Nerve Wraps In Obstetrical Brachial Plexus Palsy (OBPP): Is there a difference in outcome?
Jessica A Lee, MD1; Meg Stanger, PT2; Megan Natali, PA2; Stephanie Greene, MD2; Lorelei J Grunwaldt, MD2
1University of Pittsburgh, Pittsburgh, PA, 2Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA
Introduction: Excision of neuroma and sural nerve grafting is widely accepted for the treatment of OBPP patients requiring surgical intervention.The exact technique for microanastomosis of the graft varies by surgeon.Clarke et. al has published excellent results using a no-suture technique with tissue glue.We hypothesize that the use of a porcine submucosa extracellular nerve wrap (AxoGuard Nerve Protector, AxoGen Inc., Alachua, FL) in addition to tissue glue helps with alignment of the nerve grafts and does not negatively affect outcome.
Materials & Methods: A retrospective chart review was performed of all patients who underwent surgical exploration at our multidisciplinary brachial plexus center from 2009 to 2016.Those patients with isolated upper trunk neuromas were studied (C5 & C6).Patients with less than 6 months of follow-up were excluded. Active movement scale (AMS) scores pertinent to the upper trunk (shoulder abduction, shoulder flexion, shoulder external rotation, elbow flexion, and forearm supination) were averaged and compared pre- and post-operatively between patients who had nerve wraps plus tissue glue versus patients who had tissue glue only.
Results: 34 patients were identified from 2009 to 2016 who underwent surgical exploration.Of those 34 patients, 10 had isolated upper trunk neuromas in continuity.7 were female and 3 were male.1 injury was left sided and the other 9 were right sided.8 out of 10 patients had a shoulder dystocia.2 patients had clavicle fractures, 1 of whom also had a humerus fracture. The average age at surgery was 10 months and length of follow-up was 30 months. 1 patient was excluded for less than 6 months follow-up. 4 patients had nerve wraps used at the proximal and/or distal anastomosis in addition to tissue glue, and 5 patients had tissue glue only. Patients who had nerve wraps plus tissue glue improved in AMS shoulder, elbow, and forearm scores from 4.4 pre-operatively to 6.4 post-operatively.Those who had tissue glue only had improvement in scores from 4.7 to 6.3.There was no statistical difference in improvement between the two groups (p=0.39, Wilcoxon rank-sum test).
Conclusions: AxoGen nerve wraps can be a useful adjunct to tissue glue for the microanastomosis in sural nerve grafting in OBPP.Although this cohort is small and further follow-up is needed, early data suggests that this technique does not lead to any decrease in function.
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