Comparing the Efficacy of Triple Nerve Transfers with Nerve Graft Reconstruction in Upper Trunk Obstetric Brachial Plexus Injury:

Assessment, management, and rehabilitation of traumatic peripheral nerve injuries for non-surgeons

Electrodiagnostic evaluation is often requested for persons with peripheral nerve injuries and plays an important role in their diagnosis, prognosis, and management. Peripheral nerve injuries are common and can have devastating effects on patients' physical, psychological, and socioeconomic well-being; alongside surgeons, electrodiagnostic medicine specialists serve a central function in ensuring patients receive optimal treatment for these injuries. Surgical intervention-nerve grafting, nerve transfers, and tendon transfers-often plays a critical role in the management of these injuries and the restoration of patients' function. Increasingly, nerve transfers are becoming the standard of care for some types of peripheral nerve injury due to two significant advantages: first, they shorten the time to reinnervation of denervated muscles; and second, they confer greater specificity in directing motor and sensory axons toward their respective targets. As the indications for, and use of, nerve transfers expand, so too does the role of the electrodiagnostic medicine specialist in establishing or confirming the diagnosis, determining the injury's prognosis, recommending treatment, aiding in surgical planning, and supporting rehabilitation. Having a working knowledge of nerve and/or tendon transfer options allows the electrodiagnostic medicine specialist to not only arrive at the diagnosis and prognosticate, but also to clarify which nerves and/or muscles might be suitable donors, such as confirming whether the branch to supinator could be a nerve transfer donor to restore distal posterior interosseous nerve function. Moreover, post-operative testing can determine if nerve transfer reinnervation is occurring and progress patients' rehabilitation and/or direct surgeons to consider tendon transfers.

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.

Surgery for internal rotation contracture in infancy may obviate the need for brachial plexus nerve reconstruction: early experience

BACKGROUND

Shoulder internal rotation contracture and subluxation in the first year of life has long been recognized in some patients with brachial plexus birth injury (BPBI). Surgical management of shoulder pathology has traditionally been undertaken following nerve reconstruction as necessary. In some patients; however, shoulder pathology may impair or obscure functional neuromuscular recovery of the upper extremity. As a proof of concept, we report a highly selected subset of patients with BPBI in whom shoulder surgery undertaken before one year of age obviated the need for neuroma resection and nerve grafting.

METHODS

A retrospective review was performed of all patients with upper trunk BPBI who underwent shoulder surgery before one year of age from 2015 to 2018. Upper extremity motor function was evaluated with preoperative and postoperative Active Movement Scale scores, Cookie tests, and the requirement for subsequent neuroma resection and nerve grafting.

RESULTS

Fifteen patients with BPBI meeting the inclusion criteria underwent shoulder surgery (including a subscapularis slide and tendon transfers of the teres major and latissimus dorsi muscles) before 1 year of age. Preoperatively, no patients of the appropriate age passed the Cookie test for elbow flexion. Thirteen patients either passed the Cookie test or scored Active Movement Scale score 7 for elbow flexion at or before the last available follow-up undertaken at a median age of 3.4 [1.4, 5.2] years. One of those 13 patients underwent single fascicular distal nerve transfer to improve elbow flexion before subsequently passing the Cookie test. Two patients did not have sufficient follow-up to assess elbow flexion.

CONCLUSION

Although the exact role of shoulder surgery in infancy for BPBI remains to be defined, the findings from this study provide proof of concept that early, targeted surgical treatment of the shoulder may obviate the need for brachial plexus nerve reconstruction in a highly selected group of infants with BPBI.

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.

Management of Brachial Plexus Birth Injury: The SickKids Experience

This article describes the approach utilized by the multidisciplinary team at Sick Kids Hospital to evaluate and treat patients with brachial plexus birth injury (BPBI). This approach has been informed by more than 30 years of experience treating over 1,800 patients with BPBI and continues to evolve over time. The objective of this article is to provide readers with a practical overview of the Sick Kids approach to the management of infants with BPBI.

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.

