0850 Brachial Plexus Surgery (3) - Aetna Better Health

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Brachial Plexus Surgery

Policy History

Last Review

12/17/2020

Effective: 07/30/2013

Next

Review: 10/14/2021

Review History

Definitions

Additional Information

Clinical Policy Bulletin

Notes

Number: 0850

Policy *Please see amendment for Pennsylvania Medicaid at the end of this CPB.

Aetna considers neuroplasty (neurolysis or nerve

decompression) medically necessary in the treatment of a

brachial plexus neuromas and other brachial plexus lesions.

Aetna considers dorsal root entry zone (DREZ) coagulation

medically necessary in the treatment of brachial plexus

avulsion.

Aetna considers soft tissue reconstruction surgeries

(e.g., triangle tilt surgery and the Mod-Quad procedure)

medically necessary in the treatment of obstetric brachial

plexus injury (BPI) if functional recovery does not ensue in 3 or

more months. Note: There is a lack of reliable evidence that

one type of reconstructive soft tissue technique is more

effective than others for obstetric BPIs.

Aetna considers the following interventions experimental and

investigational because their effectiveness has not been

established:

▪ Bionic reconstruction for brachial plexus avulsion

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▪ Computer-assisted dorsal root entry zone

microcoagulation (CA-DREZ) for brachial plexus avulsion

▪ Therapeutic taping for scapular stabilization

▪ Vascularized brachial plexus allo-transplantation for

traumatic BPI.

Background

The brachial plexus is a network of nerves located in the neck

and axilla, composed of the anterior branches of the lower 4

cervical and first 2 thoracic spinal nerves that supply the chest,

shoulder, and arm. Injuries to the brachial plexus affect the

nerves supplying the shoulder, upper arm, forearm and hand,

causing numbness, tingling, pain, weakness, limited

movement, or even paralysis of the upper limb. Brachial

plexus lesions are classified as either traumatic or obstetric.

Brachial plexopathy is the pathologic dysfunction of the

brachial plexus. When the brachial plexus is injured during

delivery, the nerves become damaged and result in loss of

muscle control and paralysis. This condition is also known as

Erb’s palsy.

Brachial plexus avulsion is the tearing away or forcible

separation of nerves of the brachial plexus (a network of

nerves that conducts signals from the spine to the shoulder,

arm and hand) from the spine, the point of origin. Symptoms

of brachial plexus injuries may include a limp or paralyzed arm,

lack of muscle control in the arm, hand, or wrist, and lack of

feeling or sensation in the arm or hand. Brachial plexus

injuries may occur during birth: the baby's shoulders may

become impacted during the birth process causing the brachial

plexus nerves to stretch or tear.

Brachial neuroplasty (neurolysis or nerve decompression) is

the surgical repair or restoration of nerve tissue. The release

of adhesions around a nerve (freeing of intact nerve from scar

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tissue) is performed to relieve pain and disability. It is written

in the 2008 textbook "Frontera: Essentials of Physical

Medicine and Rehabilitation", that surgery is an option in cases

of traumatic plexopathy but has variable results. Surgical

techniques such as nerve grafting, free muscle transfer,

neurolysis, and neurotization are used. Surgeons who use

these techniques frequently differ considerably in their

approach to them, making conclusions about their efficacy

difficult. According to the textbook "Bradley: Neurology", the

surgical treatment of traumatic plexopathy depends on the

extent of the lesion. Depending on the findings, neurolysis,

nerve grafting or re-neurotization is performed. In the textbook

"Browner; Skeletal Trauma", it is written in reference to nerve

injuries of the brachial plexus, when a neuroma in continuity is

found it may be resected and repaired or neurolysis may be

performed.

Dorsal root entry zone (DREZ) coagulation (also known as

dorsal root entry zone lesion) is a surgical procedure in which

ablative lesions are made at the dorsal root entry zones of the

spinal cord. These lesions are made with a radiofrequency

lesion generator or laser through an open exposure of the cord

via laminectomy. Pain-producing nerve cells are destroyed

with radiofrequency heat lesions.

Computer-assisted dorsal root entry zone microcoagulation

(CA-DREZ) is a surgical procedure in which ablative lesions

are made at the dorsal root entry zones of the spinal cord.

These lesions are made with a radiofrequency lesion

generator or laser through an open exposure of the cord via

laminectomy. It involves electrical recording inside the spinal

cord at the time of surgery to identify regions of abnormally

active pain-producing nerve cells. These abnormal cells are

then destroyed with radiofrequency heat lesions.

The Triangle Tilt is a surgical procedure that addresses

scapular elevation in children with obstetric brachial plexus

injury (OBPI) through the bony realignment of the clavicle and

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scapula. This realignment, or tilting, is of the triangle formed

by clavicle and scapula. As the scapula elevates, the plane of

the triangle is steepened. The purpose of the triangle tilt,

therefore, is to normalize the plane of this triangle or, to reduce

the elevation of the scapula and normalize the spatial

relationship between the sides of the triangle.

Nath et al wrote in 2010 the triangle tilt surgery restores the

distal acromioclavicular triangle from an abnormal superiorly

angled position to a neutral position, thereby restoring normal

glenohumeral anatomic relationships. The findings of a study

investigating the effects of triangle tilt surgery on glenohumeral

joint anatomy in 100 OBPI patients were reported. Axial

computed tomography and magnetic resonance images taken

before and 12- to 38-months after surgery showed significant

improvements in both posterior subluxation and glenoid

version. Patients with complete posterior glenohumeral

dislocation improved from 19 % pre-operatively to 11 % post

operatively. Glenoid shape was also improved, with 81 % of

patients classified as concave or flat after surgery compared

with 53 % before surgery. The authors concluded these

anatomic improvements after triangle tilt surgery hold promise

for improving shoulder function and quality of life for OBPI

patients.

The Mod Quad procedure is considered a secondary surgery

in children with brachial plexus injury used to correct muscle

imbalances. Among the muscles injured in Erb's are the

abductors of the shoulder (that lift the arm over the head), as

well as the external rotators (that help to turn the upper arm

outward and to open the palm of the hand). At the same time,

the internal rotators (muscles that turn the arm and palm

inward) and adductors (muscles that pull the arm to the side)

of the arm are not involved in the injury because they are

supplied by the lower roots of the plexus. These strong

muscles overpower the weak muscles and over time the child

cannot lift the arm over the head or turn the palm out, because

of the muscle imbalance. In order to use the hand effectively,

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the elbow becomes bent, which eventually becomes fixed

because of weakness of the triceps (the elbow straightening

muscle). The elbow-bent posture (also known as the Erb's

Engram) contributes to the appearance of the arm being

shorter.

