Brachial Plexus Injury Nerve Grafting and Transfers

Obstetric brachial plexus palsy (OBPP) has a high percentage of injuries achieve complete recovery spontaneously, yet this does not occur in roughly 30% of patients.

For OBPP, the typical lesion in infants is a neuroma-in-continuity, incomplete stretching that allows for some axon fibers to grow through and reach distal targets.

Typical signs and symptoms are relevant to the roots and nerves involved in the injury and are discussed further in Chapter 94 .

Although the scientific evidence supporting reconstructive primary surgery for OBPP is far from ideal, the general consensus is that this approach is indicated in patients in whom the anticipated natural history is of no or inadequate spontaneous recovery, as in those with little to no return of biceps function by 3 months. Yet some surgeons advocate waiting to the age of 9 months with regular follow-up.

If the patient presents with a complete palsy and associated Horner syndrome (support possible lower brachial plexus injury), earlier surgery is generally preferred because no complete spontaneous recovery is expected.

Usually the natural course of OBPP will get to a plateau in recovery after 9 months of age with significant residual motor deficit.

After 6 to 9 months it is important to understand how severe the injury is (e.g., the baby cannot perform hand-to-mouth test) and to understand if there is improvement along time, which will allow to consider observation only.

Patients with OBPP who present late (> 12 months) are good candidates for distal nerve transfers. Other good candidates for distal nerve transfer are those suffering from the absence of proximal roots, avulsion injuries, or isolated nerve deficits.

If a procedure is performed too late, muscle atrophy appears so that no matter how many axons reach the distal muscle target, functional (motor) recovery will be limited

The use of nerve transfer as primary treatment in upper trunk injuries is still debatable.

Medically unstable.

Relative contraindication is complete muscle atrophy.