International Federation of Societies for Surgery of the Hand Committee report: the role of nerve transfers in the treatment of neonatal brachial plexus palsy

The Outcome of Spinal Accessory Nerve Transfer to the Musculocutaneous Nerve in Birth Brachial Plexus Palsy

PURPOSE

Patients with brachial plexus birth injury with limited intraplexal donors require the use of extraplexal donors. Concern regarding the potential for respiratory problems resulting from the harvest of intercostal nerves or the phrenic nerve suggests the need for other options. Transfer of the spinal accessory nerve (SAN) is one option for restoring elbow flexion in adult patients; however, there are few reports of the results of this transfer in brachial plexus birth injury. This study aimed to report the result of SAN transfer to the musculocutaneous nerve (MCN) in brachial plexus birth injury.

METHODS

Patients who had undergone SAN to MCN nerve transfer were included in this study. Patients were classified according to Narakas classification. The chart was reviewed for the time for recovery of elbow flexion according to the Active Movement Scale (AMS).

RESULTS

Eleven patients underwent SAN to MCN transfers with interpositional sural nerve grafts. Mean birthweight was 4,070 grams (range: 3,300-4,670). Mean time to operation was 6.5 months (range: 4-10). Of the 11 patients, two were of Narakas type 3, whereas the others were of type 4. One patient did not recover elbow flexion and underwent later tendon transfer, whereas the other 10 patients reached AMS grade M6 recovery. The median time for AMS grade M1 elbow flexion recovery was eight months (interquartile range: 6.2-8.8) and for AMS grade M5 was 26 months (interquartile range: 14.2-36.5).

CONCLUSIONS

Spinal accessory nerve to MCN transfer with an interposition nerve graft is a viable option for restoring elbow flexion. However, long-term outcomes of this procedure have yet to be fully demonstrated.

TYPE OF STUDY/LEVEL OF EVIDENCE

Case series IV.

Brachial plexus birth injury: advances and controversies

While there is considerable spontaneous recovery in most cases of brachial plexus birth injury, many children are left with significant problems that may lead to lifelong functional limitations, loss of work and social isolation. Detailed treatment with the right strategy can provide very valuable improvement in function. Over the past few years, the clinical approach to brachial plexus birth palsy has entered a new era in both diagnostic and surgical treatment methods. This article reviews four areas of management, the role of imaging in defining the severity of the injury, the optimal timing of for nerve exploration and reconstruction in appropriate cases, the advantages and potential complications of nerve transfers, and the role of physiotherapy. Available evidence is considered. Although it is difficult to make clear and precise inferences on a subject where there are many variables and considerable uncertainties, some currently accepted views will be summarized.Level of evidence: V.

Prospective study comparing outcomes of primary intraplexal repair versus distal nerve transfers in Narakas grade I birth brachial plexus palsy

To compare the results of intraplexal repair and distal nerve transfer in babies with birth brachial plexus palsy (BBPP), children with Narakas group I obstetric palsy were assigned to two groups of 16 each. Children in group A were treated with classical intraplexal repair and those in group B were treated by distal nerve transfers. At 6 months, all the children in group B had achieved Modified Medical Research Council (MMRC) grade 3 elbow flexion along with 8 of the 16 children in group A, which was a statistically significant difference. At 6 months, all the children in group B achieved MMRC grade 3 or higher shoulder abduction and 8 of the 16 children in group A had done so, which was also statistically significant. At the final follow-up, the distal transfer surgical treatment group had a significantly higher Mallet score. Distal nerve transfers have a significant advantage in early recovery in elbow flexion and shoulder abduction, but the outcomes became similar after 9 months.Level of evidence: III.

Rehabilitation protocols in neonates undergoing primary nerve surgery for upper brachial plexus palsy: A scoping review

INTRODUCTION

Surgical management is recommended in patients with severe neonatal brachial plexus palsy (NBPP) within the first 6 months of age to regain best possible function. Rehabilitation post-surgery remains relatively unexplored. This is a scoping review that explores, which rehabilitation modalities exist and how they vary for different microsurgical approaches in NBPP.

MATERIALS AND METHODS

A systematic search was conducted to include articles about upper trunk obstetric brachial plexus nerve microsurgery in pediatric patients that made mention of rehabilitation protocols. The aims of rehabilitation modalities varied and were grouped: "passive" movement to prevent joint contracture or stiffness, "active" or task-oriented movement to improve motor function, or "providing initial motor recovery". Surgical approach was described as either exploration of the brachial plexus (EBP) or nerve transfer without root exploration (NTwoRE). Technique was categorized into transfers and non-transfers.