For this muscle imbalance, a group of muscle releases and

transfers can put the arm in a more natural position and help

to lift the arm over the head. Known as the "quad" procedure,

it has 4 components:

▪ Latissimus dorsi muscle transfer for external rotation

and abduction

▪ Teres major muscle transfer for scapular stabilization

▪ Subscapularis muscle release

▪ Axillary nerve decompression and neurolysis).

Depending on the individual child, other nerve

decompressions or muscle/ tendon transfers (such as

pectoralis muscle releases) might be performed at the

same time (the modified quad or "Mod Quad"

procedure).

Louden et al (2013) conduct a meta-analysis and systematic

review analyzing the clinical outcomes of neonatal brachial

plexus palsy (NBPP) treated with a secondary soft-tissue

shoulder operation. These researchers performed a literature

search to identify studies of NBPP treated with a soft-tissue

shoulder operation. A meta-analysis evaluated success rates

for the aggregate Mallet score (greater than or equal to 4-point

increase), global abduction score (greater than or equal to

1-point increase), and external rotation score (greater than or

equal to 1-point increase) using the Mallet scale. Subgroup

analysis was performed to assess these success rates when

the author chose arthroscopic release technique versus open

release technique with or without tendon transfer. Data from

17 studies and 405 patients were pooled for meta-analysis.

The success rate for the global abduction score was

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significantly higher for the open technique (67.4 %) relative to

the arthroscopic technique (27.7 %, p < 0.0001). The success

rates for the global abduction score were significantly different

among sexes (p = 0.01). The success rate for external rotation

was not significantly different between the open (71.4 %) and

arthroscopic techniques (74.1 %, p = 0.86). No other variable

was found to have significant impact on the external rotation

outcomes. The success rate for the aggregate Mallet score

was 57.9 % for the open technique, a non-significant increase

relative to the arthroscopic technique (53.5 %, p = 0.63). Data

suggested a correlation between increasing age at the time of

surgery and a decreasing likelihood of success with regards to

aggregate Mallet with an odds ratio of 0.98 (p = 0.04). The

authors concluded that overall, the secondary soft-tissue

shoulder operation is an effective treatment for improving

shoulder function in NBPP in appropriately selected patients.

The open technique had significantly higher success rates in

improving global abduction. There were no significant

differences in the success rates for improvement in the

external rotation or aggregate Mallet score among these

surgical techniques.

Ali and colleagues (2014) stated that NBPP represents a

significant health problem with potentially devastating

consequences. The most common form of NBPP involves the

upper trunk roots. Currently, primary surgical repair is

performed if clinical improvement is lacking. There has been

increasing interest in "early" surgical repair of NBPPs,

occurring within 3 to 6 months of life. However, early treatment

recommendations ignore spontaneous recovery in cases of

Erb's palsy. This study was undertaken to evaluate the optimal

timing of surgical repair in this group with respect to quality of

life. These investigators formulated a decision analytical model

to compare 4 treatment strategies (no repair or repair at 3, 6,

or 12 months of life) for infants with persistent NBPPs. The

model derived data from a critical review of published studies

and projects health-related quality of life (QOL) and quality-

adjusted life years (QALY) over a lifetime. When evaluating the

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QOL of infants with NBPP, improved outcomes were seen with

delayed surgical repair at 12 months, compared with no repair

or repair at early and intermediate time points, at 3 and 6

months, respectively. ANOVA showed that the differences

among the 4 groups were highly significant (F = 8369; p <

0.0001). Pair-wise post-hoc comparisons revealed that there

were highly significant differences between each pair of

strategies (p < 0.0001). Meta-regression showed no evidence

of improved outcomes with more recent treatment dates,

compared with older ones, for either non-surgical or for

surgical treatment (p = 0.767 and p = 0.865, respectively). The

authors concluded that these data supported a delayed

approach of primary surgical reconstruction to optimize QOL.

They stated that early surgery for NBPPs may be an overly

aggressive strategy for infants who would otherwise

demonstrated spontaneous recovery of function by 12 months.

They stated that a randomized, controlled trial would be

needed to fully elucidate the natural history of NBPP and

determine the optimal time point for surgical intervention.

Tse and colleagues (2015) stated that nerve transfers have

gained popularity in the treatment of adult brachial plexus

palsy; however, their role in the treatment of NBPP remains

unclear. Brachial plexus palsies in infants differ greatly from

those in adults in the patterns of injury, potential for recovery,

and influences of growth and development. This International

Federation of Societies for Surgery of the Hand committee

report on NBPP was based upon review of the current

literature. These investigators found no direct comparisons of

nerve grafting to nerve transfer for primary reconstruction of

NBPP. Although the results contained in individual reports that

used each strategy for treatment of Erb palsy were similar,

comparison of nerve transfer to nerve grafting was limited by

inconsistencies in outcomes reported, by multiple confounding

factors, and by small numbers of patients. Although the role of

nerve transfers for primary reconstruction remains to be

defined, nerve transfers have been found to be effective and

useful in specific clinical circumstances including late

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presentation, isolated deficits, failed primary reconstruction,

and multiple nerve root avulsions. In the case of NBPP more

severe than Erb palsy, nerve transfers alone were inadequate

to address all of the deficits and should only be considered as

adjuncts if maximal re-innervation is to be achieved. The

authors concluded that surgeons who commit to care of infants

with NBPP need to avoid an over-reliance on nerve transfers

and should also have the capability and inclination for brachial

plexus exploration and nerve graft reconstruction.

An UpToDate review on "Brachial plexus

syndromes" (Bromberg, 2015) states that "Management of

neonatal brachial plexus palsy is controversial. A period of

physical therapy and observation for evidence of recovery is

often employed. Surgical intervention is advocated in select

cases if functional recovery does not ensue in 3 to 9 months,

but there is no consensus regarding the utility or timing of

surgery. Early referral to a center with expertise in the

management of NBPP may improve outcomes".

Bionic Reconstruction

Aszmann and associates (2015) stated that BPIs can

permanently impair hand function, yet present surgical

reconstruction provides only poor results. These researchers

presented for the first time bionic reconstruction; a combined

technique of selective nerve and muscle transfers, elective

amputation, and prosthetic rehabilitation to regain hand

function. Between April 2011, and May 2014, a total of 3

patients with global BPI including lower root avulsions

underwent bionic reconstruction. Treatment occurred in 2

stages: (i) to identify and create useful electromyographic

(EMG) signals for prosthetic control, and (ii) to amputate the

hand and replace it with a mechatronic prosthesis. Before

amputation, the patients had a specifically tailored

rehabilitation program to enhance EMG signals and cognitive

control of the prosthesis. Final prosthetic fitting was applied as

early as 6 weeks after amputation. Bionic reconstruction

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successfully enabled prosthetic hand use in all 3 patients.

