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Long-Term Outcomes of Brachial Plexus Reconstruction with Sural Nerve Autograft for Brachial Plexus Birth Injury
M Claire Manske1, Andrea S Bauer1, Vincent R Hentz1
1From Shriners Hospital for Children-Northern California; Harvard Medical School, Boston Children's Hospital; and the Robert A. Chase Center for Upper Limb Surgery, Stanford University.
Insights
Brachial plexus reconstruction using sural nerve grafts in infants shows reliable elbow and shoulder recovery but less predictable outcomes for external rotation and wrist extension. Further reconstructive surgeries are often needed to improve function.
Area of Science:
- Pediatric Orthopedics
- Pediatric Neurosurgery
- Microsurgery
Background:
- Infants with brachial plexus birth injury often require surgical intervention if spontaneous motor function recovery is delayed.
- Nerve autografting, specifically using the sural nerve, is a common reconstructive technique.
- Long-term outcomes of this procedure in infants are not fully understood.
Purpose of the Study:
- To evaluate the long-term functional outcomes of brachial plexus reconstruction with sural nerve autograft in infants.
- To assess the timing and extent of motor recovery following the procedure.
- To identify the need for and types of secondary reconstructive surgeries.
Main Methods:
- Retrospective review of infants undergoing brachial plexus reconstruction with sural nerve autograft (1992-2014).
- Minimum 2-year follow-up period.
- Assessment of motor recovery using the Active Movement Scale and Raimondi scale.
Main Results:
- Forty-three infants (age 7 ± 2 months) were followed for 7 ± 5 years.
- High rates of antigravity elbow flexion (91%) and shoulder abduction (67%) were observed.
- Lower rates of shoulder external rotation (19%) and wrist extension (37%) recovery were noted, with recovery taking over 12 months postoperatively.
- A mean of 2 secondary procedures were performed per child.
Conclusions:
- Brachial plexus reconstruction with sural nerve autograft effectively restores shoulder abduction and elbow flexion in infants.
- Recovery of shoulder external rotation and wrist extension is less consistent and often delayed.
- Secondary reconstructive procedures are frequently necessary to optimize functional outcomes.
Background:
Infants with brachial plexus birth injury who do not recover motor function spontaneously in a timely manner are candidates for brachial plexus reconstruction with nerve autograft. Outcomes of this intervention are incompletely understood. The authors present the long-term outcomes of brachial plexus reconstruction with sural nerve autograft in infants with brachial plexus birth injury.
Methods:
The authors retrospectively reviewed all infants with brachial plexus birth injury who underwent brachial plexus reconstruction with sural nerve autograft between 1992 and 2014 with a minimum 2-year follow-up. The authors used Active Movement Scale scores to determine the presence and timing of shoulder, elbow, and wrist recovery. They assessed recovery of hand function in infants with global brachial plexus birth injury with the Raimondi scale. The number and type of secondary reconstructive procedures were identified.
Results:
Forty-three infants who underwent brachial plexus reconstruction at age 7 ± 2 months old were followed for 7 ± 5 years. Most infants recovered antigravity elbow flexion (91 percent) and shoulder abduction (67 percent), but fewer recovered antigravity shoulder external rotation (19 percent) and wrist extension (37 percent). Mean postoperative times until observed antigravity motor strength (Active Movement Scale score >5) at the shoulder, elbow, and wrist were all greater than 12 months; evidence of initial motor recovery (Active Movement Scale score >2) was observed earlier. The mean Raimondi score in infants with global brachial plexus birth injury was 2.2 (range, 0 to 5) at final follow-up. Thirty-three children underwent 2 ± 1.2 secondary reconstructive procedures.
Conclusions:
Brachial plexus reconstruction with sural nerve autograft reliably results in recovery of shoulder abduction and elbow flexion, but recovery of shoulder external rotation and wrist extension is less predictable, and recovery often takes more than 1 year. Secondary procedures are often performed to optimize function.
Clinical Question/Level Of Evidence:
Therapeutic, IV.
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