Long-Term Results of Microsurgical Brachial Plexus Reconstruction in Late-Presenting Cases of Brachial Plexus Birth Injury

PURPOSE

The role of primary surgery in delayed presenting cases of brachial plexus birth injury is still debated. The purpose of this study was to evaluate the results of brachial plexus reconstruction performed at the age of ≥12 months.

METHODS

Twenty-nine cases were included. Five cases had upper (C5-6) palsy, 4 had upper/middle (C5-7), and 20 had total (C5-8 and T1) palsy.

RESULTS

The age at the time of primary surgery was an average of 15.6 months. The brachial plexus was formally explored and neurolysis, grafting, and neurotization were used in different combinations. Exploration revealed that 27% of the roots were avulsed and 32% were ruptured. The follow-up was an average of 7.9 years. Generally, the best functional recovery was elbow flexion followed by shoulder external rotation. Satisfactory shoulder abduction (≥6 on the Toronto Active Movement Scale [TAMS]) was achieved in 31% of cases. The abduction range was an average of 79° ± 35°; 50° in upper palsy, 103° in upper/middle palsy, and 82° in total palsy. Shoulder external rotation ≥6 on the TAMS was achieved in 62% of cases. External rotation range was an average of 58° ± 29°; 78° in upper palsy, 68° in upper/middle palsy, and 52° in total palsy. Elbow flexion and extension of ≥6 on the TAMS were achieved in 69% and 58% of cases, respectively. Wrist flexion and finger flexion of ≥6 on the TAMS were achieved in 35% and 12.5%, whereas wrist and finger extension of >6 on the TAMS were achieved in 25% and 4% of cases, respectively.

CONCLUSION

In the delayed presentation of brachial plexus birth injury, brachial plexus reconstruction results in good functional recovery of elbow flexion and shoulder external rotation but modest functional recovery of finger flexion and wrist extension. The rate of functional recovery of the elbow flexion was similar following nerve grafting and transfer. Nerve transfer for shoulder external rotation should be considered even in infants with available roots for grafting.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Clinical Assessment of Functional Recovery Following Nerve Transfer for Traumatic Brachial Plexus Injuries

Surgical reconstruction and postoperative rehabilitation are both important for restoring function in patients with traumatic brachial plexus injuries (BPIs). The current study aimed to understand variations in recovery progression among patients with different injury levels after receiving the nerve transfer methods. A total of 26 patients with BPIs participated in a rehabilitation training program over 6 months after nerve reconstruction. The differences between the first and second evaluations and between C5-C6 and C5-C7 BPIs were compared. Results showed significant improvements in elbow flexion range (p = 0.001), British Medical Research Council's score of shoulder flexion (p = 0.046), shoulder abduction (p = 0.013), shoulder external rotation (p = 0.020), quantitative muscle strength, and grip strength at the second evaluation for both groups. C5-C6 BPIs patients showed a larger shoulder flexion range (p = 0.022) and greater strength of the shoulder rotator (p = 0.004), elbow flexor (p = 0.028), elbow extensor (p = 0.041), wrist extensor (p = 0.001), and grip force (p = 0.045) than C5-C7 BPIs patients at the second evaluation. Our results indicated different improvements among patients according to injury levels, with quantitative values assisting in establishing goals for interventions.

Ultrasound assessment of glenohumeral dysplasia in infants

Brachial plexus birth injury can lead to irreversible neuromuscular dysfunction and skeletal deformity of the upper extremity and shoulder girdle, ultimately resulting in glenohumeral dysplasia. Diagnosis and treatment of affected infants requires a multi-disciplinary approach in which imaging plays a vital role. While MRI is excellent for assessing both the shoulder and spine of these children, it is costly and requires sedation and is thus typically reserved for preoperative planning. US, however, is inexpensive, dynamic and readily available and provides excellent visualization of the largely cartilaginous glenohumeral joint. As such, it has become a highly useful modality during early diagnosis and follow-up of children with brachial plexus birth injuries. In this review, we describe the relevant anatomy of the glenohumeral joint, outlining the normal sonographic appearance as well as providing tips and tricks for identifying and characterizing pathology.