After 3 months, mean Action Research Arm Test score

increased from 5.3 (SD 4.73) to 30.7 (14.0). Mean

Southampton Hand Assessment Procedure score improved

from 9.3 (SD 1.5) to 65.3 (SD 19.4). Mean Disabilities of Arm,

Shoulder and Hand score improved from 46.5 (SD 18.7) to

11.7 (SD 8.42). The authors concluded that for patients with

global BPI with lower root avulsions, who have no alternative

treatment, bionic reconstruction offered a means to restore

hand function.

Contralateral C7 Transfer for the Treatment of Traumatic Brachial Plexus Injury

The contralateral C7 nerve root is available as a donor for

extraplexus transfer but is less optimal than ipsilateral

transfers due to the long distance to regeneration (Elkwood, et

al., 2019).

Sammer and co-workers (2012) noted that in BPIs with nerve

root avulsions, the options for nerve reconstruction are limited.

In select situations, 50 % or all of the contralateral C7 (CC7)

nerve root can be transferred to the injured side for brachial

plexus reconstruction. Although encouraging results have

been reported, CC7 transfer has not gained universal

popularity. These researchers evaluated hemi-CC7 transfer

for restoration of shoulder function or median nerve function in

patients with severe BPI. A retrospective review of all patients

with traumatic BPI (TBPI) who had undergone hemi-CC7

transfer at a single institution during an 8-year period was

performed. Complications were evaluated in all patients

regardless of the duration of follow-up. The results of electro-

diagnostic studies and modified British Medical Research

Council (BMRC) motor grading were reviewed in all patients

with more than 27 months of follow-up. A total of 55 patients

with TBPI underwent hemi-CC7 transfer performed between

2001 and 2008 for restoration of shoulder function or median

nerve function; 13 patients who underwent hemi-CC7 transfer

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to the shoulder and 15patients who underwent hemi-CC7

transfer to the median nerve had more than 27 months of

follow-up; 12/13 patients in the shoulder group demonstrated

EMG evidence of re-innervation, but only 3 patients achieved

M3 or greater shoulder abduction motor function; 3/15 patients

in the median nerve group demonstrated EMG evidence of re-

innervation, but none developed M3 or greater composite grip.

All patients experienced donor-side sensory or motor

changes; these were typically mild and transient, but 1 patient

sustained severe, permanent donor-side motor and sensory

losses. The authors concluded that the outcomes of hemi

CC7 transfer for restoration of shoulder motor function or

median nerve function following post-TBPI do not justify the

risk of donor-site morbidity, which includes possible permanent

motor and sensory losses.

Chuang and Hernon (2012) stated that CC7 transfer for BPI

can benefit finger sensation but remains controversial

regarding restoration of motor function. These investigators

reported their 20-year experience using CC7 transfer for BPI,

all of which had at least 4 years of follow-up. A total of 137

adult BPI patients underwent CC7 transfer from 1989 to 2006.

Of these patients, 101 fulfilled the inclusion criteria for this

study. A single surgeon performed all surgeries. A

vascularized ulnar nerve graft, either pedicled or free, was

used for CC7 elongation. The vascularized ulnar nerve graft

was transferred to the median nerve (group 1, 1 target) in 55

patients, and to the median and musculo-cutaneous (MC)

nerves (group 2, 2 targets) in 23 patients. In another 23

patients (group 3, 2 targets, 2 stages), the CC7 was

transferred to the median nerve (17 patients) or to the median

and MC nerve (6 patients) during the 1st stage, followed by

functioning free muscle transplantation (FFMT) for finger

flexion. These researchers considered finger flexion strength

greater or equal to M3 to be a successful functional result.

Success rates of CC7 transfer were 55 %, 39 %, and 74 % for

groups 1, 2, and 3, respectively. In addition, the success rate

for recovery of elbow flexion (strength M3 or better) in group 2

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was 83 %. The authors concluded that in reconstruction of

total brachial plexus root avulsion, the best option may be to

adopt the technique of using CC7 transfer to the MC and

median nerve, followed by FFMT in the early stage (18 mo or

less) for finger flexion. They stated that such a technique can

potentially improve motor recovery of elbow and finger flexion

in a shorter rehabilitation period (3 to 4 years) and, more

importantly, provide finger sensation to the completely

paralytic limb.

Yang and colleagues (2015a) stated that CC7 transfer has

been used for treating TBPI. However, the effectiveness of the

procedure remains a subject of debate. These investigators

performed a systematic review to study the overall outcomes

of CC7 transfer to different recipient nerves in TBPIs. A

literature search was conducted using PubMed and Embase

databases to identify original articles related to CC7 transfer

for TBPI. The data extracted were study/patient

characteristics, and objective outcomes of CC7 transfer to the

recipient nerves. These researchers normalized outcome

measures into a MRC-based outcome scale. A total of 39

studies were identified. The outcomes were categorized

based on the major recipient nerves: median, MC, and

radial/triceps. Regarding overall functional recovery, 11 % of

patients achieved MRC grade M4 wrist flexion and 38 %

achieved MRC grade M3. Grade M4 finger flexion was

achieved by 7 % of patients, whereas 36 % achieved M3.

Finally, 56 % achieved greater than or equal to S3 sensory

recovery in the median nerve territories. In the MC nerve

group, 38 % regained to M4 and 37 % regained to M3. In the

radial/triceps nerve group, 25 %regained elbow or wrist

extension strength to a MRC grade M4 and to M3,

respectively. The authors concluded that outcome measures

in the included studies were not consistently reported to

uncover true patient-related benefits from the CC7 transfer.

They stated that reliable and validated outcome instruments

should be applied to critically evaluate patients undergoing

CC7 transfer.

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Yang and colleagues (2015b) noted that although CC7

transfer has been widely used for treating TBPI, the safety of

the procedure is questionable. These investigators performed

a systematic review to investigate the donor-site morbidity,

including sensory abnormality and motor deficit, to guide

clinical decision-making. A systematic review on CC7 transfer

for TBPI was performed for original articles in the PubMed and

Embase databases. Patient demographic data and donor-site

morbidity of CC7 transfer, including incidence, recovery rate,

and recovery time were extracted. The sensory abnormality

areas and muscles involved in motor weakness were also

summarized. A total of 904 patients from 27 studies were

reviewed. Overall, 74 % of patients (668 of 897) experienced

sensory abnormalities, and 98 % (618 of 633) recovered to

normal; the mean recovery time was 3 months. For motor

function, 20 % (118 of 592) had motor deficit after CC7

transfer and 91 % (107 of 117) regained normal motor

function; the mean recovery time was 6 months. Sensory

abnormality mainly occurred in the area of the hand innervated

by the median nerve, whereas motor deficit most often

involved muscles innervated by the radial nerve. There were

19 patients with long-term morbidity of the donor site in the

studies. The authors concluded that the incidence of donor-

site morbidity after CC7 transfer was relatively high, and

severe and long-term defects occurred occasionally. They

stated that CC7 transfer should be indicated only when other

donor nerves are not available, and with a comprehensive

knowledge of the potential risks.