RESULTS

Thirty-six full-text articles were included. Initiation of rehabilitation was 22.26 days post-surgery. Twenty-eight studies were EBP, and six were NTwoRE. Of studies classifiable by aims, nine were "passive", nine were "active", and five were "providing initial motor recovery". Only 27.7% of EBP studies mentioned active therapy, while 75.0% of NTwoRE studies mentioned active therapy. The average age of patients in the EBP procedure category was 7.70 months, and NTwoRE was 17.76 months. Within transfers, the spinal accessory to suprascapular group was more likely to describe an active shoulder exercise therapy, whereas contralateral C7 group was more likely to describe "initial motor recovery", especially through the use of electrostimulation. All articles on electrostimulation recommended 15-20-minute daily treatment.

CONCLUSION

Information on rehabilitation is limited post-nerve surgery in NBPP. However, when mentioned, the aims of these therapies vary with respect to surgical approach and technique. The type of therapy to employ may be a multifaceted decision, involving factors such as patient age, initial deformity, and goals of the care team.

Promoting Recovery Following Birth Brachial Plexus Palsy

Neonatal brachial plexus palsies (NBPP) occur in 1.74 per 1000 live births with 20% to 30% having persistent deficits. Dysfunction can range from mild to severe and is correlated with the number of nerves involved and the degree of injury. In addition, there are several comorbidities and musculoskeletal sequelae that directly impact the overall functional development. This review addresses the nonsurgical and surgical management options and provides guidance for pediatricians on monitoring and when to refer for specialty care.

Nerve Transfer Is Superior to Nerve Grafting for Suprascapular Nerve Reconstruction in Obstetrical Brachial Plexus Birth Injury: A Meta-Analysis

BACKGROUND

Restoration of shoulder function in obstetrical brachial plexus injury is paramount. There remains debate as to the optimal method of upper trunk reconstruction. The purpose of this study was to test the hypothesis that spinal accessory nerve to suprascapular nerve transfer leads to improved shoulder external rotation relative to sural nerve grafting.

METHODS

A systematic review of Medline, EMBASE, EBSCO CINAHL, SCOPUS, Cochrane Library, and TRIP Pro from inception was conducted. Our primary outcome was shoulder external rotation.

RESULTS

Four studies were included. Nerve transfer was associated with greater shoulder external rotation relative to nerve grafting (mean difference: 0.82 AMS 95% confidence interval [CI]: 0.27-1.36, P < .005). Patients undergoing nerve grafting were more likely to undergo a secondary shoulder stabilizing procedure (odds ratio [OR]: 1.27, 95% CI: 0.8376-1.9268).

CONCLUSION

In obstetrical brachial plexus injury, nerve transfer is associated with improved shoulder external rotation and a lower rate of secondary shoulder surgery.

LEVEL OF EVIDENCE

Level III; Therapeutic.

Recent Advances in the Treatment of Brachial Plexus Birth Injury

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Describe methods of clinical evaluation for neurologic recovery in brachial plexus birth injury. 2. Understand the role of different diagnostic imaging modalities to evaluate the upper limb. 3. List nonsurgical strategies and surgical procedures to manage shoulder abnormality. 4. Explain the advantages and disadvantages of microsurgical nerve reconstruction and distal nerve transfers in brachial plexus birth injury. 5. Recognize the prevalence of pain in this population and the need for greater sensory outcomes evaluation.

SUMMARY

Brachial plexus birth injury (BPBI) results from closed traction injury to the brachial plexus in the neck during an infant's vertex passage through the birth canal. Although spontaneous upper limb recovery occurs in most instances of BPBI, some infants do not demonstrate adequate motor recovery within an acceptable timeline and require surgical intervention to restore upper limb function. This article reviews major advances in the management of BPBI in the past decade that include improved understanding of shoulder pathology and its impact on observed motor recovery, novel surgical techniques, new insights in sensory function and pain, and global efforts to develop standardized outcomes assessment scales.

Microsurgery in pediatric upper limb reconstructions: An overview

The use of microsurgery has spread during the last decades, making resolvable many complex defects considered hitherto inapproachable. Although the small vessel diameter in children was initially considered a technical limitation, the increase in microsurgical expertise over the past three decades allowed us to manage many pediatric conditions by means of free tissue transfers. Pediatric microsurgery has been shown to be feasible, gaining a prominent place in the treatment of children affected by limb malformations, tumors, nerve injuries, and post-traumatic defects. The aim of this current concepts review is to describe the more frequent pediatric upper limb conditions in which the use of microsurgical reconstructions should be considered in the range of treatment options.

Brachial Plexus Birth Injury: Trends in Early Surgical Intervention over the Last Three Decades

Early surgical management of brachial plexus birth injury has advanced owing to targeted surgical techniques and increases in specialty-centers and multi-institutional collaboration. This study seeks to determine trends in the early surgical management of BPBI over the last 30 years.

Methods

A systematic review was performed through MEDLINE (PubMed) identifying studies limited to the early surgical management of BPBI from 1990 to current. Patients treated after 1 year of age (ie, tendon transfers and secondary reconstructive efforts) were excluded. Diagnostic tests, age of intervention, surgical treatment modalities, and outcome scoring systems were extrapolated and compared so as to determine trends in management over time.

