Timing of Nerve Recovery after Nerve Grafting in Obstetrical Brachial Plexus Palsy Patients with Isolated Upper Trunk Neuromas
Jessica A Lee, MD1; Meg Stanger, PT2; Megan Natali, PA2; Lorelei J Grunwaldt, MD2
1University of Pittsburgh, Pittsburgh, PA, 2Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA
Background: Traditionally, nerve recovery is quoted from adult literature at 1mm/day when educating families on postoperative recovery after nerve grafting in Obstetrical Brachial Plexus Palsy (OBPP). However, nerve recovery in infants and young children is typically faster than adults given shorter limb lengths, greater axonal regeneration, and increased cortical plasticity. One prior study reported a return to baseline function at 3-6 months postoperatively. However, there is a paucity of studies to corroborate this, and there have been no studies delineating the timeline to obtain clinically meaningful function.
Methods: A retrospective chart review was performed of all patients who underwent surgery by a single surgeon at a multidisciplinary OBPP Center. Patients with isolated upper trunk neuromas-in-continuity who underwent resection and grafting were identified. Demographics were analyzed. Time to return to baseline function was assessed by comparing Active Movement Scale (AMS) scores preoperatively and postoperatively. Time to clinically meaningful function, defined as an AMS score of =6, was also assessed.
Results: Of 37 patients who underwent surgical intervention, 11 had isolated upper trunk neuromas-in-continuity and underwent excision and reversed sural nerve interpositional grafting. 3 of 11 patients also underwent spinal accessory to suprascapular nerve transfers. Average age at surgery was 9.8±1.9 months (range 6.3-12.4 months). 1 patient did not have follow-up data and was excluded. Average follow-up was 37.1±16.8 months (range 9.5-63.3 months).
Median return to baseline AMS score was 7.6 months for shoulder abduction, 6.9 months for shoulder flexion, 4.2 months for shoulder external rotation, 6.7 months for elbow flexion, and 4.1 months for forearm supination. Clinically meaningful function was obtained in 8/10 patients at a median of 11.2 months for shoulder abduction, 10/10 patients at 9.7 months for shoulder flexion, 9/10 patients at 12.0 months for shoulder external rotation, 9/10 patients at 7.5 months for elbow flexion, and 10/10 patients at 9.7 months for forearm supination. The remaining patients who did not achieve clinically meaningful function all obtained scores of 5.
Conclusions: Return of nerve function after surgical intervention in OBPP patients who undergo resection of an upper trunk neuroma-in-continuity and nerve grafting is more rapid than reported in adult literature. In our cohort, return to baseline was approximately 4-8 months, as opposed to 3-6 months as previously reported. Clinically meaningful function was obtained in almost all patients by 9-15 months. Our study provides an important datapoint on timing of nerve recovery in OBPP patients.
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