984 The Efficacy of Different Nerve Transfers to Restore Elbow Flexion in Adults Following Brachial Plexus Injury: A Systematic Review and Meta-Analysis

Abstract

Aim There are numerous donors available for neurotisation of the musculocutaneous nerve, following traumatic brachial plexus injury (BPI). However, there is uncertainty over which method is most effective for restoring elbow flexion. We set out to summarise and compared different nerve transfers for restoring elbow flexion after traumatic BPI in adults. Method Medline, Embase, medRxiv and bioRxiv were systematically searched from inception to 12 th April 2021. Studies reporting outcomes of nerve transfers to restore elbow flexion in adults were included. BPIs were categorised as partial or pan plexus. The primary outcome was ≥M4 elbow flexion on the British Medical Research Council (BMRC) scale. Results We included 64 articles, describing 13 different nerve transfers. There were 1335 adults with 813 (61%) partial and 522 (39%) pan plexus injuries. 75% of patients with partial BPIs achieved ≥M4 (95% CI 69%-80%); double Oberlin or two intercostal nerves appeared to give recovery. For patients with pan plexus injuries, 45% achieved ≥M4 (95% CI 31%-60%) and each month delay from injury to reconstruction reduced the probability of achieving ≥M4 by 7% (95% CI 1%-12%) where intercostal, phrenic or spinal accessory nerves were used as donors. Conclusions The choice of donor nerve affects the chance of attaining BMRC ≥4 in upper trunk reconstruction. For patients with pan plexus injuries, delay to neurotisation appears to be detrimental to motor outcome. This information may help clinicians and patients reach shared decisions about the choice of donor nerve(s) and the timing of surgery.

Changes in Motor and Sensory Cortical Neurotransmitters Following Traumatic Brachial Plexus Injuries in Adults Measured with Magnetic Resonance Spectroscopy

“…Recent work has shown that the time from injury to reconstruction in adults with BPI is linearly associated with functional outcomes, whereby each month of delay to neurotisation reduces the odds of meaningful recovery by 7% 31 . Moreover, the choice of donor nerve(s) used for reconstruction directly in uences the chance of useful recovery 31 . This observation cannot be completely explained by local anatomical factors (such as donor-recipient axon counts) and we speculate that the plastic potential of the cortex for some donor nerves may be greater than others.…”

“…In both animals 29,30 and humans 31 early nerve repair after BPI yields better outcomes. Recent work has shown that the time from injury to reconstruction in adults with BPI is linearly associated with functional outcomes, whereby each month of delay to neurotisation reduces the odds of meaningful recovery by 7% 31 . Moreover, the choice of donor nerve(s) used for reconstruction directly in uences the chance of useful recovery 31 .…”

Updates in diagnostic tools for diagnosing nerve injury and compressions

“…injury, particularly if we do not have visibility proximal to the foramina (Bourke et al, 2021;Jivan et al, 2009;Wade et al, 2018aWade et al, , 2018bWade et al, , 2019. Specifically in adults with traumatic brachial plexus injuries, each month of delay from the time of injury to reconstruction reduces the probability of achieving M4 elbow flexion by 7% (Vernon Lee et al, 2023) Given that early reconstruction is associated with more favourable outcomes, medical tests for diagnosing nerve injury should be accurate enough to differentiate those who need early intervention from those who may recover spontaneously.…”