CLINICAL ARTICLE

J Neurosurg Spine 39:355–362, 2023

Association of upper-limb neurological recovery with

functional outcomes in high cervical spinal cord injury
Saad Javeed, MBBS,1 Jacob K. Greenberg, MD, MSCI,1 Justin K. Zhang, BS,1
Benjamin Plog, MD, PhD,1 Christopher F. Dibble, MD, PhD,1 Braeden Benedict, MS,1
Kathleen Botterbush, BS,1 Jawad M. Khalifeh, MD, MSCI,3 Huacong Wen, PhD,10
Yuying Chen, MD, PhD,10 Yikyung Park, ScD,11 Allan J. Belzberg, MD,3 Sami Tuffaha, MD,12
Stephen S. Burks, MD,9 Allan D. Levi, MD, PhD,9 Eric L. Zager, MD,5 Amir H. Faraji, MD, PhD,6
Mark A. Mahan, MD,7 Rajiv Midha, MD,8 Thomas J. Wilson, MD,4 Neringa Juknis, MD,2 and
Wilson Z. Ray, MD,1 on behalf of the Nerve Transfers in Spinal Cord Injury (NT-SCI) Consortium
1
Department of Neurological Surgery, Washington University, St. Louis; 2Physical Medicine and Rehabilitation, Washington
University, St. Louis, Missouri; Departments of 3Neurological Surgery and 12Plastic Surgery, Johns Hopkins University, Baltimore,
Maryland; 4Department of Neurosurgery, Stanford University, Stanford, California; 5Department of Neurosurgery, Hospital of
the University of Pennsylvania, Philadelphia, Pennsylvania; 6Department of Neurological Surgery, Houston Methodist Hospital,
Houston, Texas; 7Department of Neurosurgery, Clinical Neurosciences Center, The University of Utah, Salt Lake City, Utah;
8
Department of Clinical Neurosciences, University of Calgary, Alberta, Canada; 9Department of Neurological Surgery, University
of Miami School of Medicine, Miami, Florida; 10Physical Medicine and Rehabilitation, University of Alabama at Birmingham
School of Medicine, Birmingham, Alabama; and 11Department of Surgery, Division of Public Health Sciences, Washington
University School of Medicine, St. Louis, Missouri

OBJECTIVE High cervical spinal cord injury (SCI) results in complete loss of upper-limb function, resulting in debili-
tating tetraplegia and permanent disability. Spontaneous motor recovery occurs to varying degrees in some patients,
particularly in the 1st year postinjury. However, the impact of this upper-limb motor recovery on long-term functional out-
comes remains unknown. The objective of this study was to characterize the impact of upper-limb motor recovery on the
degree of long-term functional outcomes in order to inform priorities for research interventions that restore upper-limb
function in patients with high cervical SCI.
METHODS A prospective cohort of high cervical SCI (C1–4) patients with American Spinal Injury Association Impair-
ment Scale (AIS) grade A–D injury and enrolled in the Spinal Cord Injury Model Systems Database was included.
Baseline neurological examinations and functional independence measures (FIMs) in feeding, bladder management, and
transfers (bed/wheelchair/chair) were evaluated. Independence was defined as score ≥ 4 in each of the FIM domains
at 1-year follow-up. At 1-year follow-up, functional independence was compared among patients who gained recovery
(motor grade ≥ 3) in elbow flexors (C5), wrist extensors (C6), elbow extensors (C7), and finger flexors (C8). Multivariable
logistic regression evaluated the impact of motor recovery on functional independence in feeding, bladder management,
and transfers.
RESULTS Between 1992 and 2016, 405 high cervical SCI patients were included. At baseline, 97% of patients had
impaired upper-limb function with total dependence in eating, bladder management, and transfers. At 1 year of follow-up,
the largest proportion of patients who gained independence in eating, bladder management, and transfers had recovery
in finger flexion (C8) and wrist extension (C6). Elbow flexion (C5) recovery had the lowest translation to functional inde-
pendence. Patients who achieved elbow extension (C7) were able to transfer independently. On multivariable analysis,
patients who gained elbow extension (C7) and finger flexion (C8) were 11 times more likely to gain functional indepen-
dence (OR 11, 95% CI 2.8–47, p < 0.001) and patients who gained wrist extension (C6) were 7 times more likely to gain

