Understanding the management of brachial plexus birth palsy and the roles of nerve transfers

Early recognition and management of neonatal brachial plexus injury (NBPP) is key to optimizing outcomes and surgical options. Because up to a third of patients with birth palsy may require surgical intervention, the multidisciplinary team must follow up on the function and recovery of the entire upper extremity, from shoulder to fingertips, within the first few months of life. Options include neuroma resection and primary nerve grafting and/or nerve transfers, which can be intra- or extra-plexal, as adjunctive or standalone procedures. When limited proximal nerve roots are available for nerve grafting, or when too many nerve roots are involved, exceeding the supply of nerve graft, extra-plexal nerve transfers are then indicated. While early intervention is preferred (between 3 and 6 months for most authors), older children presenting late (> 1 year since birth) with partial nerve recovery may still potentially benefit from nerve transfers, which can be offered to late-presenting infants. Here we discuss the anatomy, indications, work-up, options, complications, and outcomes for such nerve transfers for upper, lower, and global plexus palsy in neonates. Nerve transfers are a common procedure done for the treatment of various types of birth plexus palsies. Currently, while there is an abundance of clinical reports and evidence, there is still a lack of clarity regarding best practices or in terms of the type of procedure and technique for the treatment of birth plexus palsy. Our hope is that this chapter provides a concise source after an extensive cumulative review of the evidence of best practices for nerve transfers in the case of birth plexus palsy.