Mathews and associates (2017) stated that the effectiveness

of CC7 transfer is controversial, yet this procedure has been

performed around the world to treat BPIs. These investigators

performed a systematic review to study whether Asian

countries reported better outcomes after CC7 transfer

compared with "other" countries. A systematic literature

search using PubMed, Embase, and 3 Chinese databases

was completed. Patient outcomes of CC7 transfer to the

median and MC nerves were collected and categorized into 2

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groups: (i) Asia and (ii) "other" countries. China was included

as a sub-category of Asia because investigators in China

published the majority of the collected studies. To compare

outcomes among studies, these researchers created a

normalized MRC scale. For median nerve outcomes, Asia

reported that 41 % of patients achieved an MRC grade of

greater than or equal to M3 of wrist flexion compared with 62

% in "other" countries. For finger flexion, Asia found that 41 %

of patients reached an MRC grade of greater than or equal to

M3 compared with 38 % in "other" countries. Asia reported

that 60 % of patients achieved greater than or equal to S3

sensory recovery, compared with 32 % in "other" countries.

For MC nerve outcomes, 75 % of patients from both Asia and

"other" countries reached M4 and M3 in elbow flexion. The

authors concluded that current data did not demonstrate that

studies from Asian countries reported better outcomes of CC7

transfer to the median and MC nerves. They stated that future

studies should focus on comparing outcomes of different

surgical strategies for CC7 transfer.

Vu and associates (2018) stated that CC7 has been described

for brachial plexus reconstruction in adults but has not been

well-studied in the pediatric population. In a retrospective

review, these investigators presented their technique and

results for retropharyngeal CC7 nerve transfer to the lower

trunk for brachial plexus birth injury. Any child aged less than

2 years was included. Charts were analyzed for patient

demographic data, operative variables, functional outcomes,

complications, and length of follow-up. A total of 5 patients

were included in this study. Average nerve graft length was 3

cm. All patients had return of hand sensation to the ulnar

nerve distribution as evidenced by a pinch test, unprompted

use of the recipient limb without mirror movement, and an

Active Movement Scale (AMS) of at least 2/7 for finger and

thumb flexion; 1 patient had an AMS of 7/7 for finger and

thumb flexion. Only 1 patient had return of ulnar intrinsic hand

function with an AMS of 3/7; 2 patients had temporary triceps

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weakness in the donor limb and 1 had clinically insignificant

temporary phrenic nerve paresis. No complications were

related to the retropharyngeal nerve dissection in any patient.

Average follow-up was 3.3 years. The authors concluded that

the retropharyngeal CC7 nerve transfer was a safe way to

supply extra axons to the severely injured arm in brachial

plexus birth injuries with no permanent donor limb deficits.

They stated that early functional recovery in these patients,

with regard to hand function and sensation, was promising.

Wang and colleagues (2018) noted that CC7 nerve root has

been used as a donor nerve for targeted neurotization in the

treatment of total brachial plexus palsy (TBPP). These

investigators studied the contribution of C7 to the innervation

of specific upper-limb muscles and examined the utility of C7

nerve root as a recipient nerve in the management of TBPP.

This was a 2-part investigation. First – anatomical study: the

C7 nerve root was dissected and its individual branches were

traced to the muscles in 5 embalmed adult cadavers

bilaterally. Second – clinical series: 6 patients with TBPP

underwent CC7 nerve transfer to the middle trunk of the

injured side. Outcomes were evaluated with the modified

Medical Research Council scale and EMG studies. In the

anatomical study there were consistent and predominantly C7

derived nerve fibers in the lateral pectoral, thoracodorsal, and

radial nerves. There was a minor contribution from C7 to the

long thoracic nerve. The average distance from the C7 nerve

root to the lateral pectoral nerve entry point of the pectoralis

major was the shortest, at 10.3 ± 1.4 cm. In the clinical series

the patients had been followed for a mean time of 30.8 ± 5.3

months post-operatively. At the latest follow-up, 5 of 6 patients

regained M3 or higher power for shoulder adduction and elbow

extension; 2 patients regained M3 wrist extension. All

regained some wrist and finger extension, but muscle strength

was poor. Compound muscle action potentials were recorded

from the pectoralis major at a mean follow-up of 6.7 ± 0.8

months; from the latissimus dorsi at 9.3 ± 1.4 months; from the

triceps at 11.5 ± 1.4 months; from the wrist extensors at 17.2 ±

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1.5 months; from the flexor carpi radialis at 17.0 ± 1.1 months;

and from the digital extensors at 22.8 ± 2.0 months. The

average sensory recovery of the index finger was S2.

Transient paresthesia in the hand on the donor side, which

resolved within 6 months post-operatively, was reported by all

patients. The authors concluded that the C7 nerve root

contributed consistently to the lateral pectoral nerve, the

thoracodorsal nerve, and long head of the triceps branch of

the radial nerve; CC7 to C7 nerve transfer is a reconstructive

option in the overall management plan for TBPP. It was safe

and effective in restoring shoulder adduction and elbow

extension in this patient series. However, recoveries of wrist

and finger extensions were poor. These preliminary findings

need to be further investigated.

Combined Human Acellular Nerve Allograft and Contralateral C7 Nerve Root Transfer for Restoring Shoulder Abduction and Elbow Flexion Following Brachial Plexus Injury

Li and colleagues (2019) noted that human acellular nerve

allograft applications have increased in clinical practice, but no

studies have quantified their influence on reconstruction

outcomes for high-level, greater, and mixed nerves, especially

the brachial plexus. Ina retrospective study, these

investigators examined the functional outcomes of human

acellular nerve allograft reconstruction for nerve gaps in

patients with BPI undergoing CC7 nerve root transfer to

innervate the upper trunk, and they determined the

independent predictors of recovery in shoulder abduction and

elbow flexion. A total of 45 patients with partial or total BPI

were eligible for this trial after CC7 nerve root transfer to the

upper trunk using human acellular nerve allografts. Deltoid

and biceps muscle strength, degree of shoulder abduction and

elbow flexion, Semmes-Weinstein monofilament test, and

static 2-point discrimination (S2PD) were examined according

to the modified BMRC (mBMRC) scoring system, and

disabilities of the arm, shoulder, and hand (DASH) were

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scored to establish the function of the affected upper limb.