ABBREVIATIONS ADL = activity of daily living; AIS = American Spinal Injury Association Impairment Scale; FIM = functional independence measure; ICSHT = International
Classification for Surgery of the Hand in Tetraplegia; MRC = Medical Research Council; SCI = spinal cord injury; SCIMS = Spinal Cord Injury Model Systems.
SUBMITTED January 21, 2023. ACCEPTED April 11, 2023.
INCLUDE WHEN CITING Published online May 26, 2023; DOI: 10.3171/2023.4.SPINE2382.

©AANS 2023, except where prohibited by US copyright law J Neurosurg Spine Volume 39 • September 2023 355

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Javeed et al.
functional independence (OR 7.1, 95% CI 1.2–56, p = 0.04). Older age (≥ 60 years) and motor complete SCI (AIS grade
A–B) reduced the likelihood of gaining independence.
CONCLUSIONS After high cervical SCI, patients who gained elbow extension (C7) and finger flexion (C8) had signifi-
cantly greater independence in feeding, bladder management, and transfers than those with recovery in elbow flexion
(C5) and wrist extension (C6). Recovery of elbow extension (C7) also increased the capability for independent transfers.
This information can be used to set patient expectations and prioritize interventions that restore these upper-limb func-
tions in patients with high cervical SCI.
https://thejns.org/doi/abs/10.3171/2023.4.SPINE2382
KEYWORDS nerve transfer; spinal cord injury; functional recovery; upper-limb function; high tetraplegia; neurological
recovery; cervical
S
pinal cord injury (SCI) is a devastating condition,
representing a significant public health problem. The
incidence of SCI is estimated to be approximately
54 cases per 1 million persons annually in the United
States, with 296,000 adults living with this condition.1,2
Approximately 27% of SCIs are high cervical (C4 and
above), resulting in debilitating tetraplegia.1,3,4 This pre-
dominantly affects young males in the prime years of their
life.2 Regaining even partial arm and/or hand control can
significantly improve the patient’s quality of life.5,6
Functional restoration after SCI has relied on maximiz-
ing the function that can be achieved by the muscles that
remain under volitional control above the level of SCI.7
Upper-limb function may also substitute for other lost
functions (e.g., wheelchair propulsion to compensate for
loss of ambulation).8 However, persons with high tetraple-
gia (i.e., C1–4 level) have no suitable residual volitional
motor function that can be utilized by current reconstruc-
tive and rehabilitative therapies (e.g., tendon transfers,
assistive arm, or hand therapies).9 Recent innovations in
reinnervation strategies utilizing nerve transfers have
shown promise in restoring paralyzed upper-limb func-
tion in patients with high tetraplegia.10–12 The reanimation
of upper-limb function in certain myotomes may translate
to functional independence in a range of activities.13 How-
ever, to what degree nerve reanimation restores functional
independence in activities of daily living (ADLs) remains
unknown.
The objective of this study was to evaluate improve-
ments in function associated with recovery of each myo-
tome from C5 to C8 after a high cervical SCI. The goal