Results

Seventeen studies met criteria, summating a total of 883 patients. The most commonly reported physical examination classifications were the Mallet and AMS scoring systems. Most patients underwent neuroma excision and sural nerve autografting (n = 618, 70%) when compared with primary nerve transfers (148, 16.8%), primary nerve transfer with autografting combinations (59, 6.7%), or neurolysis alone (58, 6.6%). There was no significant change in the proportion of patients treated with sural nerve grafting, combination graft and transfer procedures, or isolated neurolysis over time. However, there has been a significant increase in the proportion of patients treated with primary nerve transfer procedures (τ _b = 0.668, P < 0.01) over time.

Conclusion

Although neuroma excision and sural nerve autografting has been the historic gold-standard treatment for brachial plexus birth injury, peripheral nerve transfers have become increasingly utilized for surgical management.

Surgical Management of Traumatic Brachial Plexus Injuries in the Pediatric Population

OBJECTIVE

The aim of this study was to evaluate the demographics, treatment options, and outcomes of pediatric age traumatic brachial plexus injuries (BPI).

METHODS

Traumatic brachial plexus reconstructions in patients aged 17 years or younger were reviewed. Patients were stratified into pan-plexus and incomplete plexus injuries. Functional outcomes (modified British Medical Council Grade -mBMRC) were reviewed after a minimum of 9 months follow-up.

RESULTS

Seventy-one patients underwent brachial plexus reconstruction at an average age of 13.9 years (Range 2-17 years). Approximately half of patients had a pan-brachial plexus injury (n=33, 46.5%) with 59.2% having at least one preganglionic avulsion injury. Twenty-five patients with pan-brachial plexus injuries had follow-up greater than 9 months, of which 12 (48%), 24 (96%), and 17 (68%) had reconstruction surgery for shoulder, elbow, and grasp function, respectively. At last follow-up, 50%, 83%, and 29% of these patients had grade 3 or greater mBMRC in shoulder abduction, elbow flexion, and grasp, respectively. Of the 31 patients with incomplete BPI, 28 (90%) underwent reconstruction for shoulder function, and 13 (42%) had surgery for elbow flexion. At last follow=up, 71% and 100% of patients had grade 3 mBMRC testing in shoulder abduction and elbow flexion.

CONCLUSIONS

Pediatric traumatic BPI are often high energy injuries resulting in nerve root avulsions. Most patients were able to regain anti-gravity elbow flexion or stronger after brachial plexus reconstruction, and over half had similar improvement in shoulder function. Treatment should be directed with goals of elbow flexion, shoulder stability/external rotation, and rudimentary grasp.

Timing of Nerve Recovery After Nerve Grafting in Obstetrical Brachial Plexus Palsy Patients With Isolated Upper Trunk Neuromas

BACKGROUND

The timing of nerve recovery after nerve grafting in obstetrical brachial plexus palsy patients has not been well reported. One prior study reported a return to baseline function at 3 to 6 months postoperatively. However, there is a paucity of studies to corroborate this timing, and there have been no studies delineating the timeline to obtain clinically meaningful function.

METHODS

OBPP patients with upper trunk neuromas-in-continuity who were treated with resection and sural nerve grafting at a single institution were studied. Time to return to baseline function was assessed by Active Movement Scale (AMS) scores preoperatively and postoperatively. Time to clinically meaningful function, defined as an AMS score of ≥6, was also assessed.

RESULTS

Eleven patients with isolated upper trunk neuromas-in-continuity underwent excision and reversed sural nerve grafting. Three of 11 patients also underwent spinal accessory to suprascapular nerve transfers. Average age at surgery was 9.8 ± 1.9 months. One patient did not have follow-up data and was excluded. Average follow-up was 37.1 ± 16.8 months. Average return to baseline AMS score was approximately 4 to 8 months for shoulder abduction, shoulder flexion, shoulder external rotation, elbow flexion, and forearm supination. Clinically meaningful function was obtained in most patients between 9 and 15 months. The remaining patients who did not achieve clinically meaningful function had all obtained scores of 5, which reflects less than one half normal range of motion against gravity.

CONCLUSIONS

Nerve recovery after surgical intervention in OBPP patients who undergo resection of an upper trunk neuroma-in-continuity and nerve grafting is more rapid than in adults but longer than previously reported in OBPP literature. This study provides an important data point in delineating the timeline of nerve recovery.