Meaningful recovery was defined as grades of M3 to M5 or S3

to S4 based on the scoring system. Subgroup analysis and

univariate and multivariate logistic regression analyses were

conducted to identify predictors of human acellular nerve

allograft reconstruction. The mean follow-up duration and the

mean human acellular nerve allograft length were 48.1 ± 10.1

months and 30.9 ± 5.9 mm, respectively. Deltoid and biceps

muscle strength was grade M4 or M3 in 71.1 % and 60.0 % of

patients. Patients in the following groups achieved a higher

rate of meaningful recovery in deltoid and biceps strength, as

well as lower DASH scores (p < 0.01): age of less than 20

years and age 20 to 29 years; allograft lengths less than or

equal to 30 mm; and patients in whom the interval between

injury and surgery was less than 90 days. The meaningful

sensory recovery rate was approximately 70 % in the

Semmes-Weinstein monofilament test and S2PD. According

to univariate and multivariate logistic regression analyses, age,

interval between injury and surgery, and allograft length

significantly influenced functional outcomes. The authors

concluded that human acellular nerve allografts offered safe

reconstruction for 20- to 50-mm nerve gaps in procedures for

CC7 nerve root transfer to repair the upper trunk after BPI.

The group in which allograft lengths were less than or equal to

30 mm achieved better functional outcome than others, and

the recommended length of allograft in this procedure was less

than 30 mm. Age, interval between injury and surgery, and

allograft length were independent predictors of functional

outcomes following human acellular nerve allograft

reconstruction.

Therapeutic Taping

Russo and colleagues (2016) examined if therapeutic taping

for scapular stabilization affected scapula-thoracic, gleno

humeral, and humero-thoracic joint function in children with

brachial plexus birth palsy and scapular winging. Motion

capture data were collected with and without therapeutic

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taping to assist the middle and lower trapezius in 7 positions

for 26 children. Data were compared with 1-way multi-variate

analyses of variance. With therapeutic taping, scapular

winging decreased considerably in all positions except

abduction. Additionally, there were increased gleno-humeral

cross-body adduction and internal rotation angles in 4

positions. The only change in humero-thoracic function was

an increase of 3 degrees of external rotation in the external

rotation position. The authors concluded that therapeutic

taping for scapular stabilization resulted in a small but

statistically significant decrease in scapular winging. Overall

performance of positions was largely unchanged. They stated

that increased gleno-humeral joint angles with therapeutic

taping may be beneficial for joint development; however, the

long-term impact remains unknown.

Free Functioning Gracilis Muscle Transfer With Simultaneous Intercostal Nerve Transfer to Musculocutaneous Nerve for Restoration of Elbow Flexion After Traumatic Brachial Plexus Injury

Maldonado and colleagues (2017) stated that after complete 5

level root avulsion BPI, the free-functioning muscle transfer

(FFMT) and the intercostal nerve (ICN) to musculocutaneous

nerve (MCN) transfer are 2 potential reconstructive options for

restoration of elbow flexion. These investigators examined if

the combination of the gracilis FFMT and the ICN to MCN

transfer provides stronger elbow flexion compared with the

gracilis FFMT alone. A total of 65 patients who underwent the

gracilis FFMT only (32 patients) or the gracilis FFMT in

addition to the ICN to MCN transfer (33 patients) for elbow

flexion after a pan-plexus injury were included. The 2 groups

were compared with respect to post-operative elbow flexion

strength according to the modified British Medical Research

Council grading system as well as pre-operative and post

operative Disability of the Arm, Shoulder, and Hand scores.

Two subgroup analyses were performed for the British

Medical Research Council elbow flexion strength grade: FFMT

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neurotization (spinal accessory nerve versus ICN) and the

attachment of the distal gracilis tendon (biceps tendon versus

flexor digitorum profundus/flexor pollicis longus tendon). The

proportion of patients reaching the M3/M4 elbow flexion

muscle grade were similar in both groups (FFMT versus FFMT

+ ICN to MCN transfer). Statistically significant improvement

in post-operative Disability of the Arm, Shoulder, and Hand

score was found in the FFMT + ICN to MCN transfer group but

not in the FFMT group. There was a significant difference

between gracilis to biceps (M3/M4 = 52.6 %) and gracilis to

FDP/flexor pollicis longus (M3/M4 = 85.2 %) tendon

attachment. The authors concluded that the use of the ICN to

MCN transfer associated with the FFMT did not improve the

elbow flexion modified British Medical Research Council

grade, although better post-operative Disability of the Arm,

Shoulder, and Hand scores were found in this group. The

more distal attachment of the gracilis FFMT tendon may play

an important role in elbow flexion strength.

In a systematic review, Oliver and colleagues (2020)

compared post-operative elbow flexion outcomes in patients

receiving functioning free muscle transplantation (FFMT)

innervated by either intercostal nerve (ICN) or spinal

accessory nerve (SAN) grafts. These researchers carried out

a comprehensive systematic review on FFMT for brachial

plexus reconstruction using Medline/PubMed data-base.

Analysis was designed to compare functional outcomes

between nerve graft type (ICN versus SAN) as well as different

free muscle graft types to biceps tendon (gracilis versus rectus

femoris versus latissimus dorsi). A total of 312 FFMTs

innervated by ICNs (169) or the SAN (143) were featured in 10

case series. The mean patient age was 28 years. Patients

had a mean injury to surgery time of 31.5 months and an

average follow-up time of 39.1 months with 18 patients lost to

follow-up. Muscles utilized included the gracilis (275), rectus

femoris (28), and latissimus dorsi (8). After excluding those

lost to follow-up or failures due to vascular compromise, the

mean success rates of FFMTs innervated by ICNs and SAN

were 64.1 % and 65.4 %, respectively. The authors concluded

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that this analysis did not identify any difference in outcomes

between FFMTs via ICN grafts and those innervated by SAN

grafts in restoring elbow flexion in traumatic brachial plexus

injury patients.

Oberlin Transfer for Improving Early Supination in Neonatal Brachial Plexus Palsy

The ulnar to musculocutaneous nerve transfer (ie, Oberlin)

involves the transposition of fascicles of the flexor carpi ulnaris

to the biceps branch of musculocutaneous nerve [40].

Chang and associates (2018a) noted that the use of nerve

transfers versus nerve grafting for NBPP remains

controversial. In adult BPI, transfer of an ulnar fascicle to the

biceps branch of the musculo-cutaneous nerve (Oberlin

transfer) is reportedly superior to nerve grafting for restoration

of elbow flexion. In pediatric patients with NBPP, recovery of

elbow flexion and forearm supination is an indicator of

resolved NBPP. Currently, limited evidence exists of

outcomes for flexion and supination when comparing nerve

transfer and nerve grafting for NBPP. In a retrospective,

cohort study, these researchers compared 1-year post

operative outcomes for infants with NBPP who underwent

Oberlin transfer versus nerve grafting. This trial reviewed

patients with NBPP who underwent Oberlin transfer (n = 19)

and nerve grafting (n = 31) at a single institution between 2005

and 2015. A single surgeon conducted intra-operative

exploration of the brachial plexus and determined the surgical

nerve reconstruction strategy undertaken. Active range of

motion (ROM) was evaluated pre-operatively and post

operatively at 1 year. No significant difference between

treatment groups was observed with respect to the mean

change (pre- to post-operatively) in elbow flexion in adduction

and abduction and biceps strength. The Oberlin transfer

group gained significantly more supination (100° versus 19°; p

< 0.0001). Forearm pronation was maintained at 90° in the

Oberlin transfer group whereas it was slightly improved in the

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grafting group (0° versus 32°; p = 0.02). Shoulder, wrist, and

hand functions were comparable between treatment groups.