was to guide patient counseling regarding expected func-
tional outcomes and to prioritize research in upper-limb
reanimation therapies for high cervical SCI.
Methods
Study Design and Participants
This study included a longitudinal cohort of SCI pa-
tients enrolled in the Spinal Cord Injury Model Systems
(SCIMS) database.14 This database contains prospectively
collected data on SCI patients treated at one of the SCIMS
centers in the United States. A detailed description of the
SCIMS database is available elsewhere.15 This study was
approved by the institutional review board at Washington
University.
We included adult (≥ 15 years of age) cervical SCI pa-
tients admitted to one of the SCIMS centers from 1992
to 2016 with motor level of injury at C1–4 and American
356 J Neurosurg Spine Volume 39 • September 2023
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Spinal Injury Association Impairment Scale (AIS) grade
A–D. We excluded patients with AIS grade E SCI, as well
as those with paraplegia, incomplete baseline or 1-year
follow-up neurological examinations, and missing func-
tional independence measures (FIMs).
Neurological Variables
This study aimed to evaluate the association of motor
recovery in the upper limb with functional independence
to perform relevant ADLs. Extracted data included dem-
ographic variables, traumatic etiology, AIS grade, neuro-
logical level of injury, right and left motor levels, right and
left sensory levels, and manual muscle testing results of
the key upper-extremity muscles at the time of rehabilita-
tion and 1 year. All neurological examinations were per-
formed according to the International Standards for Neu-
rological Classification of Spinal Cord Injury.16
Motor Levels
We defined the motor level as the lowest key muscle
with Medical Research Council (MRC) grade ≥ 3/5 on
manual muscle testing, with all muscles rostral to this
level intact (i.e., MRC grade ≥ 4/5). All muscles caudal
to the SCI were required to have MRC grade ≤ 2/5. For
the myotomes with no clinically testable muscles (i.e., C4
and above), the most caudal dermatome with normal sen-
sory examination was the assumed motor level.17 Based
on these criteria, the C1–4 motor levels were defined as
having normal sensation (light touch and pinprick), which
assumed normal motor function at the corresponding lev-
el. To address possible left/right asymmetry in the motor
examinations, single motor level was defined on the basis
of only the best motor test result from the right and left
sides.18
For SCI severity, AIS grades were defined as motor
complete (AIS grade A–B) and motor incomplete (AIS
grade C–D). SCI was defined as symmetrical if the right
and left motor levels were the same, or as asymmetrical
if there was a difference of one or more levels.18,19 Motor
recovery at 1-year follow-up was defined as MRC grade
≥ 3/5 in a muscle that was MRC grade ≤ 2/5 at baseline.20
The included key upper-limb muscles were the elbow flex-
ors (C5), wrist extensors (C6), elbow extensors (C7), and
finger flexors (C8).
Functional Outcomes
The primary outcomes were independence in major
ADLs, as assessed in terms of FIMs at 1 year after SCI.21

