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Vascularized Plexus Allotransplantation: A New Hope in Brachial Plexus Palsy?

Brachial plexus injury is associated with significant disability, and can occur throughout life. Shoulder dystocia complicates 1% to 2% of births, of which approximately 20% result in brachial plexus palsy. Young adults have a higher incidence of penetrating trauma to the axilla or neck, as well as motorcycle accidents and low-velocity sporting injuries resulting in traction to the upper roots and trunks. Compression injuries, due to either malignancy or anatomic variations, such as cervical ribs or congenital fibrous bands, may also be implicated. Later in life, adjuvant radiotherapy to the axilla for treatment of breast carcinoma may also result in brachial plexopathy, manifesting anywhere from 6 months to 20 years after treatment. Severe plexus injuries rarely resolve spontaneously and were historically occasionally managed by amputation. The current standard of practice for treatment of severe brachial plexus injuries includes free muscle transfer, multiple nerve transfers, or nerve interposition grafts, with the primary goal of restoring elbow flexion, followed by shoulder stability and motility, and finally hand and wrist function. None of these options are without their limitations, however, be it donor site morbidity or simply limited availability of appropriate donor nerves (such as the sural ormedial antebrachial cutaneous) for interposition autografts. Furthermore, the challenging biology of nerve regeneration and the proximal level of these injuries have typically been associated with notoriously poor outcomes. There is a need for advanced surgical strategies with the potential for recovery of forearm and finger flexion in particular. In this issue of Transplantation, Chang et al describe a rat model of whole brachial plexus allogeneic interposition transplantation across a full major histocompatibility complex mismatch (RT1 to RT1). A vascularized neurocutaneous allograft composed of the brachial plexus, subclavian artery and vein, and sentinel skin patch was harvested from Norway rats and implanted into Lewis rats, bridging the C5 to T1 nerve