Surgical strategy: matching the patient with the procedure

The goal of any surgery for the tetraplegic patient is to move him or her toward a state of greater independence. This is somewhat of a relative, hard-to-define concept for most upper extremity surgeons, who are used to dealing with specific clinical problems (eg, median nerve compression) with well-established, expected outcomes of only one or two possible treatment options. In contrast, the issues confronting the surgeon who is asked to improve the life of a tetraplegic patient are considerably more complex and directly define the extreme importance of using sound, evidence based surgical strategies to make decisions that can be life-altering for the patients involved. The relationship between the surgeon and the tetraplegic patient is unique compared with other patients who have upper extremity afflictions. This uniqueness is defined by the following five irrefutable differences: The great variability in the upper limbs of patients who are injured at the same cervical spine level, which creates difficulties in developing a systematic approach based on diagnosis or on the American Spinal Injury Association (ASIA) classifications The great variability that may exist between the two hands in the same individual, which adds to the difficulty of developing a systematic approach The limited surgical armamentarium that is available to achieve the primary goal of the patient-greater independence The (hopefully temporary) enormous physical, psychologic, and social effect of essentially all surgical procedures on the tetraplegic patient The devastating consequences of complications and failure of a surgical procedure, particularly in a patient who begins treatment with so little function The differences between tetraplegic and other patients reinforce the concept of critical analysis and sound surgical decision making. As a guiding principle, the concept of matching the patient and the procedure must be much more than just another tired surgical axiom. Other chapters in this monograph deal with many of the basic principles that guide the rehabilitation of the tetraplegic patient in addition to the available surgical options for patients injured at various levels. This chapter focuses on the principles and concepts of selecting the most appropriate procedure for all tetraplegic patients.