Brain plasticity and age after restoring elbow flexion with distal nerve transfers in neonatal brachial plexus palsy and nonneonatal traumatic brachial plexus injury using the plasticity grading scale

J Neurosurg. 2023 Jun 30;139(6):1568-1575. doi: 10.3171/2023.5.JNS23673. Print 2023 Dec 1.


Objective: Ulnar and/or median nerve fascicle to musculocutaneous nerve (MCN) transfers are used to restore elbow flexion following severe neonatal and nonneonatal brachial plexus injuries (BPIs). Restoring volitional control requires plastic changes in the brain. To date, whether the potential for plasticity is influenced by a patient's age remains unknown.

Methods: Patients who had presented with a traumatic upper (C5-6 or C5-7) BPI were divided into two groups: neonatal brachial plexus palsies (NBPPs) and nonneonatal traumatic BPIs (NNBPIs). Both groups underwent ulnar or median nerve transfers to the MCN for elbow flexion restoration between January 2002 and July 2020. Only those who attained a British Medical Research Council strength rating of 4 were reviewed. The primary comparison between the two groups was the plasticity grading scale (PGS) score to determine the level of independence of elbow flexion (target) from forearm motor muscle movement (donors). The authors also assessed patient compliance with rehabilitation using a 4-point Rehabilitation Quality Scale. Bivariable and multivariable analyses were used to identify intergroup differences.

Results: In total, 66 patients were analyzed: 22 with NBPP (mean age at surgery 10 months) and 44 with NNBPI (age range at surgery 3-67 years, mean 30.2 years; mean time to surgery 7 months, p < 0.001). All NBPP patients obtained a PGS grade of 4 at the final follow-up versus just 47.7% of NNBPI patients (mean 3.27, p < 0.001). On ordinal regression analysis, after nature of the injury was excluded because of excessive collinearity with age, age was the only significant predictor of plasticity (β = -0.063, p = 0.003). Median rehabilitation compliance scores were not statistically different between the two groups.

Conclusions: The extent of plastic changes that occur for patients to regain volitional control over elbow flexion after upper arm distal nerve transfers following BPI is influenced by patient age, with complete plastic rewiring more likely in younger patients and virtually ubiquitous in infants. Older patients should be informed that elbow flexion after an ulnar or median nerve fascicle transfer to the MCN might require simultaneous wrist flexion.

Keywords: brachial plexus injury; brain plasticity; neonatal brachial plexus palsy; nerve transfer; neuroplasticity score; peripheral nerve; plasticity grading scale.

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Brachial Plexus Neuropathies* / surgery
  • Brachial Plexus* / injuries
  • Brachial Plexus* / surgery
  • Child
  • Child, Preschool
  • Elbow
  • Elbow Joint* / innervation
  • Elbow Joint* / surgery
  • Humans
  • Infant
  • Infant, Newborn
  • Middle Aged
  • Neonatal Brachial Plexus Palsy* / complications
  • Neonatal Brachial Plexus Palsy* / surgery
  • Nerve Transfer* / adverse effects
  • Neuronal Plasticity
  • Range of Motion, Articular / physiology
  • Retrospective Studies
  • Ulnar Nerve / surgery
  • Young Adult