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American Association for Hand Surgery

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Brachial Plexus Birth Injury - Trends in Surgical Interventions Over the Past Thirty Years
Matthew Eric Wells, DO1, Benjamin R Childs, MD1, William Davis, PharmD2 and Shawn Diamond, MD1, (1)Texas Tech University Health Sciences Center of El Paso, El Paso, TX, (2)Texas Tech University Paul F Foster School of Medicine, El Paso, TX

Introduction: Early Surgical management of Brachial Plexus Birth Injury (BPBI) has advanced over the past 30-years owed to targeted surgical techniques, increase in specialty-centers and multi-institutional collaboration - leading to consensus decision making. This study seeks to determine trends in surgical management of BPBI over the last 30 years.
Methods: A literature search was performed through MEDLINE (PubMed) for English-language case series involving the surgical treatment of BPBI. There was a minimum 1-year follow up requirement and patients treated after 1 year of age (i.e. tendon transfers and secondary reconstructive efforts) were excluded. Patient demographics, diagnostic tests, surgical treatment modalities, and outcome scoring systems were extrapolated and compared to determine trends in management over the last 30 years. Change over time was determined based on per decade. Significance was determined as p<0.05.
Results: Seventeen studies met criteria summating a total of 883 patients. There was a significant increase in the number of studied patients over the thirty-year period: 463 in the final decade compared to 117 in the first decade (p<0.05). Rates of preoperative testing by either imaging or electrodiagnostic studies remained stable over time with a trend toward decreasing. The majority of authors utilized clinical criteria as indications for surgery. The most commonly used physical examination systems utilized to track post operative outcomes were the Mallet and AMS scoring systems. Most patients underwent neuroma excision and sural nerve autografting (n=618, 70%) compared to neurolysis alone (58, 6.6%), primary nerve transfers (148, 16.8%) and or primary nerve transfer with autografting combinations (59, 6.7%). There was no significant change in the proportion of patients treated with neurolysis alone (τb = -0.251, p = 0.21), sural nerve grafting (τb = 0.149, p = 0.42), or combination graft and transfer procedures (τb = 0.073, p = 0.72) over time. However, there has been a significant increase in the proportion of patients treated with nerve transfer procedures (τb = 0.668, p <0.01) over time.
Discussion: While neuroma excision and sural neve autografting has been the historic gold-standard treatment for BPBI, peripheral nerve transfers have become increasingly utilized, particularly over the past decade, for surgical management. Further prospective, comparative studies between these treatments are needed to establish superiority and clinical validation.


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