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Late Nerve Repairs in Brachial Plexus Lesions

Objectives: It is a common opinion that surgical repair of brachial plexus later than 1 year from the lesion cannot lead to real functional results. This is probably true for repair by means of multiple grafts which need specially in root’s lesions a long time for reinnervation: This fact and the frequent delay in repair reduce in a substantial way the possibility to obtain good results in brachial plexus surgery. The continuous development of nerve transfers allowed shortening the time of recovery by means of very distal repairs, near to the mainly motor targets. The shortening of recovery time gives today the possibility to move forward the classical limits for nerve repair. Materials and Methods: The authors present the results obtained in 93 nerve transfers in 52 patients who underwent nerve repair after more than 1 year from the lesion. The series consists of 22 children with obstetric brachial plexus palsy and 30 adults with traumatic brachial plexus lesions all of them repaired after 1 year from the lesion with a maximum delay of 7 years. The nerve repaired by means of late transfers had been the suprascapular, the musculocutaneous, and the axillary. In all the cases, a previous electromyography detected the presence of fibrillation in the muscles that are planned to be reinnervated. Fibrillation is actually considered as a prerequisite to indicate a late nerve transfer. Results: Evaluation of results has been separate between children and adult patients. In adult patients, the results for biceps have been 30% of failures, 42% of partial results (M2/M3−), and 28% of good results (M3+/M4). The results for suprascapular have been 23% of failures, 45% of partial results, and 32% of good results. In children, the results for biceps have been 15% of failures and 85% of good results (<M3+). The results for suprascapular have been 25% of failures, 25% of partial results, and 50% of good results. No result can be reported for deltoid due to the too reduced number of operated cases. Conclusions: Nerve transfers allow in a considerable number of cases to obtain functional results, in some case even after several years of delay. A part for late observed cases we can offer in this way a second option in cases of lack of recovery from primary surgery. Actually nerve transfer is nowadays a new possibility placed in between primary microsurgical repair and classic palliative surgery. Undoubtedly better results have been obtained in children, but surprisingly useful results could be obtained in adults even if in a more reduced percentage of cases.