Nerve reconstruction: A cohort study of 93 cases of global brachial plexus palsy

Brachial plexus injury leading to flail upper limb is one of the most disabling injuries. Neglect of the injury and delay in surgeries may preclude reinnervation of the paralysed muscles. Currently for such injuries nerve transfers are the preferred procedures. We here present a series of 93 cases of global brachial plexus palsy treated with nerve transfers.

Ninety-three cases of global palsies out of 384 cases of brachial plexus injury operated by the senior surgeon (AB) were selected. Age varied from 4 to 51 years with 63 patients in 20 to 40 age group and all patients having a minimum follow up of at least 1 year post surgery ranging up to 130 months. The delay before surgery ranged from 15 days to 16 months (mean 3.2 months). The aim of the surgery was to restore the elbow flexion, shoulder abduction, triceps function and wrist and finger flexion in that order of priority. The major nerve transfers used were spinal accessory to suprascapular nerve, intercostal to musculocutaneous nerve and pectoral nerves, contralateral C7 to median and radial nerves. Nerve stumps were used whenever available (30 patients).

Recovery of ≥ grade 3 power was noted in biceps in 73% (68/93) of patients, shoulder abduction in 89% (43/49), pectoralis major in 100% (8/8). Recovery of grade 2 triceps power was seen in 80% (12/16) patients with nerve transfer to radial nerve. Derotation osteotomies of humerus (n=13) and wrist fusion (n=14) were the most common secondary procedures performed to facilitate alignment and movements of the affected limb. Better results were noted in 59 cases where direct nerve transfers were done (without nerve graft).

Acceptable function (restoration of biceps power ≥3) can be obtained in more than two thirds (73%) of these global brachial plexus injuries by using the principles of early exploration and nerve transfer with rehabilitation.