Comment on "Anatomical basis of the neurotization of the brachialis muscle to the extensor carpi radialis muscles to restore an active extension of the tetraplegic wrist".

Restoring wrist extension in patients with tetraplegia is a critical surgical objective, as it enables tenodesis and facilitates independent grasping. Ollivier et al. recently presented an anatomical study evaluating the feasibility of neurotization of the brachialis muscle nerve to branches of the extensor carpi radialis muscles for this purpose. Their findings confirm that the transfer is anatomically feasible but typically requires an interposed nerve graft, with average graft lengths of approximately 83 mm for the extensor carpi radialis longus and 121.5 mm for the extensor carpi radialis brevis. This commentary discusses several important considerations arising from these findings, including the potential impact of long nerve grafts on axonal regeneration and functional recovery, the significance of variable radial nerve branching patterns on individualized surgical planning, and the need to preserve brachioradialis function. The relative merits of nerve transfer versus established tendon transfer techniques are also examined. While the anatomical evidence supports the feasibility of this neurotization approach, prospective clinical trials are necessary to evaluate functional outcomes, strength recovery, and patient quality of life before this technique can be recommended for routine clinical practice.