Clinical and functional outcome after different surgical approaches for brachial plexus injuries: Cohort study

Introduction

Brachial plexus injury (BPI) can result in complete loss of neurological function and reduces the quality of life. Nerve transfer, nerve grafting, external neurolysis, and free functional muscle transfer are several management options that determine the eventual outcomes. Despite various methods of treatment, hardly any literature compares directly the result of these treatment options. This study aimed to analyze differences in clinical and functional outcomes after a reconstructive surgery.

Methods

A cohort retrospective study was conducted on traumatic brachial plexus injured patients aged from 17 to 65 years at one hospital in Surabaya, Indonesia, from January 2009 to December 2019. All patients were divided into 4 groups depending on the types of surgery. The clinical outcomes were measured using elbow and shoulder muscle strength, elbow and shoulder range of motion (ROM), and pain level (measured using Visual Analog Scale/VAS); the functional outcomes were measured using the overall quality of life using the DASH (disabilities of the arms, shoulder, and hand) score.

Results

This study included 316 patients comprising of 256 males with an average age of 27.53 ± 11.37, an average time from injury to surgery of 17.74 ± 35.82 months, and average follow-up duration of 59.89 ± 37.68 months. Most cases were caused by road traffic accidents (77.22%) and most were total arm type of BPI injury (70.7%). There was no significant difference in the mean values of study parameters except in VAS (p = 0.042) as nerve grafting resulted in less pain than external neurolysis (2.27 ± 1.03 vs. 3.68 ± 1.93, respectively; p = 0.017). Besides, nerve transfer procedure also resulted in less pain compared to external neurolysis (2.99 ± 1.84 vs. 3.68 ± 1.93, respectively; p = 0.036).

Conclusion

We found no significant difference between types of surgery and the postsurgical outcome. A wider multicenter study was required to define the clinical and functional outcomes clearly.

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.

Comparison of Outcomes of Spinal Accessory to Suprascapular Nerve Transfer Versus Nerve Grafting for Neonatal Brachial Plexus Injury

Neonatal brachial plexus injuries may cause critical limitations of upper extremity function. The optimal surgical approach to address neonatal brachial plexus injuries has not been defined. In this systematic review, we compare clinical results after spinal accessory to suprascapular nerve transfer and nerve graft techniques among patients with neonatal brachial plexus injury. [Orthopedics. 2022;45(1):7-12.].

Surgical Reconstruction of Isolated Upper Trunk Brachial Plexus Birth Injuries in the Presence of an Avulsed C5 or C6 Nerve Root

BACKGROUND

Avulsion of either the C5 or C6 root with intact middle and lower trunks in brachial plexus birth injury is rare. In these cases, only 1 proximal root is available for intraplexal reconstruction. The purpose of the present study was to determine the outcomes of these patients when single-root reconstruction was balanced across the anterior and posterior elements of the upper trunk.

METHODS

We performed a retrospective cohort study of prospectively collected data for patients with brachial plexus birth injury who underwent primary nerve reconstruction between 1993 and 2014. Patients were included who had isolated upper-trunk injuries with intact middle and lower trunks. The study group had avulsion of either the C5 or C6 root. The control group had neuroma-in-continuity or ruptures of the upper trunk. Outcomes were assessed with use of the Active Movement Scale and the Brachial Plexus Outcome Measure. The Wilcoxon signed-rank test was utilized to evaluate changes across treatment.

RESULTS

Ten patients with brachial plexus birth injury were included in the avulsion cohort. Surgical reconstruction entailed neuroma resection and nerve grafting from the single available root balanced across all distal targets with or without spinal accessory-to-suprascapular nerve transfer. Significant improvements were observed across treatment for both the avulsion and control groups in terms of shoulder abduction, shoulder flexion, external rotation, elbow flexion, and supination. At a mean follow-up of 54.5 ± 8.8 months, patients in the avulsion group achieved Active Movement Scale scores of 6.8 ± 0.4 for elbow flexion and 6.5 ± 0.9 for shoulder flexion and abduction, with lesser recovery observed in external rotation (3.3 ± 2.8). All patients available for Brachial Plexus Outcome Measure assessments demonstrated functional movement.

