar distribution with 2-point discrimination >8 mm, Semmes-Weinstein monofilament testing (SWMT) >4.56, or no sensory response on nerve conduction testing. Cross-palm side-to-side tension-free grafting from median to ulnar sensory components was performed using short-segment allograft or autografts. Analysis included patient etiology, procedures, nerve conduction studies, objective sensory testing, and Disabilities of the Arm, Shoulder, and Hand Disability score. Results: Forty-eight patients with severe ulnar neuropathy underwent cross-palm nerve grafting between 2014 and 2017. Twenty-four patients had adequate follow-up for inclusion. Of the 24 patients, 21 (87%) had return of protective sensation, 16 (66.7%) had return of diminished light touch sensation, and 6 (25%) had return to normal range sensation within 1 year as assessed by SWMT and/or 2-point discrimination. Patients treated with autograft demonstrated referred sensation to the median nerve distribution. Conclusions: Cross-palm nerve grafting may be a useful adjunct to enhance sensory recovery in severe ulnar neuropathy. Further study to quantify differences in sensory recovery between traditional operative techniques and cross-palm nerve grafting is required.

Median Neuropathy After Blood Draw Mimics Painful Clenched Fist Syndrome in a Child.

Background: Clenched fist syndrome is a rare disorder, often attributed to a conversion disorder without anatomic basis. Here, we review the literature surrounding clenched fist syndrome and challenge the assumption it is always psychiatric in origin, via description of a case of clenched fist syndrome responsive to surgical nerve decompression. Methods: An unusual case of clenched fist syndrome is reviewed and discussed. Results: A child presenting with clenched fist syndrome failed conservative measures consisting of formal hand therapy, multidisciplinary pain management, and psychiatric treatment. On clinical examination, she had findings consistent with median nerve entrapment. After undergoing surgical decompression of the median nerve in the forearm and carpal tunnel, the clenched fist resolved immediately. Conclusions: Nerve compression may be an unrecognized factor underlying some cases of clenched fist syndrome. Evaluation by a hand surgeon or a hand therapist skilled in the detection of peripheral nerve entrapment or injury should be considered as part of the workup for this rare disorder.

Evaluation for Late Nerve Transfer Surgery in Spinal Cord Injury: Predicting the Degree of Lower Motor Neuron Injury.

PURPOSE: Nerve transfer surgery is used to restore upper extremity function following cervical spinal cord injury (SCI) with substantial variation in outcomes. The injury pattern in SCI is complex and can include isolated upper motor neuron (UMN) and combined UMN/lower motor neuron (LMN) dysfunction. The purpose of the study was to determine the most effective diagnostic technique for determining suitable candidates for nerve transfer surgery in SCI. METHODS: Medical records were reviewed of patients who had nerve transfers to restore upper extremity function in SCI. Data collected included (1) preoperative clinical examination and electrodiagnostic testing; (2) intraoperative neuromuscular stimulation (NMS); and (3) nerve histopathology. Preoperative, intraoperative, and postoperative data were compared to identify predictors of isolated UMN versus combined UMN/LMN injury patterns. RESULTS: The study sample included 22 patients with 50 nerve transfer surgeries and included patients ranging from less than 1 year to over a decade post-SCI. Normal recipient nerve conduction studies (NCS) before surgery corresponded to the intraoperative presence of recipient NMS and postoperative histopathology that showed normal nerve architecture. Conversely, abnormal recipient NCS before surgery corresponded with the absence of recipient NMS during surgery and patterns of denervation on postoperative histopathology. Normal donor preoperative manual muscle testing corresponded with the presence of donor NMS during surgery and normal nerve architecture on postoperative histopathology. An EMG of corresponding musculature did not correspond with intraoperative donor or recipient NMS or histopathological findings. CONCLUSIONS: NCS better predict patterns of injury in SCI than EMG. This is important information for clinicians evaluating people for late nerve transfer surgery even years post-SCI. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic II.

Current Best Peripheral Nerve Transfers for Spinal Cord Injury.

LEARNING OBJECTIVES: After reviewing this article, the participant should be able to: 1. Understand the anatomy and pathophysiology of spinal cord injury and the resulting upper and lower motor neuron syndromes. 2. Recognize who may benefit from nerve transfers. 3. Understand the role of history, examination, imaging, and electrodiagnostics in the determination of time-sensitive lower motor neuron injury versus non-time-sensitive upper motor neuron injury. 4. Outline the surgical options and perioperative care for those undergoing nerve transfer and the expected outcomes in restoring shoulder, elbow, wrist, and hand function. SUMMARY: This article outlines how to localize and differentiate upper motor neuron from combined upper and lower motor neuron injury patterns in spinal cord injury by means of detailed history, physical examination, imaging, and electrodiagnostic studies to formulate appropriate surgical plans to restore function in this complex population.