Loosbrock, Michelle F.

Background: Shoulder function after spinal nerve grafting in pan–brachial plexus injuries (pan-BPI) is not well described. The authors evaluated shoulder abduction (ABD) and external rotation (ER) after spinal nerve grafting to the suprascapular nerve, axillary nerve, or posterior division of the upper trunk and determined patient characteristics, injury severity and characteristics, and nerve graft factors that influenced outcomes. Methods: A total of 362 patients undergoing pan-BPI reconstruction and spinal nerve grafting for shoulder reanimation in a single institution between 2001 and 2018 were reviewed. Patient demographics, Injury Severity Score (ISS), graft characteristics, strength, range of motion for shoulder ABD and ER, and patient-reported outcomes were recorded. Patients were divided into 3 groups based on recovery of shoulder function: no return, ABD only, and ABD and ER. Results: A total of 110 patients underwent spinal nerve grafting, with 41 meeting inclusion criteria. Seventeen (41.5%) had no return of shoulder function, 14 (34.1%) had ABD alone, and 10 (24.4%) had ABD and ER. Patients with recovery of both ABD and ER were significantly younger (18.6 ± 5.56 years), had lower body mass index (22.4 ± 4.0), and had a lower ISS (10.5 ± 6.24; P = 0.003). Multivariable analysis found that with increasing age (OR, 0.786; 95% CI, 0.576, 0.941) and ISS (OR, 0.820; 95% CI, 0.606, 0.979), odds for return of ABD and ER decreased significantly. Conclusions: In pan-BPI, 24.4% of patients demonstrated return of both ABD and ER after spinal nerve grafting to suprascapular nerve and either axillary nerve or posterior division of the upper trunk. Age, body mass index, and ISS were associated with poorer recovery of shoulder function. Careful patient selection and consideration of age, body mass index, and ISS may improve outcomes of spinal nerve grafting for shoulder reanimation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Background: In pan–brachial plexus injury, distinguishing between preganglionic and postganglionic injuries is crucial to reconstructive planning. This study aimed to identify preoperative factors that would accurately predict a reconstructible C5 spinal nerve. Methods: Patients with pan–brachial plexus injury from a single institution between 2001 and 2018 were reviewed. Patient demographics, clinical examination, diagnostic imaging, and electrodiagnostic results were recorded. C5 viability was determined based on supraclavicular exploration and intraoperative electrophysiologic testing. Univariate analysis identified significant factors for regression analysis. A multivariable parsimonious model was created using stepwise high-performance logistic regression. Results: A total of 311 patients (mean age, 29.9 years; 46 women and 265 men; mean Injury Severity Score, 17.2) were included. A total of 134 patients (43%) had a viable C5 nerve, and 50 patients (12%) had a viable C6 nerve. Intact C5 spinal nerve on computed tomographic (CT) myelogram (OR, 5.4), positive Tinel test (OR, 2.6), muscle strength greater than or equal to 4 (according to the modified British Medical Research Council scale) for the rhomboid (OR, 1.3) or greater than or equal to 4 for the serratus anterior (OR, 1.4), and rhomboid needle electromyography (OR, 1.8) were predictive of having a viable C5 spinal nerve. The multivariable parsimonious stepwise model (area under the curve, 0.77) included four factors: positive Tinel test, intact C5 spinal nerve on CT myelogram, hemidiaphragmatic elevation, and midcervical paraspinal fibrillations. Conclusions: In this cohort of pan–brachial plexus patients with major polytrauma, there was a 43% incidence of viable C5 spinal nerve. A positive Tinel test (OR, 2.1) and intact C5 spinal nerve on CT myelogram (OR, 4.9) predicted a viable C5 nerve. In contrast, hemidiaphragmatic elevation (OR, 3.1) and midcervical paraspinal fibrillations (OR, 2.92) predicted root avulsion. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.