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Published on: August 15, 2019
Outcomes of Late Microsurgical Nerve Reconstruction for Brachial Plexus Birth Injury
Michael C Daly1, Andrea S Bauer2, Hayley Lynch2
1Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA; Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, MA.
Insights
Microsurgical nerve reconstruction after 9 months of age for brachial plexus birth injury (BPBI) improves patient function. Both nerve transfers and grafts yield similar outcomes in these older BPBI patients.
Area of Science:
- Pediatric Surgery
- Neurosurgery
- Orthopedic Surgery
Background:
- Brachial plexus birth injury (BPBI) can necessitate microsurgical nerve reconstruction.
- Optimal timing for BPBI surgery is typically 3-9 months, but some patients undergo later procedures.
- Outcomes for BPBI patients treated after 9 months are not well-documented.
Purpose of the Study:
- To evaluate functional outcomes of microsurgical nerve reconstruction in BPBI patients older than 9 months.
- To compare outcomes between nerve transfer and nerve graft techniques in this patient group.
Main Methods:
- A prospective multicenter database of 750 BPBI patients (2000-2014) was analyzed.
- 32 patients undergoing nerve reconstruction after 9 months with at least 12 months follow-up were included.
- Active Movement Scale (AMS) scores were used to assess functional improvement before and after surgery, analyzing outcomes prior to secondary procedures.
Main Results:
- Median age at surgery was 11.2 months, with a median follow-up of 29.8 months.
- Total AMS scores showed modest improvement at 1 and 2+ years post-surgery.
- Shoulder abduction, external rotation, and elbow flexion improved at 1 year; no significant difference in AMS scores was found between nerve transfer and graft groups.
Conclusions:
- Nerve reconstruction in older BPBI patients (after 9 months) leads to functional improvement over time.
- Both nerve transfer and nerve graft techniques demonstrate comparable outcomes at 1 and 2+ years follow-up.
- Current findings do not favor one surgical strategy over the other for this patient cohort.
Purpose:
Microsurgical nerve reconstruction has been advocated between 3 and 9 months of life in select patients with brachial plexus birth injury (BPBI), yet some patients undergo indicated surgery after this time frame. Outcomes in these older patients remain poorly characterized. We analyzed outcomes of nerve reconstruction performed after 9 months of age and hypothesized that (1) Active Movement Scale (AMS) scores improve after surgery, and (2) there are no differences in AMS scores between patients undergoing nerve transfers versus those undergoing nerve grafting.
Methods:
From 2000 to 2014, 750 patients at 6 U.S. centers were prospectively enrolled in a multicenter database. We included patients treated with nerve reconstruction after 9 months of age with minimum 12 months' follow-up. Patients were evaluated using AMS scores. To focus on the results of microsurgery, only outcomes prior to secondary surgery were analyzed. We analyzed baseline variables using bivariate statistics and change in AMS scores over time and across treatment groups using linear mixed models.
Results:
We identified 32 patients (63% female) with median follow-up of 29.8 months. Median age at microsurgery was 11.2 months. Twenty-five (78%) had an upper trunk injury. Compared with before surgery, total AMS scores improved modestly at 1 year and 2 or more years follow-up. At 1 year follow-up, AMS scores improved for shoulder function (abduction, external rotation) and elbow flexion. Between-group comparisons found no differences in total AMS scores or AMS subscales between graft and transfer groups at 1 year or 2 or more years after surgery, so we cannot recommend one strategy over the other based on our findings.
Conclusions:
Overall, nerve reconstruction in patients with BPBI after 9 months of age resulted in improved function over time. There was no difference in outcomes between nerve transfer and nerve graft groups and 1 or 2 or more years follow-up.
Type Of Study/Level Of Evidence:
Therapeutic IV.
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