Dedicated physiotherapy and occupational therapy including splinting optimize preoperative circumstances and postoperative function. It provides the “other half” of rehabilitation by patient motivation, retraining of transferred tendons, edema control, and contracture prevention and is, besides input from rehab specialists and the patients themselves, essential for successful rehabilitation [3, 13, 14].

The abovementioned conditions are usually achieved after completing the first rehabilitation, yet strict time rules (e.g., no operations before 1 year since injury) are not appropriate. Neurological stability may be achieved after 3–6 months in complete tetraplegia. Early surgery has many advantages, such as faster reintegration. Often, however, financial, family, or work-related problems must be solved first. Notably, a tendon transfer reconstruction remains feasible even decades after SCI. In incomplete SCI, functional recovery takes longer so that treatment plans should be developed only after complete regeneration spasticity control [12].

Regarding nerve transfers, muscles in SCI can be categorized into:

The first group represents potential donor nerves; the nerves to the latter two groups are potential recipients. Early surgery (within 1 year) is critical, as neuromuscular end-plate degeneration makes the denervated muscle refractory to eventual reanimation (after about 2 years). In upper motoneuron lesions, neuromuscular degeneration is slowed which may extend the time window for successful nerve transfers [15, 16].

Surgical operations aim at better daily life performance (Table 18.4).

Reconstructive algorithms depend on the level of paralysis (Table 18.5).

Elbow extension is critical for overhead activities, weight shifting, and transfers and greatly increases wheelchair propulsion and workspace of the hand by 800 %. Elbow restoration should precede grip reconstructions because:

Procedures to restore triceps function include:

Posterior deltoid transfer reliably restores triceps function in C5/C6 tetraplegia (Fig. 18.1a, b). Candidates for biceps transfer usually demonstrate intact and functional brachialis and supinator muscles and elbow flexion contracture exceeding approximately 20°. Both techniques are time proven and provide improved arm control useful in many daily activities. Alternatively, triceps reanimation is possible by transferring fascicles of axillary (branches to posterior portion of deltoid or teres minor muscle) or musculocutaneous (brachialis branch) nerve [15, 16].

Supination contracture due to imbalance between the functional biceps brachii and supinators and weak or paralyzed pronators seriously impairs hand function and increases the risk of gravity-induced wrist extension contracture. Restoration of forearm pronation re-enabling key pinch is possible by:

Interphalangeal (IP) joint hyperflexion disturbs thumb function if extrinsic flexor function is preserved or reconstructed (e.g., by FPL reanimation) but intrinsic or extrinsic thumb extensors are paralyzed. The EPL-loop-knot (ELK) procedure has advantages compared to FPL split tenodesis or arthrodesis (Fig. 18.2) [20].