Each FIM was evaluated by clinicians trained in rating
each functional domain. Major ADLs included eating
(item A in FIM self-care), bladder/urinary management
(item G in FIM sphincter control), and bed/chair/wheel-
chair transfers (item I in FIM transfers).22 These activi-
ties were chosen because they are thought to be the most
important ADLs for tetraplegic patients requiring intact
upper-limb function.18,19 In addition, these functions can
be effectively enhanced or restored by upper-limb nerve
and tendon transfers in tetraplegia patients.23 The FIM do-
mains range from 1 (total assistance needed) to 7 (com-
plete independence). Patients were defined as independent
if they scored 6–7, partially dependent if they scored 3–5,
and fully dependent if they scored 1–2.24 The range of
FIM activities was evaluated at baseline (corresponding
to baseline upper-limb motor function) and 1 year (cor-
responding to recovery of upper-limb motor function).
Multivariable regression was performed to evaluate the
impact of motor recovery on independence in a range of
functional activities. Independence was defined on the
basis of a composite outcome that consisted of score 6–7
(complete independence) on at least two or more FIM do-
mains among eating, bladder management, and transfers.18
Statistical Analysis
Continuous variables were reported as mean ± SD or
median (range) as appropriate. Categorical variables were
reported as number (percentage). Descriptive statistics
were used to summarize independence in major ADLs at
various motor levels at baseline. The influence of recov-
ery in upper-limb motor function and resulting indepen-
dence in major ADLs was analyzed. Only the best motor
recovery between the right and left sides was included.
Stratified analyses were performed to assess the influence
of complete versus incomplete injuries and symmetrical
versus asymmetrical SCI. The proportion of AIS grade
conversions from complete to incomplete injuries from
baseline to 1-year follow-up was analyzed. The impact of
proximal motor recovery (C6 motor level) was compared
with more distal motor recovery (C7 and C8 motor levels).
The association of proximal and distal motor recovery
with independence on FIMs was assessed with multivari-
able logistic regression analysis, with adjustment for fac-
tors known to influence recovery after SCI.20,25
We evaluated multiple factors that may have confound-
ed our results in the sensitivity analyses. First, to evalu-
ate the potential impact of the better performing domi-
nant upper limb on functional outcomes, we performed
a subgroup analysis to compare outcomes from the better
dominant and nondominant sides (assuming the right up-
per limb was dominant in all patients). Second, injury to
the spinal column (i.e., traumatic SCI) can lead to worse
outcomes as compared with nontraumatic SCI. In addi-
tion, spinal surgery at the time of SCI leads to improved
outcomes. We performed a subgroup analysis to evaluate
the influence of spinal trauma and spinal surgery/decom-
pression on functional outcomes. Finally, to evaluate the
association of upper-limb motor recovery with bladder
management, a subgroup analysis was performed between
the patients who had normal micturition and the patients
who had abnormal micturition. The threshold for signifi-
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Javeed et al.
FIG. 1. The flow diagram for selection of the high cervical SCI patient
cohort.
cance was set at 2-tailed alpha < 0.05. All analyses were
performed with R version 4.2.1 (https://r-project.org).
Results
Patient Characteristics
Between 1992 and 2016, 2363 patients with cervical
SCI were admitted to one of the participating SCIMS cen-
ters. In total, 405 patients were included who had high cer-
vical SCI (C1–4) and complete 1-year data. These patients
were admitted to a rehabilitation program at a median (in-
terquartile range) 9 (1–20) days after SCI. The selection
of the high cervical SCI cohort is shown in the flow dia-
gram (Fig. 1). The clinical characteristics of the included
patients are given in Table 1. The clinical characteristics of
the included patients were similar to those of the excluded
patients from the SCIMS database (eTable 1).
Functional Independence in ADLs
At the time of rehabilitation admission, 67% of patients
had motor complete (AIS grade A–B) and 33% had motor
incomplete (AIS grade C–D) SCI. The levels of indepen-
dence in each ADL domain—eating, bladder management,
and transfers—according to the motor levels at C1–C4 are
given in Fig. 2. At baseline, patients had complete lack of
upper-limb motor function, and all myotomes below C4
were MRC grade ≤ 2. The majority of patients (97%) were
fully dependent in terms of eating, bladder management,
and transfers. There were no significant differences in the
degree of independence at baseline based on the level of
SCI (p > 0.05) (eTable 2). Patients who gained either par-
tial dependence or complete independence in ADLs at
1-year follow-up are shown in Fig. 2. The gained function
results, stratified by motor complete versus incomplete
SCI and symmetrical versus asymmetrical SCI, are given
in eFigs. 1 and 2.
Functional Independence in ADLs by Motor Recovery
At 1-year follow-up, 52% of high tetraplegic patients
recovered elbow flexion (C5), 34% wrist extension (C6),
33% elbow extension (C7), and 36% finger flexion (C8).
The proportions of patients with independence in major
ADLs were greatest among those patients who recov-
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Javeed et al.