CONCLUSIONS

In the setting of avulsion of 1 upper-trunk root, nerve reconstruction by grafting of the upper trunk from the other upper-trunk root provides improved movement, high Active Movement Scale scores, and satisfactory function according to the Brachial Plexus Outcome Measure. These data provide support for a strategy that ensures the entire upper trunk is adequately reconstructed in the setting of upper-trunk lesions.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

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.

Surgical Reconstruction of Isolated Upper Trunk Brachial Plexus Birth Injuries in the Presence of an Avulsed C5 or C6 Nerve Root

BACKGROUND

Avulsion of either the C5 or C6 root with intact middle and lower trunks in brachial plexus birth injury is rare. In these cases, only 1 proximal root is available for intraplexal reconstruction. The purpose of the present study was to determine the outcomes of these patients when single-root reconstruction was balanced across the anterior and posterior elements of the upper trunk.

METHODS

We performed a retrospective cohort study of prospectively collected data for patients with brachial plexus birth injury who underwent primary nerve reconstruction between 1993 and 2014. Patients were included who had isolated upper-trunk injuries with intact middle and lower trunks. The study group had avulsion of either the C5 or C6 root. The control group had neuroma-in-continuity or ruptures of the upper trunk. Outcomes were assessed with use of the Active Movement Scale and the Brachial Plexus Outcome Measure. The Wilcoxon signed-rank test was utilized to evaluate changes across treatment.

RESULTS

Ten patients with brachial plexus birth injury were included in the avulsion cohort. Surgical reconstruction entailed neuroma resection and nerve grafting from the single available root balanced across all distal targets with or without spinal accessory-to-suprascapular nerve transfer. Significant improvements were observed across treatment for both the avulsion and control groups in terms of shoulder abduction, shoulder flexion, external rotation, elbow flexion, and supination. At a mean follow-up of 54.5 ± 8.8 months, patients in the avulsion group achieved Active Movement Scale scores of 6.8 ± 0.4 for elbow flexion and 6.5 ± 0.9 for shoulder flexion and abduction, with lesser recovery observed in external rotation (3.3 ± 2.8). All patients available for Brachial Plexus Outcome Measure assessments demonstrated functional movement.

CONCLUSIONS

In the setting of avulsion of 1 upper-trunk root, nerve reconstruction by grafting of the upper trunk from the other upper-trunk root provides improved movement, high Active Movement Scale scores, and satisfactory function according to the Brachial Plexus Outcome Measure. These data provide support for a strategy that ensures the entire upper trunk is adequately reconstructed in the setting of upper-trunk lesions.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

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.

Nerve graft versus nerve transfer for neonatal brachial plexus: shoulder outcomes

OBJECTIVE

The decision-making in neonatal brachial plexus palsy (NBPP) treatment continues to have many areas in need of clarification. Graft repair was the gold standard until the introduction of nerve transfer strategies. Currently, there is conflicting evidence regarding outcomes in patients with nerve grafts versus nerve transfers in relation to shoulder function. The objective of this study was to further define the outcomes for reconstruction strategies in NBPP with a specific focus on the shoulder.

METHODS

A cohort of patients with NBPP and surgical repairs from a single center were reviewed. Demographic and standard clinical data, including imaging and electrodiagnostics, were gathered from a clinical database. Clinical data from physical therapy evaluations, including active and passive range of motion, were examined. Statistical analysis was performed on the available data.

RESULTS

Forty-five patients met the inclusion criteria for this study, 19 with graft repair and 26 with nerve transfers. There were no significant differences in demographics between the two groups. Understandably, there were no patients in the nerve grafting group with preganglionic lesions, resulting in a difference in lesion type between the cohorts. There were no differences in preoperative shoulder function between the cohorts. Both groups reached statistically significant improvements in shoulder flexion and shoulder abduction. The nerve transfer group experienced a significant improvement in shoulder external rotation, from -78° to -28° (p = 0.0001), whereas a significant difference was not reached in the graft group. When compared between groups, there appeared to be a trend favoring nerve transfer in shoulder external rotation, with the graft patients improving by 17° and the transfer patients improving by 49° (p = 0.07).

