Key result
The anterior approach for spinal accessory nerve to suprascapular nerve transfer showed no significant difference in shoulder abduction power at 18 months compared to the posterior approach, though initial clinical recovery was slower (8.16 vs 6.85 months; p<0.05).
Why the study?
No published randomised control trials had directly compared outcomes between anterior and posterior approaches for spinal accessory nerve to suprascapular nerve transfer in brachial plexus surgery.
Does the anterior approach improve shoulder abduction compared to the posterior approach in patients with brachial plexus injuries?
RCT (n=58)
selective randomisation with the sealed envelope technique
Does the anterior approach improve shoulder abduction compared to the posterior approach in patients with brachial plexus injuries?
Both anterior and posterior approaches for SAN to SSN nerve transfer yield similar shoulder abduction outcomes at 18 months, though the posterior approach may show earlier signs of recovery.
Anterior approach confers no long-term abduction advantage; confirms equivalent 18-month outcomes, supporting surgeon choice by anatomy or preference.
Background: In brachial plexus surgery, a key focus is restoring shoulder abduction through spinal accessory nerve (SAN) to suprascapular nerve (SSN) transfer using either the anterior or posterior approach. However, no published randomised control trials have directly compared their outcomes to date. Therefore, our study aims to assess motor outcomes for both approaches. Methods: This study comprises two groups of patients. Group A: anterior approach (29 patients), Group B: Posterior approach (29 patients). Patients were allocated to both groups using selective randomisation with the sealed envelope technique. Functional outcome was assessed by grading the muscle power of shoulder abductors using the British Medical Research Council (MRC) scale. Results: Five patients who were operated on by posterior approach had ossified superior transverse suprascapular ligament. In these cases, the approach was changed from posterior to anterior to avoid injury to SSN. Due to this reason, the treatment analysis was done considering the distribution as: Group A: 34, Group B: 24. The mean duration of appearance of first clinical sign of shoulder abduction was 8.16 months in Group A, whereas in Group B, it was 6.85 months, which was significantly earlier (p < 0.05). At the 18-month follow-up, both intention-to-treat analysis and as-treated analysis were performed, and there was no statistical difference in the outcome of shoulder abduction between the approaches for SAN to SSN nerve transfer. Conclusions: Our study found no significant difference in the restoration of shoulder abduction power between both approaches; therefore, either approach can be used for patients presenting early for surgery. Since the appearance of first clinical sign of recovery is earlier in posterior approach, therefore, it can be preferred for cases presenting at a later stage. Also, the choice of approach is guided on a case to case basis depending on clavicular fractures and surgeon preference to the approach.
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Agrawal et al. (2023) conducted an RCT in Brachial plexus injuries (n=58). Anterior approach for transfer of spinal accessory nerve to suprascapular nerve vs. Posterior approach was evaluated on Mean duration of appearance of first clinical sign of shoulder abduction (months) (p=< 0.05). The anterior approach for spinal accessory nerve to suprascapular nerve transfer showed no significant difference in shoulder abduction power at 18 months compared to the posterior approach, though initial clinical recovery was slower (8.16 vs 6.85 months; p<0.05).
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