Experimental nerve transfer model in the neonatal rat

Clinically, peripheral nerve reconstructions in neonates are most frequently applied in brachial plexus birth injuries. Most surgical concepts, however, have investigated nerve reconstructions in adult animal models. The immature neuromuscular system reacts differently to the effects of nerve lesion and surgery and is poorly investigated due to the lack of reliable experimental models. Here, we describe an experimental forelimb model in the neonatal rat, to study these effects on both the peripheral and central nervous systems. Within 24 hours after birth, three groups were prepared: In the nerve transfer group, a lesion of the musculocutaneous nerve was reconstructed by selectively transferring the ulnar nerve. In the negative control group, the musculocutaneous nerve was divided and not reconstructed and in the positive control group, a sham surgery was performed. The animal´s ability to adapt to nerve lesions and progressive improvement over time were depict by the Bertelli test, which observes the development of grooming. Twelve weeks postoperatively, animals were fully matured and the nerve transfer successfully reinnervated their target muscles, which was indicated by muscle force, muscle weight, and cross sectional area evaluation. On the contrary, no spontaneous regeneration was found in the negative control group. In the positive control group, reference values were established. Retrograde labeling indicated that the motoneuron pool of the ulnar nerve was reduced following nerve transfer. Due to this post-axotomy motoneuron death, a diminished amount of motoneurons reinnervated the biceps muscle in the nerve transfer group, when compared to the native motoneuron pool of the musculocutaneous nerve. These findings indicate that the immature neuromuscular system behaves profoundly different than similar lesions in adult rats and explains reduced muscle force. Ultimately, pathophysiologic adaptations are inevitable. The maturing neuromuscular system, however, utilizes neonatal capacity of regeneration and seizes a variety of compensation mechanism to restore a functional extremity. The above described neonatal rat model demonstrates a constant anatomy, suitable for nerve transfers and allows all standard neuromuscular analyses. Hence, detailed investigations on the pathophysiological changes and subsequent effects of trauma on the various levels within the neuromuscular system as well as neural reorganization of the neonatal rat may be elucidated. This study was approved by the Ethics Committee of the Medical University of Vienna and the Austrian Ministry for Research and Science (BMWF-66.009/0187-WF/V/3b/2015) on March 20, 2015.

Recommendations for management of neonatal brachial plexus palsy: Based on clinical review

STUDY DESIGN

Descriptive report.

INTRODUCTION

Neonatal brachial plexus palsy (NBPP) involves a partial or total injury of the nerves that originate from spinal roots C5-C8 and T1. The reported incidence of NBPP is between 0.38 and 5.1 in 1000 births.

PURPOSE OF THE STUDY

This study describes the management NBPP in the first 3 years of life and to develop an assessment framework for infants with NBPP and postoperative guidelines for those undergoing primary surgery.

METHODS

Retrospective medical record audit from 2012 to 2017.

RESULTS

Of 187 children referred to brachial plexus clinic (BPC), 138 were new referrals and included in the audit. The average number of new referrals per annum was 37; average age at referral was 6.61 week; average age at first appointment was 16.9 weeks. Of the 138 infants, 104 were initially assessed by a physiotherapist before attending BPC. The most common comorbidity was plagiocephaly.

DISCUSSION

From 2012 to 2017, birth location, birth facility, referral source, and time between referral and initial assessment have remained stable. The age at referral, age at which the child was first assessed, and the number of children who received services externally before attending the hospital all decreased. The number of children seen by a physiotherapist before attending BPC increased. An NBPP assessment framework, including critical time points for assessment, and postoperative guidelines for infants and children undergoing primary surgery were created.

CONCLUSIONS

Early referral is essential for effective management of NBPP and ideally infants should be assessed and management implemented before 3 months of age.

Brachial Plexus Birth Injuries: A Critical Analysis Review

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The incidence of brachial plexus birth injury (BPBI) in the United States is declining and now occurs in <1 per 1,000 births.

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The gold standard for predicting the need for early intervention remains serial examination.

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Early treatment of BPBI with reconstructive surgery requires the ability to perform both interposition nerve grafting and nerve transfers.

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Given the heterogeneity of lesions, the evidence is largely limited to retrospective comparative studies and case series.

Brain changes after peripheral nerve repair: limitations of neuroplasticity

Neuroplasticity is the capacity of the central nervous system to adapt to external or internal stimuli. It is being increasingly recognized as an important factor which contributes to the successful outcome of nerve transfers. Other much more well-known factors are the number of axons that cross the coaptation site, the interval between trauma and repair, and age. Neuroplasticity is mediated by synaptic and neurotransmitter changes which underlie activation of previously existing but low-active connections in the brain. Dendritic sprouting and axonal elongation might also take place, but is likely less prominent. We review different factors that play a role in neuroplasticity and functional regeneration after specific nerve transfers. These factors include, amongst others, the distance between cortical areas of the donor and receptor neurons; the presence versus absence of pre-existing low-active inter-neuronal connections; gross versus fine movement restoration; rehabilitation; brain trauma and also very important: the age. The potential for plastic adaptation should be taken into consideration if the surgical strategy and post-operative rehabilitation are planned, as its influence on results cannot be denied.