TABLE 1. Clinical characteristics of the patients with high Yet, this group had the greatest proportion of patients who
cervical SCI (n = 405) stayed fully dependent in performing functions (eTable
Characteristic No. (%) of Patients 3). From baseline to 1-year follow-up, only 8% of patients
improved from motor complete to motor incomplete SCI
Age, yrs (Fig. 4). When stratified on the basis of complete and in-
<60 337 (83) complete injuries, the degree of motor recovery and re-
≥60 68 (17) sulting functional independence gained were greater in
Sex patients with incomplete injuries (eFig. 1A–C).
Male 344 (85)
Impact of Upper-Limb Motor Recovery on Overall
Female 61 (15)
Functional Independence
Traumatic etiology
At 1-year follow up, 20% of patients achieved the com-
Motor vehicle 175 (43) posite outcome of functional independence in eating,
Assault 53 (13) bladder management, and transfers. After 1 year of follow-
Sports injury 51 (13) up, combined recovery in the distal myotomes, including
Fall 116 (28) those for elbow extension (C7) and finger flexion (C8),
Other 4 (1) was significantly associated with increased functional in-
dependence as compared with recovery in the proximal
Iatrogenic 6 (1)
myotome, i.e., that for wrist extension (C6). Detailed re-
Injury to spinal column* sults of the comparison between recovery of the proximal
Traumatic SCI 275 (82) myotome versus that of the distal myotomes are given in
Nontraumatic SCI 59 (18) eTable 4. On multivariable analysis, after adjustment for
Spinal surgery† known variables that influence functional independence,
Surgery 324 (82) combined recovery of elbow extension (C7) and finger
flexion (C8) was significantly associated with higher odds
No surgery 73 (18)
of functional independence (OR 11, 95% CI 2.8–47, p <
Motor level‡ 0.001) as compared with recovery in wrist extension (C6)
C1 21 (5) (OR 7.1, 95% CI 1.2–56, p = 0.04) (Table 2). Age ≥ 60
C2 54 (13) years and motor complete SCI had a trend toward reduced
C3 76 (19) odds of gaining independence. The results of the multi-
C4 254 (63) variable regression are given in Table 2.
Severity of SCI, AIS grade
Sensitivity Analysis of the Influence of Potential
A 222 (55)
Confounding Factors
B 48 (12)
Better performing dominant upper-limb myotomes had
C 120 (29) no significant impact (all myotomes p > 0.05) on function-
D 12 (3) al outcomes at 1-year follow-up (eTable 5). Nontraumatic
Symmetry of SCI§ SCI was significantly associated with improved functional
Symmetrical 345 (85) outcomes as compared with traumatic SCI. Spinal surgery
Asymmetrical 60 (15) at the time of SCI trended toward improved functional
outcomes; however, this finding was statistically nonsig-
* Injury to the spinal column was defined as any vertebral injury, including nificant (eTable 6). The inclusion of both variables in the
fracture or dislocation from the occiput to coccyx. multivariable regression model did not add any prognostic
† Spinal surgery was defined as any decompression, reduction, and/or fusion
surgery performed at the time of SCI.
value (both p > 0.05). Upper-limb function was signifi-
‡ Motor level was defined as normal findings on sensory examinations at the cantly associated with increased independence in bladder
C1–4 level with all C5–T1 myotomes MRC grade ≤ 2. The best motor level management among those patients who used alternative
between the right and left sides was included. means to empty their bladder (i.e., indwelling catheter,
§ SCI was defined as symmetrical if the same motor levels were noted on intermittent catheterization, and/or surgical conduit) and
the right and left sides, or as asymmetrical if ≥ 1-level difference was noted was comparable to that of the patients with normal mictu-
between the right and left sides. rition (eTable 7).

