Optimal Donor Nerve to Restore Elbow Flexion After Traumatic Brachial Plexus Injury: A Systematic Review and Meta-Analysis

Abstract

BACKGROUND:Traumatic brachial plexus injuries (BPIs) often lead to devastating upper extremity deficits. Treatment frequently prioritizes restoring elbow flexion through transfer of various donor nerves; however, no consensus identifies optimal donor nerve sources.OBJECTIVE:To complete a meta-analysis to assess donor nerves for restoring elbow flexion after partial and total BPI (TBPI).METHODS:Original English language articles on nerve transfers to restore elbow flexion after BPI were included. Using a random-effects model, we calculated pooled, weighted effect size of the patients achieving a composite motor score of ≥M3, with subgroup analyses for patients achieving M4 strength and with TBPI. Meta-regression was performed to assess comparative efficacy of each donor nerve for these outcomes.RESULTS:Comparison of the overall effect size of the 61 included articles demonstrated that intercostal nerves and phrenic nerves were statistically superior to contralateral C7 (cC7; P = .025, <.001, respectively) in achieving ≥M3 strength. After stratification by TBPI, the phrenic nerve was still superior to cC7 in achieving ≥M3 strength (P = .009). There were no statistical differences among ulnar, double fascicle, or medial pectoral nerves in achieving ≥M3 strength. Regarding M4 strength, the phrenic nerve was superior to cC7 (P = .01) in patients with TBPI and the ulnar nerve was superior to the medial pectoral nerve (P = .036) for partial BPI.CONCLUSION:Neurotization of partial BPI or TBPI through the intercostal nerve or phrenic nerve may result in functional advantage over cC7. In patients with upper trunk injuries, neurotization using ulnar, median, or double fascicle nerve transfers has similarly excellent functional recovery.

A favorable suture method for size-mismatched nerve transfer: comparison with standard perineural suture in an experimental rat study

“…In his study, 91% (10 of 11) patients who underwent intercostal-to-musculocutaneous nerve transfer achieved more than M3 elbow flexion power. Similarly, in a recent systematic review, 77.7% (539 of 703) of patients who underwent intercostal-to-musculocutaneous achieved more than M3 elbow flexion power [ 8 ]. When compared to this systematic review, Ochiai’s report showed excellent results.…”

Selective Repair of Motor Branches in the Femoral Nerve by Transferring the Motor Branches of Obturator Nerve

“…5 However, in case of extensive nerve gaps or severe pelvic adhesion, when directly coaptation or nerve graft is impossible, nerve transfer has been reported to be a simple and valid therapeutic option, especially in upper limb nerve injuries. [6][7][8][9][10] Concerning femoral nerve lesions, the obturator nerve has been recommended as an ideal donor nerve by several pieces of literature recently for nerve transfer. Campbell et al 11 first described intropelvic obturator nerve transfer to the femoral nerve in a patient with a 15-cm nerve gap caused by resection of retroperitoneal Schwannoma and reported good outcomes with a nearly normal gait and grade 4 strength of the quadriceps 2 years postoperatively.…”

“…Direct nerve repair or nerve grafting is still the criterion standard treatment for peripheral nerve injuries 5 . However, in case of extensive nerve gaps or severe pelvic adhesion, when directly coaptation or nerve graft is impossible, nerve transfer has been reported to be a simple and valid therapeutic option, especially in upper limb nerve injuries 6–10 …”