Evidence that nerve surgery improves functional outcome for obstetric brachial plexus injury

The majority of children with obstetric brachial plexus injury show some degree of spontaneous recovery. This review explores the available evidence for the use surgical brachial plexus repair to improve outcome. So far, no randomized trial has been performed to evaluate the usefulness of nerve repair. The evidence level of studies comparing surgical treatment with non-surgical treatment is Level IV at best. The studies on natural history that are used for comparison with surgical series are also, unfortunately, of too low quality. Among experts, however, the general agreement is that nerve reconstruction is indicated when spontaneous recovery is absent or severely delayed at specific time points. A major obstacle in comparing or pooling obstetric brachial plexus injury patient series, either surgical or non-surgical, is the use of many different outcome measures. A requirement for multicentre studies is consensus on how to assess and report outcome, both concerning motor performance and functional evaluation.

Morbidity of Nerve Transfers for Brachial Plexus Birth Injury: A Systematic Review

BACKGROUND

The purpose of this article is to systematically review the peer-reviewed literature on the morbidity of nerve transfers performed in patients with brachial plexus birth injury (BPBI). Nerve transfers for restoration of function in patients with BPBI that fail nonoperative management are increasing in popularity. However, relatively little attention has been paid to the morbidity of these transfers in the growing patient. The authors systematically review the current literature regarding donor site morbidity following nerve transfer for BPBI.

METHODS

A systematic review of the Medline and EMBASE databases was conducted through February 2020. Primary research articles written in English and reporting donor site morbidity after nerve transfer for BPBI were included for review.

RESULTS

Thirty-six articles met inclusion criteria, all of which were retrospective reviews or case reports. There was great heterogeneity in outcomes assessed. With 5 year or less follow-up, all transfers were relatively well tolerated with the exception of the hypoglossal nerve transfer.

CONCLUSION

Nerve transfers are a well-recognized treatment strategy for patients with BPBI and have an acceptable risk profile in the short term. Full hypoglossal nerve transfers for BPBI are of historical interest. Donor site morbidity is grossly underreported. This review highlights the need for more objective and systematic reporting of donor site outcomes, and the need for longer term follow-up in these patients.

LEVEL OF EVIDENCE

Systematic review. Level III-therapeutic.

Health-care use and information needs of children with neonatal brachial plexus palsy: A cross-sectional survey among 465 Dutch patients

To investigate health-care use (HCU) and information needs of children aged 0-18 years with neonatal brachial plexus palsy (NBPP), a cross-sectional study was performed. Patients and/or parents seen in our NBPP clinic were invited to complete a survey comprising questions on HCU due to NBPP and current information needs. Outcomes were described for three age-groups (0-1/2-9/10-18 years), based on follow-up status (early/late/no-discharge). Four hundred sixty-five parents/patients participated (59 in the 0-1, 226 in the 2-9, and 180 in the 10-18-year group). Two hundred ninety-three patients had C5-C6 lesions, 193 were discharged from follow-up, 83 of whom categorized as 'early discharged' (<1 year of age). Over the past year, 198 patients had contact with the expert team (49 in the 0-1, 81 in the 2-9, and 68 in the 10-18-year group) and 288 with at least one other health-care professional (53 in the 0-1, 133 in the 2-9, and 102 in the 10-18-year group). Of the 83 patients discharged early, 34 reported health-care use. Two hundred twenty-eight participants reported current information needs of whom 23 were discharged early. HCU and information needs of Dutch children with NBPP remains considerable even in children who were discharged. Stricter follow-up and information provision for these patients is needed.

Outcomes from primary surgical reconstruction of neonatal brachial plexus palsy in 104 children

PURPOSE

The outcome from microsurgical reconstruction of neonatal brachial plexus palsy (NBPP) varies, and comparison between different series is difficult, given the differences in preoperative evaluation, surgical strategies, and outcome analysis. To evaluate our results, we reviewed a series of children who underwent surgical treatment in a period of 14 years.

METHODS

We made a retrospective review of 104 cases in which microsurgical repair of the brachial plexus was performed. Strength was graded using the Active Movement Scale. Whenever possible, upper palsies underwent surgery 4 to 6 months after birth and total lesions around 3 months. The lesions were repaired, according to the type of injury: neurolysis, nerve grafting, nerve transfer, or a combination of techniques. The children were followed for at least 24 months.

RESULTS

The majority of cases were complete lesions (56/53.8%). Erb's palsy was present in 10 cases (9.6%), and 39 infants (37.5%) presented an extended Erb's palsy. The surgical techniques applied were neurolysis (10.5%), nerve grafts (25.9%), nerve transfers (34.6%), and a combination of grafts and transfers (30.7%). The final outcome was considered poor in 41.3% of the cases, good in 34.3%, and excellent in 24%. A functional result (good plus excellent) was achieved in 58.3% of the cases.

CONCLUSIONS

There is no consensus regarding strategies for treatment of NBPP. Our surgical outcomes indicated a good general result comparing with the literature. However, our results were lower than the best results reported. Maybe the explanation is our much higher number of total palsy cases (53.8% vs. 25% in the literature).

