Novel Nerve Transfer Is Effective in Babies With Brachial Plexus Birth Injuries 

A novel nerve transfer significantly improves shoulder function in babies with brachial plexus birth injuries, according to a new study from Children’s Hospital Los Angeles.

The case series, which included 35 patients ages 4 to 13 months, is the first to examine the effectiveness of a medial pectoral nerve to axillary nerve transfer for babies with these injuries. Previously, this pairing had only been studied in adults.

Pediatric orthopedic surgeon Erin Meisel, MD, FAAOS, presented the data at the 2024 NARAKAS Club meeting in Italy, as well as at the 2024 Pediatric Hand Study Group meeting.

“The availability of donor nerves for nerve transfer surgery can sometimes be limited,” says Dr. Meisel, Co-Director of the Brachial Plexus and Peripheral Nerve Program at Children’s Hospital Los Angeles—the largest such program on the West Coast. “We found that this pairing is an effective and viable option for those babies who need it.”

The benefits of nerve transfers

Although nerve grafts have been the traditional surgical approach for these patients, Dr. Meisel and program Co-Director Susan Durham, MD, MS, prefer to perform nerve transfers whenever possible.

With this advanced technique, surgeons “rewire a limb”—borrowing a portion of a motor nerve from a healthy muscle and connecting it directly to the nerve of the muscle they need to activate. That connects electricity to the muscle much faster than a nerve graft.

CHLA performs approximately 20 nerve transfer surgeries a year in babies with brachial plexus birth injuries—among the most in the country.

“Every week that a muscle isn’t getting any nerve signal, it’s dying,” says Dr. Durham, Associate Chief of Neurosurgery at CHLA. “The faster we can get good nerve into a muscle, the faster the recovery is, and the better that muscle functions in the long run.”

CHLA performs approximately 20 nerve transfer surgeries a year in babies with brachial plexus birth injuries—among the most in the country.

Key findings

Nerve transfers are only possible if donor nerves are available, though. The study came about because Dr. Meisel and Dr. Durham—who operate on patients together—had several cases where the nerve to the triceps was injured and could not be used as a donor for the axillary nerve.

The team decided to instead use the medial pectoral nerve, which is easily accessible and has a high number of available motor neurons.

All patients in the series underwent medial pectoral nerve to axillary nerve transfer—along with spinal accessory nerve to suprascapular nerve transfer, and single or double Oberlin nerve transfer.

Prior to surgery, most patients scored a 2 or 3 on the Active Movement Scale (AMS), which measures shoulder flexion and abduction on a scale of 1 to 7. The team found that:

• One year after surgery, shoulder function had improved by an average of two AMS grades.
• Eight of the 10 babies who had two-year follow-up scored a 5 or above on the AMS scale.
• Five patients scored a 6 two years after surgery, and one scored a perfect 7.

The importance of therapy

Dr. Meisel and Dr. Durham stress that surgery is only one factor that determines a child’s outcome. Occupational therapy is also critical.

At CHLA, certified hand therapists are key members of the multidisciplinary brachial plexus team and are specially trained to use modalities like electrical stimulation, which can help “wake up” a baby’s muscles before surgery and promote postoperative recovery.

“We work very closely with our therapists, who are highly skilled and experienced at working with these children,” Dr. Durham says. “Our program could not exist without them.”

“The surgery in isolation only gives a child a scar,” Dr. Meisel adds. “Occupational therapy is essential for helping the child to gain good function.”