American Society for Peripheral Nerve

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Shoulder ROM Improves with Long-Term Follow-Up after Brachial Plexus Nerve Reconstruction
Jung-Pan Wang, MD, PhD; Steve Lee, MD; Scott Wolfe, MD
Hand, Upper Extremity, and Microsurgery, Hospital for Special Surgery, New York, NY

Introduction: There is general agreement among brachial plexus surgeons that patients’ muscular recovery plateaus within 2-3 years after reconstructive surgery. We were unable to find literature to document objective improvement of strength and range of motion following adult brachial plexus reconstruction after this arbitrary 2-3 year window. We hypothesized that patients who underwent brachial plexus re-innervation would continue to gain strength and ROM beyond 2-3 years of follow-up.

Materials and Methods: Six male patients who had undergone plexus reconstruction prior to 2005 at our institution were available for clinical examination at 10 or more years postoperatively. The average age at the time of operation was 41 years (range 17-73). The mean preoperative time was 175.3 days. Two cases presented with C5-C6 paralysis, three cases presented with complete five level injuries, and one case presented with isolated axillary nerve injury. The average time for long-term follow-up was 9.4 years (range 5-15.5). Functional evaluation was based on the assessment of active range of motion (ROM) in degrees and the British Medical Research Council (BMRC) scale for muscle strength.

Results: We compared shoulder and elbow BMRC grade and ROM in patients who underwent plexus surgery at 2 years and average 9.4 years follow-up. EMG confirmed re-innervation of all target muscles at an average of 9 months postoperatively. Average shoulder abduction was 45±11 degrees (range 20-80) at 2 years postoperatively as compared to 90±31 degrees (range 30-160) at 9.4 years postoperatively, and average shoulder BMRC grade increased from 3.3 (range 3-4) at 2 years to 3.9 (range 3-4.5) at final follow-up. Average elbow ROM increased from 102±40 (range 0-140) degrees at 2 years to 124±19 (range 90-140) degrees at 9.4 years, and average elbow BMRC grade increased from 3.3±1 (range 0-4.5) at 2 years to 3.9 (range 2-4.5) at final follow-up. Overall, shoulder abduction showed statistically significant improvement in the 9.4 year follow-up group when compared to the 2 year follow-up group (p<0.05, Fisher’s exact tests).

Conclusion: We conclude that patients continue to gain range of motion and strength well after 2-3 years of follow-up, contrary to conventional opinion. While the precise mechanism is not known, it is likely due to terminal collateral sprouting, or to an unknown or as yet undescribed mechanism. We recommend that patients be encouraged to continue strengthening exercises well after the initial recovery period, and that more long-term data be collected to expand upon these observations.

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