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Page 8 of 12 Lin et al. Plast Aesthet Res 2024;11:8 https://dx.doi.org/10.20517/2347-9264.2023.57

While physical tests and biomechanical measurements may demonstrate gains in UE strength and
movement following surgery, the clinical significance is unclear. These outcomes may not reflect the patient
perception or experience of change [69,70] . For example, what a surgeon may view as considerable
improvement in grip may not correspond to improved hand function from the patient’s perspective. In light
of this, PROs were developed. PROs allow for the assessment of function, satisfaction, and quality of life
from the patient’s perspective [24,71] .

General PROs such as the SF-36 may demonstrate change for reasons unrelated to hand and UE function
and may be less useful in this field. System-specific PROs that evaluate generic UE function such as the
DASH and MHQ may not account for the nuances of hand and UE function in cervical SCI . For example,
[72]
questions in the DASH such as “making a bed” or “changing a lightbulb overhead” may not capture
[58]
important gains in function experienced after surgery . Disease-specific PROs such as the FIM, SCIM, and
CUE were developed to assess UE disability in the setting of cervical SCI. In particular, the SCIM has been
validated and found to be highly reproducible and a good predictor for ADL attainment [60,73] . However, in
this review, we found that these measures were rarely used.

The reviewed literature rarely included measures for UE movement quality and precision during task
execution. This is a critical deficit in NT surgery outcome studies in the current cervical SCI literature. One
of the purported advantages of NT over TT surgery is the ability to regain coordinated, natural and smooth
UE movements when performing tasks .
[23]

Future directions
By contrast, kinematic or motion analysis can provide objective and quantifiable measurement of hand
[74]
dexterity and smoothness of motion . Kinematic analysis is the study of the motion of the human body,
limbs, and joints through three-dimensional space and time. It often utilizes an optoelectronic system built
from multiple high-speed cameras and infrared diodes to capture bodily movements using active markers.
Kinematic measures of UE function have been investigated in the stroke population and have been shown
to detect minute changes that augment traditional clinical assessments [74,75] . For example, Lili et al. used a 5-
camera optoelectronic system to capture movement time, smoothness, and other kinematics findings that
correlated with the ARAT and SHFT assessments .
[76]

Capturing the smoothness and fluidity of UE motion using more complex visual imagery makes inherent
sense. In many studies investigating NT or TT surgery outcomes, post-operative videos were often included
in the online supplemental sections. In this review, 13/26 (50%) studies included post-operative video
content. Kinematic analysis extracts the intuitive visual success of this video content into quantifiable
metrics. Metrics such as hand trajectory variability, velocity, acceleration, and grip aperture have previously
been demonstrated to have excellent repeatability for the assessment of ADL performance in able-bodied
subjects .
[77]
Using kinematic analysis in the field of NT surgery in cervical SCI could improve pre-operative counseling,
surgical decision-making, and post-surgery rehabilitation. However, current kinematic analysis requires a
special set-up with multiple cameras and physical markers that are placed on the UE. Simpler methods need
to be developed. The ultimate goal for performing kinematic analysis in this population would be to capture
UE movement during ADLs and other activities outside of a research environment.

Recent work has focused on gaining an understanding of movement and its effect on independence. Future
work should compare the assessment of kinematics, strength, movement, function, and independence, as