CONCLUSIONS

In NBPP, patients with shoulder weakness experience statistically significant improvements in shoulder flexion and abduction after graft repair or nerve transfer, and patients with nerve transfers additionally experience significant improvement in external rotation. With regard to shoulder external rotation, there appear to be some data supporting the use of nerve transfers.

Association of Neurosurgical Work Relative Value Units with Objective Markers of Operative Complexity

OBJECTIVE

Relative value units (RVUs) form the backbone of health care service reimbursement calculation in the United States. However, it remains unclear how well RVUs align with objective measures of procedural complexity within neurosurgery.

METHODS

The 2018 American College of Surgeons National Surgical Quality Improvement Program database was queried for neurosurgical procedures with >50 patients, using Current Procedural Terminology (CPT) codes. Length of stay (LOS), operative time, mortality, and readmission and reoperation rates were collected for each code and a univariate correlation analysis was performed, with significant predictors entered into a multivariate logistic regression model, which generated predicted work RVUs, which were compared with actual RVUs to identify undervalued and overvalued procedures.

RESULTS

Among 64 CPT codes, LOS, operative time, mortality, readmission, and reoperation were significant independent predictors of work RVUs and together explained 76% of RVU variance in a multivariate model (R² = 0.76). Using a difference of >1.5 standard deviations from the mean, procedures associated with greater than predicted RVU included surgery for intracranial carotid circulation aneurysms (CPTs 61697 and 61700; residual RVU = 12.94 and 15.07, respectively), and infratemporal preauricular approaches to middle cranial fossa (CPT 61590; residual RVU = 15.39). Conversely, laminectomy/foraminotomy for decompression of additional spinal cord, cauda equina, and/or nerve root segments (CPT 63048; residual RVU = -21.30), transtemporal craniotomy for cerebellopontine angle tumor resection (CPT 61526; residual RVU = -9.95), and brachial plexus neuroplasty (CPT 64713; residual RVU = -11.29) were associated with lower than predicted RVU.

CONCLUSIONS

Work RVUs for neurosurgical procedures are largely predictive of objective measures of surgical complexity, with few notable exceptions.

Phrenic nerve neurotization utilizing half of the spinal accessory nerve to the functional restoration of the paralyzed diaphragm in high spinal cord injury secondary to brain tumor resection

The authors present a case of functional improvement of diaphragmatic paralysis in high spinal cord injury, performing a neurotization of the phrenic nerve with accessory spinal nerve hemisection. A C1-C2 injury of the spinal cord was diagnosed in a 12-year-old male, secondary to resection of a brainstem glioma. The patient did not have diaphragmatic motility at the moment that the mechanical ventilation was removed; however, he presented apnea. The patient underwent neurotization of the right phrenic nerve with the right spinal accessory nerve, 5 months after the injury and 6 months after nerve transfer; he had complete mobilization of the right hemidiaphragm, nevertheless persisted with paralysis of the left hemidiaphragm. This achievement reduced the use of mechanical ventilation during the day.

Reconstruction of the Suprascapular Nerve in Brachial Plexus Birth Injury: A Comparison of Nerve Grafting and Nerve Transfers

BACKGROUND

Shoulder external rotation recovery in brachial plexus birth injury is often limited. Nerve grafting to the suprascapular nerve and transfer of the spinal accessory nerve to the suprascapular nerve are commonly performed to restore shoulder external rotation, but the optimal surgical technique has not been clearly demonstrated. We investigated whether there was a difference between nerve grafting and nerve transfer in terms of shoulder external rotation recovery or secondary shoulder procedures.

