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

2018 ◽  
Vol 21 (2) ◽  
pp. 178-184 ◽  
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.

scholarly journals Effect of fascicle composition on ulnar to musculocutaneous nerve transfer (Oberlin transfer) in neonatal brachial plexus palsy

2018 ◽  
Vol 22 (2) ◽  
pp. 181-188 ◽  
Author(s):  
Brandon W. Smith ◽  
Nicholas J. Chulski ◽  
Ann A. Little ◽  
Kate W. C. Chang ◽  
Lynda J. S. Yang
Keyword(s):  
Brachial Plexus ◽  
Ulnar Nerve ◽  
Nerve Transfer ◽  
Elbow Flexion ◽  
Published Data ◽  
Brachial Plexus Palsy ◽  
Wrist Flexion ◽  
Neonatal Brachial Plexus Palsy ◽  
Nerve Fascicle ◽  
Transfer Group

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.

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

Neurosurgery ◽  
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.

Distal nerve transfer versus supraclavicular nerve grafting: comparison of elbow flexion outcome in neonatal brachial plexus palsy with C5-C7 involvement

2017 ◽  
Vol 33 (9) ◽  
pp. 1571-1574 ◽  
Author(s):  
Carlos O. Heise ◽  
Mario G. Siqueira ◽  
Roberto S. Martins ◽  
Luciano H. Foroni ◽  
Hugo Sterman-Neto
Keyword(s):  
Brachial Plexus ◽  
Nerve Transfer ◽  
Elbow Flexion ◽  
Nerve Grafting ◽  
Brachial Plexus Palsy ◽  
Neonatal Brachial Plexus Palsy ◽  
Distal Nerve

scholarly journals Median and/or Ulnar Nerve Fascicle Transfer for the Restoration of Elbow Flexion in Upper Neonatal Brachial Plexus Palsy

2014 ◽  
Vol 4 (2) ◽  
pp. e8
Author(s):  
Kevin J. Little ◽  
Dan A. Zlotolow ◽  
Francisco Soldado ◽  
Roger Cornwall ◽  
Scott H. Kozin
Keyword(s):  
Brachial Plexus ◽  
Ulnar Nerve ◽  
Elbow Flexion ◽  
Brachial Plexus Palsy ◽  
Neonatal Brachial Plexus Palsy ◽  
Nerve Fascicle

Ultrasonography for neonatal brachial plexus palsy

2014 ◽  
Vol 14 (5) ◽  
pp. 527-531 ◽  
Author(s):  
Jacob Rahul Joseph ◽  
Michael A. DiPietro ◽  
Deepak Somashekar ◽  
Hemant A. Parmar ◽  
Lynda J. S. Yang
Keyword(s):  
Brachial Plexus ◽  
Functional Results ◽  
Operative Management ◽  
Brachial Plexus Palsy ◽  
Nerve Reconstruction ◽  
Nerve Roots ◽  
Unaffected Side ◽  
Neonatal Brachial Plexus Palsy ◽  
Preoperative Mapping ◽  
Supraclavicular Fossa

Ultrasonography has previously been reported for use in the evaluation of compressive or traumatic peripheral nerve pathology and for its utility in preoperative mapping. However, these studies were not performed in infants, and they were not focused on the brachial plexus. The authors report a case in which ultrasonography was used to improve operative management of neonatal brachial plexus palsy (NBPP). An infant boy was born at term, complicated by right-sided shoulder dystocia. Initial clinical evaluation revealed proximal arm weakness consistent with an upper trunk injury. Unlike MRI or CT myelography that focus on proximal nerve roots, ultrasonography of the brachial plexus in the supraclavicular fossa was able to demonstrate a small neuroma involving the upper trunk (C-5 and C-6) and no asymmetry in movement of the diaphragm or in the appearance of the rhomboid muscle when compared with the unaffected side. However, the supra- and infraspinatus muscles were significantly asymmetrical and atrophied on the affected side. Importantly, ultrasound examination of the shoulder revealed posterior glenohumeral laxity. Instead of pursuing the primary nerve reconstruction first, timely treatment of the shoulder subluxation prevented formation of joint dysplasia and formation of a false glenoid, which is a common sequela of this condition. Because the muscles innervated by proximal branches of the cervical nerve roots/trunks were radiographically normal, subsequent nerve transfers were performed and good functional results were achieved. The authors believe this to be the first report describing the utility of ultrasonography in the surgical treatment planning in a case of NBPP. Noninvasive imaging, in addition to thorough history and physical examination, reduces the intraoperative time required to determine the extent and severity of nerve injury by allowing improved preoperative planning of the surgical strategy. Inclusion of ultrasonography as a preoperative modality may yield improved outcomes for children with NBPP.

