Elbow flexion reconstruction with nerve transfer or grafting in patients with brachial plexus injuries: A systematic review and comparison study

Brachial plexus birth injury: advances and controversies

While there is considerable spontaneous recovery in most cases of brachial plexus birth injury, many children are left with significant problems that may lead to lifelong functional limitations, loss of work and social isolation. Detailed treatment with the right strategy can provide very valuable improvement in function. Over the past few years, the clinical approach to brachial plexus birth palsy has entered a new era in both diagnostic and surgical treatment methods. This article reviews four areas of management, the role of imaging in defining the severity of the injury, the optimal timing of for nerve exploration and reconstruction in appropriate cases, the advantages and potential complications of nerve transfers, and the role of physiotherapy. Available evidence is considered. Although it is difficult to make clear and precise inferences on a subject where there are many variables and considerable uncertainties, some currently accepted views will be summarized.Level of evidence: V.

Development of a core outcome set for traumatic brachial plexus injury

The aim of the present study was to reach international consensus on the minimum set of outcomes to measure and report in adult traumatic brachial plexus injury care and research. This would facilitate comparison of outcomes from different centres and meta-analysis in research. A list of outcomes was developed from a systematic review (n = 54) and patient interviews (n = 12). The outcomes were rated in a three-round online Delphi survey completed by international surgeons, patients and therapists. Two online consensus meetings with patients and clinicians ratified the final core outcome set. A total of 72 people (20 surgeons, 21 patients, 31 therapists) from 19 countries completed all survey rounds. Thirty-eight people from nine countries attended separate patient (n = 13) and clinician consensus (n = 25) meetings. Outcomes were included if recommended by more than 85% of contributors. Pain, voluntary movement and carrying out a daily routine are the core outcome domains that should be assessed and reported when treating and researching adults with a traumatic brachial plexus injury.

LEVEL OF EVIDENCE

V.

Surgical reconstructions for adult brachial plexus injuries. Part II: Treatments for total arm type

Brachial plexus injuries (BPI) contribute not only to physical dysfunction but also to socioeconomic aspects and psychological disability. Patients with total arm-type BPI will lose not only the shoulder and elbow function but also the hand function, making reconstruction particularly challenging. Reconstructive procedures commonly include nerve repair, grafting, neurotization (nerve transfer), tendon transfer and free functional muscle transfer (FFMT). Although it is difficult to achieve prehensile hand function, most of patients with total arm-type BPI can be treated with satisfied outcomes. In addition to surgical techniques, comprehensive rehabilitation is another important factor for successful outcomes, and efficient communication can help to boost patient morale and eliminate uncertainty.

Retrograde peripheral nerve regeneration from sensory to motor pathways in rats: a new experimental concept in nerve repair

BACKGROUND

The polarity of nerve grafts does not interfere with axon growth. Our goal was to investigate whether axons can regenerate in a retrograde fashion within sensory pathways and then extend into motor pathways, leading to muscle reinnervation.

METHODS

Fifty-four rats were randomized into four groups. In Group 1, the ulnar nerve was connected end-to-end to the superficial radial nerve after neurectomy of the radial nerve in the axilla. In Group 2, the ulnar nerve was connected end-to-end to the radial nerve distal to the humerus; the radial nerve then was divided in the axilla. In Group 3, the radial nerve was divided in the axilla, but no nerve reconstruction was performed. In Group 4, the radial nerve was crushed in the axilla. Over 6 months, we behaviorally assessed the recovery of toe spread in the right operated-upon forepaw by lifting the rat by its tail and lowering it onto a flat surface. Six months after surgery, rats underwent reoperation, nerve transfers were tested electrophysiologically, and the posterior interosseous nerve (PIN) was removed for histological evaluation.

RESULTS

Rats in the crush group recovered toe spread between 5 and 8 days after surgery. Rats with nerve transfers demonstrated electrophysiological and histological findings of nerve regeneration but no behavioral recovery.