An Update on the Management of Neonatal Brachial Plexus Palsy-Replacing Old Paradigms: A Review

IMPORTANCE

Neonatal brachial plexus palsy (NBPP) can result in persistent deficits for those who develop it. Advances in surgical technique have resulted in the availability of safe, reliable options for treatment. Prevailing paradigms include, "all neonatal brachial plexus palsy recovers," "wait a year to see if recovery occurs," and "don't move the arm." Practicing by these principles places these patients at a disadvantage. Thus, the importance of this review is to provide an update on the management of NBPP to replace old beliefs with new paradigms.

OBSERVATIONS

Changes within denervated muscle begin at the moment of injury, but without reinnervation become irreversible 18 to 24 months following denervation. These time-sensitive, irreversible changes are the scientific basis for the recommendations herein for the early management of NBPP and put into question the old paradigms. Early referral has become increasingly important because improved outcomes can be achieved using new management algorithms that allow surgery to be offered to patients unlikely to recover sufficiently with conservative management. Mounting evidence supports improved outcomes for appropriately selected patients with surgical management compared with natural history. Primary nerve surgery options now include nerve graft repair and nerve transfer. Specific indications continue to be elucidated, but both techniques offer a significant chance of restoration of function.

CONCLUSIONS AND RELEVANCE

Mounting data support both the safety and effectiveness of surgery for patients with persistent NBPP. Despite this support, primary nerve surgery for NBPP continues to be underused. Surgery is but one part of the multidisciplinary care of NBPP. Early referral and implementation of multidisciplinary strategies give these children the best chance of functional recovery. Primary care physicians, nerve surgeons, physiatrists, and occupational and physical therapists must partner to continue to modify current treatment paradigms to provide improved quality care to neonates and children affected by NBPP.

Oberlin transfer compared with nerve grafting for improving early supination in neonatal brachial plexus palsy

OBJECTIVE The use of nerve transfers versus nerve grafting for neonatal brachial plexus palsy (NBPP) remains controversial. In adult brachial plexus injury, transfer of an ulnar fascicle to the biceps branch of the musculocutaneous nerve (Oberlin transfer) is reportedly superior to nerve grafting for restoration of elbow flexion. In pediatric patients with NBPP, recovery of elbow flexion and forearm supination is an indicator of resolved NBPP. Currently, limited evidence exists of outcomes for flexion and supination when comparing nerve transfer and nerve grafting for NBPP. Therefore, the authors compared 1-year postoperative outcomes for infants with NBPP who underwent Oberlin transfer versus nerve grafting. METHODS This retrospective cohort study reviewed patients with NBPP who underwent Oberlin transfer (n = 19) and nerve grafting (n = 31) at a single institution between 2005 and 2015. A single surgeon conducted intraoperative exploration of the brachial plexus and determined the surgical nerve reconstruction strategy undertaken. Active range of motion was evaluated preoperatively and postoperatively at 1 year. RESULTS No significant difference between treatment groups was observed with respect to the mean change (pre- to postoperatively) in elbow flexion in adduction and abduction and biceps strength. The Oberlin transfer group gained significantly more supination (100° vs 19°; p < 0.0001). Forearm pronation was maintained at 90° in the Oberlin transfer group whereas it was slightly improved in the grafting group (0° vs 32°; p = 0.02). Shoulder, wrist, and hand functions were comparable between treatment groups. CONCLUSIONS The preliminary data from this study demonstrate that the Oberlin transfer confers an advantageous early recovery of forearm supination over grafting, with equivalent elbow flexion recovery. Further studies that monitor real-world arm usage will provide more insight into the most appropriate surgical strategy for NBPP.

Nerve transfer to biceps to restore elbow flexion and supination in children with obstetrical brachial plexus palsy

PURPOSE

Nerve transfers to restore elbow flexion have been described for traumatic brachial plexus palsy in adults. Indications are less frequent in infants and the results are less published.

METHODS

Ten patients with obstetrical brachial plexus palsy were operated on for lack of flexion against gravity with ulnar or median nerve transfer to biceps motor branch. The primary endpoint was improvement in elbow flexion and supination.

RESULTS

Mean age at surgery was 12.5 months and mean follow-up was 2.6 years. The Active Movement Scale (AMS) was used to evaluate elbow flexion and forearm supination. At the last follow-up, the average AMS score improved from 0.3 to 5.7 for elbow flexion and from 0.6 to 5.8 for forearm supination. There was no statistical correlation between the age at surgery and the AMS score 18 months post-operatively.

CONCLUSIONS

Nerve transfer to the biceps motor branch can improve elbow flexion and forearm supination in selected patients with upper lesions and can be safely performed until the age of two years.

Distal nerve transfer versus supraclavicular nerve grafting: comparison of elbow flexion outcome in neonatal brachial plexus palsy with C5-C7 involvement

PURPOSE

Ulnar and median nerve transfers to arm muscles have been used to recover elbow flexion in infants with neonatal brachial plexus palsy, but there is no direct outcome comparison with the classical supraclavicular nerve grafting approach.

