Early Functional Recovery of Elbow Flexion and Supination Following Median and/or Ulnar Nerve Fascicle Transfer in Upper Neonatal Brachial Plexus Palsy

OBJECTIVENeonatal brachial plexus palsy (NBPP) continues to be a problematic occurrence impacting approximately 1.5 per 1000 live births in the United States, with 10%–40% of these infants experiencing permanent disability. These children lose elbow flexion, and one surgical option for recovering it is the Oberlin transfer. Published data support the use of the ulnar nerve fascicle that innervates the flexor carpi ulnaris as the donor nerve in adults, but no analogous published data exist for infants. This study investigated the association of ulnar nerve fascicle choice with functional elbow flexion outcome in NBPP.METHODSThe authors conducted a retrospective study of 13 cases in which infants underwent ulnar to musculocutaneous nerve transfer for NBPP at a single institution. They collected data on patient demographics, clinical characteristics, active range of motion (AROM), and intraoperative neuromonitoring (IONM) (using 4 ulnar nerve index muscles). Standard statistical analysis compared pre- and postoperative motor function improvement between specific fascicle transfer (1–2 muscles for either wrist flexion or hand intrinsics) and nonspecific fascicle transfer (> 2 muscles for wrist flexion and hand intrinsics) groups.RESULTSThe patients’ average age at initial clinic visit was 2.9 months, and their average age at surgical intervention was 7.4 months. All NBPPs were unilateral; the majority of patients were female (61%), were Caucasian (69%), had right-sided NBPP (61%), and had Narakas grade I or II injuries (54%). IONM recordings for the fascicular dissection revealed a donor fascicle with nonspecific innervation in 6 (46%) infants and specific innervation in the remaining 7 (54%) patients. At 6-month follow-up, the AROM improvement in elbow flexion in adduction was 38° in the specific fascicle transfer group versus 36° in the nonspecific fascicle transfer group, with no statistically significant difference (p = 0.93).CONCLUSIONSBoth specific and nonspecific fascicle transfers led to functional recovery, but that the composition of the donor fascicle had no impact on early outcomes. In young infants, ulnar nerve fascicular dissection places the ulnar nerve at risk for iatrogenic damage. The data from this study suggest that the use of any motor fascicle, specific or nonspecific, produces similar results and that the Oberlin transfer can be performed with less intrafascicular dissection, less time of surgical exposure, and less potential for donor site morbidity.

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Elbow Flexion in Neonatal Brachial Plexus Palsy: A Meta-Analysis of Graft Versus Transfer

Neurosurgery ◽

10.1093/neuros/nyz310_342 ◽

2019 ◽

Vol 66 (Supplement_1) ◽

Author(s):

Muhibullah S Tora ◽

Nathan Hardcastle ◽

Pavlos Texakalidis ◽

Jeremy Wetzel ◽

Joshua J Chern

Keyword(s):

Brachial Plexus ◽

Functional Recovery ◽

Meta Analysis ◽

Donor Site ◽

Nerve Transfer ◽

Elbow Flexion ◽

Active Movement ◽

Nerve Grafting ◽

Brachial Plexus Palsy ◽

Neonatal Brachial Plexus Palsy

Abstract INTRODUCTION Functional elbow flexion recovery is one of the main goals of neonatal brachial plexus palsy (NBPP) reconstruction. The current neurosurgical treatment options include nerve grafting and nerve transfer. The goal of the present study is to compare functional elbow flexion recovery in NBPP following nerve grafting or nerve transfer. METHODS The present study conducted a systematic literature review and meta-analysis according to PRISMA guidelines. A search was conducted on Pubmed for eligible studies published until November of 2018. Odds Ratios (OR) and 95% confidence intervals (CI) were calculated to compare functional elbow flexion outcomes between nerve graft and nerve transfer. A random-effects model meta-analysis was conducted. A Medical Research Council (MRC) score = 3 or Active Movement Scale (AMS) = 5 was considered functional recovery of elbow flexion. RESULTS The present study included 194 patients from 1990 2015 across five observational trials. Only pediatric patients with obstetric brachial plexus injury were included. The mean patient age at surgery varied between studies from 5.7 to 11.9 mo and mean follow-up from 12 to 70 mo. No complications or cases of donor site morbidity were reported. Functional recovery occurred with nerve transfer in 95.2% of patients (n = 59/62) and with nerve grafting in 96.4% of patients (n = 54/56). Overall, the outcomes for elbow flexion between the groups appeared similar (OR: 1.15, 95% CI: 0.19-7.08, I2: 2.9%). CONCLUSION The optimal approach to brachial plexus reconstruction in NBPP continues to be the subject of debate. As one of the most important outcomes, the present meta-analysis finds that functional recovery of elbow flexion does not appear to differ between nerve grafting and nerve transfer.