ered finger flexion (C8): 60% had independence in eating,
63% in bladder management, and 67% in transfers (Fig.
3). Among those who recovered elbow extension (C7), a
large proportion of patients (60%) gained independence
in transfers. Among those who recovered wrist extension
(C6), 52% were independent in eating and 55% were inde-
pendent in bladder management. The largest proportion
of patients (52%) had recovery in C5 level (elbow flexion).
Discussion
There remains a lack of knowledge about the relation-
ship between specific upper-limb motor functions and
ADLs after high cervical SCI.26 Although prior studies
have attempted to model recovery trajectories after cer-
vical SCI, evidence evaluating the impact of upper-limb
recovery in specific myotomes with functional indepen-
dence remains limited.20,27–29 This important evidence gap
actively impairs clinical decision-making regarding op-

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 Javeed et al.

FIG. 2. Baseline and 1-year FIMs of eating (A), bladder management (B), and transfers (C) by motor levels in patients with high
cervical SCI (C1–4). Figure is available in color online only.

timal treatment strategies and patient counseling after a
high cervical SCI.
In this study, we addressed this gap by utilizing a pro-
spective cohort of high cervical SCI patients to analyze
the impact of upper-limb motor recovery on functional in-
dependence in ADLs. Our goal with this analysis was 1) to
inform patient counseling regarding functional recovery
in patients with high cervical SCI and 2) to inform future
research investment on interventions targeting upper-limb
motor reanimation (i.e., nerve transfer surgery) that may
yield the most benefits in functional outcomes.
Our analysis demonstrated that high tetraplegic patients
who recover elbow extension and finger flexion function
can gain independence in a range of ADLs. In addition,
elbow extension recovery resulted in increased indepen-
dence in transfer capabilities. Consistent with established
evidence that incomplete SCI has substantial recovery po-
tential,20,28,30 incomplete injury was associated with higher
rates of functional improvement and independence in
ADLs compared with complete SCI.
Traditionally, no reconstructive therapies have been
available for high tetraplegic patients who do not recover
upper-limb motor function.3,26,31 The International Classi-
fication for Surgery of the Hand in Tetraplegia (ICSHT) is
a 10-group classification that indicates how preserved up-
per-limb motor function can be utilized for reinnervation
and/or reconstructive surgical procedures to reanimate
distal upper-limb function.9 The detailed ICSHT with po-
tential reconstructive options is given in eTable 8. Among
patients with cervical SCI, those with low tetraplegia (C5–
8 level) may have some residual motor capability, such as
those patients classified in ICSHT groups 3–4.23 These
patients usually have intact function up to wrist extension
and forearm pronation that can be utilized by traditional
reconstructive (tendon transfers) and reinnervation (nerve
transfers) therapies to restore grasp, release, and elbow
extension.12,32,33 In contrast, patients with high tetraplegia
(C1–4 level) are completely paralyzed below the neck and
have no residual upper-extremity motor function (ICSHT
group 0) (eTable 8). In these patients with high tetraple-
gia, targeted treatments used to protect the flaccid upper
limbs against contractures consist of splinting, orthosis,
and range-of-motion exercises.7,31 Despite the paralysis of
the upper limbs in ICSHT group 0, healthy motor neuron
pools exist within the spinal cord years after injury.34 Par-
ticularly, upper-limb muscles distal to the SCI maintain
their connectivity with the lower motor neuron, permitting
delayed nerve transfer surgery.35
Nerve transfer surgery is an innovative intervention
that can harness the potential of nerve regeneration to
restore distal paralyzed target muscles.10,23,36 In the con-
text of SCI, nerve transfers effectively bypass the injured
segment of the spinal cord, restoring meaningful function
in the paralyzed muscles.35 Nerve transfers were only re-

FIG. 3. Recovery of upper-limb function at 1-year follow-up and its impact on the FIMs of eating (A), bladder management (B), and
transfers (C). At each level, MRC grade ≤ 2 represents no recovery, while MRC grade ≥ 3 represents recovery. Figure is available
in color online only.