METHODS

This is a multicenter, retrospective cohort study of 145 infants with brachial plexus birth injury who underwent reconstruction with nerve grafting to the suprascapular nerve (n = 59) or spinal accessory nerve to suprascapular nerve transfer (n = 86) with a minimum follow-up of 18 months (median, 25.7 months [interquartile range, 22.0, 31.2 months]). The primary outcome was the Active Movement Scale (AMS) score for shoulder external rotation at 18 to 36 months. The secondary outcome was secondary shoulder surgery. Two-sample Wilcoxon and t tests were used to analyze continuous variables, and the Fisher exact test was used to analyze categorical variables. The Kaplan-Meier method was used to estimate the cumulative risk of subsequent shoulder procedures, and the proportional hazards model was used to estimate hazard ratios (HRs).

RESULTS

The grafting and transfer groups were similar in Narakas type, preoperative AMS scores, and shoulder subluxation. The mean postoperative shoulder external rotation AMS scores were 2.70 in the grafting group and 3.21 in the transfer group, with no difference in shoulder external rotation recovery between the groups (difference, 0.51 [95% confidence interval (CI), -0.31 to 1.33]). A greater proportion of the transfer group (24%) achieved an AMS score of >5 for shoulder external rotation compared with the grafting group (5%) (odds ratio, 5.9 [95% CI, 1.3 to 27.4]). Forty percent of the transfer group underwent a secondary shoulder surgical procedure compared with 53% of the grafting group; this was a significantly lower subsequent surgery rate (HR, 0.58 [95% CI, 0.35 to 0.95]).

CONCLUSIONS

Shoulder external rotation recovery in brachial plexus birth injury remains disappointing regardless of surgical technique, with a mean postoperative AMS score of 3, 17% of infants achieving an AMS score of >5, and a high frequency of secondary shoulder procedures in this study. Spinal accessory nerve to suprascapular nerve transfers were associated with a higher proportion of infants achieving functional shoulder external rotation (AMS score of >5) and fewer secondary shoulder procedures.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Suprascapular Ligament Release From an Anterior Approach: An Anatomic Feasibility Study

PURPOSE

The results of spinal accessory to suprascapular nerve transfers have been less reliable than other nerve transfers in the upper limb, possibly owing to compression of the nerve by the suprascapular ligament. The posterior approach has been advocated to allow for release of the ligament. The purpose of this study was to determine whether a ligament release is possible from the anterior approach.

METHODS

Nine fresh-frozen cadavers were dissected to determine whether the ligament could be approached and released from the anterior approach. Complete ligament release was demonstrated by subluxation of the nerve out of the suprascapular notch.

RESULTS

Ligament release was achieved in all specimens, although in one, confirmation of complete release required a posterior approach.

CONCLUSIONS

Release of the suprascapular ligament to eliminate a potential source of compression of the suprascapular nerve during spinal accessory to suprascapular nerve transfer is possible through an anterior approach.

CLINICAL RELEVANCE

Release of the suprascapular ligament through an anterior approach allows this procedure to be performed through the same approach as brachial plexus exploration and spinal accessory nerve to suprascapular nerve transfer. This method could reduce surgical time and patient repositioning and avoid additional incisions.

Median to radial nerve transfer after traumatic radial nerve avulsion in a pediatric patient

This case report describes an isolated radial nerve avulsion in a pediatric patient, treated by combination sensory and motor median to radial nerve transfers. After traumatic avulsion of the proximal radial nerve, a 12-year-old male patient underwent end-to-end transfer of median nerve branches to flexor carpi radialis and flexor digitorum superficialis to the posterior interosseous nerve and extensor carpi radialis nerve, respectively. He underwent end-to-side sensory transfer of the superficial radial sensory to the median sensory nerve. Pronator teres to extensor carpi radialis brevis tendon transfer was simultaneously performed to power short-term wrist extension. Within months after surgery, the patient had regained 9-10/10 sensation in the hand and forearm. In the following months and years, he regained dexterity, independent fine-finger and thumb motions, and 4-5/5 strength in all extensors except the abductor pollicis longus muscle. He grew 25 cm without extremity deformity or need for secondary orthopedic procedures. In appropriate adult and pediatric patients with proximal radial nerve injuries, nerve transfers have advantages over tendon transfers, including restored independent fine finger motions, regained sensation, and reinnervation of multiple muscle groups with minimal donor sacrifice.

