Mapping Nerve Transfer Adoption in Brachial Plexus Birth Injury Reconstruction, 2005-2024.

Abstract

Purpose: Brachial plexus birth injury (BPBI) affects up to 3 per 1,000 live births, with many children experiencing persistent disability. Although autologous nerve grafting has traditionally served as the primary reconstructive strategy for BPBI, nerve transfers are being used with increasing frequency. We analyzed national trends in nerve reconstruction for BPBI using the Pediatric Health Information System administrative database from 2005 to 2024.

Methods: We used Current Procedural Terminology (CPT) codes associated with nerve autografting or nerve transfer to identify patients in the Pediatric Health Information System database under 24 months of age who underwent surgery for BPBI. The primary outcome was the presence of procedural CPT coding events. Trends in procedures were analyzed using Cochran-Armitage analyses. Chi-square analyses and multivariate logistic regression were used to evaluate differences between autograft and transfer groups.

Results: We identified 1,047 procedural coding events between 2005 and 2024, comprising 585 autografts (55.9%) and 462 nerve transfers (44.1%). Patients who underwent autografts were notably younger than patients who underwent nerve transfer at time of surgery (6.3 ± 3.5 vs 10.2 ± 4.9 months, P < .001). Multivariable analysis confirmed year, patient age, and region as independent predictors of nerve transfer. The odds of receiving a transfer increased 21% with each calendar year (P < .001). Patient age strongly influenced procedure selection, with patients older than 8 months demonstrating nearly 7-fold greater odds of undergoing a transfer. Among patients older than 8 months, treatment by orthopedic surgeons was associated was a 68-fold increase in the odds of nerve transfer during the contemporary study period, whereas treatment by plastic surgeons was associated with a 5-fold increase. Transfers predominated in the West census region and were performed less frequently in the Northeast.

Conclusions: These findings demonstrate increasing adoption of nerve transfers in pediatric BPBI reconstruction across specialties and regions. Further investigation into long-term functional outcomes and subspecialty-specific training is needed to refine surgical decision making in this population.

Type of study/level of evidence: Prognostic III.