Upper Extremity Nerve Transfers in Acute Flaccid Myelitis: Experience and Outcomes at a Canadian Institution
Molly Jakeman, MD FRCS1, Alison Anthony, MScPT1, Emily S Ho, PhD2 and Kristen M Davidge, MD, MSc, FRCS(C)3, 1Hospital for Sick Children, Toronto, ON, Canada, 2Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children, Toronto, ON, Canada, 3The Hospital for Sick Children, Toronto, ON, Canada
Objective: Acute Flaccid Myelitis (AFM) is a rare but devastating pediatric condition. Recovery is variable and many children have residual weakness of their extremities. We present our initial experience of upper extremity nerve transfers in AFM.
Methods: A retrospective review was conducted of all children with AFM from the 2018 cohort, who underwent upper extremity nerve transfers at our institution in 2019 and 2020. Transfers to restore shoulder and/or elbow motion were performed when recipient muscles had no signs of clinical or electrophysiologic reinnervation on serial examination, and when at least one donor nerve was available. Outcomes were assessed serially, with a minimum of 2 years follow-up.
Results: Nerve transfers were performed in six children (4M, 2F) on eight limbs. Mean age at disease onset was 5.8 years (range, 3.8–8.6). D68 enterovirus was detected in two cases. Three children presented with four-limb involvement; two required respiratory support. Median time from disease onset to surgery was 13 months (range, 12-19). Among the 10 shoulder nerve transfers performed, the most common were spinal accessory to suprascapular (4) and ulnar to axillary (6). Three transfers were performed for elbow flexion using median, ulnar or intercostal nerves as donors. One radial to triceps transfer was performed for elbow extension. One transfer was aborted intraoperatively owing to weak donor nerve. Median postoperative follow-up was 29.5 months (range, 22-42). Transfers for shoulder abduction achieved a median range of antigravity motion of 85 degrees (range, 21-155). All four patients undergoing transfers for elbow flexion or extension achieved full antigravity motion. No donor site motor weakness was identified; transient median nerve paraesthesia was noted in one patient.
Conclusions: Nerve transfers in AFM were effective in restoring functionally useful upper limb motion in most cases. Recovery appears to take longer than seen in other populations. Our results support the current literature in that restoration of motion at the elbow is more consistent than that of the shoulder. Poor outcomes for shoulder abduction were related to donor nerve quality and global weakness around the shoulder girdle.
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