Neonatal Brachial Plexus Palsy

2018 ◽  
Author(s):  
Raymond Tse ◽  
Angelo B. Lipira
Keyword(s):  
Brachial Plexus ◽  
Multiple Root ◽  
Surgical Reconstruction ◽  
Delayed Presentation ◽  
Brachial Plexus Palsy ◽  
Nerve Reconstruction ◽  
Nerve Transfers ◽  
Neonatal Brachial Plexus Palsy ◽  
Severity Of Injury ◽  
Technical Details

Neonatal brachial plexus palsy occurs in approximately 1 in 1000 live births. The extent of involvement and severity of injury are variable. The chapter discusses assessment, nonsurgical treatment, and surgical treatment of neonatal brachial plexus palsy. The approach to surgical exploration is detailed and a number of scenarios are presented so that the principles of primary nerve reconstruction (including nerve graft and nerve transfers) can be illustrated. The scenarios include upper plexus injury, pan-plexus injury, multiple root avulsions, isolated deficits, delayed presentation, and failed reconstruction. Technical details of nerve grafting and nerve transfers are described. Secondary musculoskeletal consequences of brachial plexus palsy are also discussed, including strategies for prevention and options for secondary surgical reconstruction.

scholarly journals A Systematic Review of Nerve Transfer and Nerve Repair for the Treatment of Adult Upper Brachial Plexus Injury

Neurosurgery ◽  
2012 ◽  
Vol 71 (2) ◽  
pp. 417-429 ◽  
Author(s):  
Lynda J.-S. Yang ◽  
Kate W.-C. Chang ◽  
Kevin C. Chung
Keyword(s):  
Brachial Plexus ◽  
Scale Score ◽  
Brachial Plexus Injury ◽  
Nerve Repair ◽  
Nerve Transfer ◽  
Elbow Flexion ◽  
Shoulder Abduction ◽  
Nerve Reconstruction ◽  
Operative Exploration ◽  
Significant Difference

Abstract Nerve reconstruction for upper brachial plexus injury consists of nerve repair and/or transfer. Current literature lacks evidence supporting a preferred surgical treatment for adults with such injury involving shoulder and elbow function. We systematically reviewed the literature published from January 1990 to February 2011 using multiple databases to search the following: brachial plexus and graft, repair, reconstruction, nerve transfer, neurotization. Of 1360 articles initially identified, 33 were included in analysis, with 23 nerve transfer (399 patients), 6 nerve repair (99 patients), and 4 nerve transfer + proximal repair (117 patients) citations (mean preoperative interval, 6 ± 1.9 months). For shoulder abduction, no significant difference was found in the rates ratio (comparative probabilities of event occurrence) among the 3 methods to achieve a Medical Research Council (MRC) scale score of 3 or higher or a score of 4 or higher. For elbow flexion, the rates ratio for nerve transfer vs nerve repair to achieve an MRC scale score of 3 was 1.46 (P = .03); for nerve transfer vs nerve transfer + proximal repair to achieve an MRC scale score of 3 was 1.45 (P = .02) and an MRC scale score of 4 was 1.47 (P = .05). Therefore, for elbow flexion recovery, nerve transfer is somewhat more effective than nerve repair; however, no particular reconstruction strategy was found to be superior to recover shoulder abduction. When considering nerve reconstruction strategies, our findings do not support the sole use of nerve transfer in upper brachial plexus injury without operative exploration to provide a clear understanding of the pathoanatomy. Supraclavicular brachial plexus exploration plays an important role in developing individual surgical strategies, and nerve repair (when donor stumps are available) should remain the standard for treatment of upper brachial plexus injury except in isolated cases solely lacking elbow flexion.

scholarly journals Successful Nerve Transfers for Traumatic Brachial Plexus Palsy in a Septuagenarian

Hand ◽  
2016 ◽  
Vol 11 (4) ◽  
pp. NP30-NP33 ◽  
Author(s):  
Parker H. Johnsen ◽  
Scott W. Wolfe
Keyword(s):  
Brachial Plexus ◽  
Older Patients ◽  
Nerve Transfer ◽  
Elbow Flexion ◽  
The Elderly ◽  
Suprascapular Nerve ◽  
Brachial Plexus Palsy ◽  
Nerve Reconstruction ◽  
Post Injury ◽  
Nerve Transfers

Background: Conventional wisdom and the available literature demonstrate compromised outcomes following nerve reconstruction for traumatic brachial plexus palsy in the elderly. We present a 74-year-old male who was reconstructed with multiple nerve transfers for brachial plexus palsy after a ski accident. Methods: Triceps to axillary nerve transfer, spinal accessory to suprascapular nerve transfer, and ulnar to musculocutaneous nerve transfer were performed 16 weeks post injury. Results: At 11 years post-op, the patient could abduct to 65° and forward flex at M4 strength, limited only by painful glenohumeral arthritis. Elbow flexion was M5- at both the biceps and brachialis, and bulk and tone were nearly symmetrical with the opposite side. Eleven-year electrodiagnostic studies demonstrated reinnervation and improved motor unit recruitment all affected muscles. Conclusion: This case questions the widely held dogma that older patients who undergo brachial plexus reconstruction do poorly. Given the short reinnervation distance and optimal donor nerve health, nerve transfers may be an excellent option for healthy older patients with traumatic brachial plexus palsy.

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