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Javeed et al.
FIG. 4. Comparison of AIS grade of SCI and improvement from baseline
(at rehabilitation admission) to 1-year follow-up. Figure is available in
color online only.
cently utilized to restore function in patients with high tet-
raplegia.11,23,37 Although patients with high tetraplegia have
complete upper-limb paralysis, the spinal accessory nerve
usually remains intact and can be used as a viable donor to
reanimate the triceps and/or biceps muscles. Upper-limb
function can be restored partially in patients with high
cervical SCI via the transfer of a donor branch from the
distal spinal accessory nerve to either the triceps branch
of the radial nerve to restore elbow extension, or to the
biceps branch of the musculocutaneous nerve to restore
elbow flexion.23,38 However, these interventions have been
described in only a few case reports; therefore, future stud-
ies should focus on determining the efficacy of this inter-
vention in a larger cohort of individuals with high cervical
SCI.
Although nerve transfers can restore function, only a
limited supply of intact donor and/or recipient nerves is
available, thereby emphasizing the need to prioritize sur-
gery that will offer the greatest functional gains. Indeed,
our results demonstrate that recovery in elbow extension
function may enhance the capability to perform certain
ADLs such as bed/chair/wheelchair transfers. This may
improve not only functional outcomes but also enable
broad applications of assistive therapies utilizing recov-
ered motor function in the upper extremities.7 While the
recovery of finger flexion and wrist extension may signifi-
cantly enhance independent eating and bladder manage-
ment, in addition to transfers, currently no nerve/tendon
transfer options exist to restore these functions in patients
with high tetraplegia.7,35 Therefore, potential proximal do-
nor nerve branches should be explored to reanimate hand
function via the restoration of finger flexion and finger ex-
tension and thereby provide full range of motion for ADLs.
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TABLE 2. Multivariable regression analysis of factors influencing
the composite of independence in eating, bladder management,
and transfers
Variable OR (95% CI) p Value
Age ≥60 yrs 0.3 (0.05–2.1) 0.25
Male sex 2.3 (0.4–13) 0.31
Motor complete SCI 0.5 (0.1–2.1) 0.32
Symmetrical SCI 1.1 (0.3–4.8) 0.84
MRC grade ≥3 recovery
C5 8.8 (1.1–189) 0.06
C6 7.1 (1.2–56) 0.04
Combined C7 & C8 11 (2.8–47) <0.001
Boldface type indicates statistical significance (p < 0.05). Model intercept −5.8.
Future reconstructive therapies should focus on restoration
of these functions in patients with high tetraplegia in order
to yield maximal gains in ADLs.
High cervical SCI patients have devastating and perma-
nent paralysis. Prior studies have shown that nearly 4% of
patients remain ventilator dependent and may prefer end
of life in the early stages of SCI.1,3,26,39,40 Because our study
shows that there is a significant potential for spontaneous
recovery, these findings may be used to prognosticate re-
covery that enhances treatment preferences and decision-
making for patients with debilitating high cervical SCI.
With recent advancements in acute SCI care and im-
proved respiratory management, the survival rate of pa-
tients with high tetraplegia has increased to more than
50%.39,41,42 Consequently, patients with high tetraplegia
who survive more than 1 year have an average 35 years of
life expectancy.1 Yet, the majority of the current 35,500 pa-
tients living with high tetraplegia remain fully dependent
on their caregivers to accomplish simple ADLs, leading
to significant costs of living as much as $1.2 million an-
nually.1,43 Multiple studies have demonstrated that patients
with high tetraplegia may have significant improvement
in quality of life with meaningful return of upper-limb
function.26 In one study, 92% of high tetraplegic patients
reported that they were glad to be alive when activity lev-
els were restored, which significantly correlated with in-
creased self-esteem and quality of life.3,26,39 Despite the
major associated disability and potential for meaningful
recovery, there have been few interventional studies of
high cervical SCI patients. Our findings may inform ongo-
ing research regarding neurorestorative and rehabilitative
therapies focusing on motor recovery, ultimately improv-
ing functional independence and quality of life in patients
with high tetraplegia.
Limitations
Although our analysis included a relatively large pro-
spective cohort of patients who were followed up for 1
year, this study had several limitations. First, the SCIMS
database captures data at the time of admission, rehabili-
tation, discharge, and 1 year.15 Due to the large number
of missing neurological examinations and functional mea-
sures at intervening time points between rehabilitation

