Clinical Edge

Summaries of Must-Read Clinical Literature, Guidelines, and FDA Actions

Nerve Transfer Surgery Improves Function After Spinal Cord Injury

Key clinical point: Nerve transfer surgery at less than 18 months after spinal cord injury improves arm and hand function.

Major finding: Median ARAT total score improved significantly from 16.5 at baseline to 34.0 at 24 months.

Study details: A prospective case series of 16 patients with tetraplegia who underwent nerve transfer surgery after spinal cord injury.

Disclosures: The study was funded by the Institute for Safety, Compensation, and Recovery Research in Australia. The authors had no competing interests.


van Zyl N et al. Lancet. 2019 Jul 4. doi: 10.1016/S0140-6736(19)31143-2.


The data from van Zyl et al. suggest that nerve transfers restore more natural movement and finer motor control than tendon transfers do, said Elspeth J.R. Hill, MD, PhD, and Ida K. Fox, MD, plastic and reconstructive surgeons at Washington University in St. Louis, in an accompanying editorial. Patients can engage in light activity immediately after surgery, and cortical plasticity enables function to improve over time. Two disadvantages of nerve transfers, however, are that it takes months before new motion can be observed, and years before full strength can be regained.

The heterogeneity of cervical spinal cord injury requires an individualized approach to surgical assessment and management, they continued. Physicians and patients should make treatment decisions collaboratively. “We envisage a role for nerve transfers in settings where the intensive therapy and immobilization required to optimize complementary tendon transfers are unavailable,” wrote Dr. Hill and Dr. Fox.

Continuing research will be necessary to improve surgical technique and outcomes. “This research should include efforts to compare nerve transfer with tendon transfer, find the optimal timing of such surgeries, and determine which approach produces the greatest functional improvement,” they wrote. “Detailed study of the reasons for nerve transfer failure is also required, as is improving our understanding of the effects of biopsychosocial factors, including access to information and care, psychological readiness, and social support, on patient decision making and outcomes.”

Nerve transfers are a “huge advance” in the restoration of function after spinal cord injury, the authors added. “Surgeons who integrate nerve transfers into their spinal cord injury practice should take a careful and measured approach and rigorously study and disseminate their outcomes to advance this growing field,” they concluded.