Outcomes of Late Microsurgical Reconstruction for Brachial Plexus Birth Palsy: Level 3 Evidence

Abstract

There is no financial information to disclose. Microsurgical nerve reconstruction is advocated in select patients with brachial plexus birth palsy (BPBP) between 3 and 9 months of life, yet some patients undergo indicated surgery after this time frame. Microsurgical outcomes in BPBP patients older than 9 months remain poorly characterized. This study has 2 aims: (1) to critically analyze outcomes of microsurgical reconstruction in BPBP patients after 9 months of age, and (2) to test the null hypothesis that there is no difference in Active Movement Scale (AMS) scores in BPBP patients who undergo nerve transfer versus nerve graft after 9 months of age. We retrospectively analyzed prospectively collected data from a large multicenter database of BPBP patients (TOBI). We included all patients who had microsurgery after 9 months of age with minimum 12 month follow-up. Patients were evaluated using the AMS and Toronto scores. To focus on the outcomes of microsurgery only, we only included outcomes prior to secondary surgery in our analysis. We analyzed baseline variables using bivariate statistics and changes in AMS scores using the nonparametric Wilcoxon signed rank test. We identified 34 patients (59% female, 52% birth weight >4000g) treated with microsurgical reconstruction at or after 9 months of age with mean follow-up 26.2 months. Mean age at presentation was 3.9 months. Mean age at microsurgery was 12.3 months. No patient underwent revision microsurgery; no other complications were noted. Twenty-six patients (76%) had upper trunk palsy (Narakas groups 1 and 2); the remaining 8 (24%) had total palsy (Narakas groups 3 and 4). Total AMS scores were significantly improved from preoperative values at 1-year, 2-year, and >3 year follow-up (Table 1). Among 30 patients with 1-year follow-up, AMS scores significantly improved for multiple upper extremity movements, including shoulder reanimation (abduction, flexion, external rotation) and elbow flexion (Table 1; P < 0.05). When compared with nerve grafting, nerve transfers resulted in significantly improved results for shoulder reanimation (abduction, flexion, external rotation) and elbow flexion (Table 2; P < 0.05). •BPBP patients treated with microsurgery after 9 months of age demonstrate encouraging results with improved total AMS scores at 1-year, 2-year, and >3 followup.•When compared with nerve grafting, nerve transfers resulted in significantly improved results for shoulder reanimation (abduction, flexion, external rotation) and elbow flexion in this select group of older patients.View Large Image Figure ViewerDownload Hi-res image Download (PPT)