CONCLUSIONS

Ulnar nerve axons regrew into the superficial radial nerve and then into the PIN to reinnervate the extensor digitorum communis. We were unable to demonstrate behavioral recovery because rats cannot readapt to cross-nerve transfer.

Versatility of the double fascicular transfer in reconstruction of elbow flexion paralysis: Intermediate term follow-up and patient-related outcome measures

OBJECTIVES

The use of fascicle transfers in the reconstruction of traumatic brachial plexus injury is well established, but limited evidence is available regarding their use in atraumatic elbow flexion paralysis. This retrospective case review aimed to verify whether median and ulnar fascicle transfers are similarly effective in atraumatic versus traumatic elbow flexion paralysis when measured using the British Medical Research Council (MRC) scale, Brachial plexus Assessment Tool (BrAT) and Stanmore Percentage of Normal Elbow Assessment (SPONEA) scores at long-term follow-up.

METHODS

All median and ulnar fascicle transfer cases performed at the Queen Elizabeth Hospital Birmingham between August 2007 and November 2018 were reviewed to compare the outcomes of transfers performed for traumatic and atraumatic indications. Data on patient demographics, mechanism and nature of injury, date of injury or symptom onset, date of operation, and other nerve transfers performed were collected. Outcome measures collected included the British MRC scale and two patient-reported outcome measures (PROMs), BrAT and SPONEA.

RESULTS

In total, 34 patients with 45 median and ulnar fascicle transfers were identified. This included 27 traumatic and seven atraumatic brachial plexus insults. Thirty patients had sufficient follow-up to be included in MRC analysis and 17 patients had sufficient follow-up to be included in PROM analysis. No significant differences were found between traumatic and atraumatic subgroups for median MRC, BrAT, or SPONEA scores.

CONCLUSIONS

This study suggests that nerve transfers might be considered effective reconstructive options in atraumatic pathology and provides validation for further research on the subject.

Traumatic brachial plexus injury: diagnosis and treatment

PURPOSE OF THE REVIEW

Traumatic brachial plexus injuries (BPI) are devastating life-altering events, with pervasive detrimental effects on a patient's physical, psychosocial, mental, and financial well-being. This review provides an understanding of the clinical evaluation, surgical indications, and available reconstructive options to allow for the best possible functional outcomes for patients with BPI.

RECENT FINDINGS

The successful management of patients with BPI requires a multidisciplinary team approach including peripheral nerve surgeons, neurology, hand therapy, physical therapy, pain management, social work, and mental health. The initial diagnosis includes a detailed history, comprehensive physical examination, and critical review of imaging and electrodiagnostic studies. Surgical reconstruction depends on the timing of presentation and specific injury pattern. A full spectrum of techniques including neurolysis, nerve grafting, nerve transfers, free functional muscle transfers, tendon transfers, and joint arthrodesis are utilized.

SUMMARY

Despite the devastating nature of BPI injuries, comprehensive care within a multidisciplinary team, open and practical discussions with patients about realistic expectations, and thoughtful reconstructive planning can provide patients with meaningful recovery.

Nerve Transfers for Elbow Reconstruction in Upper and Extended Upper-Type Brachial Plexus Injuries: A Case Series

BACKGROUND

Nerve transfers for elbow flexion in brachial plexus injuries have been used with increasing frequency because of the higher rate of success and acceptable morbidity. This is especially true in upper and extended upper-type brachial plexus injuries.

OBJECTIVE

To present the clinical outcomes of nerve transfers for elbow flexion in patients with upper and extended upper-type brachial plexus injuries.

METHODS

A retrospective cohort review was done on all patients with upper and extended upper-type brachial plexus injuries from 2006 to 2017, who underwent nerve transfers for the restoration of elbow flexion. Outcome variables include Filipino version of the disability of the arm, shoulder, and hand (FIL-DASH) score, elbow flexion strength and range of motion, and pain. All statistical significance was set at P < .05.

