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Nerve Transfers for Improvement of Upper Extremity Weakness in Pediatric Patients with Acute Flaccid Myelitis: A Systematic Review
MariŽlle Saayman, BSc.; Ann-Sophie Lafreniere, MD; Thomas Cawthorne, MD, FRCSC; Rebecca Hartley, MD, FRCSC; Alan Robertson Harrop, MD, FRCSC; Kate Elzinga, MD, FRCSC
University of Calgary, Calgary, AB, Canada

Introduction: Acute flaccid myelitis (AFM) is a rare polio-like illness caused by destruction of anterior horn cells resulting in acute flaccid paralysis of one or more extremities. Long-term outcomes and time to recovery are variable and difficult to predict. Consequently, nerve transfers (NTs) are used to optimize function by augmenting motor power in children with incomplete recovery. This study aimed to assess outcomes in pediatric patients undergoing NTs for upper extremity weakness following AFM.
Materials and Methods: We performed a systematic review following the PRISMA guidelines to identify studies reporting upper extremity motor recovery outcomes in children with AFM undergoing nerve transfers. PubMed, EMBASE and Cochrane Review were searched from inception to July 1st 2022. Two independent reviewers reviewed titles, abstracts, and full texts; conflicts were resolved via consensus. Patients with AFM under the age of 18 undergoing NTs for upper extremity weakness were included if they had objectively documented motor power scores pre- and post-operatively measured using the Active Movement Scale (AMS) or Medical Research Council grade (MRC). Patients with muscle weakness from another cause or cases with incomplete documentation were excluded.
Results: 56 abstracts were screened and 10 studies comprising 56 patients were included in the final analysis. Among those patients, 141 upper extremity NTs for shoulder and elbow function were performed with mean time to surgery 12 months, median time to surgery 10 months and a 60% male population. Movement against gravity (MRC 3/5, AMS 5/7) was restored in 73% of patients for shoulder abduction (n = 47/64), 80% for shoulder external rotation (n = 16/20), 89% for elbow flexion (n = 25/28), and 78% for elbow extension (n = 11/14). Following NTs restoring shoulder abduction, the AMS increased by 3.51 (p<0.01) while the MRC increased by 2.79 (p<0.01). Following NTs restoring shoulder external rotation, the AMS score increased by 4.1 (p<0.01), while the MRC score increased by 3.1 (p<0.01). Following NTs restoring elbow flexion, the AMS score increased by 2.41 (p<0.05), while the MRC score increased by 3.29 (p<0.01). Following NTs restoring elbow extension, the AMS score increased by 2.76 (p<0.01).
Conclusion: NTs for persistent motor weakness show promising improvement in pediatric patients following AFM. Further research is warranted to establish an optimal time frame from symptom onset to surgery as well as looking into long term outcomes.


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