Outcomes of Spinal Accessory-to-Suprascapular Nerve Transfers for Brachial Plexus Birth Injury

PURPOSE

The results of a spinal accessory nerve-to-suprascapular (SAN-SSN) nerve transfer for brachial plexus birth injuries (BPBIs) have thus far been presented only in limited case series. Our study evaluates the recovery of shoulder function of patients who underwent an SAN-SSN for BPBI as an isolated procedure or as part of a multinerve reconstruction (MNR) surgery.

METHODS

We retrospectively reviewed the medical records of patients at a single institution who underwent an SAN-SSN after BPBI. Inclusion criteria were patients with both preoperative and a minimum 12-months postoperative active movement scale (AMS) scores. Patients for whom the primary surgery involved tendon transfers were excluded. The primary outcome measures were AMS scores for shoulder abduction, forward flexion, and external rotation and secondary outcomes included the need for further shoulder surgery to improve function.

RESULTS

Seventy-three patients met the inclusion criteria. Forty-three patients (58.9%) obtained functional shoulder motion (AMS ≥ 6) of at least 1 of 3 planes (abduction/flexion/external rotation) following surgery, with 13 patients (17.8%) achieving full recovery of 1 of these shoulder motions against gravity (AMS = 7). Fifty-six patients (76.7%) did not undergo subsequent tendon transfers or corrective osteotomies to augment shoulder function. The MNR procedures were performed in 46 patients (63%), of whom 45.7% gained a functional recovery. In 27 patients for whom SAN-SSN nerve transfer was conducted in isolation, 81.5% gained functional shoulder motion. However, isolated SAN-SSNs were conducted at a later age than MNR procedures (13.2 vs 4.8 months) and had higher preoperative AMS scores. The anterior and posterior approaches for SAN-SSN were both found to be effective when used for SAN-SSN in BPBI. When the follow-up duration cutoff was set to 3 years, the outcomes were found to be superior.

CONCLUSIONS

In 76.7% of the patients, SAN-SSN was able to recover function that was sufficient to prevent tendon transfers and corrective osteotomies. A cutoff of 3 postoperative years should be used as a benchmark for analyzing the results of this procedure.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Elbow flexion in neonatal brachial plexus palsy: a meta-analysis of graft versus transfer

BACKGROUND

Functional elbow flexion recovery is one of the main goals of neonatal brachial plexus palsy (NBPP) reconstruction. The current neurosurgical treatment options include nerve grafting and nerve transfer.

OBJECTIVE

The present study sought to examine the literature for comparison of functional elbow flexion recovery in NBPP following nerve grafting or nerve transfer. We conducted a systematic literature review and meta-analysis according to PRISMA guidelines. A search was conducted on Pubmed/Medline and Cochrane for eligible studies published until November of 2018. Odd ratios (OR) and 95% confidence intervals (CI) were calculated to compare functional elbow flexion outcomes between nerve graft and nerve transfer. A random effects model meta-analysis was conducted. A Medical Research Council (MRC) score ≥ 3 or Active Movement Scale (AMS) ≥ 5 was considered a functional recovery of elbow flexion.

RESULTS

The present study included 194 patients from 1990 to 2015 across five observational trials. Only pediatric patients with obstetric brachial plexus injury were included. The mean patient age at surgery varied between studies from 5.7 months to 11.9 months and mean follow-up from 12 to 70 months. No complications or cases of donor site morbidity were reported. From the included studies, 118 patients were reported with MRC or AMS scoring usable for odd ratio comparison. Functional recovery occurred with nerve transfer in 95.2% of patients (n = 59/62) and with nerve grafting in 96.4% of patients (n = 54/56). Overall, the outcomes for elbow flexion between the groups appeared similar (OR 1.15, 95% CI 0.19-7.08, I² 2.9%).