RESULTS

Fifty-six patients with nerve transfers to restore elbow flexion were included. There was a significant improvement in FIL-DASH scores in 28 patients after the nerve transfer procedure. Patients with C56 nerve root injuries and those with more than 2 years' follow-up have a higher percentage of regaining ≥M4 elbow flexion strength. Those with double nerve transfers had a higher percentage of ≥M4 elbow flexion strength, greater range of elbow flexion, and better FIL-DASH scores compared with single nerve transfers, but this did not reach statistical significance.

CONCLUSION

Nerve transfer procedures improve FIL-DASH scores in upper and upper-type brachial plexus injuries. After nerve transfer, stronger elbow flexion can be expected in patients with C56 injuries, and those with longer follow-up.

An Exploratory Study on Participation Following Brachial Plexus Injury

Consequences of brachial plexus injuries (BPI) would likely impact participation, but outcomes are not well understood. This exploratory study aimed to report the participation in productive, leisure and social roles for individuals following BPI. Fourteen male participants were diagnosed with a traumatic, BPI. Descriptive data reported included demographic, injury, surgical, and participation measures. Two-sample t-tests were conducted for comparative analysis with other studies following life altering conditions.Just over two-thirds reported feeling satisfied to very satisfied with their participation in everyday life. This long-term follow up study found on-going and profound impact on participation in a range of life situations for this diagnostic group. Participation in productive roles, home duties, and physical exercise were particularly impacted and need to be prioritized during rehabilitation.

The innervation of the biceps brachii and brachialis muscles in specimens with a high incidence of an accessory biceps head

We describe the patterns of motor branches to the elbow flexors in 106 fresh-frozen cadaveric upper extremities from 53 donors of the Latin American mestizo race. We identified a 20% incidence of an accessory biceps head. The innervation patterns to this accessory head were specifically described and added to the Yang classification as Type IV for the biceps and Type III for the brachialis. The patterns arising from the musculocutaneous nerve to the biceps brachii were of Type I in 69%, Type II in 9%, Type III in 7% and Type IV in 11%, and to the brachialis of Type I in 77%, Type II in 11% and Type III in 9%. In 4%, the branches did not originate from the musculocutaneous nerve. We hypothesize that the branch to the accessory biceps head might be considered as a donor for nerve transfer in selected brachial plexus injuries.

Optimal Donor Nerve to Restore Elbow Flexion After Traumatic Brachial Plexus Injury: A Systematic Review and Meta-Analysis

BACKGROUND

Traumatic brachial plexus injuries (BPIs) often lead to devastating upper extremity deficits. Treatment frequently prioritizes restoring elbow flexion through transfer of various donor nerves; however, no consensus identifies optimal donor nerve sources.

OBJECTIVE

To complete a meta-analysis to assess donor nerves for restoring elbow flexion after partial and total BPI (TBPI).

METHODS

Original English language articles on nerve transfers to restore elbow flexion after BPI were included. Using a random-effects model, we calculated pooled, weighted effect size of the patients achieving a composite motor score of ≥M3, with subgroup analyses for patients achieving M4 strength and with TBPI. Meta-regression was performed to assess comparative efficacy of each donor nerve for these outcomes.

RESULTS

Comparison of the overall effect size of the 61 included articles demonstrated that intercostal nerves and phrenic nerves were statistically superior to contralateral C7 (cC7; P = .025, <.001, respectively) in achieving ≥M3 strength. After stratification by TBPI, the phrenic nerve was still superior to cC7 in achieving ≥M3 strength (P = .009). There were no statistical differences among ulnar, double fascicle, or medial pectoral nerves in achieving ≥M3 strength. Regarding M4 strength, the phrenic nerve was superior to cC7 (P = .01) in patients with TBPI and the ulnar nerve was superior to the medial pectoral nerve (P = .036) for partial BPI.