METHODS

We retrospectively analyzed patients with C5-C7 neonatal brachial plexus palsy submitted to nerve surgery and recorded elbow flexion recovery using the active movement scale (0-7) at 12 and 24 months after surgery. We compared 13 patients submitted to supraclavicular nerve grafting with 21 patients submitted to distal ulnar or median nerve transfer to biceps motor branch. We considered elbow flexion scores of 6 or 7 as good results.

RESULTS

The mean elbow flexion score and the proportion of good results were better using distal nerve transfers than supraclavicular grafting at 12 months (p < 0.01), but not at 24 months. Two patients with failed supraclavicular nerve grafting at 12 months showed good elbow flexion recovery after ulnar nerve transfers.

CONCLUSION

Distal nerve transfers provided faster elbow flexion recovery than supraclavicular nerve grafting, but there was no significant difference in the outcome after 24 months of surgery. Patients with failed supraclavicular grafting operated early can still benefit from late distal nerve transfers. Supraclavicular nerve grafting should remain as the first line surgical treatment for children with neonatal brachial plexus palsy.

The outcome of primary brachial plexus reconstruction in extended Erb's obstetric palsy when only one root is available for intraplexus neurotization

Background

A recent review by the International Federation of Societies for Surgery of the Hand showed no studies comparing the results of nerve grafting to distal nerve transfer for primary reconstruction of the brachial plexus in infants with obstetric brachial plexus palsy (OBBP). The aim of this retrospective study is to compare two surgical reconstructive strategies in primary reconstruction of the brachial plexus in extended Erb’s obstetric palsy with double root avulsion: one with and one without distal nerve transfer for elbow flexion.

Methods

Two groups of infants with extended Erb’s palsy and double root avulsion were included in the study. Group I (n = 29) underwent reconstruction of the brachial plexus without distal nerve transfer. In group II (n = 26), the reconstruction included a distal nerve transfer for elbow flexion.

Results

Both groups had an excellent (over 96%) satisfactory outcome for elbow flexion. Group II has a significantly better outcome (P < 0.05) of shoulder abduction and wrist extension than group I.

Conclusions

The use of a distant nerve transfer for bicep reconstruction in extended Erb’s obstetric palsy with double root avulsion gives a better outcome for shoulder abduction and wrist extension; and this seems to be related to the availability of more cable grafts to reconstruct the posterior division of the upper trunk and the middle trunk.

Level of Evidence: Level III, therapeutic study

Obstetric brachial plexus injury. Knowledge among health care providers in Saudi Arabia

Objectives:

To assess the basic knowledge on obstetric brachial plexus injury among obstetricians, pediatricians, and physio-/occupational therapists in major hospitals in Riyadh. We aimed to identify if inadequate knowledge is the reason behind delayed referrals to the Hand Clinic.

Methods:

This is a cross-sectional questionnaire-based study conducted at 5 major hospitals in Riyadh, Saudi Arabia between June 2015 and August 2015. A questionnaire of 6 questions (multiple choice closed-ended questions) was given to obstetricians, pediatricians, and physio-/occupational therapists’ in these selected hospitals. The total score out of 6 was categorized as good, adequate, and inadequate knowledge if the score is 5-6, 3-4, and less than 3; respectively. The data were analyzed with Chi-square, fisher exact, Analysis of Variance, and Post-hoc tests where appropriate.

Results:

A total of 323 subjects participated in the study. For positions, the best mean score (for all 6 questions) was scored by consultants and the score was only 2.95 out of 6. For hospitals, Hospital IV scored the best mean score (2.99). The mean scores were not significantly different between different specialties.

Conclusion:

Inadequate knowledge seems to be a reason for delayed referrals of cases of obstetric brachial plexus injury to Hand Clinics in Riyadh, Saudi Arabia.

Current concepts in plasticity and nerve transfers: relationship between surgical techniques and outcomes

OBJECTIVE Neuroplasticity is analyzed in this article as the capacity of the CNS to adapt to external and internal stimuli. It is being increasingly recognized as an important factor for the successful outcome of nerve transfers. Better-known factors are the number of axons that cross the coaptation site, the time interval between trauma and repair, and age. Neuroplasticity is mediated initially by synaptic and neurotransmitter changes. Over time, the activation of previously existing but lowly active connections in the brain cortex contributes further. Dendritic sprouting and axonal elongation might also take place but are less likely to be prominent. METHODS The authors reviewed different factors that play roles in neuroplasticity and functional regeneration after specific nerve transfers. RESULTS The authors found that these different factors include, among others, the distance between cortical areas of the donor and receptor neurons, the presence versus absence of preexisting lowly active interneuronal connections, gross versus fine movement restoration, rehabilitation, brain trauma, and age. CONCLUSIONS The potential for plasticity should be taken into consideration by surgeons when planning surgical strategy and postoperative rehabilitation, because its influence on results cannot be denied.

