Long-Term Outcome of Isolated Bypass Grafting Into Suprascapular Nerve For Upper Brachial Plexus Birth Injury
Aaron J Berger, MD, PhD1, Leslie Grossman, BA2, Andrew Price, MD2,3, Herbert Valencia, RNFA2 and John A.I. Grossman, MD2, (1)Division of Plastic and Reconstructive Surgery, Nicklaus Children's Hospital, Miami, FL, (2)Nicklaus Children's Hospital, Miami, FL, (3)NYU Hospital for Joint Diseases, New York, NY
Introduction
Decision-making during primary nerve reconstruction for brachial plexus birth injury (BPBI) is challenging, often with a neuroma-in-continuity that demonstrates some preservation of function. End-to-side bypass grafting was employed by the lead author for the management of some BPBIs, in which continuity of function through the suprascapular nerve was augmented, without risking downgrade by neuroma resection and grafting or nerve transfer. In this study, we report long-term outcomes of isolated bypass grafting to the suprascapular nerve for patients with upper BPBI.
Materials & Methods
Over a 15-year period, 374 primary BPBI nerve cases were performed by the lead surgeon. 47 (12.5%) of these patients underwent isolated bypass grafting to the suprascapular nerve, in which a cervical plexus graft was used from C5 or C6 to the suprascapular nerve, with end-to-side coaptations performed on both ends.
The mean age at surgery was 13.4 months (range: 6-24 months).
Simultaneous procedures included: botulinum toxin administration (n=37; 78.7%), subscapularis slide (n=23; 49%), and pectoralis major tenotomy (n=2). Secondary procedures included: botulinum toxin administration (n=7; 15%), subscapularis slide (n=1), latissimus muscle transfer (n=5; 10.6%), and humerus osteotomy (n=3).
19 of the 47 patients are currently available for 5-year follow-up.
Results
Patients were stratified by their initial need for concomitant subscapularis slide at the time of primary nerve operation.
Of the 19 patients available for long-term (>5 year) follow-up, 7 had required concomitant subscapularis slide and 12 did not require concomitant subscapularis slide.
All patients were assessed using the Miami Shoulder Score Classification.
In the group that did not require concomitant shoulder release, 91.7% (n=11) demonstrated excellent or good shoulder function and one demonstrated a satisfactory/fair result; there were no poor shoulder outcomes.
In the group that required concomitant subscapularis slide, only 2 patients achieved excellent/good results, one demonstrated a satisfactory/fair result, while 57.1% (n=4) demonstrated poor shoulder function, ultimately requiring secondary procedures, either tendon transfer or humeral osteotomy.
Conclusions
Bypass grafting provides an option for augmenting reinnervation in BPBI. The major contraindication is in cases with significant nerve trauma that can only be repaired with neuroma resection and grafting or nerve transfer.
For patients without fixed shoulder contractures, bypass grafting is an option for augmenting innervation of the suprascapular nerve.
However, for patients with fixed shoulder contractures (requiring concomitant release), bypass grafting may not be sufficient to recover adequate shoulder function. For these patients, end-to-end grafting or spinal accessory to suprascapular nerve transfer is indicated.
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