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Prior Authorization Review PanelMCO Policy Submission

A separate copy of this form must accompany each policy submitted for review. Policies submitted without this form will not be considered for review.

Plan: Aetna Better Health Submission Date:01/01/2020

Policy Number: 0850 Effective Date: Revision Date:11/25/2019

Policy Name: Brachial Plexus Surgery

Type of Submission – Check all that apply:

New Policy Revised Policy* Annual Review – No Revisions Statewide PDL

*All revisions to the policy must be highlighted using track changes throughout the document.

Please provide any clarifying information for the policy below:

CPB 0850 Brachial Plexus Surgery

This CPB has been revised to remove the Oberlin transfer and the contralateral C7 transfer from the list of experimental and investigational interventions for brachial plexus injury.

Name of Authorized Individual (Please t ype or print):

Dr. Bernard Lewin, M.D.

Signature o f Authorized Individual:

Revised July 22, 2019 Proprietary

Proprietary

Brachial Plexus Surgery - Medical Clinical Policy Bulletins | Aetna

(https://www.aetna.com/)

Brachial Plexus Surgery

Clinical Policy Bulletins Medical Clinical Policy Bulletins

Last Review

12/06/2019

Effective: 07/30/2013

Next

Review: 09/24/2020

Review

History

Definitions

Additional Information

Clinical Policy

Bulletin

Notes

Number: 0850

*Please see amendment forPennsylvaniaMedicaid

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

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.

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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 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.

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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 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, 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.

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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 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.

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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 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 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.

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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

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-

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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 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 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

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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.

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

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median and MC nerves were collected and categorized into 2 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 CC7transfer.

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 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

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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

± 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 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

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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 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

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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

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.

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

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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 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 interpositiongrafts.

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 noted and all patients maintained good hand function. No patients

required additional procedures to further improve elbow flexionstrength.

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

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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.

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

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

CPT codes covered if selection criteria are met:

no specific code:

Neurolysis:

CPT codes covered if selection criteria are met:

64713 Neuroplasty, major peripheral nerve, arm or l eg, 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

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Code Code D escription

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: :

63170 Laminectomy with myelotomy (eg, Bischof or DREZ type), cervical, thoracic, or

thoracolumbar

64640 Destruction by neurolytic agent; other peripheral nerve o r 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]



M21.821 - M21.829

Other specified acquired deformities of upper arm [winged scapula]

P14.3 Other brachial plexus birth injury

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Brachial Neuroplasty

1. Bradley: Neurology in Clinical Practice. Fifth Edition. 2008.

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

3. Canale & Beaty: Campbell's Operative Orthopaedics. Eleventh Edition. 2007.

4. Frontera: Essentials of Physical Medicine and Rehabilitation. Second Edition.2008.

5. Kliegman: Nelson Textbook of Pediatrics. Eighteenth Edition. 2007.

6. Krishnan KG, Martin KD, Schackert G. Traumatic lesions of the brachial plexus: An

analysis of outcomes in primary brachial plexus reconstruction and secondary

functionalarmreanimation.Neurosurgery.2009;62(4):873-885;discussion885-8866.

7. Shin AY, Spinner RJ, Steinmann SP, Bishop AT. Adult traumatic brachial plexus injuries. J

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

8. 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.

9. 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.

10. Bromberg MR. Brachial plexus syndromes. UpToDate [online serial]. Waltham, MA:

UpToDate; reviewed August 2015.

11. 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.

12. 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.

13. 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.

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

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1. Friedman AH, Nashold BS Jr, Bronec PR. Dorsal root entry zone lesions for the

treatment of brachial plexus 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. Townsend: Sabiston Textbook of Surgery. Seventeenth Edition. 2004.

7. Thomas DG, Jones SJ. Dorsal root entry zone lesions (Nashold’s procedure) in brachial

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

Soft Tissue Reconstruction Procedures

1. 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.

2. 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.

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.

Contralateral C7 Transfer

1. 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.

2. 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.

3. 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

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

4. 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.

5. 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.

6. 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.

7. 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.

8. Elkwood AI, Kaufman MR,, Ibrahim Z. Surgical treatment of brachial plexus injury.

UpToDate [online serial]. Waltham, MA: UpToDate; updated August 15, 2019.

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.

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.



Vascularized Brachial Plexus Allo-Transplantation

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1. Chang TN, Chen KT, Gorden T, et al. Vascularized brachial plexus allotransplantation -

An experimental study in Brown Norway and Lewis rats. Transplantation.

2019;103(1):149-159.

Surgical Interventions for Restoring Elbow Function Following Brachial Plexus Injury

1. 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 (N Y). 2018;13(6):621-626.

2. 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).

3. 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.

4. 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].

5. Mackinnon SE, Novak CB, Myckatyn TM, Tung TH. Results of reinnervation of the biceps

and brachialis muscles with a double fascicular transfer for elbow flexion. J Hand Surg

Am. 2005;30(5):978-985.



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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 © 2001-2019 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.

www.aetnabetterhealth.com/pennsylvania revised 11/25/2019

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http://www.aetnabetterhealth.com/pennsylvania

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