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Management of Pediatric Brachial Plexus Palsy: the Role of Nerve Transfer Combined with Neurolysis or Nerve Grafting of the Upper Trunk
Wesley Sivak, MD, PhD, Brian Gander, MD, Kimberly Foster, MD, Zoe MacIsaac, MD, Stephanie Greene, MD, Anand Kumar, MD, Lorelei Grunwaldt, MD.
University of Pittsburgh, Pittsburgh, PA, USA.
Purpose: Treatment of pediatric upper brachial plexus palsy remains controversial; the role of axon transfer from regional donor nerves is poorly defined. This study evaluates the benefit of supplemental nerve transfer (i.e. - CN XI or phrenic nerve) in combination with either neurolysis or nerve grafting of the upper trunk.
Methods: A retrospective review of pediatric upper brachial plexus palsy patients was performed from 1997-2012. Patients treated with neurolysis or nerve grafting of the upper trunk with or without concomitant nerve transfers were identified (n=39). All patients had a minimum of 4 months observation from diagnosis to operative intervention.
Results: Group 1, neurolysis alone, 12 patients (4 male/8 female, average age 9.7 months) treated January 1997-March 2012. Group 2, neurolysis with nerve transfer, 9 patients (5 male/4 female, average age 6.8 months) treated December 2001-January 2007; transfers included 1 CN XI, 4 phrenic, and 4 combined procedures. Group 3, nerve graft alone, 8 patients (5 male/3 female patients, average age 6.6 months) treated September 2000-May 2012; sural nerve grafts were used. Group 4, nerve graft with nerve transfer, 10 patients (3 male/7 female, average age 6.5 months) treated March 2000-April 2012; sural nerve grafts were used and transfers included 4 CN XI, 3 phrenic, and 3 combined procedures (age and gender distribution, p>0.05 all groups). Average follow-up was 55.9, 35.0, 41.0, and 55.9 months for Groups 1-4, respectively. Median preop/postop shoulder abduction, shoulder external rotation, supination, and elbow flexion Oxford scores were 2/2.5, 0/3.5, 0/2.0, 1/3 in Group 1; 2/4, 1/3, 2/4, 4/4 in Group 2; 3.5/4, 2/3.5, 2/4, 2.5/4 in Group 3; and 2/5, 2/5, 0/4, 2/5 in Group 4, respectively (p>0.05 all groups). Combined upper extremity functional scores demonstrated greatest improvement in Group 4 relative to all other groups (p<0.036). Secondary tendon transfer occurred n=9 (70%) in Group 1 at an average age 39.1 months, n=6 (67%) in Group 2 at an average age of 33.4 months, n=3 (38%) in Group 3 at an average age 30.0 months, and n=3 (30%) in Group 4 at an average age 32 months. No major complications, wound infections or early reoperations occurred in any group; no patients required tracheostomy after phrenic nerve transfer.
Conclusions: Nerve grafting with supplemental nerve transfer demonstrated the greatest functional improvement in upper extremity function among the patient cohorts. Nerve grafting demonstrated greater improvement than neurolysis with or without nerve transfer, but improvement was less robust than nerve grafting with transfer. Patients required fewer secondary tendon transfer surgeries after undergoing nerve grafting as compared to neurolysis, and fewer still when nerve transfer techniques were employed. The use of unaffected extraplexal nerves as a source of donor axons for transfer is efficacious and safe with no demonstrated increase in morbidity.
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