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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):
G54.0 Brachial plexus disorders
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:
CPT codes not covered for indications listed in the CPB :
+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
ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):
S14.3xx+ Injury of brachial plexus [brachial plexus avulsion]
Therapeutic taping for scapular stabilization:
CPT codes not covered for indications listed in the CPB :
29240 Strapping; shoulder (eg., Velpeau) [therapeutic taping]
ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):
G54.0 Brachial plexus disorders
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.
2. Elkwood AI, Kaufman MR,, Ibrahim Z. Surgical treatment of brachial plexus injury.
UpToDate [online serial]. Waltham, MA: UpToDate; updated August 15, 2019.
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.
6. Elkwood AI, Kaufman MR,, Ibrahim Z. Surgical treatment of brachial plexus injury.
UpToDate [online serial]. Waltham, MA: UpToDate; updated August 15, 2019.
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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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