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American Association for Hand Surgery

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Reverse End-To-Side Spinal Accessory to Suprascapular "Supercharge" Nerve Transfer for Brachial Plexus Birth Injury
Weston Thomas, PA-C1, Yvette Elias, OT/L, CHT1, Verena M. Schreiber, MD1 and Aaron J Berger, MD, PhD2, (1)Nicklaus Children's Hospital, Miami, FL, (2)Division of Plastic and Reconstructive Surgery, Nicklaus Children's Hospital, Miami, FL

Brachial plexus birth injury (BPBI) usually presents with a neuroma-in-continuity that demonstrates some preservation of function. The suprascapular nerve (SSN) is often found emanating directly from the neuroma.
Management of the neuroma typically entails neurolysis alone versus excision and nerve graft/transfer. A distal branch of the spinal accessory nerve (SAN) may be utilized for nerve transfer into the SSN; published studies suggest end-to-end SAN to SSN transfer is comparable to nerve grafting from the upper roots/trunk. However, excision of the neuroma results in a temporary downgrade in SSN function.

The technique of reverse end-to-side (RETS) nerve transfer has gained popularity in recent years. It provides additional nerve input to augment motor recovery in nerve injuries that are in-continuity by providing increased motor axons in closer proximity to the target muscles. We are not aware of any reports of RETS transfer of the SAN to the SSN for patients with BPBI.

We seek to describe our experience with RETS transfer of SAN to the SSN in reconstruction of BPBI.

Retrospective review of patients with BPBI from 2016-2020 was performed to identify patients who underwent RETS transfer of SAN to SSN. All patients underwent preoperative MRI. Intraoperative images were reviewed, assessing proximity of the SAN to the SSN, as well as the relative diameter of the two nerves. Early outcomes were reviewed.

Seven patients underwent RETS transfer of the SAN to the SSN. Mean age at operation was 10.8 ± 4 months. Intraoperative image review demonstrated close proximity of the distal SAN to the distal SSN in all cases. Diameter discrepancy between the SAN and SSN was recorded.

RETS transfer of the SAN to the SSN was performed without tension in all 7 cases. No donor morbidity was noted in any patient. Concurrent Botox administration was performed in all cases. Average follow-up after reconstruction is 9.7 ± 10 months.

All patients have demonstrated some degree of SSN functional recovery. At most recent follow up, 5 out of 7 patients demonstrate full passive gleno-humeral external rotation (ER); the other two are to 80 and 60 degrees. Evidence of early recovery of active ER is present in all patients.

RETS transfer of the SAN to the SSN demonstrates potential to augment recovery of the SSN in the setting of neuroma-in-continuity. The technique provides an option for management of neuroma-in-continuity without a downgrade in function and without significant donor site morbidity.

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