The natural history and management of brachial plexus birth palsy

Brachial plexus birth palsy (BPBP) is an upper extremity paralysis that occurs due to traction injury of the brachial plexus during childbirth. Approximately 20 % of children with brachial plexus birth palsy will have residual neurologic deficits. These permanent and significant impacts on upper limb function continue to spur interest in optimizing the management of a problem with a highly variable natural history. BPBP is generally diagnosed on clinical examination and does not typically require cross-sectional imaging. Physical examination is also the best modality to determine candidates for microsurgical reconstruction of the brachial plexus. The key finding on physical examination that determines need for microsurgery is recovery of antigravity elbow flexion by 3-6 months of age. When indicated, both microsurgery and secondary shoulder and elbow procedures are effective and can substantially improve functional outcomes. These procedures include nerve transfers and nerve grafting in infants and secondary procedures in children, such as botulinum toxin injection, shoulder tendon transfers, and humeral derotational osteotomy.

Distal transfers as a primary treatment in obstetric brachial plexus palsy: a series of 20 cases

The purpose of this study was to examine the results of spinal accessory nerve to suprascapular nerve (with or without axillary nerve neurotization) and an Oberlin transfer as primary treatment in children with Narakas type I obstetric brachial plexus injuries, when parents refused to consent to conventional nerve trunk-/root-level reconstruction. A total of 20 children with poor shoulder abduction and no biceps antigravity function but with good hand function were treated with spinal accessory nerve to suprascapular nerve and an Oberlin transfer at a mean age of 5.8 months (SD 3.27; range 3-12.) All the patients were evaluated at a mean of 2.8 years (SD 0.8; range 1.5 to 3.8) post-operatively. Three patients were lost to follow-up. Of the remainder, 11 had grade 4+ power of elbow flexion and six patients had grade 4 power at 1 year follow-up; all had 4+ power of elbow flexion at final follow-up. At final follow-up the Mallet score was a mean of 15; (SD 4.22, range 9 to 20). Primary distal nerve transfers can give good outcomes in patients with obstetric brachial plexus injuries and may be an alternative to surgery on the nerve trunks

LEVEL OF EVIDENCE

IV.

Serial casting for elbow flexion contractures in neonatal brachial plexus palsy

PURPOSE

The objective of this study was to evaluate the effectiveness of serial casting of elbow flexion contractures in neonatal brachial plexus palsy.

METHODS

A prospective consecutive cohort study was performed with a median follow-up of 5 years. Forty-one patients with elbow flexion contractures ≥ 30° were treated with serial casting until the contracture was ≤ 10°, for a maximum of 8 weeks. Range of motion, number of recurrences and patient satisfaction were recorded and analyzed using Wilcoxon signed-rank and Cox regression tests.

RESULTS

Passive extension increased from a median of -40° (IQR -50 to -30) to -15° (IQR -10 to -20, p < 0.001). Twenty patients showed 37 recurrences. The baseline severity of passive elbow extension had a hazard ratio of 0.93 (95% CI 0.89 to 0.96, p < 0.001) for first recurrence. Median patient satisfaction was moderate. Four patients showed loss of flexion mobility and in two patients serial casting had to be prematurely replaced by night splinting due to complaints.

CONCLUSION

Serial casting improved elbow flexion contractures, although recurrences were frequent. The severity of elbow flexion contracture is a predictor of recurrence. We recommend more research on muscle degeneration and determinants involved in elbow flexion contractures to improve treatment strategies and prevent side-effects.

Nerve Transfers in Birth Related Brachial Plexus Injuries: Where Do We Stand?

This article reviews the assessment and management of obstetrical brachial plexus palsy. The potential role of distal nerve transfers in the treatment of infants with Erb's palsy is discussed. Current evidence for motor outcomes after traditional reconstruction via interpositional nerve grafting and extraplexal nerve transfers is reviewed and compared with the recent literature on intraplexal distal nerve transfers in obstetrical brachial plexus injury.

Nerve transfers and neurotization in peripheral nerve injury, from surgery to rehabilitation

Peripheral nerve injury (PNI) and recent advances in nerve reconstruction (such as neurotization with nerve transfers) have improved outcomes for patients suffering peripheral nerve trauma. The purpose of this paper is to bridge the gap between the electromyographer/clinical neurophysiologist and the peripheral nerve surgeon. Whereas the preceding literature focuses on either the basic science behind nerve injury and reconstruction, or the surgical options and algorithms, this paper demonstrates how electromyography is not just a 'decision tool' when deciding whether to operate but is also essential to all phases of PNI management including surgery and rehabilitation. The recent advances in the reconstruction and rehabilitation of PNI is demonstrated using case examples to assist the electromyographer to understand modern surgical techniques and the unique demands they ask from electrodiagnostic testing.

The Role of Current Techniques and Concepts in Peripheral Nerve Repair

Patients with peripheral nerve injuries, especially severe injury, often face poor nerve regeneration and incomplete functional recovery, even after surgical nerve repair. This review summarizes treatment options of peripheral nerve injuries with current techniques and concepts and reviews developments in research and clinical application of these therapies.