Surgical repair of brachial plexus injury: a multinational survey of experienced peripheral nerve surgeons

Abstract

Background Brachial plexus injuries (BPIs) are often devastating events that lead to upper-extremity paralysis, rendering it a painful extraneous appendage. Fortunately, there are several nerve repair techniques that provide restoration of some function. Although there is general agreement in the medical community concerning which patients may benefit from surgical intervention, the actual repair technique for a given lesion is less clear. Object The authors sought to identify and better define areas of agreement and disagreement among experienced peripheral nerve surgeons regarding the management of BPIs. Methods The authors developed a detailed survey in two parts: one part addressing general issues related to BPI and the other presenting four clinical cases. The survey was mailed to 126 experienced peripheral nerve physicians of whom 49 (39%) participated in the study. The respondents represented 22 countries and multiple surgical subspecialties. They performed a mean of 34 brachial plexus reconstructions annually. Areas of significant disagreement included the timing and indications for surgical intervention in birth-related palsy, management of neuroma-in-continuity, the best transfers to achieve elbow flexion and shoulder abduction, the use of intra- or extraplexal donors for motor neurotization, and the use of distal compared with proximal coaptation during nerve transfer. Conclusions Experienced peripheral nerve surgeons disagreed in important respects as to the management of BPI. The decisions made by the various treating physicians underscored the many areas of disagreement regarding the treatment of BPI including the diagnostic approach to defining the injury, timing of and indications for surgical intervention in birth-related palsy, management of neuroma-in-continuity, choice of nerve transfers to achieve elbow flexion and shoulder abduction, use of intra- or extraplexal donors for neurotization, and the use of distal or proximal coaptation during nerve transfer.