and 1-year follow-up, we were unable to determine the
exact timing of expected recovery before 1 year. Future
studies should focus on the trajectory of motor recovery
and its correlation with functional independence. Second,
1-year follow-up measures were available for only 59%
of patients. Although the characteristics of the included
and excluded patients were similar, there may have been
an unavoidable selection bias. Third, in the SCIMS data-
base, there was no documentation of reconstruction (i.e.,
nerve or tendon transfer surgery) that could have improved
upper-limb function in certain myotomes. However, these
surgical procedures are underutilized, and only 0.4% of
eligible tetraplegic patients undergo these procedures.44
In addition, a high cervical SCI (C1–4) has limited do-
nor nerve or tendon options for transfer.23 Therefore, al-
though nerve/tendon transfer surgery could be a potential
confounder, it should not interfere with our primary con-
clusions regarding how changes in neurological recovery
impacted functional independence. Fourth, in the SCIMS
database, only the functional independence measure was
available. However, recent SCI studies have used the spi-
nal cord independence measure, which is a newer outcome
metric.45 Future work should verify the reproducibility of
our findings using this alternative outcome.45 Finally, we
did not include an analysis of certain other characteristics
that could have impacted recovery, such as comorbid diag-
noses and social characteristics.
Conclusions
Our study demonstrated that, in patients with high tetra-
plegia, recovery of elbow extension and finger flexion may
significantly enhance independence in major ADLs, such
as eating, bladder management, and transfers. The recovery
of elbow extension may substantially enhance the patient’s
transfer capability. These findings can be used to counsel
patients about expected functional return and inform novel
research innovation of interventions targeting restoration of
upper-limb function in patients with high cervical SCI.
Acknowledgments
We acknowledge the National Spinal Cord Injury Statistical
Center for research support and assistance with database access.
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Disclosures
Dr. Levi receives teaching honorarium from the American Asso-
ciation of Neurological Surgeons/Medtronic and grant support
from the Department of Defense (DOD) and the National Insti-
tutes of Health (NIH). Dr. Mahan reported personal fees from
Joimax and Renerva and grants from Boston Scientific outside
the submitted work. Dr. Wilson reported personal fees from Axo-
gen and Bioventus outside the submitted work. Dr. Ray reported
consulting fees from DePuy and Globus and grants from NIH and
DOD.
Author Contributions
Conception and design: Javeed, Greenberg, Dibble, Khalifeh,
Chen, Belzberg, Burks, Levi. Acquisition of data: Javeed,
Botterbush, Wen, Chen, Faraji, Mahan. Analysis and
interpretation of data: Javeed, Greenberg, Zhang, Chen, Park,
Belzberg, Tuffaha, Burks, Levi, Faraji, Wilson. Drafting the
article: Javeed, Zhang, Plog, Botterbush, Khalifeh, Burks.
Critically revising the article: Ray, Javeed, Greenberg, Zhang,
Plog, Dibble, Benedict, Botterbush, Khalifeh, Park, Belzberg,
Tuffaha, Burks, Levi, Zager, Faraji, Midha, Wilson. Reviewed
submitted version of manuscript: Ray, Javeed, Greenberg, Plog,
Dibble, Botterbush, Khalifeh, Wen, Belzberg, Tuffaha, Levi,
Zager, Faraji, Wilson, Juknis. Statistical analysis: Javeed, Zhang.
Administrative/technical/material support: Zhang, Dibble,
Botterbush, Faraji. Study supervision: Ray, Belzberg, Faraji.
Supplemental Information
Online-Only Content
Supplemental material is available with the online version of the
article.
eTables and eFigures. https://thejns.org/doi/suppl/​10.3171/​
2023.4.SPINE2382.
Previous Presentations
This work was presented at the Congress of Neurological Sur-
geons Annual Meeting, San Francisco, CA, October 8–12, 2022.
Correspondence
Wilson Z. Ray: Washington University, St. Louis, MO. rayz@
wustl.edu.