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Serial casting for elbow flexion contractures in neonatal brachial plexus palsy

Journal of Pediatric Rehabilitation Medicine ◽

10.3233/prm-160381 ◽

2016 ◽

Vol 9 (3) ◽

pp. 207-214 ◽

Cited By ~ 5

Author(s):

B.J. Duijnisveld ◽

D. Steenbeek ◽

R.G.H.H. Nelissen

Keyword(s):

Brachial Plexus ◽

Elbow Flexion ◽

Brachial Plexus Palsy ◽

Flexion Contractures ◽

Serial Casting ◽

Neonatal Brachial Plexus Palsy

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Nerve transfers to the biceps and brachialis branches to improve elbow flexion strength after brachial plexus injuries

Neurosurgical FOCUS ◽

10.3171/foc.2004.16.5.19 ◽

2004 ◽

Vol 16 (5) ◽

pp. 313-318

Author(s):

Thomas H. Tung ◽

Christine B. Novak ◽

Susan E. Mackinnon

Keyword(s):

Brachial Plexus ◽

Ulnar Nerve ◽

Elbow Flexion ◽

Musculocutaneous Nerve ◽

Nerve Transfers ◽

Brachialis Muscle ◽

Nerve Fascicle ◽

The Mean ◽

Mean Time ◽

Flexion Strength

Object In this study the authors evaluated the outcome in patients with brachial plexus injuries who underwent nerve transfers to the biceps and the brachialis branches of the musculocutaneous nerve. Methods The charts of eight patients who underwent an ulnar nerve fascicle transfer to the biceps branch of the musculocutaneous nerve and a separate transfer to the brachialis branch were retrospectively reviewed. Outcome was assessed using the Medical Research Council (MRC) grade to classify elbow flexion strength in conjunction with electromyography (EMG). The mean patient age was 26.4 years (range 16–45 years) and the mean time from injury to surgery was 3.8 months (range 2.5–7.5 months). Recovery of elbow flexion was MRC Grade 4 in five patients, and Grade 4+in three. Reinnervation of both the biceps and brachialis muscles was confirmed on EMG studies. Ulnar nerve function was not downgraded in any patient. Conclusions The use of nerve transfers to reinnervate the biceps and brachialis muscle provides excellent elbow flexion strength in patients with brachial plexus nerve injuries.

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Oberlin transfer compared with nerve grafting for improving early supination in neonatal brachial plexus palsy

Journal of Neurosurgery Pediatrics ◽

10.3171/2017.8.peds17160 ◽

2018 ◽

Vol 21 (2) ◽

pp. 178-184 ◽

Cited By ~ 2

Author(s):

Kate W. C. Chang ◽

Thomas J. Wilson ◽

Miriana Popadich ◽

Susan H. Brown ◽

Kevin C. Chung ◽

...

