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Meteoric Rise of the Nerve Transfer: Trends in Nerve Reconstruction Techniques in Brachial Plexus Birth Injuries, 2005-2024
Alejandro J. Friedman, MA, Janet Hsu, BS; Steven M. Koehler, M.D.
Montefiore Medical Center, Bronx, NY
Introduction: Autografts are the gold standard of nerve reconstruction, but nerve transfers have gained favor in the adult population among surgeons. We aim to investigate this trend in the context of primary reconstruction of brachial plexus birth injuries and identify major drivers of procedure choice.
Materials and Methods: The Pediatric Health Information System (PHIS) database was queried and 1,349 procedures performed between 2005 and 2024 were identified by CPT codes associated with either autografts or nerve transfers. A cut-off age of 24 months was used. The primary outcome was the presence of CPT codes. Trends in procedure choice over time were investigated using Cochran-Armitage tests, and relationships between variables were investigated using chi-square analyses and/or logistic regression. Stratified analyses were carried out for census region and physician subspecialty.
Results: 729 autografts (54.1%) and 620 nerve transfers (45.9%) were observed over the study period. In 2007, there were 8 autografts and 1 nerve transfer performed; in 2024, there were 45 autografts and 94 nerve transfers performed. There was a significant trend towards the use of nerve transfers compared to autografts (Z = -14.7, p < 0.001). Significant associations were found between procedure choice and census region, physician subspecialty, clinical complexity (by Pediatric Medical Complexity Algorithm score) and patient age (all p < 0.001). Multivariate logistic regression adjusted for demographic and clinical covariates showed a 23.7% increase in the odds of a patient receiving a transfer compared to an autograft year-over-year, OR = 1.237 (1.187-1.303) p < 0.001. Additionally, orthopedic surgeons were more likely to use nerve transfers than autografts, OR = 1.57 (1.10-2.27) p = 0.014. Our model showed that there were increased odds of receiving a nerve transfer with increasing PMCA score (lower medical complexity), OR = 1.34 (1.10-1.64) p = 0.005. Finally, patients older than 8 months were over four times more likely to receive nerve transfers than autografts, OR = 4.06 (2.91-5.73), p < 0.001.
Conclusions: Nerve transfers have experienced an explosion in popularity, which we associate with various demographic and clinical factors. This recently described paradigm shift extends to the pediatric population.
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