The authors concluded that these preliminary data

demonstrated that the Oberlin transfer conferred an

advantageous early recovery of forearm supination over

grafting, with equivalent elbow flexion recovery. Moreover,

they stated that further studies that monitor real-world arm

usage will provide more insight into the most appropriate

surgical strategy for NBPP.

Double Fascicular Nerve Transfer to Musculocutaneous Branches for Restoring Elbow Function Following Brachial Plexus Injury

The Oberlin transfer can be combined with the median nerve

branch to brachialis branch of the musculocutaneous nerve

(Mackinnon or double transfer) (Mackinnon, et al., 2005;

Elkwood, et al, 2019). The average time to reinnervation in

these transfers is five months, which is considerably shorter

than plexus reconstruction using interposition grafts.

Mackinnon, et al (2005) reported on a double fascicular nerve

transfer to reinnervate the brachialis muscle and the biceps

muscle to restore elbow flexion after brachial plexus injury. A

retrospective review was performed on 6 patients who had

direct nerve transfer of a single expendable motor fascicle

from both the ulnar and median nerves directly to the biceps

and brachialis branches of the musculocutaneous nerve.

Assessment included degree of recovery of elbow flexion and

ulnar and median nerve function including pinch and grip

strengths. Clinical evidence of reinnervation was noted at a

mean of 5.5 months (SD, 1 mo; range, 3.5-7 mo) after surgery

and the mean follow-up period was 20.5 months (SD, 11.2 mo,

range, 13-43 mo). Mean recovery of elbow flexion was Medical

Research Council grade 4+. Postoperative pinch and grip

strengths were unchanged or better in all patients. No motor or

sensory deficits related to the ulnar or median nerves were

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noted and all patients maintained good hand function. No

patients required additional procedures to further improve

elbow flexion strength.

Texakalidis and colleagues (2019) noted that restriction of

elbow flexion significantly limits upper extremity (UE) function

following BPI. In recent years, the double fascicular nerve

transfer procedure utilizing ulnar and median nerve transfer to

musculocutaneous branches has shown promising functional

outcomes. In a retrospective review, these investigators

examined restoration of elbow flexion following a double

fascicular transfer in patients with BPI and identified predictors

of poor outcomes. This review included 10 consecutive

patients with BPI involving C5 to C6 root avulsions who

underwent the double nerve transfer procedure. The mean

follow-up was 12 months and the primary outcome was

assessment of elbow flexion with the use of the MRC scale.

This procedure achieved elbow flexion of MRC grade M3 or

higher in 50 % of this cohort. Time interval from injury to

surgery showed a statistically significant inverse association

with functional recovery (r = -0.73, p = 0.016). Patients who

had the surgery within 6 months of the injury, demonstrated

higher MRC grades during the follow-up (p = 0.048). There

was no association between elbow flexion recovery and age,

body mass index (BMI), gender, hypertension, diabetes or

smoking status. The authors concluded that the findings of the

current study suggested that the double ulnar and median

nerve transfer to the musculocutaneous may be a safe and

effective approach for elbow flexion restoration following C5 to

C6 root avulsions. Furthermore, it noted that functional

outcomes were adversely affected by the increase in the time

interval from injury to surgery; the double fascicular transfer

within the first 6 months was suggested by this study. No

association between MRC grades and patient demographic

characteristics was identified.


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The authors stated that this study had several drawbacks.

First, this study was retrospective, and thus limited by its non-

randomized nature. Second, despite the standardized follow-

up schedule at the authors’ institution, its duration was not

similar for all patients due to some patients missing

appointments, which might have affected the outcomes. Third,

this study was limited by its small sample size (n = 10), single

surgeon experience and lack of matched controls.

Vascularized Brachial Plexus Allo-Transplantation for the Treatment of Traumatic Brachial Plexus Injury

Chang and colleagues (2019) stated that brachial plexus

injuries are devastating. Current reconstructive treatments

achieve limited partial functionality. Vascularized brachial

plexus allo-transplantation could offer the best nerve graft

fulfilling the like-with-like principle. In this experimental study,

these researchers examined the feasibility of rat brachial

plexus allo-transplantation and analyzed its functional

outcomes. A free vascularized brachial plexus with a chimeric

compound skin paddle flap based on the subclavian vessels

was transplanted from a Brown Norway rat to a Lewis rat. This

study has 2 parts. Protocol I aimed to develop the

vascularized brachial plexus allo-transplantation-model (VBP

allo); 4 groups were compared: no reconstruction, VBP-allo

with and without cyclosporine-A (CsA) immunosuppression,

VBP auto-transplantation (VBP-auto). Protocol II compared

the recovery of the biceps muscle and forearm flexors when

using all 5, 2 (C5+C6) or 1 (isolated C6) spinal nerve as the

donor nerves. The assessment was performed on week 16

and included muscle weight, functionality (grooming tests,

muscle strength), electrophysiology and histomorphology of

the targeted muscles. Protocol I showed, the VBP-allo with

CsA immunosuppression was electrophysiologically and

functionally comparable to VBP-auto and significantly superior

to negative controls and absent immunosuppression. In

Protocol II, all groups had a comparable functional recovery in

the biceps muscle. Only with 5 donor nerves did the forearm


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show good results compared with only 1 or 2 donor nerves.

The authors concluded that the findings of this study showed

an useful vascularized complete brachial plexus allo

transplantation rodent model with successful forelimb function

restoration under immunosuppression. Only the allo

transplantation including all 5 roots as donor nerves achieved

a forearm recovery.

