Splinting versus a Novel End-to-Side Nerve Transfer Surgery for the Treatment of Glenohumeral Dysplasia in Brachial Plexus Birth Injury
Nathan Khabyeh-Hasbani, BA1, Md Sibat Noor, MD1, Ann Marie Feretti, EdD, OTR/L, CHT1, Erin Meisel, MD2 and Steven M Koehler, MD1, 1Montefiore Medical Center, Bronx, NY, 2Children's Hospital Los Angeles, Los Angeles, CA
Introduction:
Glenohumeral dysplasia (GHD) in brachial plexus birth injury (BPBI) poses significant challenges in the management. Surgery is the mainstay treatment to prevent GHD. Procedures can include nerve grafting, nerve transfer, or tendon transfer to restore function. Recently Sup-ER orthosis, a non-operative treatment, has gained attention. It offers non-invasiveness, cost-effectiveness, and early intervention. We report six infants who underwent end-to-side (ETS) spinal accessory nerve to suprascapular nerve transfer for the treatment of GHD compared to ten infants who were treated with the Sup-ER orthosis as a control. We aimed to compare the Sup-ER orthosis treatment with the ETS transfer procedures in patients with GHD secondary to BPBI.
Methods:
A total of 16 infants diagnosed with BPBI secondary GHD were included in the study. All GHD was diagnosed via US. Among them, six patients underwent ETS spinal accessory to suprascapular nerve transfer, while ten infants received Sup-ER orthosis treatment. All patients were enrolled in therapy. The recorded data encompassed various parameters, including preoperative diagnosis, pre- and postoperative Active Motion Scale (AMS) scores, pre- and serial monthly postoperative ultrasound findings, surgical exploration details, postoperative complications, rehabilitation procedures, and postoperative range of motion results.
Results:
Of the ten infants treated with the Sup-ER orthosis, four demonstrated successful improvement and resolution of GHD via US. Prior to treatment, AMS scores ranged from 0-6/7, which subsequently improved to 7/7 after the treatment. However, six patients did not exhibit improvement on US for six months of orthosis treatment. As a result, patients were indicated for surgery. In the ETS group, each patient was followed until US demonstrated GHD resolution, which occurred for all patients within six months.
Conclusion:
We report six cases of patients with GHD secondary to BPBI who were 100% successfully treated with ETS spinal accessory to suprascapular nerve transfers (Fischer exact test 0.034; p<0.05). While non-operative management using the Sup-ER orthosis shows some improvement in BPBI and GHD, the success rate of 40% raises concerns regarding its effectiveness as a standalone treatment option. Possible reasons may be compliance or severity of the nerve injury. But the nerve transfer does not rely upon parental compliance for success and the severity of the nerve injury is likewise overcome by the nature of the treatment. Thus, while seemingly aggressive in approach, the ETS nature of the surgery allows for a more expedient and reliable recovery.
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