The Impact of Tming of Primary Nerve Surgery on Shoulder Recovery in Neonatal Brachial Plexus Palsy

INTRODUCTION: Neonatal brachial plexus palsy (NBPP) almost universally impacts shoulder abduction, forward flexion, and external rotation. While nerve reconstruction options are available for restoration of these movement, the outcomes for nerve surgery for shoulder have lagged behind those at other joints. Operative timing is a potentially modifiable variable but remains controversial. METHODS: We interrogated a prospective database of all patients with NBPP who underwent primary nerve surgery at a single tertiary referral center between 2005-2020. The cohort was divided into those who underwent surgery ≤6 months old, 6-9 months old, and >9 months old. AROM for shoulder abduction, forward flexion, and external rotation was plotted over time for each group and a logistic regression and 95% confidence interval fit to each plot to visualize both absolute and rate of recovery of AROM for each group. RESULTS: 99 children with 2196 AROM measurements were included in the analysis with average follow-up of 46 months. 26 underwent surgery ≤6 months old, 47 between 6-9 months, and 26 >9 months old. Those who underwent surgery ≤9 months old had more rapid and better overall recovery of shoulder abduction and forward flexion than those who had surgery >9 months. Timing of operation did not clearly impact recovery of external rotation. Patients who presented to a multidisciplinary clinic earlier were more likely to have earlier operations. CONCLUSIONS: Surgery prior to 9 months old may improve long-term recovery of shoulder AROM in NBPP. Early referral should be encouraged to optimize timing of operative intervention.