Keyword(s):

Brachial Plexus ◽

Elbow Flexion ◽

Nerve Grafting ◽

Brachial Plexus Palsy ◽

Nerve Reconstruction ◽

Early Recovery ◽

Treatment Groups ◽

Neonatal Brachial Plexus Palsy ◽

Significant Difference ◽

Transfer Group

OBJECTIVEThe use of nerve transfers versus nerve grafting for neonatal brachial plexus palsy (NBPP) remains controversial. In adult brachial plexus injury, transfer of an ulnar fascicle to the biceps branch of the musculocutaneous nerve (Oberlin transfer) is reportedly superior to nerve grafting for restoration of elbow flexion. In pediatric patients with NBPP, recovery of elbow flexion and forearm supination is an indicator of resolved NBPP. Currently, limited evidence exists of outcomes for flexion and supination when comparing nerve transfer and nerve grafting for NBPP. Therefore, the authors compared 1-year postoperative outcomes for infants with NBPP who underwent Oberlin transfer versus nerve grafting.METHODSThis retrospective cohort study reviewed patients with NBPP who underwent Oberlin transfer (n = 19) and nerve grafting (n = 31) at a single institution between 2005 and 2015. A single surgeon conducted intraoperative exploration of the brachial plexus and determined the surgical nerve reconstruction strategy undertaken. Active range of motion was evaluated preoperatively and postoperatively at 1 year.RESULTSNo significant difference between treatment groups was observed with respect to the mean change (pre- to postoperatively) in elbow flexion in adduction and abduction and biceps strength. The Oberlin transfer group gained significantly more supination (100° vs 19°; p < 0.0001). Forearm pronation was maintained at 90° in the Oberlin transfer group whereas it was slightly improved in the grafting group (0° vs 32°; p = 0.02). Shoulder, wrist, and hand functions were comparable between treatment groups.CONCLUSIONSThe preliminary data from this study demonstrate that the Oberlin transfer confers an advantageous early recovery of forearm supination over grafting, with equivalent elbow flexion recovery. Further studies that monitor real-world arm usage will provide more insight into the most appropriate surgical strategy for NBPP.

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Medial pectoral nerve to musculocutaneous nerve neurotization for the treatment of persistent birth-related brachial plexus palsy: an 11-year institutional experience

Journal of Neurosurgery Pediatrics ◽

10.3171/2008.11.peds08166 ◽

2009 ◽

Vol 3 (5) ◽

pp. 348-353 ◽

Cited By ~ 24

Author(s):

John C. Wellons ◽

R. Shane Tubbs ◽

Jeffrey A. Pugh ◽

Nadine J. Bradley ◽

Charles R. Law ◽

...

Keyword(s):

Brachial Plexus ◽

Functional Recovery ◽

Traumatic Injury ◽

Elbow Flexion ◽

Musculocutaneous Nerve ◽

Brachial Plexus Palsy ◽

Pectoral Nerve ◽

Medial Pectoral Nerve ◽

Institutional Experience

Object Medial pectoral nerve (MPN) to musculocutaneous nerve (MCN) neurotization for recovery of elbow flexion by biceps reinnervation is a valid option following traumatic injury to the upper brachial plexus. A major criticism of the application of this technique in infants is the smaller size of the MPN and mismatch of viable axons. We describe our institutional experience utilizing this procedure and critically examine functional outcomes. Methods Office charts and hospital records of children from over an 11-year period beginning January 1997 were reviewed. Of the 53 children of various ages undergoing brachial plexus exploration for traumatic injury of any nature, 20 underwent MPN to MCN neurotization as a part of an overall procedure in the first year of life to treat birth-related brachial plexus palsy and had at least 9 months' follow-up. Medial pectoral nerve to MCN neurotization was chosen if the results of clinical examination and intraoperative electrophysiological evidence were consistent with medial cord function. Functional recovery was defined as the ability of the child to bring their hand to their mouth. Results Sixteen patients (80%) gained functional recovery. The median age at surgery was 7 months. Median time to first clinic visit documenting recovery was 11.5 months and median overall follow up was 21.5 months. Preoperative hand function was a useful predictor of recovery of elbow flexion. Conclusions Medial pectoral nerve to MCN neurotization is a valid surgical option for the reinnervation of the biceps muscle for birth-related brachial plexus palsy when the hand is functional preoperatively. Useful elbow flexion can be expected in the majority of these children.

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