CONCLUSION

Comparing nerve grafting and nerve transfer for NBPP, there is no statistically significant difference in functional elbow flexion recovery.

Nerve Transfer Surgery for Penetrating Upper Extremity Injuries

CONTEXT

Nerve transfer surgery is an option for repair of penetrating injuries of the upper extremity. In the right setting, it has advantages over tendon transfers and nerve grafting.

OBJECTIVE

To review our experience since 2006 of nerve transfer surgery in the upper extremities.

DESIGN

We included cases performed to repair penetrating trauma within three months of injury with at least three years' follow-up.

MAIN OUTCOME MEASURES

Preoperative and postoperative muscle strength of the affected extremity.

RESULTS

All 16 patients were males aged 16 to 43 years. Six patients underwent nerve transfer surgery because of elbow flexion; 5, finger extension; 3, finger flexion; and 2, wrist pronation. Nine patients (56%) had associated vascular injury, and 4 (25%) had fractures. Average follow-up was 6 years. No perioperative complications occurred. Patients had a mean of 3.7 operations after the initial trauma. All patients received physical therapy. All patients improved from 0 of 5 muscle strength preoperatively to a mean of 3.8 (range = 2/5 to 5/5) within 1 year after surgery. In all cases, strength was maintained, and 8 (50%) had continued improvement after Year 1. Ten (63%) returned to their previous employment level. Mean Disabilities of the Arm, Shoulder and Hand score improved from 68 to 83 postoperatively.

CONCLUSION

Nerve transfer is a safe, effective technique for correcting penetrating trauma-related nerve injury. In appropriate patients it offers advantages over other techniques. Outcomes can be maintained long term, and many patients can return to their previous level of function.

Effect of fascicle composition on ulnar to musculocutaneous nerve transfer (Oberlin transfer) in neonatal brachial plexus palsy

OBJECTIVE Neonatal brachial plexus palsy (NBPP) continues to be a problematic occurrence impacting approximately 1.5 per 1000 live births in the United States, with 10%-40% of these infants experiencing permanent disability. These children lose elbow flexion, and one surgical option for recovering it is the Oberlin transfer. Published data support the use of the ulnar nerve fascicle that innervates the flexor carpi ulnaris as the donor nerve in adults, but no analogous published data exist for infants. This study investigated the association of ulnar nerve fascicle choice with functional elbow flexion outcome in NBPP. METHODS The authors conducted a retrospective study of 13 cases in which infants underwent ulnar to musculocutaneous nerve transfer for NBPP at a single institution. They collected data on patient demographics, clinical characteristics, active range of motion (AROM), and intraoperative neuromonitoring (IONM) (using 4 ulnar nerve index muscles). Standard statistical analysis compared pre- and postoperative motor function improvement between specific fascicle transfer (1-2 muscles for either wrist flexion or hand intrinsics) and nonspecific fascicle transfer (> 2 muscles for wrist flexion and hand intrinsics) groups. RESULTS The patients' average age at initial clinic visit was 2.9 months, and their average age at surgical intervention was 7.4 months. All NBPPs were unilateral; the majority of patients were female (61%), were Caucasian (69%), had right-sided NBPP (61%), and had Narakas grade I or II injuries (54%). IONM recordings for the fascicular dissection revealed a donor fascicle with nonspecific innervation in 6 (46%) infants and specific innervation in the remaining 7 (54%) patients. At 6-month follow-up, the AROM improvement in elbow flexion in adduction was 38° in the specific fascicle transfer group versus 36° in the nonspecific fascicle transfer group, with no statistically significant difference (p = 0.93). CONCLUSIONS Both specific and nonspecific fascicle transfers led to functional recovery, but that the composition of the donor fascicle had no impact on early outcomes. In young infants, ulnar nerve fascicular dissection places the ulnar nerve at risk for iatrogenic damage. The data from this study suggest that the use of any motor fascicle, specific or nonspecific, produces similar results and that the Oberlin transfer can be performed with less intrafascicular dissection, less time of surgical exposure, and less potential for donor site morbidity.