Introduction: Ideal time frames for operation of traumatic (stretch and blunt) brachial plexus injuries are still a point of discussion. The goal of this review is to assess ideal delays for operation.
Methods: A systematic search was performed in January 2017 in Pubmed and Embase databases according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Search terms related to ‘brachial plexus injury’ and ‘timing’ were used. Qualitative analysis was performed on all studies. Timing of operation and motor outcome were collected from individual patient data. Patients were categorized into five delay groups (0-3, 3-6, 6-9, 9-12, and >12 months). Median delays were calculated for =MRC 3 and =MRC 4 recoveries.
Results: 43 studies met the inclusion criteria. Most articles showed significantly better muscle grades with delays <6 months, some even with shorter delays. Pain and quality of life scores were also significantly better with short delays. Nerve reconstructions performed after long delays, even >12 months, can still be useful. A total of 569 patients were described individually. 65.5% of all patients were operated =6 months and 27.4% =3 months. The highest percentage of =MRC 3 is seen in the group of 0-3 months (89.7%) (Figure 1). These numbers drop with longer delays, with only 35.7% in delays >12 months. A median delay of 4 months (IQR: 3-6 months) is seen for a recovery of =MRC 3, compared to a median delay of 7 months (IQR: 5-11 months) for non-useful recovery (Figure 2).
Conclusions: In stretch and blunt injury of the brachial plexus, ideal operative timeframes seem to be between 3 and 6 months after injury. Earlier operations are appropriate in clear cases of no spontaneous recovery. If long delays occur due to concomitant injury or delayed referral, nerve reconstruction can still be considered but will often need secondary musculoskeletal operations.
Patient Care: By evaluating the ideal timeframe in which operations should be performed in traumatic brachial plexus injury, reconstructions have the most chance of being succesful.
Learning Objectives: - Know the ideal timeframe for reconstruction after traumatic brachial plexus injury
- Know maximal delays for nerve reconstruction
- Know most common factors influencing functional outcome after brachial plexus surgery