Combined Flexor Carpi Ulnaris and Flexor Carpi Radialis Transfer for Restoring Elbow Function Following Brachial Plexus Injury

Atthakomol and colleagues (2019) stated that the result of

combined agonist and antagonist muscle innervation in TBPI

through the intraplexal fascicle nerve transfers with the same

donor function has not yet been reported. These researchers

described a patient with a C5 to C7 TBPI who had a combined

transfer of the flexor carpi radialis (FCR) fascicle to the

musculocutaneous nerve and the flexor carpi ulnaris (FCU)

fascicle to the radial nerve of the triceps. The patient returned

for his follow-up visit 2 years after his surgery. The muscle

strengths of his triceps and biceps were MRC grade 2 and 0,

respectively. Compared with his uninjured side, his grip

strength was 9.8 %, and his pinch strength was 14.2 %. The

authors concluded that this case report provided insights on

result of combined agonist and antagonist muscle innervation

through combining the motor fascicle of the FCR and FCU to

restore the elbow flexor and extensor; the result may not be

promising.

CPT Codes / HCPCS Codes / ICD-10 Codes

Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":

Code Code Description


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CPT codes covered if selection criteria are met:

Triangle Tilt Surgery, Mod-hyphenQuad Procedure - no specific code:

Neurolysis:

CPT codes covered if selection criteria are met:

64713 Neuroplasty, major peripheral nerve, arm or leg,

open; brachial plexus

ICD-10 codes covered if selection criteria are met:

D21.0 Benign neoplasm of connective and other soft

tissue of head, face and neck

D21.10 -

D21.12

Benign neoplasm of connective and other soft

tissue of upper limb, including shoulder

G54.0 Brachial plexus disorders

P14.3 Other brachial plexus birth injury

S14.3xx+ Injury of brachial plexus

Vascularized brachial plexus allo-transplantation:

CPT codes not covered for indications listed in the CPB :

64912 Nerve repair; with nerve allograft, each nerve,

first strand (cable)

64913 Nerve repair; with nerve allograft, each

additional strand (List separately in addition to

code for primary procedure)

ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):


Dorsal root entry zone (DREZ) coagulation :

CPT codes covered if selection criteria are met: :



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63170 Laminectomy with myelotomy (eg, Bischof or

DREZ type), cervical, thoracic, or

thoracolumbar

64640 Destruction by neurolytic agent; other

peripheral nerve or branch

ICD-10 codes covered if selection criteria are met:

S14.3xx+ Injury of brachial plexus [brachial plexus

avulsion]

Computer-assisted dorsal root entry zone (CA-DREZ) coagulation:


+20985 Computer-assisted surgical navigational

procedure for musculoskeletal procedures,

image-less (List separately in addition to code

for primary procedure)

Bionic reconstruction:

CPT codes not covered for indications listed in the CPB:

No specific code


S14.3xx+ Injury of brachial plexus [brachial plexus

avulsion]

Therapeutic taping for scapular stabilization:


29240 Strapping; shoulder (eg., Velpeau) [therapeutic

taping]




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M21.821

-

M21.829

Other specified acquired deformities of upper

arm [winged scapula]

P14.3 Other brachial plexus birth injury

The above policy is based on the following references:

Brachial Neuroplasty

1. Ali ZS, Bakar D, Li YR, et al. Utility of delayed surgical

repair of neonatal brachial plexus palsy. J Neurosurg

Pediatr. 2014;13(4):462-470.

2. Ali ZS, Heuer GG, Faught RW, et al. Upper brachial

plexus injury in adults: Comparative effectiveness of

different repair techniques. J Neurosurg. 2015;122

(1):195-201.

3. Bradley: Neurology in Clinical Practice. Fifth Edition.

2008.

4. Bromberg MR. Brachial plexus syndromes. UpToDate

[online serial]. Waltham, MA: UpToDate; reviewed

August 2015.

5. Browner: Skeletal Trauma. Fourth Edition. 2008.

6. Canale & Beaty: Campbell's Operative Orthopaedics.

Eleventh Edition. 2007.

7. Frontera: Essentials of Physical Medicine and

Rehabilitation. Second Edition. 2008.

8. Kliegman RM. Nelson Textbook of Pediatrics.

Eighteenth Edition. 2007.

9. Krishnan KG, Martin KD, Schackert G. Traumatic

lesions of the brachial plexus: An analysis of outcomes

in primary brachial plexus reconstruction and


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secondary functional arm reanimation. Neurosurgery.

2009;62(4):873-885; discussion 885-8866.

10. Liu Y, Lao J, Zhao X. Comparative study of phrenic and

intercostal nerve transfers for elbow flexion after

global brachial plexus injury. Injury. 2015;46(4):671-

675.

11. Maldonado AA, Kircher MF, Spinner RJ, et al. Free

functioning gracilis muscle transfer versus intercostal

nerve transfer to musculocutaneous nerve for

restoration of elbow flexion after traumatic adult

brachial pan-plexus injury. Plast Reconstr Surg.

2016;138(3):483e-488e.

12. Shin AY, Spinner RJ, Steinmann SP, Bishop AT. Adult

traumatic brachial plexus injuries. J Am Acad Orthop

Surg. 2005;13(6):382-396.

13. Tse R, Kozin SH, Malessy MJ, Clarke HM. International

Federation of societies for surgery of the hand

committee report: The role of nerve transfers in the

treatment of neonatal brachial plexus palsy. J Hand

Surg Am. 2015;40(6):1246-1259.

Computer-Assisted Dorsal Root Entry Zone (CA-DREZ) Microcoagulation

1. Daroff: Bradley's Neurology in Clinical Practice. Sixth

Edition. 2012.

2. Edgar RE, Best LG, Quail PA, Obert AD. Computer-

assisted DREZ microcoagulation: Posttraumatic spinal

deafferentation pain. J Spinal Disord. 1993;6(1):48-56.

3. Thomas DG, Jones SJ. Dorsal root entry zone lesions

(Nashold’s procedure) in brachial plexus avulsion.

Neurosurgery. 1984;15(6):966-968.

Dorsal Root Entry Zone (DREZ) Coagulation

1. Friedman AH, Nashold BS Jr, Bronec PR. Dorsal root

entry zone lesions for the treatment of brachial plexus


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avulsion injuries: A follow-up study. Neurosurgery.

1988;22(2):369-373.

2. Prestor B. Microsurgical junctional DREZ coagulation

for treatment of deafferentation pain syndromes. Surg

Neurol. 2001;56(4):259-265.

3. Samii M, Bear-Henney S, Ludemann W, et al.

Treatment of refractory pain after brachial plexus

avulsion with dorsal root entry zone lesions.

Neurosurgery. 2001;48(6):1269-1277.

4. Schwartz: Principles of Surgery. Seventh Edition. 1999.

5. Sindou MP, Blondet E, Emery E, Mertens P.

Microsurgical lesioning in the dorsal root entry zone

for pain due to brachial plexus avulsion: A prospective

series of 55 patients. J Neurosurg. 2005;102(6):1018-

1028.

6. Thomas DG, Jones SJ. Dorsal root entry zone lesions

(Nashold’s procedure) in brachial plexus avulsion.

Neurosurgery. 1984;15(6):966-968.

