Outcomes of nerve transfer and grafting for recovery of glenohumeral joint motion after brachial plexus injury

INTRODUCTION: This study reviews the outcomes and complications of reconstruction for shoulder movement after traumatic supraclavicular brachial plexus injury, including accessory to suprascapular nerve transfer. METHODS: Patients who underwent accessory to suprascapular transfer with or without axillary nerve reconstruction from 2001 to 2023 were identified from a prospective database. Assessment included range of active shoulder abduction against gravity and range of active external rotation. RESULTS: There were 46 patients, mean age 31 years (range 14 to 67). Median surgery delay was 80 days (range 11 to 414). Eighteen patients had C5-6 injuries, 11 C5-7, eight C5-8 and nine C5-T1. Axillary nerve reinnervation was achieved in 36 cases: via C5 nerve grafts (20), triceps motor branch transfer (14) and intercostal nerve transfer (2). Follow-up (mean 36 months, range 14-111) was available for 41 patients. Median active shoulder abduction was 80° (range 30 to 180) and external rotation was 0° (range -40 to 70). Patients with nerve grafts for the axillary nerve achieved a median abduction of 90°, triceps transfers 70° and no repair 50°. Shoulder abduction declined with increasing injury extent and longer delay to operation. Five patients had scapular instability owing to lower trapezius weakness after accessory nerve transfer. CONCLUSIONS: Accessory to suprascapular nerve transfer with axillary nerve reconstruction can provide satisfactory shoulder abduction and external rotation. Despite the trend towards nerve transfers, nerve grafts should be considered for the axillary nerve if the C5 root is viable. However, scapular instability remains a potential complication that may limit functional recovery. LEVEL OF EVIDENCE: III.