Nerve Grafting and Nerve Transfer in Incomplete Brachial Plexus Birth Injury: A Systematic Review

Background: Primary neuroma excision and autografting are the gold-standard surgical treatments for brachial plexus birth injury (BPBI). With the rising popularity of distal nerve transfers, it is more frequently utilised to manage BPBI. However, distal transfers for BPBI remain under investigation. We reviewed the updated evidence for nerve transfers compared to nerve grafting as a primary approach for shoulder and elbow reconstruction in Narakas I and II neonatal brachial plexus palsy. Methods: A systematic review of the literature was performed according to the PRISMA guidelines. PubMed and Cochrane Central Register of Controlled Trials were searched using the search terms: ([{brachial plexus} AND {neonatal OR obstetric}] AND [graft OR grafting]) AND (transfer OR transfers). Results: Most studies did not specify the indications for grafting versus nerve transfer. Some suggested indications for nerve transfer surgery in BPBI include late presentations and nerve root avulsions. There was significantly greater improvement in shoulder external rotation postoperatively in the nerve transfer group compared to the nerve grafting group. There was no significant difference between the nerve transfer and nerve grafting groups for shoulder flexion, abduction and total active movement scale score. Patients undergoing nerve grafting were more likely to undergo a secondary shoulder stabilising procedure, though this was not statistically significant. Conclusion: The current literature shows that there appears to be little difference in functional outcomes between nerve grafting and nerve transfers. Level of Evidence: Level III (Therapeutic).