7. Townsend: Sabiston Textbook of Surgery. Seventeenth

Edition. 2004.

Soft Tissue Reconstruction Procedures

1. Louden EJ, Broering CA, Mehlman CT, et al. Meta-

analysis of function after secondary shoulder surgery

in neonatal brachial plexus palsy. J Pediatr Orthop.

2013;33(6):656-663.

2. Nath RK, Amrani A, Melcher SE, et al. Surgical

normalization of the shoulder joint in obstetric

brachial plexus injury. Ann Plast Surg. 2010;65(4):411-

417.

Bionic Reconstruction

1. Aszmann OC, Roche AD, Salminger S, et al. Bionic

reconstruction to restore hand function after brachial

plexus injury: A case series of three patients. Lancet.

2015;385(9983):2183-2189.


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Contralateral C7 Transfer

1. Chuang DC, Hernon C. Minimum 4-year follow-up on

contralateral C7 nerve transfers for brachial plexus

injuries. J Hand Surg Am. 2012;37(2):270-276.

2. Elkwood AI, Kaufman MR,, Ibrahim Z. Surgical

treatment of brachial plexus injury. UpToDate [online

serial]. Waltham, MA: UpToDate; updated August 15,

2019.

3. Mathews AL, Yang G, Chang KW, Chung KC. A

systematic review of outcomes of contralateral C-7

transfer for the treatment of traumatic brachial plexus

injury: An international comparison. J Neurosurg.

2017;126(3):922-932.

4. Sammer DM, Kircher MF, Bishop AT, et al. Hemi-

contralateral C7 transfer in traumatic brachial plexus

injuries: Outcomes and complications. J Bone Joint

Surg Am. 2012;94(2):131-137.

5. Vu AT, Sparkman DM, van Belle CJ, et al.

Retropharyngeal contralateral C7 nerve transfer to the

lower trunk for brachial plexus birth injury: Technique

and results. J Hand Surg Am. 2018;43(5):417-424.

6. Wang GB, Yu AP, Ng CY, et al. Contralateral C7 to C7

nerve root transfer in reconstruction for treatment of

total brachial plexus palsy: Anatomical basis and

preliminary clinical results. J Neurosurg Spine. 201829

(5):491-499.

7. Yang G, Chang KW, Chung KC. A systematic review of

contralateral C7 (CC7) transfer for the treatment of

traumatic brachial plexus injury: Part 1. Overall

outcomes. Plast Reconstr Surg. 2015a;136(4):794-809.

8. Yang G, Chang KW, Chung KC. A systematic review of

contralateral C7 (CC7) transfer for the treatment of

traumatic brachial plexus injury: Part 2. Donor-site

morbidity. Plast Reconstr Surg. 2015b;136(4):480e-

489e.


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Therapeutic Taping

1. Russo SA, Rodriguez LM, Kozin SH, et al. Therapeutic

taping for scapular stabilization in children with

brachial plexus birth palsy. Am J Occup Ther. 2016;70

(5):7005220030p1-7005220030p11.

Free Functioning Gracilis Muscle Transfer With Simultaneous Intercostal Nerve Transfer to Musculocutaneous Nerve

1. Maldonado AA, Kircher MF, Spinner RJ, et al. Free

functioning gracilis muscle transfer with and without

simultaneous intercostal nerve transfer to

musculocutaneous nerve for restoration of elbow

flexion after traumatic adult brachial pan-plexus

injury. J Hand Surg Am. 2017;42(4):293.e1-293.e7.

2. Oliver JD, Beal C, Graham EM, et al. Functioning free

muscle transfer for brachial plexus injury: A systematic

review and pooled analysis comparing functional

outcomes of intercostal nerve and spinal accessory

nerve grafts. J Reconstr Microsurg. 2020;36(8):567-571.

Oberlin Transfer for Improving Early Supination in Neonatal Brachial Plexus Palsy

1. Chang KWC, Wilson TJ, Popadich M, et al. Oberlin

transfer compared with nerve grafting for improving

early supination in neonatal brachial plexus palsy. J

Neurosurg Pediatr. 2018a;21(2):178-184.




2019.

Vascularized Brachial Plexus Allo-Transplantation

1. Chang TN, Chen KT, Gorden T, et al. Vascularized

brachial plexus allotransplantation - An experimental


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study in Brown Norway and Lewis rats.

Transplantation. 2019;103(1):149-159.

Surgical Interventions for Restoring Elbow Function Following Brachial Plexus Injury

1. Atthakomol P, Ozkan S, Chen N, Lee SG. Combined

flexor carpi ulnaris and flexor carpi radialis transfer for

restoring elbow function after brachial plexus injury.

BMJ Case Rep. 2019;12(7).

2. Bhatia A, Kulkarni A, Zancolli P, et al. The effect of age

and the delay before surgery on the outcomes of

intercostal nerve transfers to the musculocutaneous

Nerve: A retrospective study of 232 cases of

posttraumatic total and near-total brachial plexus

injuries. Indian J Plast Surg. 2020;53(2):260-265.




2019.

4. Lara AM, Bhatia A, Correa JC, El Gammal TA. Intercostal

nerve transfers to the musculocutaneous -- a reliable

nerve transfer for restoration of elbow flexion in birth-

related brachial plexus injuries. Indian J Plast Surg.

2020;53(2):254-259.

5. Leland HA, Azadgoli B, Gould DJ, Seruya M.

Investigation Into the optimal number of intercostal

nerve transfers for musculocutaneous nerve

reinnervation: A systematic review. Hand (NY). 2018;13

(6):621-626.

6. Li L, Yang J, Qin B, et al. Analysis of human acellular

nerve allograft combined with contralateral C7 nerve

root transfer for restoration of shoulder abduction

and elbow flexion in brachial plexus injury: A mean

4-year follow-up. J Neurosurg. 2019 Apr 26:1-11 [Epub

ahead of print].

7. Mackinnon SE, Novak CB, Myckatyn TM, Tung TH.

Results of reinnervation of the biceps and brachialis


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muscles with a double fascicular transfer for elbow

flexion. J Hand Surg Am. 2005;30(5):978-985.

8. Texakalidis P, Tora MS, Lamanna J, et al. Double

fascicular nerve transfer to musculocutaneous

branches for restoration of elbow flexion in brachial

plexus injury. Cureus. 2019;11(4):e4517.



Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan

benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial,

general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care

services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors

in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely

responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is

subject to change.

Copyright © 2001-2020 Aetna Inc.

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AETNA BETTER HEALTH® OF PENNSYLVANIA

Amendment to Aetna Clinical Policy Bulletin Number: 0850 Brachial Plexus

Surgery

There are no amendments for Medicaid.

updated 12/17/2020

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0850 Brachial Plexus Surgery (3) - Aetna Better Health

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