What Are the Preferred Strategies for Brachial Plexus Reconstruction? Expert Opinions of Actual BPI Cases
Christopher J Dy, MD MPH, FACS1, Mihir J Desai, MD2, Bryan J Loeffler, MD3, R. Glenn Gaston, MD3, Steve K. Lee, MD4, Harvey Chim, MD5, Jeffrey B Friedrich, MD, MC, FACS6, Jason H Ko, MD, MBA7, Sameer Puri, MD8 and * PLANeT Study Group, *9, 1Washington University School of Medicine, St. Louis, MO, 2Vanderbilt University Medical Center, Nashville, TN, 3OrthoCarolina Hand Center, Charlotte, NC, 4Hand and Upper Extremity Surgery, Hospital for Special Surgery, New York, NY, 5University of Florida, Gainesville, FL, 6University of Washington, Seattle, WA, 7Northwestern University Feinberg School of Medicine, Chicago, IL, 8Indiana Hand to Shoulder Center, Indianapolis, IN, 9Lead Site: Washington University School of Medicine, St. Louis, MO
Introduction: There is tremendous variation in treatment of adult traumatic brachial plexus injuries (BPI). While there has been an appreciable shift towards distal nerve transfers, many surgeons advocate for a combination of reconstructive strategies, including nerve grafting, free functioning muscle transfers, tendon transfers, and joint arthrodesis. Our goal was to gather preferred reconstructive strategies from BPI surgeons for actual cases from a prospective multicenter cohort study of BPI patients.
Materials and Methods: We distributed 7 case files (history, physical examination, imaging results, and electrodiagnostic testing results) to 8 surgeons (all board-certified in their respective fields; all self-designated Level IV experts in BPI surgery) in the United States. The patients had been enrolled in a prospective multicenter cohort study for adult traumatic BPI. Each surgeon independently reviewed the cases and was asked to provide a preferred reconstructive plan for each patient.
Results: For a panplexus case after blunt trauma (67 year old; 13 weeks from injury): 3 of 8 surgeons would consider supraclavicular exploration and nerve grafting; there was notable disagreement in shoulder reconstruction, with 2 listing early glenohumeral arthrodesis as a primary option and 2 preferring XI to SSN transfer. For elbow reconstruction, intercostals to musculocutaneous nerve transfer was preferred by 7 of 8 surgeons (with free gracilis preferred by the other surgeon). For an upper trunk injury from a motorcycle accident (33 year old; 5 months from injury), only 1 surgeon recommended supraclavicular exploration and grafting; 6 of 8 would perform XI to SSN transfer; 8 of 8 would perform a Leechavengvong triceps-to-axillary transfer; and all would perform an Oberlin transfer (double Oberlin for all except one surgeon).
Conclusion: There is continued variability in the use of nerve grafting for BPI patients, even in cases of panplexus injury where options are quite limited. There is notable variability in how shoulder restoration and stability are managed, with some surgeons advocating for early/primary glenohumeral arthrodesis. The mixed track record of XI-to-SSN is reflected in this group’s skepticism to utilize it. Despite recent evidence demonstrating modest outcomes after ICN to MCN transfer, it is still a preferred option for many surgeons in this group. The consistent track record of the Oberlin and Leechavengvong transfers is reflected in this group’s responses, but more work is needed to establish consistent restoration of shoulder and elbow function when these intraplexal transfers are not available.
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