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Nerve Transfers Effective in Reconstructing Upper Trunk Obstetrical Brachial Plexus Injuries
Adil Ladak, MD, MSc; Michael Morhart, MD, FRCSC; Kathleen O’Grady, BSc; Ming Chan, MD, FRCP; Jaret Olson, MD, FRCSC
University of Alberta, Edmonton, AB, Canada
Standard surgical management of obstetrical brachial plexus injury is primary reconstruction of the plexus with sural nerve grafting with the addition of nerve transfers as needed. Recently, the nerve-to-nerve transfer technique has been used to treat brachial plexus injury in adults, affording the benefit of distal nerve coaptations, minimizing regenerative distance. The purpose of our study was to determine the effectiveness of nerve transfers in reconstructing isolated upper trunk injuries in obstetrical brachial plexus patients. Patients between the ages of 10 and 18 months with isolated upper trunk injuries (n=9) requiring surgery, using the active movement scale (AMS), were treated with three nerve transfers: spinal accessory to suprascapular for shoulder abduction and external rotation; branch to triceps of radial nerve to axillary nerve for shoulder abduction; and the Oberlin transfer for elbow flexion. Patients were assessed pre- and post-operatively using the AMS. Pre-operative function was regained by 3 months post-nerve transfers and improvement in elbow and shoulder function was observed between 6 and 12 months. By 6 months, all patients passed the cookie test. At 12-month follow-up, shoulder abduction improved from 3.6 to 5.5, shoulder flexion improved from 3.6 to 6.5, shoulder external rotation improved from 1.8 to 5, elbow flexion improved from 3.9 to 7 and forearm supination improved from 2 to 7. There was no clinically appreciable donor site morbidity, with no change in wrist flexion or elbow extension. With decreased recovery time to pre-operative function compared to traditional nerve grafting and significant gains in AMS by 12 months post-op, nerve transfers present a potential first line treatment option in isolated upper trunk obstetrical brachial plexus injury.
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