Nerve Surgery Techniques in Obstetric Patients: A Systematic Review and Pooled Analysis
Kevin T Rezzadeh, BA1, Megan Rose Donnelly, BS2, Karen J Noh, BS2, Themistocles Stavros Protopsaltis, MD3, Andrew E. Price, MD4 and Jacques H. Hacquebord, MD2, (1)New York University School of Medicine, New York, NY, (2)NYU Langone Health, New York, NY, (3)NYU Langone Medical Center, New York City, NY, (4)Brachial Plexus Program, Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, NY
INTRODUCTION: Nerve surgery can be used to resolve neurologic deficits left from obstetric brachial plexus injuries. These surgeries are heterogeneous in practice and can involve nerve grafting and/or nerve transfers. The purpose of this study is to characterize the use of nerve transfers in pediatric patient populations with obstetric nerve palsy.
METHODS: A systematic review of the literature was completed by two independent reviewers. Studies reporting individual outcomes of patients receiving nerve surgery for obstetric brachial plexus palsy were included. Non-English language studies were excluded. Patients with non-nerve surgeries that may serve as salvage procedures for upper extremity functionality were excluded. MRC and AMS scores were compared depending on the number of nerve surgeries completed. Additionally, nerve transfer practices were pooled and the frequency of use of nerve donors was calculated. Nerve repair surgeries, defined as nerve transfer or nerve grafting, were quantified. Pre- and post-operative functionality were compared based upon number of nerve surgeries completed.
RESULTS: There were 347 patients included in this pooled analysis from 37 studies, with 174 having pre-op and post-op elbow and/or shoulder MRC /AMS scores. Mean age at surgery was 7.9 months. The most frequently used nerve donors for restoration of elbow flexion were the C5 nerve root (23.3%), ulnar nerve (15.1%), C7 nerve root (15.1%), intercostal nerve (13.7%), and C6 nerve root (9.3%). The most frequently used nerve donors for restoration of shoulder function were spinal accessory nerve (33.8%), C5 nerve root (29.7%), C7 nerve root (15.5%), C6 nerve root (11.3%), phrenic nerve (2.6%). Patients with fewer nerve repair surgeries had better pre-operative MRC and AMS scores that approached statistical significance (p< 0.1) prior to surgery, although these differences became less marked postoperatively, with all nerve surgery groups (ranging from 1-5 nerve surgeries) achieving elbow/shoulder AMS scores between 5-7 and all elbow shoulder MRC scores being between 2-3 and elbow MRC scores being between 3-4. Elbow function was better restored than shoulder function on average at final follow-up.
DISCUSSION AND CONCLUSION: Pediatric patients undergo a variety of nerve surgeries to restore upper extremity functionality. Nerve root grafting and nerve transfer surgeries are both common methods of reanimating the upper extremity in patients with obstetric brachial plexus injury. Nerve surgery can help equalize differences in preoperative motor functionality scores post-operatively. The restoration of shoulder function is not as successful as the restoration of elbow function after nerve surgery regardless of the surgery undertaken.
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