American Society for Peripheral Nerve
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Nerve Transfers for Brachial Plexus Reconstruction in Patients over 60 Years of Age Never too Old to Train your Brain!
Andreas Gohritz, Dr. med.1; Gregor Laengle, MD2; Clemens Gstoettner, MD2; Oskar C. Aszmann, MD3
1Basel University, Basel, Switzerland; 2Medical University of Vienna, Vienna, Austria; 3Department of Surgery/ CD Laboratory for Restoration of Extremity Function & Division of Plastic and Reconstructive Surgery, Medical University of Vienna, Vienna, Austria

Background: Nerve transfers are an established surgical technique in the treatment of brachial plexus injuries, however, most reported cases in the literature have focused on treatment of younger individuals. There has been a negative correlation of age with functional outcome after nerve reconstruction leading to discouragement in surgical treatment of older patients. Therefore, negative expectations regarding nerve reconstruction in the elderly also prevail in the literature, but little is known about the effectiveness of nerve transfers in patients with brachial plexus injuries aged beyond 60 years.
Methods: We present a series of 5 patients (1 female, 4 male) aged between 60 and 81 (mean, 66) years who underwent nerve reconstruction using multiple nerve transfers in brachial plexopathies. The causes of brachial plexus injury included trauma, (n=2) and iatrogenic origin, such as spinal surgical laminectomy, tumor excision and radiation for breast cancer (n= 3).
Results: All but one patient underwent a one-stage reconstruction including neurolysis and extra-anatomical nerve transfer alone (n=2) or combined with anatomical reconstruction by sural nerve grafts (n=2). One patient had anatomical brachial plexus reconstruction first and additional nerve transfer at a later stage. Neurotisations were performed as double (n=3), triple (n=1) or quadruple (n=1) nerve or fascicular transfers. Overall, at a minimum follow-up of 12 months, successful outcomes, defined as a restored muscle strength of at least M3 was achieved in all cases, two patients achieved M4 grading in elbow flexion.
Conclusion: This patient series challenges the widely held dogma that brachial plexus reconstruction in older patients will produce only very weak outcomes. Distal nerve transfers may be especially advantageous as they shorten the reinnervation distance and allow modality matched reinnervation. This study pronounces the effectiveness of nerve transfers in patients over 60 years with brachial plexus injuries, as the preserved regenerative and cognitive potential legitimates surgical reconstruction even in elderly people. Targeted rehabilitation methods appear even more important with age. Therefore, healthy, aged patients should be offered the whole spectrum of reconstructive methods and postoperative rehabilitation concepts to regain useful arm and hand function and thus preserve independence after a traumatic or nontraumatic brachial plexus lesion.


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