CONCLUSION

Neurotization of partial BPI or TBPI through the intercostal nerve or phrenic nerve may result in functional advantage over cC7. In patients with upper trunk injuries, neurotization using ulnar, median, or double fascicle nerve transfers has similarly excellent functional recovery.

Traumatic Brachial Plexus Injury in Indonesia: An Experience from a Developing Country

Background  Brachial plexus injuries (BPI) cause severe physical disability and major psycho-socioeconomic burden. Although various countries have reported BPI incidence, the data from Indonesia as the fourth most populated country in the world remains unknown. We aim to assess the distribution of traumatic BPI, patients' characteristics, and treatment modalities in Indonesia.

Methods  A retrospective investigation was performed comprising 491 BPI patients at a tertiary referral hospital in Indonesia from January 2003 to October 2019. Demographic and outcomes data were retrieved from medical records.

Results  The average BPI patients' age was 27.3 ± 11.6 years old, with a male/female ratio of 4.6:1. Motorcycle accidents caused the majority (76.1%) of all BPI cases. Concomitant injuries were present in 62.3% of patients, dominated by fractures (57.1%) and brain injuries (25.4%). BPI lesion type was classified into complete (C5-T1, observed in 70% patients), upper (C5-C6, in 15% patients), extended upper (C5-C7, in 14% patients), and lower type (C8-T1, in 1% patients). The average time to surgery was 16.8 months (range 1–120 months), with the majority (76.6%) of the patients was operated on six months after the trauma. Free functional muscle transfer (FFMT) was the most common procedure performed (37%). We also analyzed the functional outcomes (active range of motion (AROM) and muscle power), DASH (Disabilities of the Arm, Shoulder, and Hand) score, and VAS (Visual Analogue Scale) across four most frequent procedures involving nerve reconstruction (FFMT, nerve transfer, external neurolysis, and nerve grafting). We found that FFMT was significantly better than nerve transfer in terms of DASH score and VAS ( p  = 0.000 and p  = 0.016, respectively) in complete BPI (C5-T1). Moreover, we also found that nerve grafting resulted in a significantly better shoulder abduction AROM than nerve transfer and external neurolysis in extended upper BPI (C5-C7) ( p  = 0.033 and p  = 0.033, respectively). Interestingly, no significant differences were observed in other measurements.

Conclusion  This study provides an overview of traumatic BPI patients in a single tertiary trauma center in Indonesia, expressing the profile of their characteristics and functional outcomes after surgical procedures.

Developing a core outcome set for traumatic brachial plexus injuries: a systematic review of outcomes

OBJECTIVE

To identify what outcomes have been assessed in traumatic brachial plexus injury (TBPI) research to inform the development of a core outcome set for TBPI.

DESIGN

Systematic review.

METHOD

Medline (OVID), EMBASE, CINAHL and AMED were systematically searched for studies evaluating the clinical effectiveness of interventions in adult TBPIs from January 2013 to September 2018 updated in May 2021. Two authors independently screened papers. Outcome reporting bias was assessed. All outcomes were extracted verbatim from studies. Patient-reported outcomes or performance outcome measures were extracted directly from the instrument. Variation in outcome reporting was determined by assessing the number of unique outcomes reported across all included studies. Outcomes were categorised into domains using a prespecified taxonomy.

RESULTS

Verbatim outcomes (n=1491) were extracted from 138 studies including 32 questionnaires. Unique outcomes (n=157) were structured into 4 core areas and 11 domains. Outcomes within the musculoskeletal domain were measured in 86% of studies, physical functioning in 25%, emotional functioning in 25% and adverse events in 33%. We identified 63 different methods for measuring muscle strength, 16 studies for range of movement and 63 studies did not define how they measured movement. More than two-thirds of the outcomes were incompletely reported in prospective studies.

CONCLUSION

This review of outcome reporting in TBPI research demonstrated an impairment focus and heterogeneity. A core outcome set would ensure standardised and relevant outcomes are reported to facilitate future systematic review and meta-analysis.

PROSPERO REGISTRATION NUMBER

CRD42018109843.